Derbyshire Healthcare NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Staff and leaders told us they had been involved in the trusts new vision and strategy around the new planned provisions for acute services. However, when we reviewed the staff survey we found leaders had not planned an action plan around the areas of concern identified within this. Staff we spoke to felt leaders and managers were kind and compassionate. However, not all staff we spoke to said that senior leaders were visible enough on the wards. All staff had access to a freedom to speak up guardian and the trust had a freedom to speak up/ whistleblowing policy in place, which promoted speaking up when staff had concerns. However, we did not find effective governance processes were in place. The trust had not made appropriate improvements since the last inspection and some of the same areas of concern were highlighted again. The trusts audit processes in place had not identified when staff had failed to put appropriate risk management plans in place and not responded to complaints in line with the trust policy. Managers did not have oversight of the lack of risk management plans for patients and ward area, particularly in areas where patients had tied ligatures on a regular basis.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers we spoke with at the Radbourne Unit described the vision and strategy for the planned new build and environmental upgrade of the female wards and how they had involved staff, patients and partners with this. The majority of managers and staff we spoke to were able to describe the vision and strategy of the organisation. Specifically discussing the improvement plans for the new unit opening in February/March 2025. The development plans for the new unit were co-produced with patients and the trust had recently run a competition for staff and patients to name the new unit (Derwent). Managers told us that they try to foster an open culture where they lead by example, have an open-door policy and listen to concerns. However, not all staff we spoke to were aware of the trusts vison and values and informed us that senior leader team were rarely visible on the unit.

The trust had a 3-year strategy in place which had last been updated in 2023. This included the trusts core values, approach being based on best clinical evidence. The trust completed regular staff surveys. The results from the last survey completed in: 2023 showed 80% of staff at the Hartington Unit but only 63% of staff providing acute inpatient services in the south of the county (including Radbourne Unit) who responded in the staff survey felt that team members had a set of shared objectives. 23% of staff at the Hartington Unit who responded in the staff survey had experienced bullying or harassment from managers or colleagues. The survey report did not clearly show how the trust were going to address these concerns.

Staff we spoke to at the Radbourne Unit told us that leaders at a local level are visible and lead by example modelling inclusive behaviours. We were also told that staff vacancy levels were low, however all staff we spoke with said wards were frequently understaffed. Staff told us that there was a culture of acceptance relating to working long hours (14.5 hours) without planned breaks. Staff we spoke to at the Hartington Unit said that overall leaders were capable and compassionate. Staff felt able to speak about their concerns and managers helped on the ward when staffing numbers were low. However, not all staff we spoke to said that senior leaders were visible enough on the wards and some staff didn’t feel listened to by senior managers when they raise concerns about low staffing levels.

The trust had a detailed recruitment policy in place that had last been updated in October 2023. The policy guided staff to ensure there is always a diverse panel and gave guidance on pre-employment checks and the processes around shortlisting candidates.

At the Radbourne Unit we were told that managers had requested pressure pads for the top of bathroom and toilet doors following multiple ligature incidents which had sadly led to 2 patients’ death. This was refused and managers were unable to give us a reason for this decision. At the Hartington Unit, most staff we spoke to said that leaders act with openness, honesty, and transparency. They felt that there was an open-door culture on the unit where concerns could be raised. However, leaders acknowledged that some staff groups feel vulnerable, specifically newly qualified members of staff. Incidents have occurred where staff have accessed freedom to speak up in these cases. Leaders would then discuss concerns with the ward management teams. Not all staff we spoke to were aware of the process for accessing freedom to speak up at the unit. One staff member gave a recent example where a colleague had asked for advice to raise concerns following a restraint incident relating to the way staff had spoken in a derogatory manner to the patient. Staff member said that the colleague didn’t initially feel safe reporting the incident because nothing would be done. Staff member signposted to the freedom to speak up guardian.

The trust had a freedom to speak up policy and procedure in place. The policy guided staff on how raise concerns and directed staff to complete training on this too. It gave staff information on who they could raise concerns to including senior leaders and the Care Quality Commission. Staff had access to a freedom to speak up guardian to whom they could raise concerns to. There was a clear process in place which allowed the freedom to speak up guardian to escalate concerns to trust management at a board level. 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.

