Derbyshire Community Health Services NHS Foundation Trust

Overall, we rated community and young people’s services as good.

There were arrangements in place to minimise and mitigate the risks to children and young people receiving care and to staff working alone in the community. Staffing levels were safe although there was currently pressure on some teams due to high demands and the current staffing capacity. The service had a ten percent staff vacancy rate that they were in the process of recruiting to.

Incident reporting was consistent and there was a good awareness amongst staff of how to manage incidents. There were effective systems in place to learn from incidents both within individual teams and across the organisation.

Services were effective, evidence based and focussed on the needs of children and young people. We saw examples of good multidisciplinary work. Care and treatment was evidence based, staff were competent and people using the service were protected from inappropriate care or treatment for which they had not given proper consent. There were policies and procedures in place to support staff and ensure that services were delivered effectively and efficiently. Parents and caregivers felt well supported and involved with their children’s treatment and told us that staff displayed compassion, kindness and respect.

Services delivered by the trust were caring. Staff were dedicated to their patients and worked hard to ensure that patients received the best treatment and support possible. Patients were involved in decisions and understood the services being delivered to them. Emotional support was available to patients who were dealing with difficult circumstances. Staff undertaking home visits were dedicated, flexible, hardworking, caring and committed.

We found the service was responsive to needs of children and families. Effective multidisciplinary team working, including external partners, ensured children and young people were provided with care that met their needs, at the right time and without avoidable delay. The service was in general well led with effective decision-making and strategic planning. The board and senior managers had oversight of the reported risks and had measures in place to manage these risks.

Overall, we rated the community health inpatient service as good, with outstanding for caring.

We found:

The service protected patients from avoidable harm and abuse. There was an embedded system in place to keep people safe and a good level of staff knowledge on how to safeguard patients from abuse. There was evidence of an open and transparent culture in relation to the reporting of incidents and we saw evidence of staff learning from investigations. All of the areas that we visited were visibly clean and staff actively participated in keeping their patients safe from infections. There were well embedded systems in place to recognise a deteriorating patient and we saw evidence where escalation of treatment was correctly identified and acted upon. All wards had good staffing levels with proposed staffing always matching the planned staffing. On occasions where additional staffing was required, staff told us that they were supported to increase the staffing.

The trust participated in local and some national audits, and was also looking into participating in other national outcome audits. All local policies and guidance were evidence-based and followed National Institute for Health and Care Excellence (NICE) guidance. Staff comprehensively assessed patients to produce individualised care plans. Care plans accounted for patients’ physical, mental and clinical needs. Staff were competent to undertake their roles and responsibilities and the trust supported staff to continue their professional development. We saw evidence of staff providing a cohesive team approach to patient’’s care involving all members of the multi-disciplinary team, including discharge planning and transferring to other teams. Staff had knowledge and understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards.

We observed patients being treated with the upmost respect and dignity during their admissions. Staff valued patients as individuals and empowered them to become partners in their care. Feedback during the inspection was positive from patients with words including ‘excellent’ and ‘brilliant’ often being used. Staff welcomed the relatives of patients to also become involved in their care and we saw evidence of where the staff involved the relatives in decision making. Staff empowered the patients and their relatives to have a voice and realise their own potential.

People’s individual needs and preferences were central to the planning and delivery of the services. The service was proactive in its approach to understanding the needs of different groups of people and delivered care in a way that met the needs of patients. We saw evidence during our inspection where staff made considerable efforts to meet the needs of vulnerable patients and those with complex needs. Waiting times and cancellations were minimal and staff took appropriate action to rebook procedures for patients in the event of cancellations. There was a well-established complaints procedure which was well publicised and patients felt comfortable in raising complaints and concerns.

There was a clear vision and set of values which was publicised by the trust. All staff we spoke with were aware of the ‘DCHS Way’ which reflects the vision and values. There was a good governance structure in the service and there was a flow of information that went both ways. Risk was assessed at all levels and residual risks were held on a trust risk register, which all staff had access to. There was positive leadership in the service and staff demonstrated high levels of satisfaction stating they felt appreciated and supported in their roles.

End of life care services at this trust was rated as good overall.

