All inspections: Derbyshire Healthcare NHS Foundation Trust

Date of Assessment: 16 to 17 December 2024. This was a scheduled assessment to review the trust compliance with the urgent enforcement action we took in April 2024.

Derbyshire Healthcare NHS Foundation Trust provide acute wards for working age adults for people in Derbyshire at the Hartington Unit and Radbourne Unit. This service was last inspected in March 2024 and was required to take urgent action to as the Commission believed a person will or may be exposed to the risk of harm if we did not do so. We imposed the following condition on the trust’s registration at the Radbourne Unit:

• The Registered Provider must not admit any new service users to Radbourne Unit, Ward 33 and 35 without the written permission of the Care Quality Commission.

• The Registered Provider must immediately reduce risks within the physical environment.

• The Registered Provider must devise and implement an effective system to

• ensure that all service user risk management plans are in place, accurate effective, reviewed as appropriate and updated regularly.

• The Registered Provider must provide a report to CQC on 19 May 2023 by

• 10am and on the Friday of each week thereafter by 10am setting out the steps and progress undertaken to implement the actions as detailed in the above conditions.

The service had made significant improvements and is no longer in breach of regulations. The risk or potential risk to people is no longer a concern. We have rated the service as good and removed the conditions on the providers registration. Staff now assessed and mitigated risk within the ward environment and individual patients had accurate and effective risk management plans in place. Patients felt safe, supported and involved in their care and outcomes for patients had improved. Governance process had been redeveloped, effective in identifying risks and audits were completed to make positive changes in practice and learn lessons from incidents and address feedback from stakeholders.

Date of the assessment 9 April 2024 to 23 May 2024.

This inspection was a focussed, unannounced inspection of acute wards for adults of working age provided by Derbyshire Healthcare Foundation NHS Trust. The inspection was focussed to specific areas of the 5 key questions and specifically on Ward 35 at the Radbourne unit.

At our last inspection we rated the acute wards for adults of working age and psychiatric intensive care units as requires improvement.

We carried out this unannounced focused inspection because we had concerns about the quality of services following a routine visit by a Mental Health Act reviewer and to look at those parts of the service that did not meet legal requirements following our last inspection in 2019.

As this was a focussed inspection for Ward 35 at the Radbourne unit, we have not rated the service and the previous rating of requires improvement remains in place. Ward 35 is a 20 bedded female acute and admission ward.

We previously inspected the trust’s acute wards for adults of working age and psychiatric intensive care units (PICUs) at the Radbourne Unit in November 2019. The November 2019 inspection was a routine inspection. The main areas of improvement identified during the inspection in November 2019 were around blanket restrictions, staff training and governance processes.

The concerns raised by the Mental Health Act reviewer were around patients not knowing their rights under the Act, incidents not being reported and followed up appropriately, patients not being able to store personal possessions securely, patient risks not being assessed and care planning not being in place for patients.

The purpose of this inspection was to look into these concerns and to see if the trust had met the requirements of the previous inspection on Ward 35.

Due to the seriousness of the concerns following our site visit, in September 2023 we used our powers under Section 31 of the Health and Social Care Act, to request assurances from the trust to ensure the ward was safe, patients received the right care and treatment and appropriate measures were in place to monitor these changes. The trust responded immediately and put appropriate measures in place with a detailed action plan.

We raised a number of immediate concerns with the trust and they took immediate actions to make improvements on the ward including immediate improvement with the ward environment, restrictive practices, informing patients of their rights and improving and updating care plans and risk assessments.

We found:

The trust still had dormitories but had a dormitory eradication programme was in place for all the trust’s sites and it is planned this work will be completed for Ward 35 in March 2026.
Managers did not ensure patients and staff received appropriate support after being involved in or witnessing serious incidents.
Staff did not always have a thorough handover that included incidents and support required by patients after incidents.
The clinic room was not cleaned regularly, and medication audits were not robust and did not assess, monitor and improve medication management. Staff were not aware of the illicit drug policy and the correct recording processes around this.
The ward ligature risk assessment was not robust and did not give clear guidance on mitigating measures in place for all ligature anchor points.
Staff sickness levels were high and increasing on the ward and appropriate systems and support was not in place to reduce this.
The ward had a high usage of bank and agency workers that were not trained in the trusts restrictive intervention programme and therefore were unable to support the ward if restrictive interventions were required.
Staff were not supported through regular managerial supervisions.
The service did not operate effective systems and processes to ensure that managers monitor assessed and improved quality of services.

However:

Staff mandatory training compliance rates had improved since our last inspection.

How we carried out the inspection

During our inspection on 19 and 20 September 2023, we visited Ward 35, an acute ward for adults of working age at The Radbourne Unit.

During the inspection we:

observed how staff cared for patients.
spoke with 5 patients who were using the services.
spoke with 10 staff including a ward manager, nurses, nursing assistants, clinical leads and an advanced clinical practitioner.
looked at the quality of the ward environment.
reviewed 4 patient records.
reviewed 9 incident records.
reviewed a range of policies, procedures and other documents relating to the running of the services.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

During the inspection we spoke with 5 patients and 2 family members. All 5 patients and both family members we spoke to told us staff were generally kind, but they were always rushed, and the ward felt understaffed. In addition, they also told us they were not aware they could have access to their care plans and had not been involved in their developing these.

One patient told us the occupational therapists were really good and there were activities available every day.

Two informal patients told us they both had only been informed of their rights 2 days ago. One patient detained under the Mental Health Act told us staff had tried to explain their rights to them, but this was not done clearly so they did not really understand their rights.

Three out of the 5 patients we spoke to told us they had belongings that had been stolen and 1 felt as nothing was labelled, they ended up using other people’s items.

The acute wards for adults of working age are based on two sites: the Hartington Unit is located on the Royal Chesterfield Hospital site and the Radbourne Unit is located on the Royal Derby Hospital site. We only inspected the Hartington Unit at this inspection. There are three wards there:
Pleasley Ward- 20 beds mixed gender – there are 12 beds for older adults.
Tansley Ward- 22 beds mixed gender (reduced to 19 during COVID-19 pandemic)
Morton Ward – 22 beds mixed gender (reduced to 21 during COVID-19 pandemic)
The provider is registered to provide at the Hartington Unit the Regulated Activities of:
Treatment of disease, disorder or injury;
Assessment or medical treatment for persons detained under the Mental Health Act 1983;
Diagnostic and screening procedures
At our previous inspection in November 2019 we rated the core service of acute wards for adults of working age as requires improvement overall; requires improvement for Safe and Well led and Good for effective, caring and responsive.

