Derbyshire Healthcare NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People we spoke to at the Hartington and Radbourne Unit told us that they generally felt safe on the wards and that staff were approachable. However, we found that although complaints were discussed weekly these were not always acted upon. Staff we spoke to knew how to identify safeguarding concerns but not all were aware that they could raise safeguarding concerns directly to the local authority safeguarding team and stated that they would only raise concerns with senior staff or management. We found not all staff had completed appropriate safeguarding training. We found risks were not always managed well and some patients did not have a detailed risk management plan in place. Staff and patients were not always offered a debrief after incidents had occurred. The trust had failed to make appropriate improvements to the environment since concerns were raised about safety at the last inspection in September 2023. During this inspection, we identified similar incidents of patients using doors to ligate and the trust had failed to update their ligature risk assessments after serious incidents of patient deaths. The trust used a high level of bank and agency staff, meaning there were occasions where there were only bank or agency staff on shift on a ward.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients on both units felt safe and supported to understand and manage risks and gave examples of when staff had responded to risk. At the Radbourne Unit, staff listened to patients and gave examples of how the service had improved things following issues raised at community meetings. One example was the hospital chef attending the meeting to discuss the quality of food provided to patients. At the Hartington Unit patients had been given information about how to complain, although this information was not accessible for patients with visual impairments. Patients reported that staff listen to feedback, however, community meeting minutes showed that repeated patient complains about staff shortages impacting patient safety and patients not having access to care plans had not been recorded as action points, therefore there was no evidence of follow up. Most patients had access to information and advice about their health and medication management and were involved in their care planning. However, most patients did not have access to their care plans and some patients told us they were not aware of their rights.

We spoke with 49 members of staff across the two units and found inconsistencies relating to the leaning culture at ward level. At the Radbourne Unit there was limited evidence of a proactive and positive culture of safety based on openness and honesty. We attended one ward team meeting and were told that the agenda had recently changed (during the inspection) to include learning from incidents, despite staff telling us that the trust sent out updates following serious incidents. There were no examples discussed or recorded at this meeting. Findings from complaints and incidents are not always acted upon. We reviewed notes from a staff team briefing which highlighted continued issues described by patients. For example, not having access to care plans, their rights read or access to a named nurse. Staff felt that communication regarding incidents and complaints needs to improve at a local level and they needed to be empowered to deal with complaints and apologise when things go wrong. However, risks were discussed at daily rapid review meetings and information was uploaded to patient records and disseminated during staff handover meetings. Complaints were discussed at weekly operational meetings and the patient experience team brings together complaints to identify trends. For example, improvements had been made in relation to recent AWOL incident at the unit.

Staff had access to a freedom to speak up guardian on Radbourne unit and Hartington unit. 2 issues had been raised with the freedom to speak up guardian in the last 3 months and they were separate individual human resource issues. The trust had processes in place with the freedom to speak up guardian to bring issues to the board if themes are identified.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The majority of patients across both units told us that overall, they felt safe and supported on the wards. At the Radbourne Unit patients said they felt that the staff knew them well and although the wards were short staffed, they were able to discuss their concerns. Most patients on the Hartington unit felt risks were managed well and gave examples of staff responding well to aggression on the ward. All patients we spoke to had not experienced restraint whilst on the ward and were comfortable raising concerns with staff. However, some patients were not aware of their rights and felt it was not safe to leave their valuables in their rooms.

The majority of staff across both units had a good understanding of safeguarding and how to take appropriate action. At the Radbourne Unit we looked at 12 care records and saw evidence that safeguarding incidents had been reported appropriately by staff. At the Hartington Unit we saw evidence during a ward round that safeguarding referrals are discussed and there is a commitment to taking immediate action to keep people safe. A safeguarding meeting is held every week where cases are discussed, and actions taken. However, some staff were not aware that they could raise safeguarding concerns directly with the local authority safeguarding team and stated that they would only raise concerns with senior staff or management. We were not assured that all staff were aware of the reporting mechanisms for safeguarding referrals. A recent incident highlighted that the safeguarding team had not been notified, this resulted in an assault on a patient which could have been mitigated.

During our observations at both units, we saw that most people were supported to understand safeguarding and what it means to be safe to them. At the Radbourne unit we saw one patient disclose sensitive information which was acted upon appropriately by staff. Both units had noticeboards displaying information on safeguarding and how to access support and advocacy. At the Hartington Unit we observed safeguarding information displayed in a number of formats across all wards. There were posters on the walls and a TV in the patient waiting area on each ward displaying relevant safeguarding information. We also saw evidence of ‘you said we did posters’ and observed staff discussing safeguarding concerns with patients during MDT meetings. We observed staff providing a number of patients with 2:1 support on the ward.

