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

Safe - This means we looked for evidence that people were protected from abuse and avoidable harm.

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

This meant patients were protected from avoidable harm. The environments were safe, clean, well maintained, and fit for purpose. Staff managed risks effectively, safeguarded patients from abuse, worked well with partner agencies, managed medicines safely, and responded appropriately to patient safety incidents.

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.

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

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

Staff demonstrated a proactive approach to safety and learning. They reported incidents and near misses through an electronic reporting system. Learning from incidents was embedded in team meetings and governance processes, collaborative working strengthened risk management and reduced re-occurrence.

Staff felt supported to raise concerns and participated in regular debriefs, reflective practice, and lessons learned sessions, promoting continuous improvement, patient safety, and recovery.

One staff member told us, “We are caring for very vulnerable people. We have to learn lessons, as it ensures we can support people in the best and safest possible way.”

Staff exercised the duty of candor consistently and were open and honest when things went wrong.

There had been no serious incidents in the 6 months prior to our visit.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

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

Patients felt supported throughout referral, admission, transfer, and discharge processes, helping to reduce anxiety during transitions. Staff provided accessible information tailored to individual needs and followed robust procedures to ensure referrals, admissions. Discharge planning was coordinated with partner agencies. For example, the perinatal community mental health team (PCMHT), the community mental health team (CMHT) and the adult and child social care teams within the local authority, worked together to support discharge plans to promote people's independence when discharged.

Communication during transitions of care was effective, which ensured staff managed risks appropriately during admission, transfer and discharge processes, which promoted continuity of care, recovery and positive patient outcomes across the service.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

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

Patients felt safe using the service. Staff worked with them to promote safety, wellbeing, and quality of life, while supporting their right to live free from abuse, discrimination, and avoidable harm. Safeguarding concerns were identified and acted on promptly.

One patient told us, “The staff are brilliant, and there always there for you. I know that me and my baby are safe, and I honestly have no clue what I would have done without them.”

Staff had access to a safeguarding lead and social worker within the service and an organisational safeguarding team for advice and support when required.

All staff completed a comprehensive safeguarding training package and demonstrated a good understanding of how to identify, report, and escalate concerns. They worked effectively with partner agencies to protect adults and children from avoidable harm, discrimination and breaches of their rights, including those with protected characteristics under the Equality Act 2010. Safe arrangements were in place for children visiting the inpatient service.

There had been 5 safeguarding referrals in the three months prior to our assessment. All had been investigated with the appropriate involvement from external partner agencies.

Mental Capacity Act

Over 91% of staff had completed training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles.

Patients admitted to the ward were either informal or detained under the Mental Health Act.

The service had a Mental Capacity Act policy, including Deprivation of Liberty Safeguards. Staff were aware of the policy and knew how to access advice and support when needed.

Staff took practical steps to support patients to make their own decisions. Where capacity was impaired, staff completed decision-specific assessments and, when necessary, made best-interest decisions that reflected patients’ wishes, feelings, culture, and history.

Service leaders had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

There were no patient’s subject to Deprivation of Liberty Safeguards at the time of our visit.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

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

We reviewed 10 care records, which included individual patient risk assessments and management plans, across inpatient and community services. However, we found that 4 risk management plans that lacked sufficient detail and did not have plans in place to reduce or mitigate risks for the individual. Whilst staff had completed risk formulations, staff had not regularly reviewed them with patients when risks changed. For example, a person had disclosed continued illicit substance use. The potential impact on parenting capabilities and infant safety had not been appropriately updated with no actions taken to mitigate the potential risks.

Following our feedback, leaders implemented an action plan to address these issues and committed to demonstrating improvement by providing us with regular progress updates on improvements made.

On the mother and baby unit, staff followed clear observation policies and ensured observation levels reflected patients’ assessed needs and risks. Observation requirements were regularly reviewed to maintain a least restrictive approach and to respond to changing needs.

Staff actively promoted least restrictive, person-centred care, supporting patients’ wellbeing, recovery, independence, and autonomy. Opportunities to reduce restrictive practices were regularly reviewed and monitored to maintain standards.

Staff used restraint only as a last resort after de-escalation attempts had failed. Staff participated in the organisation’s restrictive interventions reduction programme and delivered safe, person-centred care that promoted independence and wellbeing. Community staff received breakaway and diversion training to enhance safety in community settings.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

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

Staff maintained clean, well-equipped environments that supported the safe delivery of care. Equipment was routinely cleaned, audited, appropriately maintained, safely stored and used in line with local procedures.

Staff completed regular environmental safety and security audits, including checks for ligature risks, and addressed identified concerns promptly. Personal alarms and nurse call systems enabled staff and patients to access support when needed. Facilities, equipment and technology supported staff to provide safe and effective care.

Within community teams, patients did not always attend staff office bases. Wherever possible, care was delivered in less clinical settings, such as patients’ own homes, to promote comfort and engagement.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

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

Patients felt safe and very well supported by staff, describing them as knowledgeable, attentive and responsive to their needs.

Leaders maintained safe staffing levels across both inpatient and community services, supporting the delivery of person-centred care. Use of agency and bank staff was low and primarily related to short-term sickness absence. Leaders regularly reviewed staffing requirements and adjusted staffing levels in response to patients’ needs and service demands.

Patients had access to a full multidisciplinary team, including psychiatrists, psychiatric nurses, community psychiatric nurses, psychologists, occupational therapists, nursery nurses, nursing assistants and recreational workers. Staff were experienced, appropriately qualified, and supported through role-specific training, supervision, appraisals, and professional development.

The organisation completed appropriate pre-employment checks for all staff. Bank staff were familiar with the service and completed an organisational induction before undertaking shifts.

The service also maintained appropriate medical cover across a 24-hour period, with medical and pharmacy support available to respond promptly in emergencies.

Staff had access to the training, supervision and resources required to meet patients’ needs effectively. Mandatory training compliance was 96%, and staff reported that training was relevant to their role and supported their professional development. Staff received regular supervision and annual appraisals, with 95% compliance, and performance concerns were managed appropriately.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

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

Patients were confident in the infection prevention and control measures in place and felt reassured that staff took the appropriate precautions to protect them from the risk of infection.

Staff received regular infection prevention and control training to ensure practice remained in line with current guidance and best practice. Staff followed infection prevention and control procedures, including hand hygiene, appropriate use of personal protective equipment, and equipment cleaning. Environments were clean, tidy, and well maintained. We found evidence of regular cleaning schedules and audits and clear staff accountability for maintaining safety and hygiene.

Effective processes were in place to assess, monitor, and manage infection risks. Policies aligned with national guidance, audits were completed regularly, and identified concerns were addressed promptly. Staff had access to an organisational infection prevention and control team for advice and support. There was clear accountability for infection, prevention and control across the service.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

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

Staff explained medicines clearly and involved patients in decisions about their treatment. Patients felt informed, supported, and able to make choices about their care, while developing the skills and confidence to manage their medication independently in readiness for discharge.

Medicines were managed safely and effectively. Staff followed national guidance for the prescribing, storage, administration, recording, and disposal of medicines, and completed appropriate training and competency assessments.

Medicines, including controlled drugs, were stored and managed safely. Regular pharmacy audits identified areas for improvement, with actions monitored through clinical governance processes. Medicines reconciliation was completed promptly, and accurate records supported continuity of care during admission, transfer, and discharge. Emergency medicines and resuscitation equipment were available and regularly checked.

Medicines were routinely reviewed by the multidisciplinary team, with patients involved in treatment decisions wherever possible. Staff documented consent, preferences, and capacity appropriately, monitored the physical health effects of medicines, and regularly reviewed PRN medication to ensure its safe and appropriate use.

There had been two medication errors in the three months prior to our assessment. Both were categorised as minor, caused no harm, and were managed appropriately.