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

At our last inspection we rated this key question as requires improvement. At this inspection the rating has changed to good.

Good: Staffing levels were sufficient and shifts were consistently filled by bank and agency staff when required. We found the service shared learning from incidents and staff received appraisals and supervision. Medicines were managed well with embedded support for teams and attendance at multidisciplinary team (MDT) meetings. However, the service did not always manage the number of people on the waiting list correctly, or ensure that people on caseloads received regular appointments. Staff were not aware of the availability of personal alarms during off-site visits. People’s care record documentation did not always include up to date risk assessments or care plans.

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

In the 3 months before our inspection, 254 incidents were reported across all teams. Of those 254 incidents, no harm was identified in 144, 90 resulted in minor injuries, 52 resulted in moderate injuries and 9 incidents resulted in death. The service reported 23 serious incidents in the 12 months before our inspection. We reviewed evidence of investigation and subsequent learning to prevent reoccurrence. For example, post-incident actions included joint visits with substance misuse teams to optimise care for people who were on both caseloads. We reviewed team meeting notes and saw that learning from incidents was a standard agenda item for discussion.

Staff told us about the different types of incidents that occurred within the adult community mental health service. During one reported home visit, a significant risk to staff safety was identified, which led to the discontinuation of home visiting arrangements. Staff described other incidents of safeguarding and self-harm. All staff and managers told us how to report incidents on the service’s computer system.

Learning from incidents was shared in different ways. Senior managers attended weekly serious incident meetings. Ongoing incidents were discussed along with learning points and feedback from staff and family members. Staff described formalised feedback in monthly business meetings and email bulletins. Staff told us about increased availability of supervision sessions following a serious incident.

The service told us there were no never events in the last 12 months. Never events are defined as wholly preventable patient safety events.

The trust updated their suicide and self-harm prevention strategy in 2025, including areas of focus from priorities identified in the National Suicide Prevention Strategy. They included updates from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) 2024. The updated policy had strategic priorities with clearly defined actions, outcomes and accountability, with evidence of input from a wide range of staff at different locations.

The service did not receive any prevention of future deaths reports from the coroner in the 12 months before our inspection.

The trust implemented the Patient Safety Incident Response Framework (PSIRF). PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. The trust’s PSIRF policy defined the roles and responsibilities of all teams and individuals in response to a safety incident. Staff and managers were aware of this policy, the importance of it and the focus on a learning culture rather than blame.

The trust’s mortality review process investigated all deaths closely and identified trends and any improvements. We saw evidence in improvements to the trust’s mortality review processes which involved improved collaboration with other nearby trusts, police and local authorities to learn and share best practice.

Staff and managers understood the duty of candour. Managers explained the process and how they contacted the person or their family to apologise and arranged further contact as agreed. Following our inspection, we reviewed 6 duty of candour reports for the adult community mental health teams and found detailed actions with reflective commentary. The duty of candour is a legal obligation for healthcare providers to be open and honest with people who use services, or their families, when something goes wrong with their care or treatment and causes harm or has the potential to cause harm.

At the time of our inspection, not all pathways were safely managed. The service did not always ensure that people on waiting lists received their first appointment within the correct timescale. Not all people on existing caseloads were visited in line with trust policy. Managers did not ensure that staff were aware of the availability of personal alarms during home visits. However, managers ensured that staff had access to personal alarms during on-site appointments and the service had systems in place to ensure day-to-day safety of people’s care with clear escalation processes.

Referrals to each service were allocated to a single point of access (SPOA) for review and allocated to a waiting list for the relevant service. We observed multi-disciplinary referral meetings where discussions were held about whether to accept the referral. Appropriate signposting occurred where the referral did not meet the threshold or further enquiries were made if more information was required.

The trust’s policy stated that the first appointment should happen 4 weeks after the referral. Data provided to us following the inspection confirmed some people experienced a delay in receiving their initial CMHT appointment. In January 2026, Erewash CMHT had 166 people waiting for their first SPOA appointment with an average wait time of 6 weeks. Amber Valley CMHT had 125 people waiting for their first SPOA appointment with an average wait time of 5 weeks. However, this did not apply to all teams within the service. Both early intervention in psychosis (EIP) teams, North Dales CMHT, Bolsover CMHT and Clay Cross CMHT had very low numbers of people on waiting lists.

