Derbyshire Community Health Services 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 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.

When incidents such as falls or episodes of aggression occurred, staff responded promptly, reported them accurately, and updated care plans and risk assessments appropriately. Following any incidents patients and staff had debrief meetings, and depending on the incident type, staff had reflective practice sessions with the Psychology team. Staff demonstrated a strong understanding of the duty of candour. When things went wrong, they spoke openly and honestly with patients and families, offered clear explanations, and apologised whenever required.

Managers and clinical leads provided staff with regular feedback following investigations. Teams discussed learning during patient safety meetings, handovers and team meetings to identify areas for improvement. Staff used feedback—both positive and negative—as learning opportunities to improve care delivery.

Patients felt reassured and well-supported during the referral and admission process, which helped reduce anxiety during transitions. They had information about what to expect from their care and treatment available to them in a variety of formats.

Staff and leaders explained that the service had robust systems in place to ensure safe admissions and discharge planning. They reviewed referral documents carefully, including clinical history, risk assessments, and care plans. Staff said this process helped ensure they could safely meet each patient’s needs. Leaders highlighted the importance of early planning and communication across teams. Discharge planning involved coordination between services to ensure safe and supported transitions, and ongoing care. Where delays occurred, they were clearly justified and reflected the need to secure appropriate care and support that would meet the needs of the patient. Staff made every effort to avoid unnecessary delays and remained focused on achieving timely discharges wherever possible.

The service had admission meetings and handovers to prepare staff for each new patient, ensuring a smooth and safe transition into care. The service followed a structured process where staff completed a checklist when a patient was admitted, this was reviewed at 72 hours, and any follow up information used to support safe and timely care planning, and assessment of risk.

Patients consistently felt safe and were empowered to raise concerns, knowing staff would respond appropriately. if they felt unsafe or had any concerns about others.

Staff demonstrated a thorough understanding of safeguarding, confidently identifying and responding to concerns to protect patients from harm. They took appropriate and timely action to protect patients from abuse, neglect, or discrimination and worked collaboratively with external agencies when required. Staff discussed safeguarding incidents in safeguarding meetings, multidisciplinary team meetings (MDT), and staff meetings. Staff also understood and applied the Deprivation of Liberty Safeguards (DoLS) appropriately, ensuring they were only used in the patient’s best interests. Staff explained patients’ rights, including their rights under the Mental Health Act 1983 (amended 2007), Mental Capacity Act 2005 and the Equality Act 2010. Leaders ensured staff had the knowledge, support and confidence to act appropriately and without delay to safeguard the patients they cared for.

The service had effective safeguarding systems, policies and practices in place that upheld patients' human rights and promoted a culture of safety. We reviewed the safeguarding incidents log for the period of time March 2025 to May 2025 and found that concerns were thoroughly investigated, escalated without delay, and outcomes and learning shared.

We reviewed 5 risk management plans, staff understood patients’ individual risks which ensured that they intervened promptly to support patients if their risks increased, and to minimise any distress.

Risk assessments were person-centred and reviewed in line with trust policy. The service took a balanced, proportionate approach to risk, adjusting wellbeing checks and observation levels based on patients' needs. The patient records we reviewed showed that observations were being completed as prescribed.

Staff were proactive, and managed patients' physical and emotional needs positively, protecting their rights and preserving their dignity. A calm informed approach was taken by staff when addressing any incidents of distress which mitigated further risks.

Staff involved patients and, where appropriate, their families and carers in risk assessments, participation was evidenced in multidisciplinary team meeting reviews in the records we reviewed. Staff supported patients to understand their risks and how to manage them by adapting communication methods for those with potential language barriers or other complexities.

Patients and staff felt the environment was safe. The service maintained well-equipped environments that were conducive to the physical, and mental wellbeing of the patient and supported the safe delivery of care. Equipment was well-maintained, stored securely, and used appropriately for its intended purpose.

Staff completed regular risk assessments of the environment and used the “How safe is your space” audit tool. This ensured any potential hazards were identified and mitigations put in place to reduce the risks. Ligature risks were assessed, and the appropriate assessments were in place to effectively manage and reduce these risks. The environment had convex mirrors throughout, this supported and safeguarded both patients and staff against the potential risk of blind spots.

Staff carried personal alarms, and patients had access to nurse call systems to ensure they could request assistance when needed.

The clinic room was fully equipped with accessible resuscitation equipment and emergency medicines, which staff checked and audited regularly to ensure they were prepared for any emergency situations.

Equipment, and technology was well-maintained and supported staff to deliver safe and effective care and treatment. The service had effective processes to monitor the safety and upkeep of the premises.

A well-equipped sensory room was available for patient use and therapy delivery.

Leaders and staff considered how environments could keep people safe from psychological harm as well as physical harm, including attention to sexual safety and sensory needs.