The trust had 9 safeguarding incidents at the Hartington unit between January and March 2024. All of these has been closed and no further action had been required. The trust had 23 safeguarding incidents at the Radbourne unit between January and March 2024. 10 of these had been resolved and 13 were still ongoing investigations. Out of the 7 investigations in January 2024, 3 were still ongoing investigations. The local authority informed us the delays were on their part and the trust always responded and investigated concerns in a timely manner. The trust safeguarding policy gave staff guidance on types of abuse, how to report concerns and make referrals directly to the local authority safeguarding team. Staff safeguarding training compliance was above the trusts target rate of above 80% for all but one ward. 36% of staff on Pleasley ward had not completed the required safeguarding training.

People we spoke to at both units told us that they felt safe on the ward and knew how to keep themselves safe. At the Radbourne Unit, patients said they were usually invited to contribute and attend their ward round meeting and staff were supportive and helpful. However, patients felt that the wards were consistently short staffed meaning they did not always receive support from staff when they needed it. Patients at the Hartington Unit said that risks were managed well and that they had not been restrained or experienced any aggression to self or others. They reported that staff are considerate, kind and are responsive to concerns on the ward, for example, intervening when a patient was bullying others on the ward. However, one patient had informed staff that they had been assaulted by another patient on the ward and felt that staff had not listened.

We found inconsistencies in the management of risk across the two units. At the Radbourne Unit we looked at 12 care records; whilst staff had completed a risk assessment tool in all cases they had not completed a robust risk management plan which identified known risks such as ligation and self-harm. We noted a lack of planning to reflect actions taken following an incident to reduce a recurrence of self-harm. At the Hartington Unit our review of care records showed that most had up to date, comprehensive risk assessments. During 2 multi-disciplinary team meetings, we saw evidence of risk discussion’s with patients. Assessments were person-centred and discussed aspects of positive risk taking, which identified managing concerns around substance use and associated risks during planned section 17 leave. A graded leave plan was discussed, and observation levels were reviewed with a supportive and compassionate approach. We saw examples of a rapid review meeting which demonstrated that notes were uploaded to individual patient records; actions tasks are documented, and any new tasks added to the meeting template which will be discussed and shared during handover so that all staff are aware of any risks and tasks which require follow up. Staff told us that patients at high risk of suicide are placed in one of the side rooms and patients with similar risks are not placed together to reduce incidents of suicidal contagion and suicidal collusion. Staff told us that de-briefs took place after incidents of restraint and that managers were mostly approachable and supportive.

The trust had a robust patient and patient possession search policy in place.The policy outlined the level of training required by staff to undertake searches, types of searches and the level of communication required with patients and their family members. The trust had a number of policies and processes in place to guide staff when assessing and managing patient risks. This included a data quality policy, safety needs assessment and management of safety needs policy, inpatient therapeutic observations and engagement policy and a detailed handover policy. The Radbourne and Hartington Units had a combined total of 182 incidents that involved the use of chemical or physical restraint between January 2024 and March 2024. However, they did not always offer patients and staff debriefs after these incidents. They only offered patients a debrief following 150 of the 182 incidents involving restraint. Staff were offered a debrief after 137 of the 182 incidents involving restraint. This was identified as an action in the last focussed inspection of the trust in September 2023. The trust had still not met this requirement during our inspection in April 2024.

At both units we found that some patients were not always supported to manage risks on the ward. At the Radbourne Unit 6 patients said they had difficulties coping when levels of disturbed behaviour increased, especially when they were in shared bedrooms. Four patients said they were concerned about the amount and frequency whereby illicit substances such as drugs and alcohol had been brought onto the ward. Two carers were concerned that their relative had managed to leave the ward even though they were detained. The majority of patients at the Hartington Unit said that they felt safe and supported on the unit. However, 2 patients told us that their valuables were not safe on the ward and that there had been incidences where people had been going through their possessions. Although there was no lockable storage in patents bedroom area, there were lockable lockers within the ward area. Patients told us that privacy was a problem on the unit, which could be hectic at times. The quiet room wasn’t very private, and conversations could be overheard.