The trust implemented a ‘support while waiting’ policy for people waiting for their first appointment under a ‘waiting well’ process. Everyone on a waiting list for CMHT or EIP treatment received a welcome call within 5 working days of the referral. This was followed by a ‘waiting well’ letter that was sent to confirm their place on the waiting list with contact details if they needed support. The trust policy had a clear escalation mechanism if someone’s risk profile had changed, for example to be reviewed in the next daily safety huddle or by the multi-disciplinary team. Senior managers undertook an audit of people who were waiting longer than 11 weeks for further clinical review with further oversight at 18 weeks and 6 months.

Upon acceptance to a CMHT or EIP caseload, the trust used a management and supervision tool (MaST) to monitor risk of people. This approach included electronic analysis of care records for discussion at daily safety huddles, analysis of individual staff caseloads and analysis of MaST was used at multi-disciplinary meetings. Information from MaST was used to monitor patients who were due for renewal of their Community Treatment Order (CTO) and for people who needed medication reviews within the next 12 weeks. A (CTO) isa legal order under the Mental Health Act that allows a person with a mental health problem to be treated in the community instead of hospital, provided they follow specific conditions (like medicines or appointments).

Following our inspection, we asked the trust for the number of people who used services who required a follow up, but this had not been completed and / or there had been no further contact in the last 12 months. The trust provided data which showed that 33 people who used services had not been seen by any member of staff in over 365 days. The trust had identified these people as a result of an internal review. A new consultant was recruited at Amber Valley CMHT to address these concerns. The trust told us that they had routine data quality reviews and validation activities were embedded within business-as-usual governance processes.

The service ensured that staff had enough alarms for on-site appointments. However staff across across all locations said they did not have access to personal alarms during home visits. Staff referred to strict use of a check-in and out process and use of a safe word when calling staff for support. We did not find any concerns with the use of on-site alarms at Killamarsh CMHT, Erewash CMHT, Amber Valley CMHT or Derby City CMHT.

We raised concerns about availability of staff personal alarms during our inspection. Senior managers provided a response which included a policy for lone working, assurance of availability of personal alarms for staff and established procedures for checking on-site alarms at each location.

We reviewed the trust’s updated ‘Working Alone in Safety Policy and Procedure’ from January 2026 which detailed a personal safety smartphone application for staff to use on home visits. We saw evidence that the trust provided information about this personal safety application on employee screensavers to ensure all staff were aware. Risks associated with lone working have been on the trust’s risk register since July 2025.

The service demonstrated different methods to manage risks of people who used their services. We observed safety huddles at North Derbyshire EIP, and multi-disciplinary team (MDT) meetings at Derby City and South Derbyshire EIP and Killamarsh CMHT. Staff discussed risks of people who were allocated to their teams which included any recent incidents, contact with the NHS 111 option 2 mental health crisis line or presentations at local emergency departments. They used this information to make risk-based decisions such as urgent visits, dual staff visits or a request for on-site appointments due to safety concerns.

The trust had a policy for staff to follow if people did not attend appointments. Staff told us that people should not be discharged from caseloads if they did not engage and used other methods such as contact with family or carers. Staff who worked with people with complex needs were particularly aware of this guidance and the importance of using different ways to maintain a therapeutic relationship with people. Staff said people who disengaged with services were discussed at safety huddles and we observed this during our inspection.

The trust worked with other nearby mental health trusts, police, local authorities and the voluntary sector to create a clearly defined Right Care, Right Person process. Right Care, Right Person is a national initiative designed to ensure that people experiencing mental health crises receive the most appropriate response from the right service, rather than defaulting to police intervention. The trust policy included clear guidance for staff to follow if they were concerned about someone’s welfare with several flowcharts and links to relevant documents.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff received training in safeguarding children and adults. Data received after our inspection confirmed average staff training compliance across the service was above 91% for Safeguarding Adults Level 1 to 3, and above 94% for Safeguarding Children Level 1 to 3.

Staff received prevent training as part of Adults Level 1 to 3 Safeguarding training and was included in compliance data shown as above. Prevent training is a UK government strategy module designed to teach staff how to identify individuals who could be vulnerable to radicalisation and how to report concerns.

We observed discussions around safeguarding during safety huddles. Staff showed a good understanding of safeguarding and worked together to agree appropriate actions. We reviewed care plans and risk assessments which included references to safeguarding and alerts were visible to staff when they opened people’s electronic records.

Staff told us about the safeguarding risks and demonstrated awareness of different types, such as emotional and financial abuse. They described the process of how to report an incident and knew the importance of this due to often high levels of vulnerability of people using the service.

The trust’s safeguarding policies for adults and children were detailed with clear guidance for staff to follow. The trust updated their joint child and adult safeguarding strategy in 2024 with increased emphasis placed on a closer working relationship with the Derby and Derbyshire Safeguarding Children Partnership.

