Derbyshire Community Health Services 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 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 inspection for this service. This key question has been rated 'Good', reflecting the quality of care provided.

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 that were able to participate in their care and treatment planning said they felt involved, listened to, and their needs were understood and met. Dependent on diagnosis and cognitive impairment, some patients were not always able to be fully involved. On these occasions, staff supported involvement as much as possible and followed the appropriate legal and best interest processes when patients lacked capacity to engage and make informed decisions. Where patients were unable to communicate their needs directly, staff supported their families, and carers to have input. Advocacy services were also used to inform assessments and care planning.

Staff completed comprehensive assessments of patients’ physical, mental, emotional, and communication needs in a timely manner. The assessments were person-centred, and reviewed regularly with the patient, and if appropriate, their families or carers wherever possible. Staff used clinical tools alongside professional judgment to build a comprehensive understanding of each person's individual needs. When patients had reduced capacity, staff adhered to legislation, and best practice which ensured decisions were made lawfully and, in the person’s, best interests. The patients families and carers were also supported in their roles, with appropriate information and resources available to them.

We reviewed 5 care records during the assessment. All records showed that a full mental health assessment either on admission or shortly afterwards had been completed, and also a physical health assessment. Care plans were carefully developed to reflect each person’s needs and were person-centred, holistic, and focused on achieving meaningful outcomes. Records showed that care, and treatment plans were reviewed and updated regularly. Communication needs and preferences were clearly recorded, and where necessary, adjustments were made with large print easy read information or visual prompts which improved the patients understanding and participation.

The service had an effective, structured approach to identifying, assessing and reviewing needs. Staff assessed each person’s mental health, physical health, emotional wellbeing, and communication needs. Care records demonstrated that patient needs were routinely updated. Assessments were completed in line with best practice. Care planning was tailored to meet the patients individual needs, and preferences.

The service delivered a range of care and treatment interventions, The psychology team formulated and promoted positive behavioural support planning (PBS) and completed behavioural assessments. Music therapies were delivered by specialist dementia music therapists. Reminiscence Interactive Therapeutic Activities (RITA) were also provided and delivered by therapists and staff either in groups or on a one-to-one basis and were adapted to suit individual patient needs. Staff followed guidance from the National Institute for Health and Care Excellence (NICE) and had access to regular clinical updates. We observed care during our visit that was consistent with current best practice guidance.

Specific dietary requirements were facilitated, and individualised support was given. Hydration and nutrition needs were assessed and monitored in line with national guidance and consistently documented in patients’ care records.

Staff were encouraged to explore new, research-backed approaches to improve outcomes. Staff took part in clinical audits, benchmarking, and quality improvement projects. For example, the dementia quality of life outcome tool (DEMQOL). DEMQOL was a self-reported measure related to health-related quality-of-life in patients with dementia. DEMQOL takes cognition, negative emotion, positive emotion, social relationships, and loneliness into consideration.

People experienced coordinated care across teams and services. The service promoted a multidisciplinary team approach, including doctors, nurses, psychologists, speech and language therapists (SALT), occupational therapists (OTs), occupational therapy technicians (OTTs), occupational therapy assistants (OTAs), health care assistants (HCAs) and external partners, for example, the dementia rapid response team (DRRT) and community-based mental health teams. Relevant professionals were invited to care and treatment reviews, which ensured continuity for patients, their families and carers.

Staff prided themselves on having strong collaborative working relationships within their teams, the wider organisation and with external partners. They held regular multidisciplinary team meetings where care and treatment plans were reviewed and updated. Handovers were effective, and took place before the start of every shift, with information shared consistently throughout the teams. Staff also reported good communication with other external services, for example, community residential care homes. We observed handovers which were well-structured, informative and effective. There were effective processes in place that ensured care was well coordinated when patients moved between services. Discharge planning began on admission and always considered the individual needs and circumstances of the patient. The discharge coordinator had oversight and worked collaboratively with other services to ensure as smooth a transition as possible for the patient, and their families between services. Clinical tasks were delegated appropriately and referrals made, so that safe and effective care and treatment was maintained by sharing accurate and up to date information in a timely way.

Staff empowered and supported patients to manage their health and wellbeing and encouraged them to make healthier choices and to retain as much independence as possible. Health-promoting activities were encouraged, for example, healthy eating advice. Physical activity was also promoted, for example, Tai Chi, walking groups, and gardening. Chair based activity, and exercises were promoted for patients with reduced mobility. The service also promoted cognitive stimulation activities, for example, orientation learning, and memory games. Healthy meal options were available, with staff encouraging and supporting people to make nutritious choices.

Health assessments were carried out regularly, and staff referred patients to specialist services, for example, Speech and Language Therapy (SALT), and occupational therapy (OT) to meet their individual needs. The service focused on identifying potential health risks early, ensuring timely interventions to maintain wellbeing and to prevent deterioration.

Staff routinely monitored people’s care to achieve positive and consistent outcomes. They used recognised rating scales, for example, Malnutrition Universal Screening Tool (MUST), and physical health screenings to assess severity and track progress, for example, Waterlow score for monitoring skin integrity and pressure areas. This helped to align care with clinical expectations and meet the individual needs of people using the service.

The service had effective systems in place to ensure that care and treatment outcomes were consistent and positive. The service promoted, and its staff actively participated in monitoring and improving care, using technology where appropriate. Regular reviews of care plans ensured they remained effective, and aligned with people’s changing needs, and external benchmarking schemes and clinical audits were used to maintain and improve treatment pathways. The service engaged in and promoted continuous quality improvement initiatives and projects (QI), working collaboratively with other services. For example, Bone health QI Project undertaken by ward Doctors and the physiotherapy team. The project shared education and information regarding bone health, and what factors contributed to bone density and deterioration, designed to identify those at most risk and improve the overall management of osteopenia/osteoporosis. The project provided information which was used in conjunction with the Inpatient Falls Prevention and Management Policy, and fracture risk assessment.

The service ensured that patients were supported to make their own decisions about their care, treatment and support wherever possible. For patients with reduced mental capacity, staff assessed and recorded their capacity on a decision-specific basis, with particular emphasis placed on significant decisions in order to safeguard the patient. The process adhered to the Mental Capacity Act 2005 (MCA), ensuring that individuals were supported in making decisions for themselves wherever possible. When patients were unable to make decisions, best interest meetings were held, and where appropriate family members and people who knew the person well were involved in any of the decisions made on their behalf, and in line with the MCA guidelines. Patient’s wishes, feelings, cultural and social background, and history were always considered when any decisions were made.

For patients who were detained under the Mental Health Act 1983 (amended 2007), staff also adhered to the legal requirements, and framework of the act. The rights of individuals were respected and ensured they were informed of their rights; this included their right to appeal. For example, staff read patients their Section 132 rights on admission and then monthly or when their mental health act status, Responsible Clinician (RC) or treatment plans changed. Staff consistently recorded reading of Section 132 rights in the patient care records. Consent to treatment regarding medicines, T2 and T3 forms were evident for the patients that required them. No concerns were identified with the records we reviewed.