Staff in one team did not feel respected, valued and well supported by leaders. They did not feel able to raise concerns without fear of retribution and did not always receive managerial supervision, debriefs or support. Morale in the team was low and there were high rates of staff sickness.
The service had a large number of mandatory training courses which did not meet the compliance target of 75%.
The service did not have a clear protocol for the use of alarms in community bases.
The service included patients who were not ready to receive treatment on their waiting lists. This meant it was not clear how long most patients waited to receive the service.
Managers did not always complete actions in response to incidents in a timely manner.

However:

The service provided safe care. The number of patients on staff caseloads was not too high to prevent staff from giving each patient the time they needed. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed detailed care plans informed by a comprehensive assessment and in collaboration with patients and carers. They provided a range of treatments that were informed by best practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Most teams received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care received information on when they could expect to receive it. The criteria for referral to the service did not exclude patients who would have benefitted from care.

Our rating of this service improved. We rated it as outstanding because:

The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

When we reviewed the cleaning audit for the physiotherapy team, we found it difficult to assess whether the cleaning had been completed or whether the premises had not been used.
Staff were unable to give examples of feedback including lessons learnt from incidents external to the service.
The service had a text messaging service that children and young people could access for advice. This was manned between working hours and staff were unsure of the protocol should a young person contact it in crisis out of hours
The service did not have standard agendas for team meetings and as such could not evidence where information such as learning from incidents and complaints had occurred.

There have been significant improvements in the ethos, culture and services in the trust since the last inspection. Staff told us the trust was more clinically led and they were more empowered.

Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff. Leaders had embedded methods of communication and engagement with staff since the last inspection.

All staff we spoke with felt positive and proud about working for the trust. Throughout the inspection staff described how teams worked well together. Staff told us the trust had come a long way to improve culture and that they were listened to and given space to make changes.

Staff knew and understood the trust vision and values and how they were applied in the work of their team.

There was a good relationship between the trust board and council of governors. The council of governors held the non-executives to account.

Governance processes operated effectively at trust and operational, performance and risk were managed well.

Staff collected and analysed data about outcomes and performance and engaged actively in local and national quality improvement activities.

There was good systemic leadership within the local Sustainable Transformation Partnership, with board and service leaders engaged actively with other local health and social care providers to ensure that an integrated health and care system was commissioned and provided to meet the needs of the local population.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well. When things went wrong, staff apologised and gave patients and their families honest information and suitable support.

Staff provided a range of care and treatment interventions suitable for patient groups and consistent with national guidance on best practice. Staff ensured that patients had good access to physical healthcare and supported patients to live healthier lives. We saw significant change in the acute admission wards.

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.

Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. There was good engagement with patients and carers in the transformational plans for clinical services.

Service were easy to access. Referral criteria did not exclude patients who would have benefitted from care. Where waiting times were still a concern, people could access the service when they needed it and received the right care in a timely way. Staff followed up patients who missed appointments. Discharge was rarely delayed for other than clinical reasons.

Staff well being was a priority in the trust. Staff recognition for good work schemes were in place.

The trust was implementing a quality improvement approach, participated in audits, research and development. Lessons learnt from incidents, deaths, audits, service transformation were shared with staff.

However:

There was a long list of mandatory courses, of which 39 failed to score above 75%. Of concerns were the poor compliance figures for;- safeguarding adults and children level 3, adult basic life support, basic life support, first aid at work, suicide awareness and response, medicines management, dementia awareness, falls prevention.

Ward staff did not always store and dispose of illicit substances in line with policy. There was no accessible up to date British National Formulary for staff on any of the wards.

Health-based places of safety staff did not assess and record the outcome of risk assessments clear and consistently.

Not all teams had adequate leadership to provide staff with managerial supervision, clinical guidance and support with incidents.

Our rating of this service improved. We rated it as good because:

The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood the principles underpinning capacity, competence and consent and managed and recorded decisions relating to these well.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The service was easy to access, and staff and managers managed waiting lists and caseloads well. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly and those who did not require urgent care did not wait too long to receive help.
The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

Our rating of this service improved. We rated it as requires improvement because:

There were still ongoing staffing challenges and a high number of vacancies, but we did see evidence the trust had improved the way they managed these.
Ward staff did not always store and dispose of illicit substances in line with policy. We found staff did not store illicit drugs and paraphernalia in tamper proof bags in medicines cupboards and in one example these had been there for several months. This was not in line with policy.
We saw that there were several blanket restrictions for patients in seclusion. Staff did not follow the Mental Health Act Code of Practice in their seclusion record keeping. Staff did not always attach consent to treatment forms to medicine cards. This meant that staff did not have information indicating what patients' agreed treatments were.
Not all staff were compliant with their mandatory training.
Staff did not always provide appropriate physical healthcare to patients. We saw one record where staff had not followed a patient’s diabetes care plan and had not completed physical health observations and blood glucose tests.
There were still dormitories on the wards. However, the trust had a plan in place to improve and change these into individual rooms for patients. There were blind spots in the seclusion room, which meant it was not possible for staff to see patients all the time.
The trust did not have a psychiatric intensive care unit for patients and there was not one in the local area. This meant some patients had to travel out of area for care and treatment.

However:

The trust had made improvements since our last inspection and these were completed in a timely way. There were improved governance processes including increased meetings, clearer lines of communication, increased audits and visible leadership.
The ward environments were safe and clean. Staff assessed and managed risk well. They managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare. Discharge was rarely delayed other than for clinical reasons.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness. They actively involved patients and families and carers in care decisions.

Our rating of this service improved. We rated it as good because:

Clinical premises where patients were seen were safe and the physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff assessed and managed risk and followed good practice with respect to safeguarding.
Staff working for the mental health crisis teams developed holistic care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The mental health crisis service and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
The service was well led and the governance processes ensured that the service’s procedures ran smoothly.

However:

Within health-based places of safety, staff practices to risk assess and record the outcomes of risk assessments were not clear and staff did not always check emergency equipment to the frequency directed by trust guidance.
Records were not always available to guide staff about what to clean, when to clean it and where to record when cleaning had been completed.
Of the mandatory training courses listed by the trust, 39 failed to achieve the trust’s target completion rate.
Crisis resolution and home treatment staff practices to assess and record the severity of symptoms and outcomes with people was not consistent across all the services.
Records did not demonstrate that staff routinely shared copies of care plans with people using the service.
Staff did not routinely offer people using the service with verbal or written information about raising a concern or making a complaint.
Audit tools did not prompt staff to measure all areas of the service previously identified as requiring improvement.