At both units we were not assured that people were always being cared for in safe environments that met their individual needs. At the Radbourne unit managers told us that staff were deployed to sit in a specific area to observe identified blind spots of the wards not covered by mirrors. However, we saw occasions where staff were not observed to be in the specified areas and noted that even if staff sat in the nominated area they were unable to observe all areas as there were “dog legs” on all three wards. Managers completed ligature risk assessments which clearly documented good observation by design of areas which were located within blind spot areas, for example side rooms. At the Hartington Unit staff, we spoke to were able to identify how they detect and control potential risks in the care environment, including arrangements for appropriate risk audit. Blind Spots had been identified during audit and staff told us that these areas are monitored during observation rounds. Staff gave examples of managing risk appropriately within the ward environment, specifically when patients returned from the activity hub with restricted items or learning from incidents where patients had gone AWOL; staff used CCTV to track back and make mitigations. Managers told us that a patient is currently in long term segregation for their own safety, and this is now being managed by a specialist service providing observation on the unit. Managers reviewed CCTC as part of incident reviews. They identified that patients presenting with psychosis is more common now. The new unit which will open in February/March 2025 will have seclusion rooms to improve safety on the ward.

People were not always being cared for in safe environments designed to meet their individual needs. At the Radbourne Unit seclusion rooms were fit for purpose due to blind spots. We were not assured how patients were kept safe whilst in seclusion. All 3 wards had multiple blind spots which had not been mitigated or identified on the environment audit. Staff were not situated in areas to clearly observe ward or blind spots. At the Hartington Unit we observed that equipment used to deliver care and treatment is suitable for the intended purpose, stored securely and used properly. Facilities, equipment, and technology are well-maintained and support staff to deliver safe and effective care. Emergency medications and equipment were stored safely. The accessible bathroom with a hoist was not fit for purpose, and the accessible toilet did not have a hand rail, so patients were unable to use this facility safely. Staff did inform us that alternative facilities were available. There was one ward which was mixed sex, however dorms were single sex and were separated to mitigate any sexual safety risks. Storage was an issue on some of the wards and identified a large clinical waste bin stored in the assisted bathroom. We found a bed on Morton still in use which had been identified as a ligature risk, however, it had been risk assessed appropriately and risk items were not allowed in the room. We also found a number of blind spots across the unit, which staff said had been identified during risk assessments and would be monitored 24 hours a day; we did not see evidence of this during our visit.

Effective processes were not in place to monitor the safety and upkeep of the premises. We found inconsistencies in how wards detect and control potential risks within the care environment. Although wards had ligature risk assessments in place, they had not all been reviewed annually as per the trusts policy. We were aware of three serious incidents of ligation within the service. Hartington and Radbourne units completed regular environmental audits using different systems. The Radbourne Unit had a clear system in place showing where job requests after audits had been raised, who was responsible in completing them and when they would be completed. However, within the Hartington Units environmental audits, it was not clear from these audits what actions had been identified, when they should be completed and who was responsible to complete them. The trust did not provide gender specific designated assisted toilet provision in all inpatient wards/areas, gender specific disabled (assisted) bathroom provision in all inpatient wards/areas or gender specific designated bariatric bedrooms and bathrooms in all inpatient/ward areas. We were concerned that that was not in line with the MHA Code of Practice (paragraph 8.25-6) The trust has a seclusion and a long-term segregation (LTS) policy in place which clearly states the trust does not have the facilities to provide this type of service. However, a patient was being nursed in LTS due to the complexities of their needs. The service was working closely with stakeholders to make sure the care, treatment and environment were optimal for this patient.

We were not assured that there were enough qualified, skilled, and experienced staff to effectively provide safe care that meets peoples individual needs. At the Radbourne Unit patients told us the wards were frequently short staffed and this affected their ability to take section 17 leave and have fresh air breaks. Two patients told us they were worried because patients were bringing drugs and alcohol to the wards after returning from planned leave and staff were unable to search them due to staff shortages. One patient told us that they became very frustrated when staff could not unlock the door in a timely manner, and this led to them becoming disruptive and aggressive on occasion. One informal patient said they waited long periods for staff to unlock the ward door. At the Hartington Unit the majority of patients said they felt safe and supported on the unit, but that staff shortages would often impact the care they received. Most patients told us there was not enough staff and that the unit regularly used agency staff, particularly at the weekend. Most patients we spoke to were not able to identify their named nurse. Patients complained about the lack of access to psychological therapies and that activities, although planned, were often facilitated in the hub due to OT numbers, meaning some patients could not attend. However, patients told us that they felt cared for, safe and respected. Patients reported that they were able to request support from a Dr quickly and were informed of changes to medication etc.

