Derbyshire Community Health Services NHS Foundation Trust

On this page

• 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, fair culture. 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.

The service demonstrated a clear shared vision and culture based on openness, honesty, equality, diversity, and inclusion. Staff aligned with and applied the trust’s values in their daily working roles. Leaders effectively communicated the vision to all staff, this ensured alignment with the service’s aims and ambitions.

Staff had opportunities to contribute to discussions regarding the service’s strategy, especially through changes and transformation, this made them feel valued. Staff told us how their roles and practice helped to maintain the delivery of high-quality care and treatment.

Leaders actively addressed workforce inequalities and fostered a culture of inclusion, resulting in more equitable and person-centred care for all patients. They showed a strong understanding of, and consistently promoted equality, diversity, and human rights.

The provider’s strategy focused on delivering safe, effective, and compassionate high-quality care while promoting equality, partnership working, and putting people at the centre of everything they did. All staff received regular, and clear communication promoting shared goals and the direction of the organisation. This ensured they felt included and valued, which fostered a positive culture.

Leaders had the experience, knowledge, and skills to perform their roles effectively. They had defined roles and accountability which ensured each leader understood their responsibilities and were aware of any issues and service priorities.

Leaders demonstrated a deep understanding of the services they managed and explained how they supported their teams to deliver high-quality and effective care. They were visible, available, and approachable to patients, their families and staff modelling inclusivity which embodied the organisation’s values.

Career development opportunities were available for all staff, with multiple examples of staff progression from lower NHS bands to higher levels. Leaders valued their staff and proactively challenged and addressed any cultural issues that could impact care or have a detrimental impact on the wellbeing of staff.

A Freedom to Speak Up policy and procedure was in place. Staff had access to the Freedom to Speak Up Guardian and service. They told us they were supported to raise concerns and felt safe to speak up when needed.

Leaders promoted an open culture where concerns were listened to, fully investigated, and acted on. Staff received training on whistleblowing and were confident to raise concerns.

Freedom to Speak Up concerns were monitored and audited, if any common themes were identified, action plans were formulated and put in place to address any issues found. Staff felt confident that concerns were taken seriously and led to positive change.

No Freedom to Speak Up concerns had been raised in the 3 months prior to our on-site assessment.

There was a strong and visible commitment to equality, diversity, and inclusion (EDI) across the organisation. The organisations values were central to how care was delivered and how staff were supported. Leaders took regular action to improve the culture, making sure all staff were treated fairly, with kindness, dignity, and respect. They identified and addressed any unfair treatment or differences in experience, particularly for staff with protected characteristics or from marginalised groups. Reasonable adjustments and flexible working arrangements were made wherever possible to support individual needs.

The organisation participated in a successful sponsorship programme for overseas staff. Overseas staff were supported professionally, and personally by the clinical educator, who ensured they completed all role-relevant training and were competent in their roles. They were recognised as valued team members who contributed positively to the workforce.

Employment procedures ensured prompt, fair and equal treatment of all applicants in accordance with Equality Act 2010, and the trust’s Equality, Diversity and Inclusion Policy. The organisation actively promoted LGBTQ+ employment opportunities, and had a trans-equality policy in place to ensure the workforce was diverse and reflective of the people using the service. Staff told us they felt heard, valued, and confident that raising issues would lead to real change.

Leaders promoted a culture of inclusion and took steps to prevent and address bullying and harassment. They also worked to make sure that all staff, including those who may be less heard, were involved in shaping services. Equality, diversity, and inclusion were clearly embedded in the organisation’s values, policies and strategic priorities.

The service had clear governance and management processes that worked well and supported safe, high-quality, and sustainable care. Staff understood their roles and responsibilities and were held accountable by leaders where appropriate.

Team meetings consistently covered key topics such as incidents, complaints, safeguarding, patient admissions, and discharges. Staff learned from audits and reviews and acted on any recommendations given, this demonstrated a culture of ongoing learning, improvement, and service development.

Staff collaborated and communicated well with internal and external colleagues to meet the needs of the patients they cared for. The services risk register was current, accessible, and regularly reviewed with staff escalating concerns promptly, and appropriately. Emergency response plans were in place, for example, in the event of infection outbreaks or other service disruptions.

IT systems were reliable and supported staff to complete their clinical work, while information governance processes ensured that patient information was managed securely and confidentially.

Managers accessed timely and accurate performance data, which maintained effective oversight. Leaders submitted required notifications promptly to external bodies, for example, CQC in accordance with their legal responsibilities.

Leaders implemented recognised quality frameworks and supported innovation through informed and proportionate risk management practises. This ensured that governance structures remained resilient, flexible, and sustainable.

Staff and leaders were consistently open, transparent, and proactively engaged with external stakeholders, and partners in care. They worked collaboratively with commissioners, and other relevant organisations to support and maintain service delivery and integrated care.

Leaders shared learning across local, and national networks and used partnerships to support, and drive continuous improvement. Leaders valued feedback from partners and communities and used this information to shape services and identify innovative ideas, and practice to improve outcomes for people.

The organisation promoted a culture of continuous learning and improvement. Staff and leaders understood how to drive change and consistently applied quality improvement methods and projects to enhance care. For example, Derbyshire had a higher than national average diagnosis rate of younger people living with dementia, the trust responded to this and developed young onset dementia projects across Derbyshire and Derby City to enhance the care and support available. The trust had also increased the capacity of its dementia support services, which enabled them to respond to 40% more referrals. This ensured that much needed care and support was available to more people in need.

The organisation learned from patients and their families which led to meaningful service changes. For example, families communicated that discharge planning wasn’t clear or robust enough. In response the trust created and funded a discharge co-ordinator who supported patients and families approaching discharge. Support and guidance in identifying onward placements was also provided.

The service participated in relevant national audits and clinical benchmarking schemes. For example, the Dementia Quality of Life tool, (DEMQOL) is a recognised and evidence-based outcome measure developed for individuals with a diagnosis of dementia. The service also supported staff to engage in research and embedded evidence-based practice into care delivery.

Strong external links supported innovation. Leaders maintained open and clear communication with staff and promoted a culture of trust where ideas for change were encouraged, welcomed and acted upon.