Safety was rated as good. Patients were protected from avoidable harm; staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and, arrangements to minimise risks to patients were in place. Patients were protected from abuse; staff had an understanding of how to protect patients from abuse, could describe what safeguarding was, and the process to refer concerns.

We rated the effectiveness of this service as good. Patients received effective care and treatment that reflected current evidence-based guidance, standards and best practice. Patients had a comprehensive assessment of their needs, which included pain management, nutrition and hydration and physical and emotional aspects of their care.

Care from a range of different staff, teams and services was coordinated effectively; there was effective multidisciplinary working, with staff, teams and services at this trust and external organisations working in partnership to deliver effective care and treatment.

Staff understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005; this was reflected in the ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) orders reviewed during our inspection.

The care provided to patients in end of life care services was good. Patients were truly respected and valued as individuals and were empowered partners in their care. Feedback from patient’s, relatives and carers was consistently positive and there were many examples of staff going ‘above and beyond’ when delivering care.

We found the responsiveness of end of life care services to be good. Patients' needs were mostly met through the way end of life care was organised and delivered. However, the rapid discharge of those patients expressing a wish to die at home was not monitored. We could not therefore be assured this was happening in a timely way.

The leadership of end of life care services was good. This was an evolving service with a developing vision and a strong focus on patient centred care. There were robust mechanisms in place to share learning across end of life care services. However, not all incidents and complaints specific to end of life care had been identified and used to improve the quality and safety of end of life care services and, good practice was not always recognised and widely shared across end of life care services.

Overall, we rated urgent care services provided by the minor injury units as outstanding.

Feedback from patients was continually positive about the way all staff treated them. There was a strong, visible person-centred culture; patients described being treated as “individuals” rather than a “number”. Patients and relatives told us all staff go the extra mile and the care they received exceeded their expectations. One relative of a child told us they chose to attend the unit with their child as staff “understand" the needs of children and their experiences have always been “positive”. They told us staff went “above and beyond” what was expected of them. Other patients described being treated like “family” describing the service as “absolutely brilliant” and said the care was more “attentive” than at bigger hospitals. Staff across all units were highly motivated to offer care that was kind, compassionate and promoted patient’s dignity. During our inspection we were particularly impressed with the interpersonal skills demonstrated by staff.

The services provided by the minor injury units (MIUs) were tailored to meet the needs of the individual patient and were delivered in a way to ensure flexibility, choice and continuity of care. Patients could access the service in a way and time to suit them. The units had set up nurse led fracture clinics to reduce the numbers of patients having to transfer to acute hospitals for the management of simple fractures. The MIUs also offered clinics for patients requiring follow up treatment or review of conditions such as burns, foreign body removal, eye problems and wounds. There was a proactive approach to understanding the different needs of people and delivering care to meet those needs. Waiting times and delays were minimal and managed appropriately if they did occur. The service exceeded targets in respect of time spent in MIUs and the time people waited for treatment.

Patients attending MIU were protected from avoidable harm and abuse. We saw effective and reliable systems and processes in place for infection control, medicines management, patient records and assessing and responding to patient risk. The systems and processes were sufficient to protect patients from avoidable harm. We saw an effective system in place to ensure patients received appropriate initial assessment by appropriately qualified clinical staff within 15 minutes of arrival to MIU in line with best practice. Staff across all MIUs were up to date with mandatory training. Staffing levels and skill mix were appropriate to keep patients protected from avoidable harm. The safeguarding of vulnerable adults, children and young people was given sufficient priority. Staff were actively engaged in local safeguarding procedures and worked effectively with other relevant organisations.

Patients’ care and treatment was planned and delivered in line with current evidence based guidance and standards. Staff were qualified and had the skills they needed to carry out their roles effectively. Patients had a comprehensive assessment of their needs, which included clinical needs, mental health, physical health and wellbeing needs.

There was a clear statement of vision and values, driven by quality and safety, staff knew and understood the trust vision and values. Unit managers had the experience, capacity and capability to lead the services and prioritised safe, high quality, compassionate care. There was a high level of staff satisfaction. Staff said they were encouraged and supported to develop, were proud of the teamwork within the units and the willingness to help and support each other and said there was a positive regard for their welfare. Over 30% of the compliments received by the trust related to the positive care and experiences of people attending the MIUs.     

