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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This was the first assessment for the service. This key question has been rated good.

Staff assessed patients’ physical and mental health on admission and developed personalised care plans that were regularly reviewed and updated. Care and treatment followed national guidance and best practice, delivered by a multidisciplinary team with access to the specialist expertise required to meet patients’ needs. Staff worked collaboratively and fulfilled their responsibilities under the Mental Health Act effectively.

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.

Description: We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

We scored the service as 2. The evidence showed some shortfalls.

Although staff took the time to listen to and involve patients in decisions about their care and treatment. We found that care plans did not address all aspects of an individual care and identified needs.

We reviewed 10 care records and found staff had not always completed comprehensive, timely, and person-centred assessments of patients’ physical, mental health, emotional, and communication needs. We identified examples where some care plans lacked meaningful detail about the person's individual needs, strengths, goals and the support required to achieve positive outcomes. For example, some care plans contained only broad objectives and did not adequately reflect the person's protected characteristic, autism diagnosis, mobility needs or other individual circumstances.

Following our feedback, staff arranged appointments with the patients whose records we’d identified and fully updated their care, safety and risk plans. Leaders also implemented an action plan to address these issues and committed to demonstrating improvement by providing us with regular progress updates on improvements made.

Assessments involved patients and their families where appropriate. Nursery nurses also completed care plans for babies to ensure their individual needs were also met, and we found these to be present, regularly reviewed and effective.

Staff used recognised assessment tools and professional judgement to understand patients’ needs. Where patients lacked capacity to make specific decisions, staff followed relevant legislation and best practice to make lawful best-interest decisions on their behalf.

Occupational therapists assessed patients’ strengths, needs, and independent living skills to inform care planning and measure progress. Assessments included shopping and budgeting, laundry and household tasks, and organising appointments and responsibilities. Findings were shared with the multidisciplinary team to support care and monitor outcomes.

Staff supported fathers or patients’ partners to complete the “what about you” self-assessment. This could be completed antenatally or postnatally, to identify their own mental health and support needs. This enabled staff to signpost them to the appropriate support. Staff also provided information, one to one support, carers groups, community services and formal carers assessments where appropriate. A dedicated carer lead also provided support and guidance to staff, patients and families when needed.

Staff made timely referrals to external healthcare services, including GP’s and specialist physical health providers. Patients’ needs and progress were regularly reviewed through multidisciplinary team meetings to ensure care remained responsive and appropriate for their current needs.

Description: We plan and deliver people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

We scored the service as 3. The evidence showed a good standard.

Staff planned and delivered care in accordance with the royal college of psychiatry perinatal quality network, relevant legislation, national guidance and best practice. Staff demonstrated a clear understanding of their responsibilities under the Mental Health Act and Code of Practice.

The psychology team delivered a comprehensive range of evidence-based interventions that were personalised to meet patients’ individual needs. These included therapies such as cognitive behavioural therapy (CBT), compassion focused therapy (CFT), eye movement desensitisation and reprocessing therapy (EMDR) and video interactive guidance (VIG). VIG was a short-term, strengths-based intervention recommended by the National Institute for Health and Care Excellence (NICE) which supported and enhanced parent-baby relationships and bonding.

Care was delivered through a structured treatment pathway supported by a multidisciplinary team. This enabled patients to develop insight, build practical and social skills, manage risk positively, and increase independence in line with their recovery goals and discharge plans.

Patients had access to appropriate physical healthcare throughout their admission, and ongoing physical health monitoring, which ensured patients received appropriate interventions, and felt their physical and mental health needs were considered together.

Mental Health Act

Over 90% of staff had completed training in the Mental Health Act.

Staff were trained and had a good understanding of the Mental Health Act, the Code of Practice and guiding principles. Staff had access to administrative and legal support regarding the Mental Health Act and Code of Practice and knew how to access Mental Health Act administrators when needed. The service had the relevant policies and procedures that reflected the most recent guidance.

Patients could access independent mental health advocacy, and staff explained their rights in a way they could understand, repeating and recording this as required.

Staff requested an opinion from a second opinion appointed doctor when necessary.

When patients had been detained under the Mental Health Act staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

The ward displayed a notice to tell informal patients that they could leave the ward freely.

Description: We work effectively across teams and services to support people, making sure they only need to tell their story once by sharing their assessment of needs when they move between different services.

We scored the service as 3. The evidence showed a good standard.

