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

Well led - This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open and fair culture. This was the first assessment of the service. This key question has been rated Good. This meant the service was consistently managed and well-led.

This service scored 79 (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 shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

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

Staff were actively involved in shaping the service strategy and demonstrated a clear understanding of the organisation’s vision, values, and objectives, which were reflected in their daily practice. The trust’s commitment to safe, compassionate care and a culture of openness, honesty, and inclusivity were consistently evidenced throughout the service.

The provider’s vision and values were embedded throughout the service and reflected in day-to-day practice. Leaders promoted an inclusive culture of openness, respect, equality, and diversity, while patients and staff were encouraged to shape service development through accreditation reviews, meetings, and feedback processes.

Managers described how the service’s values, culture, and ways of working had evolved through meaningful engagement with patients and staff. The overarching principles were embedded in recruitment, training, supervision, and performance management processes.

Senior leaders led by example, promoting a positive and open culture with a strong focus on equality, diversity, and inclusion. Regular staff engagement meetings and team away days encouraged involvement and shared ownership, while opportunities to take on lead roles, for example, domestic violence lead and freedom to speak up champion positions promoted accountability and staff empowerment.

Staff were encouraged to contribute to service development and direction, with leaders keeping them informed through regular meetings and effective communication. Clinical and non-clinical staff received tailored training, including specialist perinatal mental health recovery training, to support their roles and to meet patients’ needs.

The provider’s strategy focused on delivering safe, effective, compassionate, high-quality care while promoting equality, collaboration, and partnership working. Leaders communicated organisational priorities clearly, and staff reported feeling valued, included, and listened to, which contributed to a positive and supportive culture across the service.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

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

Service leaders demonstrated the appropriate skills, knowledge and experience to carry out their roles effectively. They had a clear understanding of the services they managed and were able to articulate how teams delivered safe, effective and person-centred care.

Leaders were visible, accessible, and approachable to staff, patients, and families. Staff described a culture of openness and transparency where they could raise concerns without fear of reproach. Regular updates and ward round summaries helped keep staff informed about service developments and patient care.

Staff had access to leadership development opportunities through comprehensive training programmes. Leaders supported staff to develop their skills and knowledge, while non-clinical staff received additional training to enhance their understanding of the service and patients’ needs.

Leaders demonstrated a commitment to supporting and valuing their workforce. They proactively identified, challenged and addressed behaviours or cultural issues that could adversely affect the quality of care or the wellbeing of staff, which helped to maintain a positive, supportive and inclusive working environment.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

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

Patients, families and carers were given various opportunities to provide feedback in ways that met their needs and preferences. Feedback was consistently positive, with friends and family test results showing extremely high levels of satisfaction across the service.

Leaders promoted a positive, open, and inclusive culture where patients, carers, and staff were encouraged to share their views. Feedback was gathered through a range of channels, including direct discussions and community meetings. Patients said they felt listened to, supported to raise concerns, and kept informed of outcomes and actions taken.

Service leaders had effective arrangements to support staff to speak up and raise concerns. A freedom to speak up policy was in place, with information on how to access the service displayed throughout the environments we visited. Staff had access to freedom to speak up champions, an organisational freedom to speak up team and guardian for confidential advice and support. Staff felt confident raising concerns, described managers as open and responsive, and reported that concerns were investigated appropriately, with learning shared to support continuous improvement.

Clear escalation routes were available beyond the local service, ensuring staff and patients could access additional support when needed. For example, patient’s, staff, family members and carers could contact the care quality commission (CQC) to report any concerns they may have. Details on how to contact the care quality commission were displayed throughout the environments we visited.

Opportunities to engage with senior leaders reinforced a culture of openness and accessibility. Staff reported that leaders acted with honesty and transparency when things went wrong, providing prompt explanations, apologies where required, and information on actions taken to prevent re-occurrence.

There had been no freedom to speak up concerns raised across the service in the 6 months prior to our assessment.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

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

Leaders promoted an inclusive and respectful culture with a clear zero-tolerance approach to bullying, harassment, and discrimination. Staff were encouraged to contribute to service development and improvement, and equality, diversity, and inclusion principles were embedded throughout the organisation’s values, policies, strategy, and day-to-day practice.

Managers supported flexible working arrangements to meet the diverse needs of staff, including caring responsibilities, health conditions, cultural requirements, and other personal circumstances. Reasonable adjustments were made where required, and workforce equality was monitored through governance processes, including the workforce race equality standard (WRES) and the workforce disability quality standard (WDES), to identify and address any potential inequalities.

The trust provided a range of wellbeing support, including a 24/7 employee assistance programme and access to an online GP. Additional tailored support was available following incidents via debrief and reflective practice sessions, which were facilitated by the psychology department, and wellbeing champions used staff feedback to provide targeted support where needed.

The organisation developed a clear anti-racism approach and provided staff with guidance on responding to racist abuse. It was also developing the “No Excuse for Abuse” programme, with workstreams focused on physical violence and verbal abuse, sexual safety, anti-racism, appropriate reporting to the police and safety.

Equality, diversity, and inclusion were embedded within the organisation’s values and reinforced through mandatory training. Staff had access to a range of support networks, including multicultural networks, LGBTQ+ networks, women’s networks, and disability groups. The organisation was recognised as a Disability Confident and age-friendly employer, with additional equality, diversity and inclusion support available through the employee assistance programme.