We rated the community dental services at this trust as outstanding.

• Staff protected patients from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.
• Infection control procedures were in place. The environment and equipment were visibly clean and well maintained and medicines and emergency equipment was available at each site we visited.
• The dental services were effective and focused on patients and their oral health care.
• We found clinical staff delivered care according to best practice guidelines for dentistry; this included special care dentistry, conscious sedation for dentistry in primary care, paediatric dentistry and preventive dental care.
• Patients, relatives and carers said they had positive experiences of care within the service. We saw good examples of staff providing compassionate and effective care. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed their dedication to what they did.
• Staff responded to patients’ needs at each clinic we visited. The service kept treatment delays for routine and complex dental treatment within reasonable limits through effective resource management.
• The community dental service was well led. Organisational, governance and risk management structures were in place. The service’s operational management team was visible and the working culture appeared open and transparent. Staff were aware of the organisation’s vision and way forward and they said they felt well supported and they could raise any concerns.
• The service vision and strategy was an evolving one. This was because the service was being placed out for tender in the coming months which had brought a period of uncertainty. Despite this, we spoke to dentists and dental nurses who said the service had forward thinking and proactive clinical directors who were well supported by senior managers within the trust.
• The culture of the service was one of continuous learning and improvement. At each clinic we visited, we saw staff worked well together and there was respect between all members of the dental team.
• The morale of the staff appeared good at each clinic with staff adopting a positive ‘can do’ philosophy about their practice and the challenges they faced.

We rated Derbyshire Community Health Services NHS Foundation Trust as good because:

• Patients and carers were positive about the standard of care and described the care as excellent.
• Wards were clean, clutter free and safe.
• De-escalation techniques such as distraction, talking and guiding patients to quiet areas were widely used to manage patient behaviours.
• Staff undertook both physical and mental health assessments on admission. Staff updated assessments frequently as patient needs changed.
• There was a range of mental health professionals available to patients. All wards had access to psychological therapies and social work input.
• Patients and carers were able to give feedback on the service they received via comment boxes and meetings.
• Access to advocacy was available to all patients on all wards
• Effective and detailed handovers took place on all wards. Handover meetings gave staff the understanding of current patient need.

However:

• Patients were not given copies of their care plans.
• On all four wards there was no systematic recording relating to section 17 leave. We noticed old section 17 leave forms not crossed through.
• Staff did not have access to the computer care recording system used by Derbyshire Healthcare NHS Foundation Trust, therefore did not have access to all patient information.

We rated wards for people with learning disabilities as good because:

• Staff were aware of patients’ needs and risks as thorough up to date information was available, including personalised care plans and activity plans.
• We found the wards to be safe, clean, spacious and comfortable with a good quality of furnishings and decoration throughout, including outdoor areas for fresh air.
• Staff knew their patients’ well and had built up good relationships. There was good staff to patient ratio, across all sites.
• The service had a good structure to ensure that staff were up to date with training and supervision. Staff managed incidents well, they had a system that encouraged learning within the staff group, and staff had awareness of when to report incidents and deal with complaints.
• There were processes in place to ensure staff were working within the Trust policies and procedures.

However:

• Staff received regular clinical supervision in line with the trust policy, however not all staff received regular management supervision.  
• Bedroom doors did not have locks on. Patients were unable to lock their rooms at night if they wished.

We rated Derbyshire Community Health Services C community learning disability service as good because:

