Derbyshire Healthcare 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 and leaders could not only describe the vision and strategy for this service but had been involved in the plans for opening the new wards and the refurbishment of the female wards at the Radbourne unit. They lived the shared direction of the service. Feedback provided from the ICB evidenced that the trust’s strategic plan was aligned to the national framework and three year plan. This was filtered down into each service and they all had a role to achieve the set goals.

Since the last assessment senior leaders were more visible on the units to speak with staff and provide positive feedback about the work the staff had completed to make the required changes in practice to keep patients safe. There was a rota of senior leaders who regularly visit the wards within the service. Staff felt that all leaders were skilled and knowledgeable. They were supportive and would listen to our feedback and lead the team to make positive changes to improve the outcomes for patients. For example, the trust had developed and implement a robust and effective process in place to ensure that risk management plans were in place and completed fully which assured the Commission they had mitigated the concerns we found at the last assessment. Leaders completed a daily report to provide assurance that risk management plans were in place. A weekly audit of 3 patient case records was carried out. The purpose of the audit was to ensure that the content and the triangulation of the risk reflected individual needs with the patients care plan. In November 2024 the outcome of the audit was 89% compliance. If the audit highlighted actions that needed to be taken, then staff had 48 hours to make the changes and case notes were re audited. Additionally, the trust had developed a quality dashboard for inpatients wards to monitor the quality and safety of the risk management plans.

A freedom to speak up policy and procedure was in place. Staff had access to a freedom to speak up guardian who supported staff to speak up. Staff felt that they were able to speak up, if they were required to do so and knew that their concerns would be acted on. In addition, staff were trained in whistleblowing so were aware of what they needed to do and where to access support. Data from the trust evidenced that from 01 April to 30 November 2024 26 concerns had been raised with the freedom to speak up guardian. 35 of those speaking up were from BAME communities. A process for monitoring and learning from Freedom to Speak Up concerns was in place. Themes, profession and ward/departments areas were identified, with escalation routes and action plans in place to address the concerns.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At the last assessment, governance processes were in place but not effective in identifying risks. With the support and oversight from senior leaders and the ICB processes had improved and the service is no longer in breach of Regulation 17. The management of ligature risks within the service had improved. Up to date ligature risk assessments with heat maps were in place. Blind spots had been mitigated. Systems were in place to monitor the convex mirrors for discolouration which would impede visibility. The service had a risk register in place which was monitored by leaders. These were closely monitored by the Divisional Performance Review (DPR) Meeting to monitor and mitigate. Leaders had addressed the concerns regarding the AWOL figures at the Radbourne Unit as part of a quality improvement project. . This had been completed in line with the Mental Health Act Code of Practice guidance and standards, which included regular reviews within the services governance structure. Leaders reviewed compliance with nursing and zonal observations. This identified that the digital recording of observations had been problematic. This information was recorded and shared in the restrictive practice group and was fed into the Mental Health Act Committee. Due to this process the trust was aware of the digital recording issues and took action to address it. Bed occupancy was monitored to ensure that it was reducing to meet the national benchmark of 90.2%. As of September 2024, acute inpatient beds reported a 97% occupancy rate. This was an improvement from March and April 2024 when the occupancy rated was above 100%. Leaders monitored complaints and made sure that any lesson learnt were shared with staff to enhance their clinical practice. From 01 April 2024 there had been a total of 56 complaints. All of which had been or were being investigated and the outcomes shared with patients. This was an improvement since the last assessment.

It was evident in patients case records that staff worked with external agencies and community mental health teams to ensure that patients care provision was appropriate to their needs during their admission and when planning their discharges. For example, liaising with external social workers. Patients confirmed that this happened especially when planning their discharge.

Since the last assessment it was evident that the service had learnt from the urgent action the commission took as we believed a person would or may have been exposed to risk of harm if we did not do so. They shared learning across the whole service and been proactive in making change to improve the experience and care for patients. Senior leaders reached out to other trusts to learn from them and to implement this into practice. Staff felt that the service had improved since the last inspection. This was clear in not only the evidence that we collated thought the assessment but the feedback from patients and staff but the culture within the service.