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 requires improvement. At this inspection the rating has changed to good.

Good: The mental health crisis service had a learning culture in which learning from incidents, other services and trusts was shared and led to changes in practice. Staff assessed and managed risks to people and themselves well and shared information with other teams and services as needed. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. All work and care and environments were safe, clean, well-equipped, well-furnished, well-maintained and fit for purpose. The service used systems and processes to safely prescribe, administer, record and store medicines. However, there was not always sufficient staff on shift in all teams. This sometimes led to health-based places of safety being closed and some crisis resolution and home treatment teams (CRHTTs) being short staffed.

This service scored 72 (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.

Staff and managers across all teams we visited told us the mental health crisis service had a strong focus on learning from incidents to improve services. All staff told us they knew how to report and record any incidents. Some staff told us examples of incidents they had reported, such as instances when people who used services were aggressive towards them.

‘Learning the lessons’ meetings had recently been established as part of the new organisational structure. Learning from incidents was shared with staff and changes to practice were made as needed. Some staff told us they were regularly told about lessons learnt from incidents and safeguarding in monthly team meetings. The meeting minutes were shared with everyone in the team. Staff told us about learning from incidents that had led to improvements in care. For example, some staff told us a joint working protocol had been developed with perinatal teams following an incident.

The mental health helpline and NHS 111 Option 2 staff told us they monitored how frequently they contacted ambulance services and what the outcome was. They told us understanding outcome themes helped inform training. For example, they reviewed the types of situations in which people refused help from ambulance staff or chose not to be taken to hospital.

In the 3 months prior to our inspection, the mental health crisis service recorded 122 incidents across the 4 crisis resolution and home treatment teams (CRHTT). Of the 122 incidents, 1 was rated as major, 32 were rated as moderate, 65 were rated as minor and 24 were rated as insignificant. Of the 122 incidents recorded, the most common category, with 37 recorded incidents was ‘access, appointment, admission, transfer, discharge’. The second most common category was ‘abuse or aggression’ with 24 incidents, followed by ‘self-harm’ with 18 incidents. When identified through initial analysis, incidents that met the criteria for further investigation were reviewed using the NHS 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 service recorded 13 serious incidents in the 12 months prior to our inspection. Of those, 4 were recorded by South County CRHTT, 4 were recorded by Chesterfield CRHTT, 3 were recorded by High Peak CRHTT and 2 were recorded by Derby City CRHTT. We saw evidence staff reported incidents in a timely manner, and they were thoroughly investigated and actions and learning were identified. These included reflective practice, support for families and risk assessments being updated. One lesson learnt was to consider multidisciplinary meetings (MDM) to plan people’s discharge. Some staff told us that discharge MDMs had been introduced, which they told us improved communication and oversight of discharges from the service.

The trust had undertaken several investigations and thematic reports into learning from deaths in the year prior to our inspection. We saw these had identified learning that was relevant for the mental health crisis service. For example, the trust carried out a review of 5 patient safety incident investigations and concluded that more consistent use of risk formulation was required. We observed information in staff offices about the use of a nationally recognised risk formulation tool.

The trust’s learning from deaths policy and procedure clearly set out the level of investigation needed in different situations. It also stated the responsibilities of different staff roles in relation to investigating and learning from deaths.

In the 12 months prior to our inspection, the trust had not received any prevention of future deaths reports from coroners in relation to the mental health crisis services and health-based places of safety (HBPoS).

The trust was part of the Derbyshire Self-Harm and Suicide Prevention partnership forum. The trust had introduced a co-produced 3-year suicide and self-harm prevention strategy in 2025. To support the strategy, the mental health crisis service had made changes to some of its processes. For example, it had increased its use of safety plans. We reviewed 25 care records, and each person had an up to date, personalised safety plan. Staff in the mental health crisis service had to complete in depth suicide and self-harm prevention training.

Staff and managers understood their responsibilities regarding the duty of candour. 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. Staff and managers were open and transparent and gave people who used services and families a full explanation if and when things went wrong. The last 3 incidents that met the threshold for duty of candour prior to our inspection occurred in Chesterfield CRHTT, all in October 2025. Managers wrote duty of candour letters that provided an apology and an explanation about what happened. Learning from those incidents was shared with staff and the duty of candour letters were added to people’s care records.

The service had recorded no ‘never events’ in the 12 months prior to our inspection. Never events are defined as wholly preventable patient safety events.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was monitored and managed. They made sure there was continuity of care, including when people moved between different services.