Recruitment processes promoted fair and equitable treatment of applicants, which supported a diverse workforce reflective of the population it served. Staff also had access to structured development opportunities, including nursing career pathways, preceptorship programmes, and other routes for professional growth.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

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

Service leaders had governance systems and processes in place, but this were not effective as they could be.

Governance arrangements had not identified concerns relating to care plans, risk assessments, safety plans, and risk management documentation. We found examples where risks identified in assessments were not reflected in care or safety plans, risk assessments had not been updated to reflect changes in patients' presentations, and risk management plans lacked sufficient detail to guide staff in managing significant risks. As these issues had not been identified through routine audit and governance processes, leaders were unable to assure themselves that risks were being consistently assessed, reviewed, and managed. Following our feedback, leaders developed an action plan to address these concerns and committed to providing regular updates to demonstrate progress and improvement.

Staff understood their roles and responsibilities and were appropriately supported and challenged by leaders to maintain accountability and good practice.

Leaders had established a structured programme of team meetings to communicate and review key information. Incidents, complaints, safeguarding concerns, and performance data were routinely analysed to identify learning and drive improvement. Staff also participated in clinical audits and took action in response to findings.

Leaders promoted collaborative working internally and with external partners to meet patients’ needs effectively. This included engagement with the getting it right first time (GIRFT) network and peer review and site visit audits to maintain Perinatal Quality Network accreditation.

Comprehensive business continuity arrangements were in place to manage potential disruptions, including adverse weather, flu outbreaks, and other unforeseen events. Leaders also ensured cost improvement programmes did not compromise the quality or safety of patient care.

Senior leaders and managers had access to timely performance, workforce, and patient outcome data to support decision-making and identify areas for improvement. Quality improvement frameworks were embedded across the service, with innovation supported by effective risk management, helping ensure governance systems remained responsive, robust, and sustainable.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 4. The evidence showed an outstanding standard.

Patients were supported to maintain contact with professionals involved in their care, including community psychiatric nurses. External partners, such as care coordinators, social workers and health visitors regularly attended multidisciplinary team meetings to contribute to care planning, reviews, and decision-making.

Staff and leaders demonstrated openness and transparency in their engagement with external stakeholders and partner organisations. They worked collaboratively with commissioners and healthcare providers to support effective service delivery, continuity of care, and integrated care pathways.

Leaders actively shared learning through local and national forums and partnerships to drive quality improvement. For example, the service was accredited with the perinatal quality network (PQN), contributing to peer review, accreditation, and national quality improvement initiatives that improved specialist perinatal mental health services.

The trust was the lead for perinatal services within the East Midlands Provider Collaborative, a regional partnership overseeing specialist perinatal inpatient and community care and pathway support for women experiencing severe perinatal mental illness. An embedded experts-by-experience network of mothers with lived experience actively co-produced service improvements and standards of care.

The Beeches Mother and Baby Unit collaborated with other regional Mother and Baby Units to facilitate access to specialist inpatient care when required. During periods of reduced local capacity, patients were supported with admission to alternative regional mother and baby units, which maintained access to specialist care, treatment and support at the time when people needed it most.

The service operated within NHS England’s specialised commissioning arrangements and worked with regional provider collaboratives to manage patient flow, capacity, repatriation, and specialised inpatient care. Roles across mother and baby units, community teams, crisis services, and provider collaboratives were clearly defined, and leaders contributed to national performance reporting and service improvement initiatives.

Staff and leaders encouraged engagement with patients, local communities, and partner organisations to share learning and best practice. Established networks supported innovation, continuous improvement, and better patient outcomes and experiences.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 4. The evidence showed an outstanding standard.

Strong links with external organisations and professional networks supported the adoption of best practice and new ways of working. Leaders maintained open communication with staff and fostered a culture in which ideas for improvement were encouraged, valued, welcomed and translated into meaningful service developments.

Leaders demonstrated a strong commitment to continuous learning, service development, and innovation. Staff were actively involved in quality improvement initiatives and benchmarking that enhanced patient care and outcomes and monitored performance to ensure care remained evidence-based and aligned with current national standards.

Following consultation with a national safer sleep charity, staff and leaders completed a quality improvement project to maintain infant room temperatures between 16°C and 20°C. When challenges were identified during warmer periods, leaders approved air conditioning for patient rooms to ensure safe and consistent sleep temperatures.

Leaders completed a quality improvement project to address inappropriate admissions and their impact on patient safety and inpatient ward dynamics. A revised referral process and criteria reduced incidents and improved the safety and therapeutic quality of the environment, which supported and enhanced wellbeing and recovery.

Staff identified that fixed-brightness bedroom lighting disrupted mothers and babies during night-time care and observations. To address this, staff completed a quality improvement project which resulted in adjustable ambient lighting being installed in patient bedrooms, which improved rest, recovery, and infant care.

Staff implemented innovative approaches to supporting carers and families, including psychological support and tailored aftercare following discharge from community or inpatient services. Home assessments supported safe periods of leave and informed effective discharge planning.

Staff embedded SafeWards principles and trauma-informed care into daily practice to enhance patient safety, experience, and recovery, while research and evidence-based practice informed service delivery.