• Patients and carers told us the service was excellent. They told us that staff treated them with respect and compassion. They told us that nothing was too much trouble for staff in the service.
• Staff compliance with mandatory training in the Mental Health Act and Mental Capacity Act was 100%.
• Staff supervision rates were 100%.
• Staff appraisal rates were 100%.
• Staff lone working practices were safe and well embedded within each team .
• Staff sickness rates in the 12 months prior to our inspection was 6%.
• There were no staff vacancies in any of the teams.
• Managers were supportive of staff with difficulties. We spoke with a member of staff who had received support and access to specialist equipment to help him do his job when managers discovered he had dyslexia.
• Managers supported staff in accessing education and training relevant to the service.
• Teams were well-led at a local level and at a senior management level.
• The service had received no complaints in the 12 months prior to our inspection.
• The service had received 33 compliments in the 12 months prior to our inspection.
• Teams could respond the same day to patients in crisis.
• Staff conducted a risk assessment of every patient at initial triage of the patient.
• We saw an excellent example of an adapted ABC chart which a nurse in the Darley Dales team had created. How information is gathered may be different for each person collecting the data and depending on the complexity of the situation. One format involves directly observing and recording situational factors surrounding a problem behaviour using an assessment tool called an ABC chart. An ABC chart is an assessment tool used to gather information that should evolve into a positive behaviour support plan. ABC refers to: antecedent - the events, action, or circumstances that occur before a behaviour; behaviour - the behaviour. Consequences - the action or response that follows the behaviour. The adapted document made it simple for carers to complete by ticking boxes when the patient was at home on leave. This meant that the information staff were gathering from the document was more accurate and detailed.
• Patients had positive behaviour support plans (PBS plans). A PBS plan is a document created to help understand and manage behaviour in patients who have learning disabilities and display behaviour that others find challenging. A PBS plan provides carers with a step by step guide to making sure the patient not only has a good quality of life, but also enables carers to identify when they need to intervene to prevent an episode of challenging behaviour. A PBS plan is based on the results of a functional assessment and uses positive behaviour support (PBS) approaches. A formulation summarises the patient’s core problems and shows how the patient’s difficulties may relate to one another by drawing on psychological theories and principles. The plan contains a range of strategies which not only focus on the challenging behaviour, but also include ways to ensure the person has access to things that are important to them.
• Care records contained up to date, personalised, holistic, recovery-oriented care plans. Patients had contributed to their care plans. Care plans were available in easy-read format if the patient required. There was a reasonable adjustments section in the care record which allowed for the adaptation of documents, such as pictorially.
• Patients had health action plans and communication passports which they could take with them to other services or accommodation providers.
• Staff adhered to relevant national institute for health and care excellence (NICE) guidelines.
• The multidisciplinary teams communicated effectively with each other.
• Patients could self refer to the service as well as be referred by other professionals such as the GP.
• The Quality Always programme provided a robust audit strategy with RAG (red, amber, green) rated outcomes.
• There had been no serious incidents in the 12 months prior to our inspection.
• There had been no never-events in the 12 months prior to our inspection.
• There was clear evidence of learning from when things go wrong.
• The trust scored above the England average for staff who would recommend the trust as a place to work (70% compared to 62% England average) whilst also having a lower number of staff who would not recommend the trust (13% compared to 19% England average).
• The trust scored 12% above the England average for staff who would recommend the trust as a place to receive care (91% against 79%).

However;

• Signage in reception areas was not always available in accessible formats.
• Safeguarding children training was at 48% staff compliance. This was because the trust had initially identified the incorrect safeguarding children training for staff so staff were having to re-attend the training.

Letter from the Chief Inspector of Hospitals

Derbyshire Community Health Services NHS Foundation Trust cares for patients across a wide range of services, delivered from 133 sites including 13 community hospitals and 28 health centres. It covers the city of Derby, the rural communities of Derbyshire and also provides some services into Leicestershire. It provides care for more than 4,000 patients every day. The trust employs approximately 4,500 staff, serving a patient population of more than one million. The trust was authorised as an NHS Foundation Trust in 2014, being one of the first Community Trusts in England.

This was the trust’s second inspection using our comprehensive inspection methodology. We had previously inspected this trust during our pilot testing phase in 2014 but we did not publish any ratings.

We carried out this comprehensive inspection between the 9 and 13 May 2016. We also carried out an unannounced inspection from the 22 to 23 May 2016.

Overall we found the provider was performing at a level which led to the judgement of good, with some elements of outstanding. We inspected 10 core services; two were rated as outstanding, seven were rated as good and one was rated as requiring improvement.

Our key findings were as follows:

Safe

• The trust had a mature patient safety culture and incidents were managed well with evidence of learning across the organisation. We found the sexual health service needed to improve its incident reporting processes. However, this was a service which had been subject to change because of the new way it was being commissioned. There were contractual arrangements that still needed to be made clearer. These issues were hampering the process for incident reporting and learning across the whole service.
• There was a good understanding of safeguarding children and adults amongst staff.
• Staffing levels were generally able to meet the needs of patients, although there were some vacancies in the community adult’s service.