There were various routes to access help and support from the mental health crisis service. People could self-refer to the CRHTTs by calling the freephone mental health helpline, NHS 111 Option 2, or direct to the crisis teams. Other professionals such as GPs, inpatient services and community mental health teams could also refer people to CRHTTs. Professionals could also call the professional line for advice.

CRHTTs operated a duty function. This meant there was an allocated member of clinical staff who triaged phone calls to the crisis team and oversaw daily appointments. The duty worker also managed their team’s “flight plan”. We saw flight plans were used in each CRHTT to plan the day’s visits, assessments and staffing.

We observed several duty calls during our inspection. Staff took time to understand people’s situation and current risks. After discussion with colleagues, they then determined whether the referral was an emergency, which required an assessment within 4 hours, or urgent, which required an assessment within 24 hours. Staff could signpost people to other sources of help and support if they did not meet the threshold for CRHTT input. In all cases, we saw staff ensured the person calling had a safety plan in place.

Staff ensured they had sufficient information to assess whether someone met the criteria for admission to the service. We observed a duty call in which staff clearly explained to another professional why someone did not meet the threshold for CRHTT support. They provided advice and signposted to more suitable services.

Some staff told us, and we observed, that where other support needs were identified, such as social support, they signposted to appropriate support services. Follow up letters were sent to the person who used services, their GP, and the referrer.

The mental health helpline and NHS 111 Option 2 were delivered in partnership between the trust and a third sector organisation. The partner staff were call operators, who worked with the mental health crisis service’s clinical staff to support people who made contact.

People who contacted the mental health helpline or NHS 111 Option 2 initially spoke to the first available call operator. We observed, and saw in care records, that calls were appropriately escalated to clinical staff when needed. Clinicians conducted a thorough and effective mental state assessment by phone and call operators successfully called people back when calls became disconnected.

All teams within the mental health crisis service used the same electronic care record system. This enabled staff to quickly access important information about people to help assess risk and necessary intervention. Some staff in the mental health helpline, for example, told us there were alerts on people’s care records to highlight if people had an existing care plan, so they could follow that when supporting them on the phone.

Staff worked with each other and other teams and services to provide robust oversight of people’s care. Most staff told us, and we saw evidence in care records, of continuous communication with community mental health teams (CMHT). This supported joint working, information sharing and management of risk. Staff did not wait for the next multidisciplinary meeting to escalate concerns and instead contacted or spoke to other professionals promptly when concerns arose.

Some CRHTT staff told us about how they supported early discharge from inpatient services. They told us they attended ward rounds to review people who were ready to be discharged and see if home treatment would support their discharge. They told us this helped to ensure people had all the necessary support in place to support a successful discharge, such as ensuring any referrals were not outstanding, or that they knew where to collect prescriptions from. CRHTTs also undertook 48-hour reviews of people who were discharged from inpatient services if they were not on the community mental health team (CMHT) caseload. The national requirement is for follow up appointments to happen within 72 hours of discharge from inpatient services. Data showed between January 2025 and January 2026, CRHTTs and CMHTs completed 90% of 72-hour reviews of people who were discharged from inpatient services.

Teams had handovers between every shift and daily safety huddles. We observed handovers, multidisciplinary meetings, safety huddles and referral allocation meetings were all documented.

Some staff told us about, and we saw records of, risk strategy meetings. Risk strategy meetings were held with all relevant teams and services who supported people who had presented with high levels of risk.

Staff in the mental health helpline had developed a frequent caller pathway and call care plans were developed for frequent callers to ensure they were appropriately supported.

The service had a ‘did not attend’ / ‘was not brought’ policy. Care records showed that when visits could not take place, staff followed up by making phone calls or carried out unannounced visits.

The service had a strong culture of safeguarding people who used services and their families. They concentrated on improving people’s lives while protecting their right to live in safety, free from abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The mental health crisis service had a proactive safeguarding culture. We observed that safeguarding concerns were recorded on the trust’s incident reporting software and in people’s care records. CRHTTs had safeguarding leads who linked in with the trust’s safeguarding team. Safeguarding leads provided additional support to staff to ensure the correct action was taken to record safeguarding concerns or make safeguarding referrals. Staff told us they were confident about how to raise safeguarding referrals, or who to contact for safeguarding advice and support. A monthly safeguarding email was shared with teams.

