Derbyshire Healthcare NHS Foundation Trust

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• 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

At our last inspection we rated this key question as good. At this inspection the rating has remained as good.

Good: Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the trust’s vision and values and how they applied to their work. The service worked well with partners to support people who used services. Staff had opportunities to be involved in research and quality improvement projects. Most staff felt respected, supported and valued. However, governance processes were not always effective at identifying risks within the service. Audit processes to review people’s outcomes were not effective. There were differences in the quality of people’s care records across teams and staff felt unsettled by workforce transformation.

This service scored 71 (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 shared vision, strategy, and culture strategy. However, some staff were concerned about recent and ongoing changes to the service.

The service was in the process of making significant changes to senior clinical roles at the time of our inspection. Following our inspection, senior leaders shared a presentation which included evidence of working with other NHS trusts and gave an example of improvements that were made to computer systems as a result of staff feedback. Senior leaders said that no patient-facing roles were being affected by the transformation process.

The trust’s current strategy from 2024 to 2028 referenced the requirement for transformation to continue to provide high quality care for people with more complex needs, alongside pressure to make financial savings. Managers and senior leaders clearly understood the aims and objectives of the transformation. However, several members of staff said they were aware of the new strategy, but many teams were focused on day-to-day care of people who used services.

Most staff understood the community transformation’s main aims were to provide more preventative care and treatment in people’s local areas. They also told us they were aware that not all teams currently worked in the same way and that standardisation was needed to reduce health inequalities for people who used services.

Staff and managers continued to demonstrate the trusts values of being caring, inclusive, ambitious, belonging and collaborative to provide the best possible care for people.

Previous changes had been made to divisional clinical roles, which did not affect day-to-day running of services, but several members of staff felt unsettled by the current transformation being made at clinical service lead level.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

Leaders had the skills, knowledge and experience to perform their roles. They spoke with pride, honesty and passion about the care and treatment being provided to people across contrasting demographics of Derby and Derbyshire. Leaders were also aware of areas that the service needed to improve on, such as communication.

Leaders clearly understood the services they were responsible for. They recognised the importance of engaging families and carers in care pathways and spoke positively about improvements such as data analysis to identify and address health inequalities.

Staff said leaders at service level were very approachable, supportive and had high levels of knowledge and experience. Despite being the subject of current transformation, clinical service leads were highly committed, professional and continued to provide support to their staff under challenging circumstances.

Most staff said senior leaders were visible. The trust’s Chief Executive held engagement sessions and undertook site visits. Staff felt that divisional leaders were visible and supportive.

Most staff said they had access to development opportunities, particularly within occupational therapy roles. Some staff spoke about being promoted to higher clinical roles within the service. Service leaders said additional training was available for staff who worked with people who suffer with psychosis. Senior leaders described the importance of developing the service from within to retain skills and improve care provided to people who used services. Some staff said new recruitment and development opportunities were delayed as a result of the current transformation process.

Previous changes had been made to divisional clinical roles, which did not affect day-to-day running of services, but several members of staff felt unsettled by the current transformation being made at clinical service lead level.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The trust’s Freedom to Speak Up (FTSU) policy and procedure was available to all staff with clear steps for people to take when they wanted to raise a concern. Senior leaders presented a six-monthly update to the trust board with themes of concerns raised. Speaking up was included as part of the 2024 to 2028 overall trust strategy.

The trust had a full time FTSU guardian and FTSU champions across services. Staff and managers were aware of the Freedom to Speak Up process and told us they felt able to raise any concerns within their team. All managers said they hoped staff would feel comfortable to raise any concerns with them and had an open-door approach for all staff.

Between January 2025 and January 2026, the service received 29 concerns through FTSU channels. Themes included workforce wellbeing, staffing levels and standards of behaviour. Each concern had specific actions taken and some actions were resolved following informal conversations.

However, some staff said concerns they had raised to FTSU had not always been fully resolved. Staff said this had improved since the introduction of fortnightly reflective practice sessions.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust had health and wellbeing champions across services. Champions were from all staff levels, demographics and backgrounds. They signposted colleagues to various support networks to offer support, promote inclusion and change across the trust. Staff networks included Christian and Multi-faith, armed forces, black and ethnic minority, disability and wellbeing and women’s groups.

The trust’s website had a dedicated section for equality, diversity and inclusion (EDI) with a monthly update for key awareness dates and relevant campaigns. Equality and diversity were frequently discussed by the CEO during all-staff engagement.

The trust’s EDI action plan was implemented in 2024 with clear objectives such as establishment of an EDI steering group and to ensure all appraisals included mandatory objectives for EDI.

The trust reviewed its 2024/2025 Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) results. Positive findings included improved adjustments for staff with long term conditions, a reduction in recruitment disparities between disabled and non-disabled people and increased diversity for new employees in clinical and medical roles. Both reviews included action plans to improve equity for disabled staff and for people from black and minority ethnic (BME) backgrounds.

Staff said they were aware of flexible working arrangements which included specialist equipment, reduced working hours to recognise childcare commitments and blended working between home and service location.

The service did not always monitor the risks within their own service environments. Governance processes were not always effective or consistent across the service. However, the service mostly acted on information about risk, performance, and outcomes.

During our review of care records, we identified differences in up-to-date care plans and risk assessments between teams. We were provided with a list of audits, which included review of people’s care records, but we found several care records that were not up-to-date.

The trust completed a range of environmental audits, but the service did not recognise the risk of safety to people who used reception areas at Killamarsh community mental health team (CMHT) until we highlighted this during our inspection.

The trust had several processes in place to monitor and review how it supported people who were under Community Treatment Orders (CTO) to ensure they were made aware of their rights. However, data showed that people did not always have their rights under CTOs explained to them in line with trust policy.

Staff and managers said information was provided through governance systems, which we corroborated by review of various meeting notes such as care group performance reviews and divisional meetings.

However, the trust had implemented a revised governance structure in January 2026 to strengthen oversight, assurance and organisational learning.

Each service had a business continuity plan in the event of emergencies. Each document confirmed clear actions for managers to take to limit the impact on service delivery and people who used the service.

Information governance systems protected the confidentiality of people’s information, such as electronic care records. The trust’s policy had clear definitions of actions to take in the event of a suspected information breach and relevant contact information.

Managers said they had access to sufficient information to help them in their roles. Managers had access to caseload information, training compliance and other information that they needed.

The service had their own risk registers which fed into a service-wide risk register. The risk register items matched the issues that staff told us about, for example staffing levels, lone working and the broken lifts at Bayheath House where Chesterfield CMHT and North Derbyshire EIP were located. However, not all risks were rated correctly or identified, such as reception areas at Killamarsh CMHT and Erewash CMHT.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Managers and staff recognised the importance of working with partner agencies to provide personalised, safe and effective care to people who used services. Staff told us about improved relationships with local authorities relating to safeguarding referrals and increased use of dual referrals to treat physical health alongside their mental health. The service received feedback from Healthwatch colleagues and took appropriate actions.

Staff described improved interaction with other teams within the trust, particularly when people on their caseload were due to be discharged from hospital. Staff attended ward rounds before people were discharged so that the transition from hospital to community was smooth and they were aware of any changes to their treatment plan. Staff said they were involved in attendance at Multi Agency Public Protection Arrangements (MAPPA) meetings, Multi Agency Risk Assessment Conference (MARAC) and Multi Agency Vulnerable Offenders Panel (MVOP) meetings where appropriate.

The Trust’s 2024–2028 strategy acknowledged its established partnerships with the local Integrated Care System (ICS) and primary care services, with services across Derby and Derbyshire aligned to support the delivery of integrated care for people with learning disabilities and/or neurodevelopmental needs. A draft of the trust strategy was shared with partner agencies for feedback before being introduced.

System partnership was a key part of the trust board papers. For example, board papers we reviewed included information about an alliance with other trusts in the Midlands and partners within the voluntary sector to improve learning and share best practice.

The trust consistently reported serious incidents to relevant bodies, such as the Care Quality Commission (CQC) and local authorities. Senior managers said they attended meetings to review serious incidents.

We reviewed the trust’s assertive outreach plan. This was used to monitor escalation of issues that people who used services had, such as housing, non-engagement and earlier referrals to other services such as substance misuse.

The trust had involved local partners in development of their Patient Safety Incident Response Framework (PSIRF). Their governance process included improved oversight of the investigation process and to work with local commissioners to review and make recommendations for improvements.

The Trust contributed data to the National Enquiry into Suicide and Homicide and substance misuse and is also part of the enquiries national benchmarking system.

The service focused on continuous learning, innovation, and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice, and research.

Continuous improvement was a key feature in the trust’s board papers. Managers told us about quality improvement ideas such as simplification of referral documents, increased use of signposting between services, changes to the CMHT duty system and reduction in CMHT caseloads for consultants to provide more holistic and effective care for people who used services.

Most staff told us about quality improvement work that was in progress. The trust had a transformation and improvement lead; smaller projects were tested within local teams. For example, the North Derbyshire EIP team had identified an inconsistent approach and proposed a standardised assessment process for use by both EIP teams.

Staff at Derby City CMHT told us about a pilot scheme to improve care for people with complex needs, this involved more intensive treatment and therapy. Other improvements included increased involvement with carers during discharge planning. All staff could submit improvement ideas on the trust website.

Managers said introduction of the management and supervision tool (MaST) enabled them to have proactive and improved oversight of staff caseload, complexity and any follow up appointments. Managers said staff were encouraged to develop their own quality improvement ideas and action plans to meet their specific people’s needs.

The trust had a process to monitor quality improvement projects to ensure their effectiveness and make recommendations. For example, changes were made to information leaflets as a result of feedback provided by people who used the service.

Some staff said they didn’t have the capacity to look at quality improvement and prioritised day-to-day care of people who used the service. Other staff said the ongoing transformation process was a potential barrier for improvement ideas because senior leaders focus was on transformation and not day-to-day service improvements.