Derbyshire Healthcare NHS Foundation Trust

On this page

• 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

Effective – this means we looked for evidence that patients care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Requires Improvement. At this assessment, the rating has changed to Good, reflecting that people’s outcomes were consistent, and care was delivered in a personalised, recovery-focused, and proactive way. Patients and families described the service as good and supported independence.

Staff assessed the physical and mental health of every patient on admission and developed personalised care plans that were reviewed regularly through multidisciplinary discussions. Care and treatment outcomes were monitored effectively through internal audits, quality improvement initiatives, and benchmarking against comparable rehabilitation services.

A wide range of evidence-based treatments and interventions were delivered in line with national guidance and best practice, with staff demonstrating skill, knowledge, and responsiveness. The service had access to the appropriate specialist practitioners required to meet patients’ diverse rehabilitation needs, which ensured care was coordinated, patient-focused, and anticipatory.

Staff demonstrated a comprehensive understanding of their roles and responsibilities under the Mental Health Act 1983 and the Code of Practice, applying this knowledge confidently and consistently to support patient rights, autonomy, and involvement. Leadership ensured that these practices were embedded throughout the service, were audited regularly, and evaluated against internal and external benchmarks.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients felt confident that their individual needs had been fully assessed, understood, and that staff had taken the time to listen to, and involve them in their care and treatment planning. One patient told us, “I have regular discussions with staff, and they let me know when things change and remind me if I forget.”

We reviewed 5 care records which evidenced staff had completed comprehensive and timely assessments of patient’s physical, mental, emotional and communication needs. Assessments were person-centred and reviewed regularly with the patient and their families if appropriate. Staff used clinical tools alongside professional judgment to build a comprehensive understanding of each patient’s individual needs. If a person lacked capacity to make decisions, staff adhered to legislation and best practice which ensured decisions were made lawfully, and in the person’s best interests.

Occupational therapists used the model of human occupation screening Tool (MOHOST) to assess capability, and need, this was used as a baseline and to track patients progress, the results were shared with the multidisciplinary team to ensure progress was being made, and the patients' needs were being met. Occupational therapists also completed assessments of patients daily living skills, for example, road safety awareness, public transport use, shopping and budgeting, washing and dressing and kitchen use and cooking.

Families or carers were also supported with appropriate information and resources available to them, for example, carers assessments and signposting to numerous external resources of support. The activity coordinator was also the carers champion and available to offer support when required. The appropriate referrals were made to external services to support patients’ wider health needs, including GP’s, dentists and specialist physical health clinics. Patient’s needs were also reviewed and amended through regular multi-disciplinary meetings.

Staff applied their learning effectively, leading to positive outcomes and enhancing patients’ independence and quality of life. They also considered carers’ needs during assessments, helping carers stay well and providing them with safe, effective support.

The service planned and delivered care and treatment which was in line with legislation, best practice and co-produced with patients, and focused on individual need. Staff demonstrated a thorough understanding of their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice, applying this knowledge confidently, consistently, and effectively.

The service delivered a comprehensive range of interventions which were person centred, including medication management and psychological therapies, such as Acceptance and Commitment Therapy (ACT) Informed Approaches, Cognitive Behavioural Therapy (CBT), Compassion Focused Therapy (CFT), and Psychoeducational interventions around difficulties, strengths, and relapse prevention. The psychology team also delivered psychological aftercare for patients’ and their families and carers. All interventions were delivered in line with guidance from the National Institute for Health and Care Excellence (NICE), ensuring care was effective and safe. This contributed to, and reinforced a therapeutic, person-centred environment.

The service delivered care through a clearly defined and structured model of care for mental health inpatient rehabilitation, which supported patients from assessment through to recovery and discharge. Care was delivered through a multi-disciplinary approach, with coordinated input from medical, nursing, psychology, and occupational therapy teams across staged phases of assessment, engagement and recovery. Patients developed insight, built practical and social skills, managed risks positively, and increased independence at a pace aligned with discharge and their preparedness for change.

Patients had access to physical healthcare. Staff completed comprehensive physical health assessments on admission and maintained monitoring through regular observations, such as nutrition and hydration. Staff supported patients to attend GP appointments, and specialist hospital appointments. Effective record-keeping and monitoring systems ensured that physical health checks were attended, and patients reported feeling confident and reassured that their physical health was effectively managed alongside their mental health.

Innovation was embedded throughout practice. Staff led a quality improvement project focused on streamlining the psychology referral pathway which led to more effective and timely psychological interventions, and enhanced patient outcomes which promoted safer, more responsive care.

The service had accessed a full range of specialists required to meet patients’ needs, including doctors, nurses, psychologists, occupational therapists, pharmacists and nursing assistants. Staff were experienced, skilled, and received training relevant to their roles. Regular supervision, annual appraisals, and opportunities to further develop skills and knowledge, ensured competency and effective delivery of care. Managers identified learning needs, addressed performance issues promptly, and ensured new staff completed a thorough induction. Staff also had access to regular team meetings to reflect on practice, share learning, and continually improve care.

Staff participated actively in clinical audit, benchmarking, and quality improvement initiatives, ensuring care was consistently measured against national standards and aligned with best practice.