The trust had a separate safeguarding adults policy with a clear checklist and process for staff to follow and contact details for each local authority.

The trust worked with a wide range of local partners such as the local integrated care board (ICB), police, ambulance service and local council. They discussed referral trends, alongside ongoing and concluded safeguarding reviews to share learning.

The service did not always work well with people to understand and manage risks. Care records were not always updated within agreed timescales or when risk factors changed. However, up to date risk assessments were detailed and person-centred.

During our on-site inspection we reviewed 32 care records of people who used services. We found that 6 records did not have an up-to-date risk assessment. Out of those, 3 were over 12 months old and 3 had not been updated since their discharge from hospital in October 2024, March 2025 and October 2025 respectively.

However, for those that did have an up to date risk management plan and risk assessment in place, they demonstrated evidence of the voice of people who used services. We saw evidence of consent being obtained and documentation if someone did not want their risk assessment to be discussed with anyone else. Risk assessments and management plans included quotes from people with their thoughts and individual de-escalation techniques for when their mental health deteriorated. Risk assessments also included input from family members and carers, including any safeguarding concerns with details of anyone else involved in their care.

Staff regularly discussed risk in safety huddles and MDT meetings. Staff could also raise concerns with the duty nurse during the working day to create a short-term solution to keep people safe. We reviewed notes of safety huddle meetings where decisions for people’s risk ratings were clinically appropriate with clearly documented actions for relevant staff.

We observed appointments at different CMHT locations and in people’s homes. Staff were aware of all current and historical risks and discussed any immediate safety concerns with people and their carers in a compassionate and sensitive manner.

The service did not always detect and control potential risks in their reception areas. Not all areas were accessible to patients with mobility needs. However, managers took quick and effective action to resolve concerns.

At Killamarsh community mental health team (CMHT) we observed the reception area was not staffed on Monday or Tuesday each week. We identified that this reception area was used by people waiting for medication and appointments from CMHT services, alongside paediatric services that were provided by the local primary care trust. There was a risk of an unwitnessed incident occurring in the shared reception area without any staff observation. This was recorded as a low risk on the service’s risk register and appropriate action had not been taken to maintain safety of everyone in the shared reception area.

We raised these concerns during our inspection, the service advised that the building belonged to a local primary care trust but they operated CMHT services from it. The service took immediate action which included implementation of staff presence in the reception area on Mondays and Tuesdays to ensure safety oversight of people who used CMHT and paediatric services.

We identified concerns at Ilkeston Resource Centre, which provided Erewash CMHT community-based mental health treatment for adults of working age and older adults. We saw an unattended open door from the reception area into the adjacent older adults day services hospital. Reception staff were on duty and any risk to people who accessed the day hospital was mitigated by their own reception staff and locked doors which prevented unauthorised access.

Ligature audits were completed for all locations alongside environmental risk assessments. A ligature point is any fixture, object, or part of the environment that someone could use to attach a rope or other material to attempt to harm themself. We reviewed the ligature risk assessment for the Ilkeston Resource Centre which confirmed oversight of ligature risks but they did not account for the safety risks that could be caused by unsupervised access from the CMHT reception area. We raised concerns about this during our inspection. Senior managers reported the day hospital operated on Mondays and Tuesdays. The service took immediate actions to maintain safety which included locking of this door during CMHT operating hours, increased management visibility and regular discussion at team meetings.

We found that neither of the external elevators at Bayheath House were working at the time of our inspection, this provides services for Chesterfield CMHT and North Derbyshire EIP teams and additional services outside of the scope of this inspection. Managers said the lifts had been non-operational since early January 2026 and were waiting for equipment to repair them. Internal lifts remain available and in use for staff. The trust had implemented actions such as using alternative venues for appointments, provision for virtual appointments and completion of individual risk assessments.

We identified that the clinic room at Killamarsh CMHT was very small and raised this concern with the trust during our inspection. This had been placed on the risk register and people who used the service did not have access to it.

We found there were security processes in place to keep staff safe. Building security measures included staff-only areas with secure swipe-access and panic alarms were located within consultation rooms.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service ensured that staff received appropriate training for their roles. Their mandatory learning policy framework provided information for managers about their responsibilities and on management of mandatory learning. Compliance with mandatory training was monitored by the trusts local mandatory learning oversight group. Data provided to us after our inspection confirmed mandatory training compliance ranged between 87% at Derby City and South Derbyshire EIP to 100% at 99% at Chesterfield CMHT against a trust target of 85%.