Patients felt fully involved in their care and treatment and that staff from different teams worked well together to support them. Families and carers were involved where appropriate, and communication between professionals was effective and coordinated.

One patient told us, “The staff have been amazing, and they have supported me so much. They’ve worked well with other people involved in my care. I don’t know what I would have done without them!”

Robust systems ensured patients received coordinated support from specialist services, including occupational therapy, psychology, nursing, paediatric liaison, and community mental health teams. Care was delivered in a joined-up, person-centred way that promoted recovery, independence, and achievement of individual goals.

Staff demonstrated effective multidisciplinary and inter-team working. Structured and informative shift handovers ensured key information was shared consistently, supporting continuity of care and a coordinated approach to treatment and recovery.

Staff shared assessments, risk information, and care plans promptly during transfers and discharge, promoting continuity of care which reduced distress during transitions and periods of change.

Multidisciplinary team meetings were held regularly with the relevant professionals and partner agencies where appropriate. Discussions covered risk management, physical health, patient goals, therapeutic engagement, and discharge planning, ensuring coordinated, recovery-focused care. Outcomes and actions were shared electronically to support effective communication and collaborative working.

Description: We support people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

Quality Statement Score: 3. The evidence showed a good standard.

Patients were encouraged to take an active role in managing their health and wellbeing, which promoted independence and recovery. They described staff as proactive, knowledgeable, and supportive, helping them build confidence, independence, and improve their quality of life. Named staff provided consistent support, including practical advice on sleep, diet, exercise, and wellbeing.

One patient told us, “Every single member of staff is awesome, and they have helped me, my baby and partner so much with advice on so many things to keep us all well. I honestly have no idea where we’d be without their help.”

Staff promoted recovery and healthy lifestyles through group and individual interventions, health education, and practical support such as smoking cessation, nutrition, and physical activity programmes.

Staff identified and responded to health risks early, providing targeted support for physical health and wellbeing needs. They used physical health monitoring tools effectively. Such as, the malnutrition universal screening tool (MUST), and encouraged patients and their families to access community support and peer groups where appropriate.

A range of therapeutic and community-based activities supported recovery, health, and wellbeing. These helped patients improve physical health, develop daily living skills, build confidence, and increase independence, with participation and outcomes regularly reviewed to ensure support remained personalised, effective and progress towards recovery goals were sustained.

Description: We routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

We scored the service as 3. The evidence showed a good standard.

Patients’ progress and outcomes were monitored regularly using recognised outcome measures and clinical data. Staff used tools such as, the health of the nation outcome scales (HoNOS) and the national early warning score (NEWS2) to assess health, wellbeing, and recovery, which ensure care remained effective and responsive to individual needs.

Patients achieved positive outcomes across the service, including improved social and daily living skills, greater participation in activities, increased confidence, independence, resilience, and sustained progress in recovery that aligned with their personal goals and aspirations.

Service managers maintained effective governance processes to monitor performance, review outcomes, and identify improvements. Leaders and staff used audits, quality improvement initiatives, and shared learning to enhance care quality and support consistent, person-centred, recovery-focused outcomes.

The service was accredited by the Royal College of Psychiatrists’ Perinatal Quality Network (PQN), which set evidence-based standards and used a peer review process where multidisciplinary teams and patient representatives visited services to evaluate performance, inspect environments, and share best practice.

PQN accreditation was awarded for three years, with interim self-reviews to ensure services continued to meet high standards of safety, quality, and patient dignity. The accreditation process involved patients, carers, and experts by experience throughout the review and standard-setting process.

Description: We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

We scored the service as 3. The evidence showed a good standard.

Staff helped patients to understand their rights, treatment options and choices about their care. Staff used a range of communication methods to ensure information was accessible, clear and tailored to individual needs, supporting patients to make informed decisions about their treatment.

Staff followed legal processes and ensured patients understood their rights.

Staff supported patients to understand and exercise their rights under the Mental Health Act around consent and decision-making, promoting independence, choice, and autonomy. Where capacity concerns arose, staff completed and documented decision-specific mental capacity assessments in line with the Mental Capacity Act 2005.

When patients lacked capacity to make specific decisions, staff followed legal requirements and best practice to make decisions in their best interests, taking account of their wishes, feelings, values, culture, and personal history. Accessible information and advocacy support helped patients participate in decisions as fully as possible.