Patients felt they were well supported, and staff were always present and available. Patients were offered and supported to have regular one-to-one time with their named nurse and occupational therapist, and occupational therapy technician. This maintained therapeutic relationships and ensured continuity of care.

Staff were present in communal areas at all times. There was adequate medical cover throughout the day and night, with doctors and pharmacists available to respond quickly in emergencies.

Leaders regularly reviewed staffing levels and aligned them to the needs of the patients. We saw evidence of how staff levels were increased when patients’ needs changed. The service adhered to the mental health optimal staffing tool (MHOST), and staffing rotas confirmed the required numbers, and the appropriate skill mix was met on all shifts, with any gaps covered in a timely and efficient way to maintain care provision.

We reviewed vacancies, staff turnover and sickness absence levels in the past 12 months and found no concerns.

Bank staff were only used as a last resort to maintain safe staffing levels, and their use was minimal. When used, bank staff received the appropriate induction, support and training and were familiar with the patient group, and ward environment.

Recruitment processes were robust and ensured that all staff, including bank staff were suitably qualified, experienced, and competent. Disciplinary and capability processes were fair, reviewed regularly, and free from bias related to protected characteristics

Staff felt supported through regular supervision and appraisal. They had completed and were up to date with role specific mandatory training, staff at the service also completed specialist dementia specific training and were accredited by a leading university specialising in dementia care. One staff member told us “The training is really good. We have protected time to complete our training and feel well supported” The training undertaken was appropriate for the patients being supported. Staff demonstrated confidence and competence in care delivery. Opportunities for learning and development were available at all levels. Where gaps in training were identified the service had a clinical educator who formulated and delivered additional training packages. Any poor performance was managed appropriately.

Patients were confident in the infection prevention and control processes in place and felt assured that staff were taking necessary precautions to protect them from the risk of infection. One patient told us “It’s always clean, there are people coming around cleaning throughout the day, and it always smells nice.”

Staff followed infection prevention and control processes and consistently followed handwashing guidance, they used personal protective equipment (PPE) appropriately, and cleaned equipment in line with guidance, and best practice.

We observed that all ward areas were clean and well-maintained. Cleaning records were up to date and showed that areas were cleaned, and audited regularly, ensuring the environment was hygienic and safe. Staff were observed following appropriate handwashing and infection control procedures and had a good understanding of their roles in maintaining the cleanliness of the environment. Hand sanitizing stations were situated throughout the ward to protect and mitigate the risk of infection.

The service had clear processes in place for assessing and managing infection risks. The infection prevention and control procedures aligned with current national guidance. Cleaning and infection prevention and control audits were completed regularly, with all concerns addressed promptly. Information about infection risks was shared appropriately with staff, patients, visitors to the service and external partners. There were clear roles and responsibilities for infection prevention and control, and staff received ongoing training in line with best practice guidance.

Staff supported patients to be involved in decisions about their medicines. For those who had capacity, staff ensured they understood what their medicines were for and involved them in any discussions regarding changes to their treatment. Where a patients had reduced capacity, and were unable to fully understand or participate, due to dementia or other cognitive impairment, staff followed best-interest decision-making processes in line with the Mental Capacity Act 2005 and the Mental Health Act 1983 (amended 2007). Care plans reflected each person's cognitive abilities and level of understanding and documented the level of involvement they had in making decisions about their medicines and treatment.

Staff followed safe and effective practices in all areas of medicines management, including storage, dispensing, administration, reconciliation, recording, and disposal. The service adhered to national guidance and best practice, and demonstrated how they involved patients, and their families or carers in discussions and decisions about their care and treatment where possible. If covert medication was necessary, the trusts covert medicines policy was adhered to, and the appropriate legal processes followed, including capacity assessments, best-interest meetings, and regular reviews. Staff reviewed the effects of medicines on patients’ physical health, particularly in those prescribed a high dose of antipsychotic medication, in line with NICE guidance.

We observed staff administering medicines safely, explaining their use clearly, and supporting patients with kindness, compassion, dignity and respect. Medicines were stored securely, including controlled drugs, which were managed under the required legal frameworks. Fridge and room temperatures were checked daily, and all medications were within date. Expired or unused medicines were disposed of safely. Staff ensured that medicines were used appropriately and were not used purely to control behaviour.

The service had robust and effective systems in place for the management of medicines and adhered to current best practice, prescribing followed national guidance. Where medicines errors were identified, they were addressed and the appropriate actions taken to mitigate the risk of harm, or reoccurrence. Continuity of care was maintained during transitions between care settings through effective medicines reconciliation and clear documentation. Controlled drugs were managed safely and audited regularly, and any outcomes from audits were acted on, ensuring a learning culture through incident reporting and review. Staff had received training and competency assessments to support the safe, effective, and appropriate use of medicines.