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

We looked for evidence that staff involved patients in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.
At our last assessment, we rated this key question as good. At this assessment, the rating has remained good.
 

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff assessed and reviewed patients’ health, care, wellbeing, and communication needs with them, but care plans did not always reflect these assessments in a clear and consistent way.
Care plans did not always provide sufficient guidance for staff, and important information was sometimes fragmented across the system and generic templates. This made it more difficult for staff to locate essential details quickly, increasing the risk of inconsistent or unsafe care. For example, one patient was prescribed a specialist diet in line with a speech and language therapy (SALT) recommendation, but the food served did not match this guidance, placing the person at increased risk of choking. Discussions with staff confirmed that a more detailed and specific care plan was needed to ensure staff had clear instructions about what the person could safely eat.
Other areas where care plans lacked sufficient detail included catheter care, mobility, and skin integrity. For instance, catheter care plans did not consistently record when to change the bag or catheter, or the patient’s personal preferences. Mobility plans often relied on generic templates rather than specifying the individual support required, and skin care assessments were not always clearly linked to care actions, such as pressure area prevention. These gaps meant that staff sometimes had to piece together information from multiple sources, increasing the risk of inconsistent or unsafe care. Strengthening the clarity, organisation, and detail of care plans would support staff to deliver safe, personalised, and consistent care.
People’s communication needs were not always clearly recorded in care plans, which could limit staff’s ability to provide fully personalised support. While assessments captured relevant information about health, care, wellbeing, and communication, fragmented documentation reduced the accessibility of key information and could compromise safe care delivery.
Despite these concerns, feedback from patients and their relatives was largely positive. Patients felt involved in assessments of their needs and were confident that staff understood their individual and cultural requirements. Staff generally understood people’s current needs, and assessments considered health, care, wellbeing, and communication requirements. Carers’ needs were also recognised and addressed, supporting their ability to provide safe care.
Occupational therapists played a key role in promoting independence through functional assessments and goal setting. Health care assistants led many activities and provided one-to-one support for patients who were isolated or confused, adapting approaches to individual needs.
On Fenton Ward, staff went the “extra mile” to support people’s dignity and self-esteem, particularly for those without family support. This included supporting access to appropriate clothing, personal care, and grooming products. Where gaps in psychological support were identified, such as for patients following amputations, staff proactively sought support from external charities to provide additional guidance and resources.
 

Staff planned and delivered people’s care and treatment with them, including what was important to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with national legislation, evidence-based guidance, and required standards. Clinical records reviewed demonstrated that care was provided in line with current guidance, including National Institute for Health and Care Excellence (NICE) guidance and internal clinical policies and procedures.

Patients were informed about relevant good practice relating to their care and were involved in how this was reflected in their care plans. People’s nutrition and hydration needs were met in line with current guidance, and care planning reflected individual requirements and risks.

Staff worked well across teams and services to support people. They ensured patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services.
Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. Information was shared effectively between teams and services to support continuity of care, including where clinical tasks were delegated.
Staff worked closely with a range of internal and external services to meet people’s individual needs and reduce unnecessary admissions to acute hospitals. This included regular liaison with community teams, district nurses, GP care coordinators, and the team-up service to support patients at home and ensure continuity of care following discharge. Staff also worked collaboratively with adult social care teams to support timely assessments and care planning.
People’s care was coordinated through effective multidisciplinary working. This included involvement from services such as speech and language therapy, podiatry, continence services, and local hospices, ensuring specialist input was available when required. Referrals, transitions, and discharge planning considered people’s individual circumstances, ongoing care arrangements, and expected outcomes.
Leaders promoted collaborative working through regular meetings, shared training, and structured away days, which supported effective communication, team cohesion, and inclusive working for permanent, bank, and student staff.

Staff supported patients to manage their health and wellbeing to maximise their independence, choice, and control. In addition, they supported patients to live healthier lives and where possible, reduce their future needs for care and support.

Staff focused on identifying and responding to risks to people’s health, including those receiving end-of-life care and patients at risk of developing long-term conditions. Staff supported national priorities and health promotion initiatives, including smoking cessation, reducing caffeine intake, addressing obesity, and wellbeing campaigns such as dry January. For example, staff supported a bariatric patient to achieve weight loss to improve mobility and independence, enabling safer use of equipment at home.
Staff promoted healthier lifestyle choices through ongoing conversations and practical support. Staff encouraged reduced caffeine intake, which had led to improved sleep patterns for some people. Smoking cessation advice was offered, and national health campaigns were used to support engagement where appropriate.
Staff took a holistic approach to wellbeing, recognising the impact of people’s physical, mental, and social circumstances on health outcomes. For example, staff worked closely with adult social care to support a person whose home environment had deteriorated due to hoarding behaviours. The person received emotional support alongside practical interventions, enabling a safe discharge home and improved wellbeing.
 

Staff routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of patients themselves.
The records we reviewed evidenced patients using the service consistently experienced positive outcomes in line with legislation, national standards, and evidence-based clinical guidance. On Oker Ward, this was reflected in a Gold-level quality improvement accreditation, demonstrating a sustained focus on improving care delivery and outcomes.
Staff had effective systems to monitor people’s care, treatment, and outcomes. This included the use of audits, incident reporting systems, falls monitoring, and quality improvement projects. For example, staff were involved in a project to improve the timely administration of critical medications, and the end-of-life care group completed regular ReSPECT audits, with findings shared to support learning and improvement.
Leaders and teams actively identified areas for improvement and took action to enhance care. A significant quality improvement project focused on continence care aimed to reduce reliance on commodes and disposable pads, promoting dignity, skin integrity, mobility, and wellbeing. This also contributed to a reduction in single-use plastics. Hydration was monitored and supported through initiatives such as the introduction of hydration jelly drops for patients with low fluid intake.
Staff regularly reviewed care planning and documentation to ensure accuracy and consistency. Where discrepancies were identified between MDT handovers, mobility plans, and bedside information boards, managers implemented additional checks and huddle discussions to improve consistency and reduce risk. Improvement actions were monitored and reviewed.
Staff worked closely with therapy teams, adult social care, community services, and carers to monitor outcomes and support safe discharge planning. This helped reduce unnecessary acute admissions and ensured patients were discharged to appropriate settings that met their needs. The service also contributed to wider system improvement work through involvement in integrated care initiatives.
 

Staff respected people’s rights around consent, involved patients or those lawfully acting on their behalf in planning and reviewing care, and ensured consent was obtained and recorded before care and treatment were delivered. Staff told patients about their rights around consent and respected these when delivering person-centred care and treatment.
Staff understood and applied legislation relating to consent and the Mental Capacity Act (MCA) 2005. Staff consistently sought, obtained, and recorded consent before delivering care or treatment. One staff member said, “We always try to get consent from the patient, if they don't have capacity, we do the appropriate assessments to protect them and their interests.”

Clinical records clearly documented people’s capacity, consent decisions, and how staff supported patients to make informed choices. Staff took people’s views and wishes into account when planning care and supported everyday decision-making, such as choices about clothing, food, and fluids.
Staff ensured patients understood their care and treatment by explaining information in ways patients could understand and by giving them appropriate time and support to make informed decisions. When staff had reason to believe a person might lack capacity, they completed decision-specific MCA assessments focused on care and interventions on the ward. Staff carried out assessments when patients were most alert and, where possible, after allowing at least 24 hours to maximise people’s ability to participate.
When patients lacked capacity, staff followed best-interest decision-making processes and consulted families, carers, and other relevant professionals. Staff completed Deprivation of Liberty Safeguards (DoLS) applications when required and referred decisions outside the ward’s remit to adult social care for further assessment.
Staff made Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in line with legislation and national guidance. Records showed that these decisions reflected people’s wishes, circumstances, and best-interest discussions where appropriate.