All CMHTs had low rates of staff sickness. The overall sickness rate across all services was 4.91% against a trust target sickness rate of 5%.

The trust had a staff turnover target of between 10% and 12% across the adult community mental health services. The average staff turnover across all locations was 15.5%. The teams with staff turnover above the trust target were South Dales CMHT at 27%, Bolsover and Clay Cross CMHT at 25%, North Derbyshire EIP at 23%, Derby City and South Derbyshire EIP at 22% and Chesterfield CMHT at 14%.

Most of the teams had either none or very low vacancy rates. The highest total full-time vacancy rate was 2.49 working time equivalent at Erewash CMHT.

We reviewed the use of bank and agency staff across teams, including in the team's where staff turnover was higher. At South Dales CMHT, 35 shifts were requested and filled in the 3 months before our inspection. Similarly, at Chesterfield CMHT, 25 shifts were requested and filled by bank and agency staff during the same period to cover short term staff sickness.

The service ensured that staff received regular management supervision and appraisals. We were not provided with information for each specific team but data provided from January 2026 confirmed overall staff appraisal compliance rate of 91%. Overall medical staff appraisal was 93%. Management supervision compliance was 86% and staff clinical supervision 87%.

The trust-wide induction policy included a requirement for all substantive, bank, agency and volunteers to attend the trust corporate induction before completion of local induction. The policy included clear actions for managers to follow with new staff which included an individual induction programme for completion within 3 months to reach full competence in their new role.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service ensured that staff in the service received infection, prevention and control training. Overall compliance in Infection, Prevention and Control Level 1 across teams was recorded as 96%.

We saw consistently clean and well-maintained premises and equipment during our inspection, including consultation rooms and reception areas. This was corroborated by up-to-date cleaning records that we reviewed at Amber Valley CMHT and Erewash CMHT.

Clinic rooms were equipped with hand washing facilities to enable staff to provide people with safe care and treatment in accordance with the trust’s infection, prevention and control policy.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened.

The service had systems and processes in place to support the safe and effective use of medicines in community mental health settings. Pharmacy support was embedded across community teams and contributed towards medicines reconciliation. Pharmacy staff provided specialist medicines advice and guidance to support safe and effective prescribing of mental health medicines and to improve people’s understanding of their medicines. Pharmacy staff were actively involved in MDT meetings. There was a supportive network and clinical oversight for non-medical prescribers and advanced clinical practitioners.

Medicines were stored safely and securely with regular temperature monitoring. Tamper-proof bags available for transporting medicines when people were administered their long-acting injections (depot) at home.

There were clear processes for medication administration and physical health monitoring in line with national guidance. People prescribed antipsychotics were supported to use a recognised side effect monitoring tool to help ensure any emerging issues were identified and managed. Staff worked closely with the community teams to ensure continuity of care. Where people’s results were outside the normal range, staff escalated to the psychiatrist and documented this comprehensively in care records.

People had their medicines reviewed at least annually. The trust used data reports to identify people who were overdue their medical reviews and ensured that they were recalled for this to be completed.

Medicines information was available to people in different languages and in easy read formats.

The service used the same electronic patient record systems as most GPs in the area. This allowed sharing and access of information of people’s care and treatment. Prescriptions were sent electronically to community pharmacies allowing people to receive their medicines closer to home.

We reviewed 8 care plans with an increased focus on people’s medicines. This review showed that, while most included person‑centred information about the medicines prescribed for people, the level of detail was not consistent. Some plans did not provide sufficient information to support people with more complex needs. For example, in the care plan of a person with a learning disability who had been prescribed clozapine, there was no record of any reasonable adjustments made during their clinic appointments. Other care plans also lacked detail on potential side effects or specific monitoring requirements associated with certain medicines.

The service adopted trust-wide medicines prescribing guidance which clearly outlined responsibilities for physical health and cardiometabolic monitoring. Physical health teams were well established and completed the necessary physical health monitoring for people initiated on antipsychotics or mood stabilisers and used a nationally recognised tool to assess cardiometabolic risks, signposting to healthy living services where appropriate. Data received from the trust showed that 93% of patients on their caseload had been seen in the last 12 months.

There was a good incident reporting culture, with themes and trends analysed. Audits of clinical use of medicines and safe storage were being completed, with action plans in place to address identified gaps.

Clozapine (a medicine requiring strict blood monitoring) and depot (long-acting antipsychotic injection) clinics were well-managed in most locations. However, there were no clinics in North Dales CMHT and South Dales CMHT, and blood monitoring was carried out by the GP.