Our rating of this service stayed the same. We rated it as inadequate because:

Overall, the service had not made enough improvement in the nine months since the last full inspection. There were some issues that the trust had resolved. However, there were ongoing issues and issues where the trust had started to make improvements but needed to improve further. There were lapses of governance on wards and a number of these related to the safety of staff and patients.
Staff did not always manage risks well. This included ligature risks and patients’ access to razors. Patients smoked in and around the hospitals. This presented a fire risk. Observation practices had improved but staff did not always carry these out in line with good practice; staff did not carry out intermittent observations at varied times which could increase risk for patients who self-harmed.
The trust had increased staff numbers since our last inspections, but there were still staffing issues and overall the vacancy rate was 14%. The trust had over recruited unqualified staff as they had a shortage of qualified nursing staff. Having less qualified staff sometimes affected the frequency of patients’ one to one sessions and meant there was not always a qualified nurse out in communal areas of the wards.
Staff did not always create detailed care plans that described all of the patients’ needs and these were not always recovery focused and personalised. We saw that staff did not always record when they had offered patients a care plan. We reviewed 31 records and saw that on seven occasions staff had not recorded that they had offered patients a copy of their plan.
Training compliance for mandatory physical intervention training, life support training and level three safeguarding training was low. This meant that not all staff that should have been were skilled to restrain patients and use life support skills.
There were dormitories on all the wards. However, the trust had discussed dormitory plans with commissioners and there were plans to take a staged approach to this to replace these in time in line with national guidance.
There were blanket restrictions in place across the wards that were not individually risk assessed. These varied throughout the wards but reduced the liberty of patients who did not always present with specific risks that the restrictions were in place to reduce.
Staff did not always ensure the privacy and dignity of patients. We observed staff unlocking doors to patient bathrooms, without knocking when they were in use. The ward environment was not always suitably designed to protect patients’ privacy and dignity.
There were some omissions where staff had not always signed to say patients had received their medication.
The main treatment model of care on the wards was psychiatry, occupational therapy and nursing. The trust had made some improvements to develop access to psychology. However, only a limited number of patients were able to access psychological interventions.
Staff did not always respond to physical health needs or make records where needed. We saw two occasions when staff had not acted when a patient’s blood pressure was outside of the normal range. Staff had failed to complete an insulin care plan and record their observations and reviews of one episode of seclusion.

However:

The trust had started on a journey of improvement. There was evidence of some improvements following our recommendations from earlier inspections.There was improved oversight and assurance by senior managers and increased stability in ward leadership.
Staff had reduced the use of restrictive interventions since our inspection in May 2018. The trust had a programme in place to review and reduce restrictive interventions.
Staff reviewed the effects of medication on patient’s physical health as recommended by the National Institute for Health and Care Excellence. Staff completed blood tests for patients prescribed medication that needed additional monitoring and monitored patients after they had administered rapid tranquilisation.
Ward managers were skilled and experienced. There was increased ward leadership stability throughout the service. Ward managers demonstrated how they supported their teams and staff felt well supported by their immediate managers.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff reported incidents and they shared learning after incidents took place. Staff supported patients to make complaints and responded to them appropriately.
We observed staff were kind and caring in their interactions with patients and patients were happy with the way staff treated them. Doctors discussed treatment options with patients at ward round meetings and staff encouraged patients to engage with advocacy services.
The trust had a low number of delayed discharges. The average over the 12 months prior to our inspection was 1%. The trust had a robust process to monitor and review discharge pathways with the support of professionals both internal and external to the trust to improve outcomes for patients.
Managers and staff involved patients and carers in service developments. The trust had developed a forum for staff, carers and patients to improve coproduction. The trust had a centre for research and development and there was evidence of quality improvement projects in place.

We only looked at parts of the five questions at this inspection that related to the concerns raised.

We did not rate the core service at this inspection as we only inspected the Radbourne Unit and looked at specific issues relating to the concerns we had received.

There were still some shifts where the skill mix of staff was not appropriate and did not meet the minimum staffing level for the ward.
Staff were still unclear of and applied inconsistently the trust’s policy and guidance on contraband and risky items and the smoke – free policy.
Some records showed gaps in the monitoring of patients’ physical health.
Staff did not always respect patients’ privacy and dignity.
The trust did not always ensure repairs were completed in a timely manner.
Managers did not always identify risks to patients and staff and take action to reduce these.

However:

Patients said that staff were kind and caring and we observed this.
Staff had good knowledge of the Mental Capacity Act 2005.

Our rating of the trust stayed the same. We rated it as requires improvement because:

We rated safe, effective, responsive and well-led overall as requires improvement and caring as good.This includes the previous ratings of three services that we did not inspect on this occasion. We rated four of the trust's 10 core services as good and four as requires improvement, one as inadequate and one as outstanding.
Although the trust leadership team had a comprehensive knowledge of current priorities and challenges and acted to address them, the pace of change was slow, which we highlighted in previous inspection. This meant that we did not see enough improvement in clinical services, and a deterioration in the acute admission wards. We found a lack of leadership in some core services such as the acute admission wards and crisis service.
The quality committee did not have robust oversight and assurances of drug and therapeutics and medicines management in the trust. There were no clear measures for performance management of the pharmacy service or evaluation of the impact of staff shortages.
Staff in four clinical settings did not check the fridge temperatures for stored medication regularly. This meant that there was a risk that medicines would deteriorate and be unfit to use. We flagged up this problem at our last inspection.
Four core services did not have enough staff. For example there was a shortage of, speech and language therapists, psychologists. This meant that longer waiting times occurred for dysphagia assessments and psychologist assessments. There was also a shortage of nurses and psychiatrists. Besides the care coordinators ,we found this in the previous inspection.
There was a lack of trained staff for the health based place of safety. Staff mandatory training, supervision and appraisals still did not meet the trust targets.
We found there were small groups of staff who did not feel valued and involved in strategic decision making, for example, allied health professionals and psychologists. We found this in our previous inspection.
Not all staff had heard of the Speak Up Guardian role. There was a perceived conflict of interest between the post holder carrying out the Speak Up Guardian role and being a human resources manager at the same time.
Staff in three clinical services did not check emergency bags regularly in accordance with trust policy, to make sure they were ready to use.
Staff in three clinical services had not completed incident forms when making safeguarding referrals in accordance with trust policy. This meant they would not have accurate data.
Some staff did not implement the smoking policy as they did not wholly agree with the non smoking policy directives, this meant smoking occurred within buildings and within hospital grounds posing a fire risk.
The quality of care plans, physical health assessments and physical health care plans undertaken by staff was still not consistent across clinical services. This meant staff would not have all the information required about a patient to provide care.
We continued to find that not all patients were involved in their care plans or given copies of their care plans. Not all patients had crisis plans in place. There was variability in the use of advance decisions across core services. Patients make advance decisions to indicate their preferred treatment in particular situations.
The ward environments did not support safe care. Acute admission wards had blind spots along their bedroom corridors and lacked parabolic mirrors, and staff were not always present in these areas. The cleaning trolleys used on the wards at Hartington Unit held hazardous cleaning materials but had broken doors that did not lock. The health based place of safety had ligature points ( these are places were a ligature could be tied to self harm).
Slow IT systems impacted on the quality of care, for example staff found the log in and log out process for recording 15-minute observations hindered the recording of real time observations.
The trust did not have up to date service level agreements with one local acute trust to support Mental Health Act functions and psychiatric liaison services.

However:

The trust board had the range of skills, knowledge and experience to perform its role. Significant improvement had occurred in the stability of the trust board and board development since our earlier inspection. The trust chief executive continued to give good systemic leadership in the Sustainable Transformation Partnership and the mental health workstream.
There was improvement in the extent most staff felt respected, supported, and valued in the trust since our previous inspection. The trust recognised staffing challenges and had a robust recruitment strategy using a range of initiatives.
Since our previous inspection the trust had made improvements in the human resources department, in relationships with trade unions and in its approach to equality and diversity.
Since the previous inspection the trust had improved its governance structures to support the delivery of its strategy. Non-executive and executive directors were now clear about their areas of responsibility.
There was improvement in the relationship between the trust board and council of governors'. Improvements in the composition, accountability, functioning and training of the governors’ council had occurred since our previous inspection. The governors held the non executives to account.
The wards and clinical bases that we visited were clean.
There were good systems in place to support staff, patients, and carers when serious incidents occurred.
There was good management of complaints and there was an increase in compliments.
Patients had safety plans and recovery hubs provided patients with a range of activities. Care and treatment followed the National Institute Health and Care Excellence (NICE) guidance. Information was available to patients on a range of issues. .
Patients and carers said staff were compassionate, caring and kind. Staff listened and treated patients with dignity and respect. Staff knew their patients and patents gave positive feedback on the quality of care.
Staff had good knowledge of the Mental Health Act. Improvements had occurred in relation to the Mental Capacity Act and recording of capacity and consent.
Good multi agency working occurred and staff said there was good team working. This resulted in good discharge planning.

Our rating of this service stayed the same. We rated it as good because:

The service had enough staff to provide care and treatment. Staff had access to a range of training opportunities that included courses about caring for patients with dementia. Managers ensured staff had regular access to supervision practices and appraisals.
Teams were multi-disciplinary and met regularly to review patient care and treatment. Staff reported effective working relationships with other teams within the trust and external to the trust. Staff worked with external organisations and supported carers to assist patients to remain in their own homes
Staff provided patients with advice, help and support. These were delivered professionally with warmth and respect. Staff used an electronic patient record to document the care and treatment provided to patients. Staff involved patients in their care and, where appropriate, involved and supported families and carers.
The trust provided a range of community services to meet the mental health needs of older adults. Services were accessible for disabled people and those with communication needs. The trust had processes in place that enabled everyone who had contact with services to provide feedback on their experience.
The trust had a vision for what it wanted to achieve. The trust demonstrated how it was working to meet the recommendations of previous inspections and address areas of service delivery where challenges had been identified.

However:

Staff did not always follow policies and procedures to ensure that medicines and emergency equipment remained safe for use. This included failing to transport medicine in the community safely.
Staff practices around assessing patients’ physical health and care planning were not consistent across the teams visited.
All teams continued to have waiting times to access psychology services.

Our rating of this service stayed the same. We rated it as requires improvement because:

Staff reported low morale due to shortage of staff and impact on workloads. Staffing shortages were significantly impacting the average waiting time for patients to access speech and language therapy.
Patient records were not always complete and actions from audits had not been completed. Patient assessments, risk assessments and care plans and prescription charts were all areas where we found out of date or incomplete documents. Staff could not always locate documentation in electronic records or had completed documents inconsistently across the service.
Care plans did not all reflect the views of patients and carers and staff had not always recorded whether they had been offered a copy.
There was no consistent application of use of outcome measures with patients. Staff did not routinely monitor the effectiveness of care and treatment. We requested evidence of specific outcome measures used with patients and the service was unable to provide a consistent response or demonstrate how outcome measures were recorded or used.

However:

Staff were skilled and knowledgeable in working with people with learning disabilities. Staff had completed mandatory training and were up to date with supervision and appraisal.
Staff recognised and responded to safeguarding concerns without delay. Staff reviewed and made changes to the service following lessons learnt through the Learning Disabilities Mortality Review.
Staff knew their patients well and understood individual needs. They treated patients with kindness and dignity and feedback from carers and patients was overwhelmingly positive. Observations of staff demonstrated they were respectful towards their patients and responsive to their needs.
Staff worked well with internal and external organisations to ensure good handover of patient care. Multi-team working between the assessment and treatment support service and the community learning disabilities team was good.
Information given to patients was presented in accessible and learning disability friendly formats to ensure patients understood their treatment. Patients could access advocacy and were supported to do so.
The trust had a vision for what it wanted to achieve for learning disability services and was going through consultation with involvement from staff, patients, and carers.

Our rating of this service stayed the same. We rated it as requires improvement because:

Waiting lists for care coordinators, clinical psychology, outpatients were long across the service and there was no plan in place to show how these would be reduced.
Waiting lists did not show what interventions each patient was waiting for, their level of risk and whether they were open to another part of the service.
Staff relied on patients and/or referrers to alert them if their mental health deteriorated while waiting.
Records showed not all teams checked fridge and room temperatures daily. The emergency bag in one team had not been checked for a year.
There was no psychiatry cover at Dale Bank View and the manager was unable to tell us what actions have been taken by the trust to improve recruitment or provide adequate cover.
Team managers did not use a caseload management tool, this meant managers did not have effective tools to monitor the high caseload numbers in order to support staff.
Rating scales and outcome measures were not being routinely collected and analysed to improve service delivery and ensure interventions offered were effective.
There were not enough rooms across the teams to see patients in and some environments were cluttered and in need of repair.

Most wards at Radbourne Unit still had high numbers of vacancies for registered nursing staff, and had difficulties in filling shifts with the appropriate skill mix. Not all staff were up-to-date with their mandatory training and most ward staff at Radbourne Unit did not receive regular supervision or their annual appraisals.
The trust’s new system for recording observations electronically in real time was onerous for staff and potentially unsafe as it did not allow them to maintain patients’ observation levels at the assessed levels. The electronic records system placed a burden on staff in accessing, locating and updating patients’ records due to technical issues and inconsistent records management and documentation processes.
Staff on the wards at Hartington Unit did not always recognise and report safeguarding concerns and incidents. Assessments and care plans lacked detail and staff did not always update them routinely or following changes.
Staff on all the wards were unaware of the trust’s policy and guidance on contraband and risky items. Some staff conducted searches of patients’ property without adequate training.
Staff on Pleasley ward did not comply fully with the guidance on eliminating mixed sex accommodation, for example, male patients used the female-only lounge.
Staff and patients at both units struggled to comply with the trust’s smoke-free policy. Some staff tolerated smoking to prevent incidents.
The service lacked a multidisciplinary approach to assessment and treatment, and had an over reliance on a medical approach to treatment. Patients had little or no access to psychological assessments and therapies. The wards had a lack of ward-based therapeutic activities for patients who were not well enough to leave the wards to attend the recovery hubs.
Records showed gaps in the monitoring of patients’ physical health, and gaps in the reviews required for secluded patients in line with the Mental Health Act Code of Practice and the trust’s policy.
The enhanced care ward at Radbourne Unit had an outside area that did not give patients privacy and dignity. Not all patients had access to safe storage in their bedroom areas and not all of the wards had robust systems for safekeeping patients’ valuables.

However:

Wards at Hartington Unit now had stable staff teams and low vacancy levels, and a good supervision programme for staff. The staff reported good morale and teamwork, and felt looked after.
Staff now had good knowledge of the Mental Capacity Act. Mental Health Act administrators kept Mental Health Act documentation up-to-date and in good order.
Wards were spacious, tidy and uncluttered. Staff had a good awareness of ligature risks on their wards and took action to reduce the risks.
Patients described the staff as caring, supportive and non-judgemental. Patients felt staff listened to them and provided them with appropriate emotional and practical support.
Each unit had a recovery hub away from the wards that had a range of facilities and activities, including a gym, for patients who were well enough to attend safely.

Our rating of this service stayed the same. We rated it as requires improvement because:

We rated safe and effective as requires improvement, and caring, responsive and well-led as good.
The environments of the health based places of safety did not ensure patients were safe at all times. Staff working in the health based places of safety did not robustly assess all patients’ risks.
There were not enough staff in the City and County South crisis resolution and home treatment teams to meet the needs of all patients. There was a lack of operational leadership in the City and County South crisis resolution and home treatment team.
The safety plan was new and there were some delays in how staff accessed this so they could clearly know patients’ risks.
Lone working practices were not robust enough to ensure the safety of all staff.
Staff did not always assess and monitor patients’ physical health needs. Staff did not assess all patients’ needs.
Staff did not record patients’ involvement in their care plans.

However:

Staff knew how to safeguard patients from abuse and harm.
Staff made sure patients had their prescribed medicines at the right time and stored these safely.
Managers supervised and appraised staff.
Staff had a better understanding of the Mental Capacity Act 2005 than at our previous inspection.
Staff were kind, caring, compassionate and respected patients and carers.
The crisis resolution and home treatment teams responded to individual patients’ needs and helped to prevent them being admitted to hospital.
All staff knew the vision and values of the trust and agreed with them. Senior managers in the trust were more visible.

Our rating of this service improved. We rated it as good because:

Lessons learned were shared and staff were supported following serious incidents. Staff felt able to report incidents.
Staff were observed to be caring and respectful of patients’ privacy and dignity.
A number of measures had been implemented to try and reduce short staffing on the wards, although they remained regularly short staffed.
Staff undertook risk assessments to identify patients who might be at risk of falling. They also ensured that patients had access to good physical healthcare.
Staff provided appropriate support to patients to ensure that they ate sufficient food and drank enough to keep properly hydrated.
Ward staff worked closely with the community teams that would provide care for the patients after they were discharged. They also planned discharge well to ensure that services met patients' care needs when they left the ward.

However:

We found several omissions from patient observations and a need for increased observations were not always recognised and responded to.
Staff reported difficulties using the electronic record system for recording patient observations.

Our rating of this service improved. We rated safe, effective, caring, responsive and well led as good because:

The ward manager had taken action to make sure that requirement notices made at our previous inspection had been met to improve the service. These requirement notices were about the safety of the environment, staff understanding of the Mental Capacity Act 2005, staff training and staff assessment of patient risk.
Staff consistently assessed patients for their risk of violence through completion of risk assessments.
The trust made sure that staff had the training they needed to ensure patients’ safety and wellbeing.
The trust had completed the refurbishment of the unit which included the seclusion suite and reduced environmental and ligature risks to patients.
The trust had bought new furniture for the unit which was clean and in good condition.
Patients were involved in their care plans and this included ongoing monitoring of their physical health needs.
Staff managed patient's medicines well and where appropriate staff supported patients to manage their own medicines.
Staff had formally assessed and recorded patients’ capacity to consent to care and treatment.
Staff offered patients the opportunity to record their preferences in an advance directive (a statement written with the patient about their decision to refuse treatment at a time they may not have the mental capacity to make this decision).
Staff offered patients scheduled activities in the evenings and at weekends.
Staff displayed information relating to the complaints procedure, patient advice and liaison service and the Care Quality Commission on the wards.

We only looked at parts of the three questions at this inspection that related to the concerns raised. These were:

Is it safe?
Is it effective?
Is it well led?

We did not rate the service at this inspection as we only inspected one ward and looked at specific issues relating to the concerns we had received.

We found the following issues that the service provider needs to improve:

Staff completed patient observations but did not always record these.
Staff had not reported an incident or their concerns in a timely way to ensure patient safety.
Staff did not always update assessments following incidents or changes to patients’ needs.
Staff did not always assess and record appropriately decisions made about patients who had impaired mental capacity.
Bank staff did not have access to all the training and supervision that permanent staff had. The ward had not had a permanent manager for over 18 months which had impacted on staff morale.
Work had not been completed to improve the ward to enhance the experience of patients living with dementia.

However, we also found the following areas of good practice:

The ward was clean and the provider ensured that equipment was regularly serviced.
Managers supervised and appraised permanent staff.
The multi-disciplinary team worked well together to care for the needs of the patients.
Staff interacted with patients in a caring and compassionate way.
Improvements were being made to the way that staff cared for patients to prevent them from falling.

In June 2016, we inspected the core service as requires improvement for effective. We identified that across all teams, not all patients had a care plan in place, care plans did not represent patient views, strengths, goals, and some patients were not given a copy of their care plan.Staff did not always carry out an assessment of capacity to consent in a consistent way.
In February 2017, we inspected the community mental health services for people with learning disabilities and autism rated as requires improvement for effective. During this inspection, we looked at patient electronic records, clinical audits and spoke with staff.
When we inspected this service in February 2017, we found the trust had made some improvements in this area. The trust was in the process of scanning all patients’ paper records onto electronic patient records. Policies on Health Records and Mental Capacity were updated and three audits were completed to assess how staff applied the updated policies.
Out of the 20 patient records selected from across the teams we looked at, we found six electronic patient records did not have a completed care plan, eight records had no care plan review date, seven records had no evidence of patient involvement in developing their care plan and 12 patients had not received a copy of their plan. Twelve out of 20 records we saw recorded of a patient’s mental capacity on a specific decision and three mental capacity assessments were incomplete and did not follow the five guiding principles.

We did not change the rating, it remains as requires improvement.

We rated wards for older people with mental health problems as requires improvement overall because:

Staff had not completed all cleaning records to show that staff had cleaned all areas of the wards.
Some staff needed training in the use of strategies for crisis intervention and prevention.
Some staff had not recorded observations of patients’ physical health needs.
Staff did not always apply the Mental Capacity Act correctly and some staff did not fully understand how it related to the patients they cared for.
Staff had not correctly recorded all documents relating to the Mental Health Act.
Some staff were not aware of what to do if a patient who was not detained under the Mental Health Act wanted to leave the ward.
Staff had not recorded the discharge plan for each patient and showed that planning began at the point of admission.
Not all staff had received specialist training so they knew how to care safely for all patients.
Staff had not offered all patients a range of activities to interest them and meet their need.
Managers had not regularly supervised all staff.
Staff had not fully completed records and assessments relating to the Mental Capacity Act.
The wards for older people with mental health problems were now meeting Regulations 13 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We re- rated forensic inpatient/secure services as requires improvement overall:

Staff did not consistently assess patients for their risk of violence through completion of risk assessments for two patients.
Staff had not received the training needed to ensure patients’ safety and wellbeing.
Building work on the seclusion suite was in progress but not yet completed.
The work that the trust had identified was needed to reduce environmental and ligature risks had not been completed at the time of the inspection. However, building plans and a schedule of works was available.
Staff had not removed all unsafe items from the garden so that patients were at risk of harm.
Some furnishings for use by patients were not clean and not in good condition.
Patients’ capacity to consent to care and treatment had not always been formally assessed and recorded.
Staff did not offer patients the opportunity to record their preferences in an advance directive (a statement written by the patient of their decision to refuse treatment at a time they do not have the mental capacity to make this decision).
Scheduled activities in the evenings and at weekends were not always available for patients.

However, at this inspection we also found the following improvements had been made:

Patients were involved in care planning.
Doctors requested second opinion appointed doctors (doctors employed by the care quality commission to gives a second opinion where patients are detained under the Mental Health Act) in a timely manner.
Medicines were stored at the correct, safe temperature.
Robust systems and processes were in place to support safeguarding patients. Safeguarding referrals were made when appropriate.
Staff cleaned seclusion rooms and changed bedding between uses.
A clock was visible from the seclusion room to allow patients to know the time.
Staff completed patients’ detention papers and filed them appropriately.
There was a way of informing ward staff whether temporary staff booked to work were competent and up-to-date with ‘control and restraint’(physical intervention that staff may use to help patients calm down) training.
Gender ratios of staff were appropriate to meet the needs of patients in a timely manner.
Training provided to staff was factually accurate.
Audit processes identified missing parts in patients’ care records.
Patients had their medicines dispensed in a location which upheld their privacy, dignity and confidentiality.
Staff displayed information relating to the complaints procedure, patient advice and liaison service and the care quality commission on the wards.
Staff completed a physical health assessment of each patient on their admission to the service.
The seclusion and long-term segregation policy was accurate.

Following our inspection in June 2016, we rated the service as good for responsive.

The forensic inpatient/secure service were now meeting Regulations 13, 15 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We have rated Derbyshire Healthcare NHS Foundation Trust as requires improvement overall because:

The trust lacked robust leadership. This had resulted in variation in the quality and safety of services provided. The CQC had undertaken a joint inspection of the trust with Deloitte in January 2016. This criticised the quality of leadership. Although some improvements had been made since that joint inspection, the pace of change and ability of the senior leadership to grasp the seriousness of the deficits has not been quick enough. As a group, the executive team lacked the full depth and breadth of skills required to enable the improvements needed in culture, governance and HR throughout the trust.
Trust assurance and reporting systems had failed to recognise serious safeguarding issues that had occurred on the wards for older people with mental health problems since 2011. Although senior staff were aware of the issues, no decisive action had been taken to effectively safeguard and protect patients from potential abuse.

Some front-line staff lacked confidence in the leadership team and felt detached from the central management functions. Although the trust leadership team has started work to improve engagement with staff, there is still much to be done in this area.

The quality of clinical services varied. We have rated the forensic wards and wards for older people with mental health problems as inadequate. This was mainly due to the safety of the environments, concerns about safeguarding and a lack of staff understanding on how to interpret and apply the Mental Health Act and the Mental Capacity Act. In a number of core services, staff were not recording risk assessments, best interest decisions or care plans well.

However:

We found the staff to be consistently caring and they treated patients with kindness, dignity and respect. The feedback received from both patients and carers regarding the quality of care was positive and demonstrated a staff group who have the patients’ best interests continually in mind.

Following our inspection, CQC has issued the trust with a Section 29a warning notice.

NHS Improvement launched an investigation into Derbyshire Healthcare NHS Foundation Trust in 2015, in respect of governance concerns identified from the judgement of an Employment Tribunal, and concerns raised by other third parties. In February 2016, based on evidence from independent reviews commissioned by the Trust, a focussed inspection by the Care Quality Commission and an independent review of governance arrangements, NHS Improvement formally found the Trust to be in breach of its licence. The Trust has agreed a number of enforcement undertakings with NHS Improvement which it is required to implement, and has developed an action plan to secure delivery of the enforcement actions and return to compliance with its licence.

The CQC and NHS Improvement meet with the trust leadership on a monthly basis; we will be continuing this approach to agree an action plan to assist them in improving the standards of care and treatment.

The service was well led locally, however staff reported that the executive team were not visible and there was a mixed knowledge of the trust‘s strategy and governance arrangements.

Medical staffing was not at establishment, the paediatricians were having difficulties finding suitably qualified staff to fill their vacancies.

Where there were long waiting lists there were strategies in place to minimise the effect this had on the children and young people.

Not all members of staff had completed mandatory training to comply with the trust target.

Safeguarding procedures were in place with clear lines of reporting. Staff were aware of these procedures and their responsibilities for safeguarding of children and young people. However not all staff had three monthly safeguarding supervision.

The Derbyshire Healthcare NHS Foundation Trust had systems in place for incident recording, investigating and monitoring. Lessons were learnt, when necessary, to prevent similar incidents from happening again.

The feedback from children, young people, their parents and carers was extremely positive at all the locations and programmes we visited. Staff were kind and caring; we observed excellent interactions between staff, children, young people, and their parents or carers. Everyone we spoke with on the telephone, face to face and met in clinics were overwhelmingly positive about staff, they told us staff were kind, caring and listened to their concerns. Staff ensured people experienced compassionate care which promoted their dignity. Staff coordinated care for the whole family and were committed to helping meet people’s emotional, social and welfare needs in addition to their health needs.

Services were located where people could access them, and offered a range of times to accommodate people’s preferences. Overall, children, young people and families received timely community healthcare services. Services met their performance targets with very few exceptions.

The trust worked in partnership with other agencies such as neighbouring trusts, the local authority, education authority and voluntary organisations. We saw evidence that partnership working was routinely included in every aspect of their work. Staff were passionate about their role and they were continually looking how to improve services for children and young people.

The trust provided some unique services to children and young people. These included parent training programmes for Autistic Spectrum Disorders (ASD) and Attention Deficit Hyperactivity Disorder (ADHD).

We rated community mental health services for people with learning disabilities as requires improvement because:

Across all teams, staff did not complete agreed dates of review on care plans and not all patients had a care plan in place. Not all care plans at Amber Valley team fully contained patients’ views, strengths and goals.

Staff did not always carry out assessment of capacity to consent in a consistent way in all teams. Some records where patients had been identified as lacking capacity had no associated documentation in place.

There have been long average waiting lists of 27 weeks for psychology and 41 weeks for speech and language therapists across the community learning disability teams.

However:

All of the teams completed patients’ comprehensive assessments and risk assessments that were reviewed and updated by the multidisciplinary team. The teams used a variety of clinical outcome measures.

Staff had completed mandatory training and had the skills and knowledge to meet patients’ needs. Staff assessed and supported patients with their physical health care needs.

Staff reported incidents and the managers discussed lessons learnt from incidents to improve practice. Each team had a safeguarding lead and staff had good awareness of safeguarding procedures.

The teams worked well as a multidisciplinary team and with other external organisations to ensure that patients were given the right support. The teams responded a timely manner to patients referred in a crisis
Staff in all the teams spoke and behaved in a way that was respectful, kind and polite. Staff involved patients in their care and treatment planning. Staff supported patients with access to advocacy. Patients were given information in easy read format.
The teams had objectives that reflected the trust’s values and objectives. Staff felt morale was good within the teams and their team managers supported them.

We rated community mental health services for older people as Good because:

Skilled staff worked within a multidisciplinary approach to ensure they were responsive to urgent referrals or patient crisis. They consistently reviewed and monitored patient risk, and worked collaboratively with carers to promote independent living and avoid hospital admission.

There were adequate numbers of staff available to prioritise and monitor waiting lists, providing information to patients, carers and referrers ensuring they knew what to do if patient’s condition deteriorated.

The teams had developed good external links to GPs, social services and other local agencies, to ensure patient’s holistic needs were thoroughly care planned.

Patients told us staff were caring, compassionate and responsive to their needs, providing emotional and practical support. They told us staff involved them and their carers within their care and looked after their best interests.

Staff received regular supervision and support from their team managers, and attended to their training needs. Staff told us morale was good and they worked well as a team.

However:

We found that although staff were trained in the Mental Health Act & Mental Capacity Act, their knowledge of key areas that related to their patient group, such as community treatment orders, was limited. This was reflected in the lack of documentation in the care records. We also found that patients were not consistently given a copy of their care plan

The service missed opportunities to learn from incidents, complaints and audits. Staff recognised incidents but did not always record them.

Patients told us they did not receive written information on how to make a complaint, such as Patient Advocacy and Liaison (PALS) leaflets, although they told us they would speak with their care co-ordinator.

Waiting lists for psychological interventions were long, which prevented patients receiving appropriate treatment when they needed it.

We rated CAMHS as outstanding because;

The teams delivered a good range of evidence based care and treatment and there was high use of routine outcome measures.
Urgent referrals and deterioration in mental health were responded to quickly and the development of the rapid intervention, support and empowerment team meant that staff were accessible seven days a week, 08.00 to 23.00.
Routine referrals were seen within an average time of six weeks and urgent referrals were seen within 24 hours. The target for routine referrals was 18 weeks.
Risk assessments were completed and updated regularly and care plans were up to date and patient focused.
Feedback from young people and families was very positive and the team were described as going the extra mile.
The inspection team observed staff showing warmth and being respectful to young people and their families.
There was a high level of participation by young people and parents throughout all levels of the service.

.

We rated crisis mental health crisis services and health-based places of safety as requires improvement because:

The health-based place of safety located in the Hartington Unit had multiple ligature points and other risks, including blind spots. It lacked emergency equipment and ligature cutters.
The door to the health-based place of safety at the Hartington Unit had an uncovered clear glass panel that people in the reception area could see through.
All the crisis resolution and home treatment (CHRT) teams had low training rates for medicines management and the Derby City and County South team had low rates for basic life support training.
Patients’ medication records for the Derby City and County South team showed gaps for medicine reconciliation and the recording of patients’ allergies.
Care plans in the Derby City and County South team lacked detail and were not always up-to-date.
Although staff had recognised and reported safeguarding issues internally, the Derby City and County South team had not made any referrals to the local authority.
The lone working arrangements for staff in the High Peak team were not robust or safe.
Staff in the Derby City and County South team did not receive regular one-to-one supervision and appraisals.
The Derby City and County South CRHT experienced difficulties transferring patients to community mental health teams because of long waiting lists.
Staff in the Derby City and County South team did not feel assured that their service would remain safe during the transition to integrated community services.
The trust did not routinely measure performance on key activities such as four-hour response times to referrals.
Governance systems and processes to help ensure effective practice were inconsistent across the teams.
The health-based places of safety did not contain clocks. The health-based place of safety at the Hartington Unit did not have anything for patients to lie down on

However:

All CRHT teams had safe staffing levels for their respective caseloads at the time of our inspection.
The CRHT teams had good risk assessment and management systems and processes.
Staff undertook comprehensive assessments of patients’ needs taking into account social, psychological and physical needs.
Patients and relatives gave positive feedback about the CRHT service and described the staff as kind and helpful.
The CRHT teams had local systems in place to help provide continuity of care, wherever possible.
The CRHT teams fully involved patients (and relatives, where appropriate) in care planning.
Staff ensured that assessments of patients detained in the health-based places of safety started as soon as possible after their admission.
All CRHT teams had good access arrangements covering 24 hours a day, seven days a week, and had no exclusion criteria as long as the presenting issue was mental ill health.
The CRHT teams prevented hospital admissions by providing intensive short-term support to patients in their own home.
Patients received timely support, tailored to their needs, in their own home. Staff negotiated the type and frequency of contact with patients.
All CRHT teams had a clinical leadership model to team and service management, which helped ensure that clinical and managerial needs informed practice and service development.
The new local leadership team for the Derby City and County South team had made significant improvements to the service following a prolonged period of crisis.
Staff in the Chesterfield and High Peak teams described good team working, and staff in the Derby City and County South team reported improvements in team morale, and trust and confidence in the team’s new managers.
The trust participated in a multi-agency group concerned with the operation of section 136 of the Mental Health Act.