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

Managers did not have good governance processes and systems in place to manage and deliver good quality care and treatment. They failed to act on risk information, performance and outcomes in order to reduce the risk to people using the service. Managers were aware of the blind spots on the wards and in the seclusion room but did not take any action to mitigate this risk. Managers did not act upon the outcomes of audits into seclusion practice. The audit highlighted that medical and nursing reviews were incomplete on six occasions and physical health had not been assessed on 8 occasions. We looked at 29 seclusion records for the period Jan to March 2024 and found 9 reviews had not been recorded and patients physical health had not been assessed on 10 occasions. We found significant issues relating to observations for patients in seclusion not being completed within the required timescales, this was due to poor IT connectivity. We were told this had been reported on numerous occasions but this remained an issue. Managers did not ensure staff offered food and fluids to patients in seclusion according to Trust policy. We were concerned that some managers were not aware of the safeguarding lead for the trust and therefore had no governance arrangements in place to monitor that the safeguarding process were being utilised effectively. We were not assured that communication between managers and staff was effective to promote the improving practices on the ward. Managers often cancelled staff meetings due to staff shortages. When they did take place there were not minuted to share with all staff. Whilst managers acknowledged significant staffing issues and had mechanisms to monitor staffing levels, including weekly forecast and escalation at a daily senior review, staffing numbers did not meet the acuity of the patients on the ward. This impacted on patients utilising their leave and one to one time with nurses.

Governance processes in place had not identified when staff had not followed trust policies including responding to complaints in line with the trust policy. Following an increase in ligature incidents an action plan had been devised to support staff, this included ligature knife processes and training around ligature reduction for staff. This showed the trust had identified ligature incidents as a risk and were putting mitigation in place. However, no specific additional measures had put in place to support staff on specific wards where there were significantly more ligature incidents than any other acute wards. This shows that although the trust had oversight group meetings and governance processes in place these were not effective at reducing patient risks at a ward level. Processes in place failed to identify where risks had not been identified including ligature risks on ward areas. The trust also failed to act upon identified risks and put appropriate measures in place to safeguard patients. There had been two patient safety incidents in September 2023 across the different units. A third patient safety incident occurred in April 2024, 8 months after the first. We found some commonality between those patient safety incidents in that they used the same area of the ward although not all patient safety incidents were on the same units or ward. The trust had a risk register in place this had been updated as incidents were reported. The risk register had 5 items referring to various ligature risks across acute services. Details around the control measures in place varied however, these were not transferred onto the ward level ligature risk assessments in place. This showed that management plans were not being communicated effectively to staff on the wards.

Patients at the Radbourne Unit told us that staff worked with them to build ties within the community. At the Hartington Unit the majority of patients did not raise concerns overall and felt supported on the ward to approach staff with issues. They did not raise any concerns around how staff worked or helped them to build partnerships in the community. However, not all patients felt listened to and told us that repeated complaints about not having access to care plans had not been actioned by staff. we spoke to 20 patients on the ward, attended one community meeting and reviewed a sample of community meeting minutes.

Managers at both the Radbourne and Hartington Unit told us they worked with partners to ensure patients care provision was appropriate by collaborating with all relevant internal and external stakeholders and agencies. At the Hartington Unit we observed a multi-disciplinary team meeting where staff and patients linked in with external social work teams to discuss housing options post discharge from the ward.

We spoke to local stakeholders including the local integrated care board and local authorities. All felt the trust and leaders worked in partnership with them and played an active role in meetings relating to safeguarding, safeguarding board, and discharge. The trust and ward staff actively involved community teams including housing teams when it was appropriate.

The trust ensured every patient had regular care programme approach meetings. This included partners including social workers and community teams to ensure patient care and progress was monitored regularly.

At the Radbourne Unit, managers did not have oversight of the lack of risk management plans for patients. We found patients on the female wards were tying ligatures on a regular basis and there was little evidence that managers effectively learnt from serious events. We were not assured that all managers at the Hartington Unit had a good understanding of how to make improvements happen and we found an inconsistent approach to measuring outcomes. Some managers told us the unit did not have a robust approach to learning lessons from incidents. We observed blind spots identified as risks not being observed by staff. We were told that incidents were reported using the DATIX system and staff attend a trust safety day to ensure they are aware of the process for reporting incidents. However, meetings to discuss incidents were not always recorded and immediate actions could therefore not always be evidenced. Not all wards on the Hartington Unit had a robust approach to audit. For example, on Tansley de-briefs following incidents such as restraint were not always coded correctly on internal systems meaning they were not always identified for audit purposes. However, people using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives. We visited the new development due to open at the Hartington Unit in November 2024 and were told by staff that plans had been co-produced with patients. The trust had also run a competition for patients and staff to name the new unit.

The Trust had a suicide prevention strategy in place, but this had not been updated since April 2016. This strategy stated the trust would review ligature points as per the ligature review policy, as a minimum annually or more regularly on identification of new information or new risks. The Trust had quarterly learning from death meetings. At this meeting they reviewed all deaths that occurred during that time and identified learning and recommendations. Clinical leads completed monthly quality audits for patient records and clinical notes. 3 records were reviewed per ward per month. These audits often identified areas for improvement which were linked to actions that needed to be completed by ward staff.