Effective

• Evidence based practice was embedded throughout the trust and services followed national guidance.
• A range of audits were undertaken across the trust.
• Multidisciplinary working was well established across the trust.
• Staff were able to demonstrate a good understanding of the principles of mental capacity.We noted the approach to mental capacity assessment, best interest assessment and restraint within the learning disability service was particularly good.

Caring

• Patients were treated with kindness, compassion, dignity and respect throughout all of the services we inspected.
• During our observations of staff and patients interaction we found staff were focused on the individual needs of patients making them feel valued and respected.
• Staff were observed going above and beyond what they were expected to do so they provided the best possible care for their patients.

Responsive

• Services were planned around the needs of individual patients.
• There were a range of services offered to vulnerable groups. There was a flagging system in use within the electronic patient record system to identify patient who had a learning disability.
• Frail elderly patients and children, those living with dementia or a learning disability were prioritised for care in the Minor Injuries Unit (MIU).
• The MIU was providing a very responsive service. It was consistently exceeding targets in respect of time spent in MIU and the time patients waited for treatment.
• We found evidence throughout the trust that people were supported to raise concerns, complaints and compliments.

Well led

• There was a clear vision in place supported by objectives and values which staff understood.
• The Chief Executive and Chairman worked well together but their relationship had an appropriate balance between high challenge and high support. The Chief Executive and Chairman were visible and many staff commented on the strong leadership they provided.
• We received many positive comments about the non-executive and executive leadership from staff at all levels in the organisation.
• The trust valued its staff, there was a real sense that they cared about them and saw them as their greatest asset. Morale amongst the majority of staff was very good. Staff enjoyed working at the trust and felt valued by the executive team and their line managers. Where morale was not as high it was usually because of the impact from service reconfiguration.
• The trust had an established governance structure which was there to support the provision of assurance to the board.
• The trust had a commercial focus which was also centred on providing the best possible care for patients. This had made the trust well placed to respond and adapt to changes in direction arising from new local and national policy.
• A culture of putting the patient first was evident throughout the organisation.

We saw several areas of outstanding practice including:

• We were extremely impressed with the work the trust had done on transgender. Walton hospital had a display of photographs and quotes from people undergoing transition. This work had been in place for some time. We found the work on display promoted equality and diversity and brought issues of transgender to the fore in a very positive, open and accepting manner.
• The community inpatient services had worked hard to provide a service which was dementia friendly. There were activities being provided across the trust and work had begun to update the wards where possible to be suitable for patients living with dementia. Staff were dementia friends and had completed external training to increase their knowledge and competence in providing care for patients living with dementia.
• The pharmacy service provided on the community inpatient wards was outstanding and integral to the patients’ discharge planning.
• Patients were left with comment cards on Oker Ward so they could write down any questions they may have about their care and treatment. The staff on the ward would regularly review these cards and answer the patient’s questions.
• We found clinical staff delivered care over and above best practice guidelines in relation to dentistry; this included adaptations to provide individualised special care dentistry, conscious sedation dentistry in primary care, paediatric dentistry and preventive dental care through detailed patient assessment and individualised treatment plans which took into consideration each patient’s specific dental and special care needs.
• The community dentistry service coordinated treatment input for patients living with special needs who were undergoing general anaesthesia. This included podiatry, venepuncture and other interventions which would be distressing to the patient. This also reduced the number of health care attendances required by patients.
• The Derbyshire Alliance End of Life Care (Eolc) Toolkit was a readily accessible online toolkit. This comprehensive toolkit provided both professionals and members of the public with access to a range of learning materials polices and Eolc documentation. The toolkit was designed collaboratively by professionals who worked across Derbyshire and had received national recognition. The toolkit provided national guidelines and local Derbyshire- wide guidelines for all agencies offering unified documentation bespoke for staff working in, primary and secondary care settings, including hospices, social care, ambulance services and the voluntary third sector. A range of information leaflets were available on the website that staff were able to print and share with patients and carers. Training opportunities were also provided supported by notification of forthcoming events by personal emails and ‘training flyers’.
• Staff at Ripley Minor Injuries Unit (MIU) were able to call a “pit stop” in the unit. The “pit stop” was a way of gaining an overview of the units and prioritising patient needs in the unit. All staff would attend the “pit stop” and create a plan.
• The MIUs had adopted safeguarding children supervision. Safeguarding children supervision was a formal process of professional support and learning, which aimed to ensure clinical practice promoted the child and young person’s welfare. This was achieved by staff thinking and talking about what they had observed, heard or read, doing so supported the development of good quality practice and was a way of ensuring staff were up to date and knowledgeable in safeguarding procedures. We saw records of these sessions.
• A nurse led fracture clinic had been set up across all MIUs; led by the Emergency Nurse Practitioners (ENPs) this aimed to reduce the numbers of patients having to transfer to acute hospitals for the management of simple fractures. This benefited patients from the local community as well as visitors to the area. ENPS saw patients with simple fractures; they assessed, diagnosed, treated and followed-up patients in the same hospital. This had shown to be a positive experience and benefit to patients particularly children, as all hospital experiences have the potential to be frightening.
• Patients had access to ENP clinics, patients could book to attend these clinics for follow up treatment or review of conditions such as burns, fractures requiring x-ray, foreign body removal, eye problems and wounds.
• MIU had access to short stay beds on the wards nearest to the unit. The beds could be used for variety of reasons for example, a simple observation period following treatment, application of plaster of paris, awaiting x- ray opening times or for safety concerns whilst awaiting home support. Access to these beds prevented admissions to the acute NHS Trusts.
• Live waiting times for Ripley and Ilkeston MIU were available on the trust’s website, local newspaper’s, and clinical commissioning group’s website. The times were displayed against the current waiting times at the local acute emergency department, this encouraged patients to attend MIU where their conditions allowed and reduce the demand on the local emergency department.
• Staff hours of work in the community learning disability services could adapt in response to the needs of patients. For example, if a patient had an engagement out of hours in the evening or at a weekend, staff would alter their working hours to provide any support required by the patient or their family.
• Staff in the community learning disability services could adapt or design healthcare documents to meet the needs of patients better. A documents group in the trust would review the documents usefulness and safety with a view to ratification and implementation. We saw an excellent example of an adapted ABC chart created by a nurse in the Darley Dales team.
• Staff in the community learning disability services were dedicated and creative about engaging with patients who were reluctant to engage with services. They would devise clever ways of engineering meetings with patients which would appear casual and therefore less threatening.
• Staff in the community learning disability services had developed links with local dentists and the local acute hospital. This meant they were able to offer patients de-sensitisation visits to the dental practices and the acute hospital. Patients were able to spend time in the environments and reduce their fears and anxieties. This service extended to operating theatres where patients could visit and have theatre staff explain all the machinery to them and answer any questions.
• Staff on Riverside, Melbourne and Linacre Wards, facilitated by the Occupational Therapist, were regional partners in the Dementia and Imagination programme understanding art in dementia friendly communities, ran by Bangor University. The aim of this research programme was to explore the use of visual arts within the dementia community.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure there is a robust process for maintaining a register of serial numbers for prescription pads in community health services for adults.
• Ensure medicines are transported in securely sealed or tamper evident containers in community health services for adults.
• The trust must ensure incidents in Integrated Sexual Health Services (ISHS) are reported and investigated in a timely and consistent way.
• The trust must ensure learning from incidents and complaints is shared with all staff in ISHS.
• The trust must ensure that all staff working within Derbyshire Community Health Services ISHS follow the same guidance, policies and procedures in all areas.
• The trust must work towards national guidance for service provision, including return postal addresses for undelivered mail, management and follow up for patients who did not wait to be seen or did not attend appointments and monitoring of calls that are unanswered on the central booking service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall we rated community health services for adults as good.

The service protected patients from avoidable harm and abuse. There was a culture of reporting incidents and we saw evidence that actions were taken as a result. Staff anticipated and managed the risks to people who use services and had a good understanding of how to safeguard patients from abuse. Staffing levels were planned and reviewed to ensure there were safe levels of care. Clinic areas were visibly clean and tidy and staff demonstrated good infection prevention and control procedures. Patients care records were accurate, complete, up to date, and legible and were stored securely. However, we noted the trust’s medicine code was not always adhered to.

Care and treatment was planned and delivered in line with current evidence based guidance and standards, although there was no consistent approach to monitoring and auditing the quality of the service. We saw effective multidisciplinary working within the integrated community teams (ICT) and staff had the knowledge, skills and experience to deliver effective care and treatment. We saw evidence of staff knowledge and understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Most referrals to the service were handled by the single point of access (SPA) who assessed and triaged referrals to ensure that patients were directed to the most appropriate service. However, referrals to the community nursing teams based at Derby city were handled by a separate district nurse liaison service. Staff reported this service was ineffective, resulting in delays and inaccurate information being relayed to nurses.

Most patients had a single electronic patient record, which ensured all staff had access to information to provide effective care.

We spoke with patients using the services and all of the feedback was positive about the care they received. They told us they were treated with compassion, dignity and respect and were included in the planning and delivery of their care. The interactions we observed between patients and staff were consistently respectful and compassionate, with staff taking time to support, listen and reassure patients. Results from the NHS Friends and Family test (FFT) were consistently above 97%.

Services were planned and delivered to meet the needs of people. Care was provided locally and patients were seen in a timely manner. Community health services were provided by integrated community teams, which ensured patients received joined-up care. Community matrons were available to co-ordinate the care of patients with long term conditions. Specialist services were available, although the continence advisory service was not accessible to all patients in the community. This was because the service was commissioned differently between the city and county, however the trust were working with the commissioners to ensure an equitable service. . Staff ensured care was provided for those people in vulnerable circumstances and that care was accessible to all. Staff responded proactively to complaints, aiming to resolve issues quickly.

Staff were familiar with the trust’s vision and the ‘Derbyshire Community Health Services (DCHS) Way’, they consistently demonstrated the trust’s values in their day-to-day work. There was a good governance structure; managers were aware of the risks in their areas and could discuss the actions being taken to reduce these risks. Local leaders were visible and staff told us that they felt supported and valued. Staff said managers were approachable and they felt able to raise concerns. Staff felt listened to and able to influence service delivery. Staff spoke positively about the organisation; were proud to work for their team and enjoyed their role.

Overall we rated integrated sexual health services at this trust as requiring improvement.

Safety was rated as requires improvement. Staff did not have a full understanding of the systems and processes in place to identify and respond appropriately to the results of patients who had sexually transmitted infection screening. Staff understood and fulfilled their responsibilities to raise incidents however, internal governance processing of incidents was complicated, feedback and shared learning was not apparent and some staff were not aware of how to access the electronic system to report incidents.  The service had failed to meet local targets for staff mandatory training.

We rated the effectiveness of this service as good. Services were provided in line with current best practice, with guidelines available to staff. Staff understood guidelines around consent. Most staff received appraisal.

The care provided to patients in sexual health services was good. Patients told us staff were friendly and sensitive to their needs. Young people felt included and valued as an individual. We observed receptionists talking to patients in a respectful way. Patients told us nursing staff and doctors explained clearly what options were available to them.

We found the responsiveness of sexual health services required improvement. There were no effective processes in place to manage or monitor the number of people who did not attend or did not wait to be seen. A Central Booking Service (CBS) did not have processes in place to audit flow, demand or record numbers of missed calls. There was reduced availability of emergency treatment and delays of treatment due to demand. Sharing and learning from complaints was not evident for all staff.

The leadership of sexual health services required improvement. Following the integration of the sexual health service with two local acute trusts governance systems and processes did not operate effectively, some systems to monitor performance and safety issues were not in place. Staff attendance at team and locality meetings was low. There was a lack of unity and identity of the service.

In order to make our judgement we visited 12 locations across Derby and Derbyshire. We spoke with 52 staff including consultants, specialist nurses, health care assistants, managers, administration and support staff. We observed how staff of all levels interacted with patients during various types of clinics. We spoke with 11 patients and one carer about their experiences. We examined 14 sets of patient records.