Staff were able to clearly explain the process to follow if they had any safeguarding concerns and we saw they had easy access to safeguarding information. For example, we observed safeguarding process information containing clear flowcharts for staff to follow located near the duty desk in Chesterfield CRHTT. Some staff and managers told us they never felt afraid to ask a safeguarding question, as they could always access supportive and helpful advice.

Staff demonstrated a good understanding of the types of safeguarding concerns they might encounter for people who used services, their families and carers. For example, most staff told us about the need to be aware about domestic violence, self-harm, exploitation, and drug or alcohol use, particularly around any children in a household.

Staff consistently considered safeguarding not only for the adult using the service, but also for any children or other adults within their family. Some staff told us about recent safeguarding situations they had supported people with and the outcomes. For example, additional support was provided by other health and social care partners after raising a safeguarding referral during a parent’s mental health crisis.

The trust had a specific safeguarding children supervision policy and procedure, and some staff told us about their regular safeguarding supervision. Safeguarding supervision ensured protected time was given to staff involved in safeguarding children work. It supported them to reflect on management of cases and personal development needs toenhance best practice.

Incident records included safeguarding referrals that were appropriately made. For example, we saw an example of a safeguarding referral that was made after someone told staff they always carried a weapon on them. We also saw evidence in care records about communication with other professionals and agencies in relation to safeguarding, which ensured everyone necessary was aware of the situation to safeguard the individual.

Staff were trained in safeguarding. The trust confirmed that its adult safeguarding training included training staff on how to identify and support people who may be at risk of radicalisation. The mental health crisis service had high rates of safeguarding training compliance, with the following average compliance rates across the service:

• safeguarding adults level 1 – 100%
• safeguarding adults level 2 – 100%
• safeguarding adults level 3 – 92%
• safeguarding children level 1 – 93%
• safeguarding children level 2 – 98%
• safeguarding children level 3 – 90%

We observed meetings in which safeguarding issues were discussed. For example, in one multidisciplinary meeting updates were shared on any safeguarding referrals the team had made, including what action had been taken.

Senior leaders told us all changes that happened as part of the trust’s transformation had safeguarding impact assessments carried out and these acted as an extra safeguard to ensure there was no negative impact on people’s safety.

The mental health crisis service worked with partners to safeguard people who used services and their families. We saw trust representatives regularly attended local Safeguarding Adults Board meetings. We saw in care records, and some staff told us, they linked with the Local Authority Designed Officer (LADO), multi-agency risk assessment conference (MARAC), and multi-agency public protection arrangement (MAPA) colleagues as needed.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people and themselves well. Staff in health-based places of safety used restraint only after attempts at de-escalation had failed.

Staff involved people in safety planning and risk assessments. We reviewed 25 care records and looked at their risk assessments and safety plans. People had safety plans within 48 hours of their first assessment. All 25 records contained comprehensive, holistic and up to date risk assessments. There was evidence of people and carers’ direct involvement in creating risk assessments, such as carers’ observations or concerns about people’s risks being included. Risk assessments and safety plans were regularly reviewed and updated.

Safety plans were personalised and tailored to the individual. For example, we saw they included specific hobbies or interests people had that they identified as being helpful distractions when in crisis, or specific triggers that were unique to that person.

We saw evidence that people received copies of their safety plans. We observed duty calls in which duty staff checked that people had safety plans in place and knew what to do if they needed emergency help.

Staff discussed risk in multidisciplinary meetings. We saw staff shared their professional judgement as well as representing the views of people who used services and carers.

Staff had access to the information necessary to assess people’s risk. For example, if people had already accessed services, staff could view that information on their electronic patient record system. Some staff told us this helped reduce people’s need to explain their story multiple times.

When patients arrived to the HBPoS, the police searched them, if needed, to remove anything that could be used to harm themselves or others. Staff then carried out an initial joint police nurse risk assessment to determine someone’s initial level of risk. Staff told us this helped to understand the level of risk associated with the person and determined when the police could be released from the HBPoS. After this, staff completed property check lists and documented patients’ property on their care record. Items would be removed from people if it was assessed they posed a risk, such as shoelaces for example.