Patient’s felt that everyone involved in their care and treatment worked well together and encouraged them and where appropriate their families/carers to be as involved as possible. Patients consistently described joint working as smooth and well organised. One patient told us, “All my people work really well with me, and they come to my meetings with the doctor.”

The service worked effectively across teams, handovers were concise and effective and took place before the start of every shift, with accurate information shared consistently. This ensured patients experienced coordinated care that supported recovery and progress toward them rejoining their communities. Staff shared all assessment outcomes, and care plans promptly when patients moved between services or transitioned to community living, reducing the need for patients to repeat themselves and avoiding potential unnecessary trauma.

Multi-disciplinary meetings were held regularly and attended by the full multi-disciplinary team (MDT) and external partners when required. Meetings were structured and covered areas such as, risks, physical health, patient goals, activity engagement, and progress toward discharge, which reflected the focus on rehabilitation. Minutes were shared electronically which ensured a cohesive approach, and effective collaborative working.

Systems ensured patients were supported by multiple rehabilitation teams, including OT, psychology, nursing, activity coordinators, the specialist autism team (SAT) and community mental health teams (CMHT), Care remained coordinated, recovery-focused, and centred on individual goals.

Patients felt supported, and motivated to take control of their health. They described staff as proactive, encouraging, and skilled at helping them make positive changes. All patients had a named nurse, occupational therapist and nursing assistant. They valued practical support with sleep, diet, exercise, and general wellbeing, and told us these interventions improved their confidence, independence, and quality of life. One patient told us, “The staff are great, they’re always around to give good advice.” The service effectively supported patients to manage their health and wellbeing and focused on promoting independence and preparing patients for community living. Staff supported patients to develop personalised approaches to health that reflected their goals, preferences, and level of independence. Patients were fully involved in health assessments, progress reviews, and physical health monitoring.

Multi-disciplinary meetings ensured patients accessed the right health and social care support at the right time. Staff encouraged patients to make meaningful and sustainable lifestyle changes through group programmes, and 1 2 1 sessions which covered motivation, relapse prevention, substance misuse awareness, and education. Staff promoted healthier living through practical initiatives such as smoking cessation support and diet and nutrition advice. Staff anticipated risks early, and offered targeted interventions, such as, substance misuse, and general health and wellbeing. Staff were trained in relevant physical health monitoring tools and used these in line with rehabilitation goals. The service also encouraged and supported patients to attend health support groups.

A wide range of service and community activities supported patient recovery and promoted long-term health, including walking groups, gardening groups, swimming and gymnasium visits, and relaxation sessions. Activities promoted independence, improved physical health, and prepared patients for successful community reintegration. Participation and outcomes were monitored to ensure progress was sustained and support remained tailored to individual goals.

Staff monitored patients’ progress and used data to continuously improve the quality and effectiveness of care. Staff ensured that outcomes were positive and aligned with both clinical expectations and individual goals. Recognised tools, such as the Health of the Nation Outcome Scales (HoNOS) and National Early Warning Score 2 (NEWS2) and Malnutrition Universal Screening Tool (MUST) were used to monitor changes and progress against rehabilitation targets. Assessments were regularly reviewed to ensure treatments remained effective and met patients’ needs.

The service promoted improving independence, autonomy, and wellbeing alongside clinical outcomes. Work to reduce restrictive practice increased opportunities for extended periods of leave, participation in structured group work, in preparation for community living. The service developed a QI project for post discharge housing provision and developed a housing triage form that was completed at the earliest possible opportunity, staff also developed good relationships with housing providers which provided better outcomes for patients rejoining their communities and acquiring suitable accommodation. It also had a measurable impact in regard to reducing the patient’s length of admission.

Patients achieved a wide range of outcomes during their admission, including vocational achievements, development of social and daily living skills, and participation in walking, sports, and wellbeing programmes. Personal goals included building confidence, progressing in community-based activities, and preparing for future transitions. Patients successfully rejoined their communities, which demonstrated improved independence, resilience, and sustained recovery.

The service maintained effective governance systems, monitored themes, identified learning, and implemented improvements. Shared learning from other rehabilitation services supported staff to adapt practice and continue to improve outcomes, ensuring patients received consistent outcomes, and recovery-focused care.

Staff helped patients understand their rights and treatment options, using different communication methods to ensure information was clear and understood.

Staff informed patients about their rights around consent when delivering person-centred care and treatment. They took practical steps to enable patients to make their own decisions, promoting independence and choice in line with the principles of rehabilitation. Where patients might have impaired mental capacity, staff completed and recorded decision-specific capacity assessments appropriately in accordance with the Mental Capacity Act 2005.

If a patient lacked capacity to make certain decisions, staff made decisions in their best interests, considering their wishes, feelings, cultural background, and personal history. Staff used accessible formats, including Easy Read information and advocacy involvement, to support understanding and involvement.

Staff followed the correct legal processes and ensured patients were kept informed of their rights. Staff supported patients to express their views and be involved in planning and reviewing their care as much as possible, maintaining a strong focus on recovery, rehabilitation and empowerment.