We rated community based mental health services for adults of working age as requires improvement because:

Not all locations where patients were seen and treated had access to emergency equipment.
Waiting lists for psychological interventions were long, which prevented patients receiving treatment when they needed it.
Levels of training and appraisal for staff were below the target levels set by the trust.
Not all areas of buildings were clean and well maintained which impacted negatively on patient comfort, privacy and confidentiality.
Staff did not routinely participate in clinical audit activities; this meant that the care provided was not being reviewed against agreed standards.
Staff did not routinely give patients on community treatment orders their S132 rights in line with the Mental Health Act Code of Practice and did not routinely provide patients with information on advocacy services or how to complain. Care plans did not consistently demonstrate patient involvement or a focus on recovery.
Staff felt that there was a lack of leadership from board level in the organisation and little ongoing guidance was provided on service transformation and the implementation of the Neighbourhood model. Staff did not consistently report that senior managers were visible or accessible.

However:

Patients and carers were happy with the way that staff worked, describing them as respectful, caring, and responsive.
There was a range of information leaflets available to patients and carers.
We saw local examples of good and innovative work practices including equine therapy and initiatives to reduce the stigma of mental health.
Staff supported patients with physical health, accommodation, employment, recreation and financial needs.

We rated forensic inpatient/secure ward as inadequate because:

Patient safety was compromised by the lack of staff training in key aspects of care such as basic life support and intermediate life support.
Monitoring of patients’ physical health following restrictive interventions and/or rapid tranquillisation was inconsistent.
Environmental risks identified had not been addressed despite action plans indicating mitigating actions to be taken.
We found that care plans were not holistic, personalised or recovery-focused. Patients input into their care plans were not evident. Provision of physical health assessments for patients on admission to the service was inconsistent.
Patients were not provided with the opportunity to create advance decisions detailing their preferences for care and treatment.
The seclusion rooms did not comply with the guidance set out in the Mental Health Act (1983) or the Code of practice (2015).

However:

Nursing staff had undertaken nursing risk assessments called functional assessment of the care environment (FACE) of patients upon admission. Nurses had updated these risk assessments regularly to reflect any changes in risk. FACE risk assessments are not as detailed as HCR20v3 risk assessments.
Staff knew to report and record all risk incidents, and all near misses, and did this consistently. They were open and transparent and explained to patients when things went wrong.
Patients had wellness recovery action plans (WRAP) which were personalised and staff had created these in collaboration with the patient.
The service was participating in the Quality Network for Forensic Mental Health Services. They were also engaged in Commissioning for Quality and Innovation (CQUIN) towards the provision of a recovery college and reducing the use of restrictive interventions.
Bed occupancy was low; the average length of stay for patients was short and readmissions within 90 days were low.
Staff were responsive to patients’ needs and they were supportive. Patients told us staff were kind and caring.

Staff morale was good and they were very positive about the leadership by the new unit manager. They spoke very positively about their team; they were proud of their team and were supportive of one and other.

We rated long stay/rehabilitation wards for working age adults as good because:

Staff completed risk assessments on admission and updated them regularly. Potential risks to patients were discussed ward handovers. Staff had received safeguarding training and understood when to make a referral. Medicines management was of a high standard and used a system that considered patient safety while also promoting independence
Patients said that they staff were open and honest with them. Staff treated them with dignity and respect and there were high levels of staff engaging with patients. Carers felt fully involved and appreciated being able to attend carers groups.
Patients had access to lounges, outside space and were encouraged to shop for their own food and prepare this. Staff offered support and guidance around healthy eating if required. The wards and the rehabilitation occupational therapy team provided access to a wide range of community based activities, which promoted recovery and independence.
Staff showed a high level of commitment to the patients. They felt well supported by managers and were engaged in making improvements to the services by giving feedback. This support allowed them to feel confident in being open and transparent with patients when incidents.

However:

Staff were not always clear about the use of the Mental Capacity Act and Deprivation of Liberty Safeguards, or when to use this legislation.
Patients at Cherry Tree Close felt the five-week rotation of multidisciplinary team meetings meant they had to wait to discuss their treatment. They felt they would like to have appointments that are more regular.

We rated acute wards for adults of working age as requires improvement because:

The trust did not consistently ensure the safety of those using services. This was due to a combination of high levels of bank/agency staff, low levels of staff training and by not carrying out the action plans from environmental risk assessments.

Staff did not always monitor and record care interventions in line with trust policies or national guidelines. The lack of integrated care notes made information less accessible and increased the risk of miscommunication between clinical staff.

Staff understanding of the Mental Capacity Act varied, many staff relied on the doctors to assess. Staff did not always indicate reasons for capacity assessments or fully complete the forms. Staff did not always implement care and treatment in line with the Mental Health Act and Mental Health Act Code of practice.

Most inpatient beds were on dormitory style wards. Three wards segregated beds by curtains. This compromised patients’ privacy and dignity. The trust had no plans to phase out this style of ward.

Governance systems in place were weak. Not all staff had the opportunity to discuss lessons learnt with each other; staff business meetings were irregular and time limited due to wards being short staffed. Ward managers were often unable to complete ward duties when on call, as they needed to manage the health-based place of safety and respond to incidents within the units. The trust did not always learn from lessons and systems to share information with staff were ineffective.

However,

The Trust were part of the national ‘Triangle of Care’ scheme. The ‘Triangle of Care’ scheme encourages a therapeutic relationship between patient, staff member and carer that promotes safety, supports recovery and sustains wellbeing.

Both units offered a wide range of therapeutic and recreational interventions across seven days and throughout the evenings.

In July 2015, Monitor opened an investigation into the Trust, due to governance concerns identified from the judgement of an Employment Tribunal. Monitor also has concerns following related complaints raised by other parties including individuals who have approached Monitor in line with its whistleblowing policy. The Trust is currently undertaking two pieces of work to respond to the issues raised by the judgement and by the Monitor investigation:

An independent investigation into the findings of the judgement, both as they relate to the performance and conduct of individuals and to wider issues of standards of corporate governance.
An independent investigation into individual complaints raised by current or ex-members of staff about the behaviour of current or ex-members of staff.

The Trust appointed an external agency to carry out a focused review of specific elements of its governance arrangements. Monitor, the Care Quality Commission (CQC) and Deloitte looked into the leadership and governance arrangements and into the performance of the HR and related functions at the Trust. Each body will report separately. This report describes the findings of the CQC focused inspection.

This focused inspection looked specifically at the following:-

Vision, values & strategy
Are recruitment and performance management processes objective and transparent?
Are there clear roles and accountabilities in relation to board governance (including quality governance)?
Does the board actively and effectively engage patients, staff, governors and other key stakeholders on quality, operational and financial performance?

We would like to thank the trust and its staff for their help and co-operation throughout the review.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

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