The mental health crisis service recorded incidents of restrictive practices. CRHTTs used no restrictive practices in the 6 months prior to inspection. In the HBPoS, the service recorded 9 instances of physical restraint used in Carsington Unit, 12 in Radbourne Unit and 13 in Derwent Unit in the 6 months prior to inspection. Two of those restraints were carried out in the prone position, which meant they were held face-down. In both instances, prone restraint was used after other methods had been unsuccessful. In 10 of the incidents, chemical restraint was also used. Chemical restraint refers to the use of rapid tranquilisation medicines to sedate someone or restrict their movements. Incident logs showed that patients were appropriately monitored after chemical restraint was used. There was evidence from the incident logs that in all instances, staff used physical restraint as a last resort to maintain people’s safety, after attempts to de-escalate had failed. Staff provided debriefs for patients following restraint when it was safe and appropriate to do so.

Staff ensured that people could access advocacy. We observed advocacy posters and information leaflets in all locations we visited.

The service detected and controlled potential risks in the care environment, to ensure staff and people who used services were kept safe.

All sites we visited were well maintained and fit for purpose. All team office bases had suitable security measures in place to ensure only authorised people could enter staff-only areas. People who received treatment from any of the CRHTTs were visited in their homes or at GP surgeries. People who received treatment from Chesterfield CRHTT could also attend the team’s building for appointments.

The Chesterfield CRHTT building was accessed through a remote video entry communication system into a staffed reception area. The waiting area was always visible to reception staff and people could use an accessible toilet. The appointment rooms were locked and staff told us people were always supervised by staff when inside appointment rooms. We observed and staff told us about their safety alarm system. Some staff told us about an incident when staff had to use their alarm. They said the response from colleagues and security staff was immediate and helped to resolve the situation quickly. Senior leaders told us staff carried out weekly audits of safety alarm systems to ensure they worked efficiently. They were also addressed at monthly managerial meetings.

Staff in the HBPoS carried out frequent risk assessments and health and safety checks. The HBPoS had anti-ligature fittings and fixtures to prevent patients being able to ligature from a fixed point. Staff could view patients through observation panels, positional mirrors and CCTV. Staff were aware of any ‘blind spots’ in the HBPoS environments and ensured they mitigated these appropriately to keep people safe.

The trust had an estates strategy and it shared data that showed buildings were regularly reviewed to ensure they were fit for purpose.

The service did not always make sure there were enough staff on shift. Sometimes health-based places of safety had to close due to staffing levels. However, staff were qualified, skilled and experienced, and received effective support, supervision and development.

CRHTTs and HBPoS were not always fully staffed. Managers could deploy bank or agency staff when needed to ensure shifts were sufficiently staffed. In the 3 months prior to our inspection, most teams’ bank and agency staff shift requests were filled at least 89% to cover staff sickness, absence or vacancies. However, High Peak CRHTT had only 49% of shifts filled and Chesterfield CRHTT had 60%. This meant there was insufficient staff to provide care and treatment to everyone on those teams’ caseloads. We saw evidence that staff recorded any incidents when staffing levels affected timeliness of assessments or ability to visit people as planned. In the 3 months prior to our inspection, 7 incidents were recorded which included low staffing levels as a contributing factor. Of those 7, 2 were recorded by Derby City CRHTT, 2 were recorded by South County CRHTT and 3 were recorded by Chesterfield CRHTT.

Most staff and managers told us that when there was insufficient staff to cover the HBPoS, they were closed to admissions. Between 1 July 2025 and 31 January 2026, there were 68 closures of HBPoS due to insufficient staffing levels.

The mental health crisis service co-delivered a response vehicle with a local ambulance trust. The mental health helpline and NHS 111 Option 2 team provided clinical staff to support joint emergency responses. Staff and managers told us there was no dedicated funding for the response vehicle, meaning staff had to be allocated as needed from the helpline team. They told us this impacted the number of staff in the helpline office at times.

The trust told us senior managers met weekly to review staffing and redeployed staff as necessary to address any gaps.

Between January and December 2025, some of the teams in the mental health crisis service had high rates of sickness. The trust’s target sickness rate was 5%. Chesterfield CRHTT averaged 10.41%, High Peak CRHTT averaged 13.27%, South County CRHTT averaged 7.86% and the mental health helpline averaged 9.75%. During the same period, Derwent Unit had 13.71% staff absence and Carsington Unit had 13.6%. The small staff sizes of the HBPoS disproportionately affected their absence rate figures compared with CRHTTs. The inpatient wards provided 50% of the staff for the HBPoS. Each ward had staff absence rates below or around the trust target of 5%.