The trust did not have enough qualified, skilled, and experienced staff to effectively provide safe care that meets peoples individual needs. Both units were frequently short of staffed. Staff did not feel safe and struggled to manage contraband items, to facilitate 1:1 care and escorted leave was sometimes postponed. Managers told us that they would add themselves into ward staff numbers, but this was only a short-term solution. Staff were working up to 14.5-hour shifts without any planned breaks. Staff were unable to carry out patient searches following leave on occasion due to staff shortages. Staff had protected time to complete mandatory training, but this was not always facilitated, and they often have to complete during quieter periods on the ward. Staff are given clinical supervision once a month and felt supported by their managers. They work together to support each other, and occupational therapists will often provide relief on the wards so nurses can take their breaks. However, this is not always possible, and staff often miss meals during their shift. There is a limited number of psychologists at the unit meaning patients are waiting for therapeutic interventions.

Staffing rotas showed that planned staffing levels were achieved but the levels off staff did not meet the needs of patients fully or allow staff to take regular breaks. Managers reviewed the number and grade of nurses, AHP’s and healthcare assistants in handovers and rapid review meetings. Managers attended weekly meetings which discussed staffing issues and hot spots throughout the service. A daily senior review meeting was also held every day at 12pm to discuss the 3-day staffing forecast. Acuity of patients was taken into account and observation levels discussed. Managers signed off cover from bank and agency staff to cover gaps in the rota. Safe staffing at night was discussed, including cover of the 136 suite and bleep holder arrangements. We observed an MDT where we saw evidence of staff working well together to provide safe care and meet peoples individual needs.

The service had 3% staff vacancies. The trust had a high usage of bank and agency staff during the night shift across the 6 wards (Pleasley ward, Tansley ward, Morton ward, Ward 33, Ward 34 and ward 35) assessed. 61% of the staff of the staff at night in March 2024 were bank or agency staff. This was particularly higher for Pleasley ward, where 84% of staff were bank or agency at night in March 2024. There were at least 4-night shifts where there were only bank or agency staff working on the ward. The trusts mandatory training program consisted of a range of training including moving and handling, fire safety, equality and diversity and the Oliver McGowan training (the Oliver McGowan Mandatory Training on Learning Disability and Autism is for people who require general awareness of the support autistic people or people with a learning disability may need). All wards, apart from Pleasley ward, staff had a mandatory training compliance of over 80%. Pleasley wards mandatory training compliance was 77%. Managers did not support staff through regular, constructive managerial supervision of their work. 30% of staff had not received a managerial supervision in line with the trust policy. On Tansley ward the supervision compliance was lower than the other acute wards average with 42% of staff not receiving a managerial supervision in line with the trust policy.

People said that ward areas were always clean and well maintained, and no concerns were raised around infection, prevention and control.

Housekeeping staff were an integral part of the ward team and they were proud of their work. Overall, there is an effective approach to assessing and managing the risk of infection, which is in line with current relevant national guidance and people are protected as much as possible from the risk of infection. Fridge temperatures are managed and monitored correctly. The domestic teams across all wards worked well together to support staff in maintaining a clean ward environment. This included a daily handover process for morning and evening staff. However, managers informed us that not all of the wards have clear roles and responsibilities for managing IPC, for example, a designated IPC lead and there have been times when there has not been enough clean bed linen for patients.

All ward areas were clean, had good furnishings and were well-maintained. Cleaning records were up to date and staff adhered to infection control principles, including handwashing. Staff followed IPC policy and we observed staff adhering to bare below the elbow guidance. However, we found several toilets and bathrooms did not have towel or soap dispensers at the Radbourne Unit. These were put in place before the team left the wards.

The trust had systems and processes in place to effectively assess and manage the risk of infection. The infection prevention and control policy was reviewed every 3 years by the Physical Health Care Committee and Assistant Director of Public and Physical Healthcare. The policy gave staff guidance on various areas including Personal Protective Equipment (PPE) and handling of sharps. The trust also had a special infection control formally isolation policy and procedure policy in place. This outlined the key responsibilities and duties of managers, matrons, ward staff and all employees. It gave guidance on special infection control precautions including isolation and staff training requirements.

Patients across the units told us that staff ensured they received their medication and were involved in decisions regarding changes to their medication, including discussions about how to manage side effects. However, medication was occasionally administered late due to staffing shortages on the wards.

On all wards staff made sure that medicines and treatments are safe and meet peoples needs. Staff gave positive feedback regarding the electronic prescribing system and told us that patients are appropriately involved in decisions about their medicines.

On all wards staff followed good practice in medicines management including dispensing, administration, medicines reconciliation, recording and disposal. At the Hartington unit we observed staff following good practice in medicines management. Patients medications and physical health are reviewed daily. We observed pharmacy staff conducting audit checks, including dispensing, administering and reconciliation. We reviewed a sample of controlled drugs records where we found no concerns.

We reviewed a sample of medicines records at both units and found that staff completed medicines records accurately and kept them up-to-date in line with trust policy. Staff followed systems and processes to prescribe and administer medicines safely. Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines.