Derbyshire Healthcare NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question as good. At this inspection the rating has remained as good. People received a wide range of treatment that was based on national guidance. Multi-disciplinary teams were well staffed with the skills and knowledge for people’s needs. However, not all staff were compliant when the reading of people’s rights was required when renewing Community Treatment Orders. Most staff were compliant with Mental Capacity Act training and reading of people's rights when renewing people's Community Treatment Orders, However, care plans were inconsistent between teams, people’s consent was not always recorded in care records and staff did not always maintain people’s confidentiality.

This service scored 63 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing, and communication needs with them.

The quality of care plans varied between teams. We reviewed 32 care records and found that 3 did not have an up-to-date care plan. Out of those, 2 people’s care plans had not been completed correctly, which meant their full care plans had not been updated since their discharges from hospital in 2024 and 2025. The other care plan had not been updated since the person was discharged from hospital in 2025.

One of the key findings from the trust’s December 2025 ‘fundamental of care standards visit feedback’ for community mental health teams (CMHTs) and early intervention in psychosis (EIP) teams included inconsistent documentation of risk assessments and care plans. An action plan included bespoke staff training to be completed by the end of January 2026. Senior managers completed monthly audits of care plan compliance. Data for all services from the 12 months before our inspection confirmed an average of 93% of people had a care plan in place against a target of 95%. An average of 70% of people had their care plan reviewed in the last 12 months, against a target of 95%.

As a result of a service-wide audit in October 2025, the service identified concerns with how physical health of people who used services was being monitored and introduced an action plan in October 2025 to address this. Data provided to us after our inspection confirmed an average of 59% compliance during the 12 months before our inspection. Their aim was to improve compliance to 85% and sustain this by 31 March 2026. Actions included standard agenda items for physical healthcare in staff and senior management meetings, improved audit processes and implementation of local physical health champions within each location.

However, within the care plans that were up to date, we found consistent themes of person-centred care which focused on people’s specific needs. An example of this were clear instructions for staff to follow when visiting someone with a learning disability at home.

Alongside the physical health action plan from October 2025, the trust had an established physical health monitoring team. Data provided after our inspection confirmed 93% of all people who were started on anti-psychotic or mood stabilisation medicines received a physical health check which included results for blood pressure, weight, smoking status and cholesterol. People were given appropriate advice and referrals.

The service offered a range of evidence-based care and treatment options, and most staff were compliant with Mental Health Act training. However, the service did not always follow legislation and current evidence-based good practice and standards regarding Community Treatment Orders.

People had access to a wide range of specialist staff. In addition to consultants and nurses, their multi-disciplinary teams (MDTs) were attended by specialists such as psychologists, occupational therapists and medical prescribers and advanced practitioners.

Each team had two managers, one with clinical responsibility and the other responsible for day-to-day team management and oversight. Staff felt supported by both managers and they provided cover to the other role during leave periods.

Staff said they had the clinical expertise to do their jobs well and keep people safe. They knew where and how to request help if they needed it. Staff said their professional development was discussed during appraisal meetings and could be discussed in between if necessary.

We reviewed team meeting notes where staff discussed set agenda items such as incidents, learning from incidents and staffing.

We reviewed compliance with Mental Health Act (MHA) training across the service. Trust-wide average compliance in MHA training was 93% against a target of 85%. The only locations below the 85% target were North Dales CMHT at 82% and South Derbyshire CMHT at 73% respectively.

Managers said they dealt with poor performance effectively. During our inspection we identified concerns with care records at Erewash CMHT and North Derbyshire EIP. Managers said they had discussed these findings with staff.

From 1 October to 31 December 2025, 95 people were subject to a Community Treatment Order (CTO). A CTO enables people who have been detained in hospital under the Mental Health Act 1983 for treatment to leave hospital and continue their care in the community. CTOs set out certain rules or conditions for people to follow in the community.

The trust had a process to monitor if patients had been given their rights under a CTO, but this was not always effective. Data provided by the trust confirmed that from 1 October to 31 December 2025, 7 people out of 96 (93%) receiving care under a CTO had not had their rights explained to them in line with trust policy, or for over 6 months after they were due. This meant not all people were made aware of their statutory rights under the Mental Health Act 1983. Following our inspection, managers told us they had taken immediate action to ensure people on a CTO were made aware of their rights. Managers took immediate action to ensure that the relevant patients were given their rights. Section 132a of the Mental Health Act states that hospital managers must provide information to people and their nearest relatives about the legal provisions that apply to them under their CTO, and about the rights and safeguards they are entitled to.

However, staff told us about the importance of discussing CTO rights with patients. Upcoming or recent CTO renewals were discussed in safety huddles and team meetings. Staff said CTO-related letters were available in different languages and in easy read format for people with a learning disability. Staff knew who to contact if they had any queries that related to the Mental Health Act.

The service worked well across teams and services to support people. They shared information with other teams to enable a smooth transition between teams and services.

In addition to regular and effective MDT meetings, staff regularly held management decision meetings (MDM) to discuss people with complex needs. MDMs were attended by other specialist teams, such as substance misuse and housing, to discuss concerns and solutions. MDMs regularly included discussions about people who did not engage with services and notes agreed actions for joint visits with occupational therapy (OT) and psychology staff to improve engagement.

We observed safety huddles at North Derbyshire EIP where important information was discussed such as overnight incidents, if people had presented to local hospitals along with ongoing discussion about people’s risk ratings and consideration of joint staff visits.

Staff said they attended ward rounds of patients on their caseload who were due to be discharged from hospital, to gain awareness of any changes in their treatment plan and improve people’s engagement in the community.

Managers said CMHTs and EIP teams had good relationships with people who made referrals, mainly GPs. They dealt with them sensitively and rejected referrals were sent with appropriate feedback.

Staff and managers highlighted the importance of effective partnership working with the police and described ongoing efforts to strengthen these relationships, particularly where there were challenges in responding to welfare concerns.

CMHTs were responsible for follow up calls to patients following their discharge from hospital. Data provided for all services between January 2025 and January 2026 showed that follow up calls or face to face contact was made within 72 hours of hospital discharge in 90% of cases, against a trust target of 80%.

The service supported people to manage their health and wellbeing to maximise their independence, choice, and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service had a strong commitment to support people to live healthier lives. Staff told us the importance of maintaining people’s physical health was as important as their mental health. Someone who used services said an occupational therapist (OT) had given them healthy eating advice and exercises during a home visit. They also had equipment installed at their home as a result of the OT assessment to help with mobility needs.

Each of the 32 care records that we reviewed included an element of physical healthcare consideration, documented in risk assessment, care plans and in daily entry notes. Care records included referrals to smoking cessation and weight loss groups. People had access to a football group with the local professional football team and bespoke groups to improve sleep, anxiety and wellbeing.

We saw posters in each location that promoted healthier lifestyles which included walking groups and support with smoking cessation. Staff said walking groups were popular with people and various sport sessions were available.

During observation of MDT meetings, staff discussed referrals to wound management teams and empowered people who hurt themselves.

The service did not always routinely monitor people’s care and treatment to continuously improve it.

The service used a variety of nationally recognised outcome measures to monitor people’s care. Our review of care records found these were being used in most teams. We reviewed data that showed an audit of compliance and observed consistent improvement from less than 5% in April 2024 to 17% in January 2026.

During our review of care records, we identified consistent use of outcome measures in South Derbyshire CMHT, Erewash CMHT and Amber Valley CMHT. Staff in other services said they experienced challenges with people who used services who did not want to provide personal information about their family relationships or finances as they would be included within outcome measures.

However, the trust undertook a yearly service-wide audit which included feedback from friends and family, care plan and risk assessment compliance and the number of complaints received. Examples of actions taken to address areas of improvement were improved electronic access to give feedback within posters and leaflets, promotion of the survey within engagement groups and implementation of tablets within reception areas.

Not all staff followed the trust’s consent policy or were compliant with Mental Capacity Act training; however most care records recorded people’s consent appropriately.

During our inspection, a manager told us about a recent complaint from someone who used services. Information about their treatment plan had been given to family members without their consent and their confidentiality had been breached. The complaint was upheld and learning actions included refreshed messages and emails to staff about the importance of consent and consideration of when to share information.

We reviewed 32 care records and found 4 records without appropriate consent documentation. However, staff we spoke to were aware of the importance of obtaining consent.

During our inspection, we observed several appointments. The assessment team ensured that consent was obtained and documented before the appointment started. We observed medicines clinics where staff obtained people’s consent for us to observe; they explained the treatment being given and secured consent before administering the prescribed medicines. Staff told us the importance of obtaining people’s consent at all stages of treatment and were aware of examples where risk assessments had not been shared with family members or carers. We found evidence of these decisions in those people’s care records.

We saw posters at different locations with contact details for advocates and staff told us the importance of ensuring that people knew about their availability.

Most service teams were compliant with Mental Capacity Act training. Compliance across all service teams was 94% against a target of 85%. The teams to fall below target were Derby City and South Derbyshire EIP, South Dales CMHT and Bolsover and Clay Cross CMHT with 83% against a target of 85%.