Staff were appropriately qualified and trained in a range of subjects necessary to carry out their roles. The trust’s target for training compliance was 85%. All teams achieved the trust’s target. Team mandatory training compliance rates in January 2026 were as follows:

• Chesterfield CRHT 87%
• Derby City CRHT 90%
• High Peak CRHT 93%
• South County CRHT 90%
• Medic Urgent Assessment 88%
• Mental health helpline 85%
• Derwent Unit 96%
• Carsington Unit 98%
• Radbourne Unit 100%

Most teams in the mental health crisis service had staff turnover rates well below the trust target of 12%. However, from January to December 2025, High Peak CRHTT staff turnover was 27.7% and South County CRHTT’s turnover was 23%. The HBPoS were staffed 50% by substantive staff and 50% by staff from nearby inpatient wards. The HBPoS had 0% staff turnover in the 12 months prior to our inspection. However, Ward 36, which provided 50% of the staff for the Radbourne Unit, had a turnover rate of 25% for staff nurses in the 12 months prior to our inspection.

Across the CRHTTs and mental health helpline, there were 18.7 full time equivalent (FTE) vacancies in December 2025, against an establishment number of 121.2 FTE. Of those 18.7 FTE vacancies, the highest number was in South County CRHTT, which had 6.1 FTE vacancies, with 4.52 FTE of those for band 6 nursing roles. Across the 3 HBPoS, vacancies in January 2026 were 3.6 FTE out of an establishment number of 19.6 FTE. We saw that staffing capacity was listed on the trust’s risk register. Staffing in the mental health helpline team had been on the risk register since May 2023, staffing in County South CRHTT had been on the risk register since November 2024 and staffing in Chesterfield CRHTT had been on the risk register since October 2025. Some staff in those teams told us staffing levels could be challenging, however, we did not see any evidence of negative impact on people’s safety because of staffing challenges.

All staff completed corporate and local inductions and completed mandatory training relevant to their role. New staff had to complete an induction checklist in their first 4 weeks in post. The induction policy applied to substantive, agency and bank staff, as well as volunteers.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

All areas were clean and were well-maintained. Furniture was in a good state of repair.

Staff maintained equipment and cleaned it between uses. For example, in the Chesterfield CRHTT, we saw a physical health kit that was marked as clean.

We observed hand sanitising gel and hand hygiene posters in all teams we visited. Most staff told us that although they did not work in a clinical setting, they ensured they maintained good hand hygiene. Some staff told us that occasionally they would carry out drug screening, for which they had access to suitable personal protective equipment.

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 safely support people with their medicines in HBPoS and in CRHTTs. People’s medicines were regularly reviewed by the multidisciplinary team for clinical and side effects of medicines.  Staff had access to time sensitive medicines in HBPoS to ensure that people received them safely.

Staff had access to GP care records including people’s current medicines and physical health results, which supported with medicines reconciliation and prescribing decisions.

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 including prescribing responsibilities.

However, following a review of a serious incident, the trust had identified that one of the contributing factors had been that the GP practice was not on the same system as the trust. As a result of this, action plans were in place to add alerts to people’s notes to raise awareness with staff, that they would need to follow alternate communication processes.

Staff reviewed the effects of each person’s medicines on their physical health in accordance with National Institute for Health and Care Excellence (NICE) guidance. People’s medicines were regularly reviewed by a multidisciplinary team when under a CRHTT. Concerns could be escalated to a meeting each morning where cases were discussed, reviewed and actions put in place to ensure people remained safe with their care and treatment.

In Chesterfield CRHTT, we observed there were processes in place to initiate and titrate clozapine (an antipsychotic requiring regular blood monitoring). Staff ensured that they completed the required monitoring to ensure this was carried out safely. We reviewed one record of an individual who had been initiated on clozapine, and following a safety concern had been appropriately escalated.

Pharmacy technicians were embedded across the service and supported medicines reconciliation and safe supply of medicines. Support from pharmacists was available on an ad-hoc basis for clinical queries.

Medicines information leaflets were provided in multiple languages and easy-read formats.  

Medicines were stored safely and securely in locked cabinets with regular stock checks and temperature monitoring. Pre-packs of medicines were used appropriately for urgent supply in CRHTT. Emergency medicines such as adrenaline were available.   

Records showed that compliance with medicines had been discussed with people, and where necessary, CRHTT had provided support with daily administration. Staff ensured that they documented the supply and administration of medicines on the system.

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