Derbyshire Community Health Services NHS Foundation Trust

Updated 30 March 2022

Our rating of the trust improved. We rated it as outstanding because:

• At core service level we rated safe, effective, responsive and well led as good, and caring as outstanding. In rating, we took into account the current ratings of the nine services not inspected this time.
• We rated well-led for the trust overall as outstanding. The rating for well led is based on our inspection at trust level, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement.

Updated 23 September 2016

Overall we rated community health services for adults as good.

The service protected patients from avoidable harm and abuse. There was a culture of reporting incidents and we saw evidence that actions were taken as a result. Staff anticipated and managed the risks to people who use services and had a good understanding of how to safeguard patients from abuse. Staffing levels were planned and reviewed to ensure there were safe levels of care. Clinic areas were visibly clean and tidy and staff demonstrated good infection prevention and control procedures. Patients care records were accurate, complete, up to date, and legible and were stored securely. However, we noted the trust’s medicine code was not always adhered to.

Care and treatment was planned and delivered in line with current evidence based guidance and standards, although there was no consistent approach to monitoring and auditing the quality of the service. We saw effective multidisciplinary working within the integrated community teams (ICT) and staff had the knowledge, skills and experience to deliver effective care and treatment. We saw evidence of staff knowledge and understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Most referrals to the service were handled by the single point of access (SPA) who assessed and triaged referrals to ensure that patients were directed to the most appropriate service. However, referrals to the community nursing teams based at Derby city were handled by a separate district nurse liaison service. Staff reported this service was ineffective, resulting in delays and inaccurate information being relayed to nurses.

Most patients had a single electronic patient record, which ensured all staff had access to information to provide effective care.

We spoke with patients using the services and all of the feedback was positive about the care they received. They told us they were treated with compassion, dignity and respect and were included in the planning and delivery of their care. The interactions we observed between patients and staff were consistently respectful and compassionate, with staff taking time to support, listen and reassure patients. Results from the NHS Friends and Family test (FFT) were consistently above 97%.

Services were planned and delivered to meet the needs of people. Care was provided locally and patients were seen in a timely manner. Community health services were provided by integrated community teams, which ensured patients received joined-up care. Community matrons were available to co-ordinate the care of patients with long term conditions. Specialist services were available, although the continence advisory service was not accessible to all patients in the community. This was because the service was commissioned differently between the city and county, however the trust were working with the commissioners to ensure an equitable service. . Staff ensured care was provided for those people in vulnerable circumstances and that care was accessible to all. Staff responded proactively to complaints, aiming to resolve issues quickly.

Staff were familiar with the trust’s vision and the ‘Derbyshire Community Health Services (DCHS) Way’, they consistently demonstrated the trust’s values in their day-to-day work. There was a good governance structure; managers were aware of the risks in their areas and could discuss the actions being taken to reduce these risks. Local leaders were visible and staff told us that they felt supported and valued. Staff said managers were approachable and they felt able to raise concerns. Staff felt listened to and able to influence service delivery. Staff spoke positively about the organisation; were proud to work for their team and enjoyed their role.

Updated 27 September 2016

Overall, we rated community and young people’s services as good.

There were arrangements in place to minimise and mitigate the risks to children and young people receiving care and to staff working alone in the community. Staffing levels were safe although there was currently pressure on some teams due to high demands and the current staffing capacity. The service had a ten percent staff vacancy rate that they were in the process of recruiting to.

Incident reporting was consistent and there was a good awareness amongst staff of how to manage incidents. There were effective systems in place to learn from incidents both within individual teams and across the organisation.

Services were effective, evidence based and focussed on the needs of children and young people. We saw examples of good multidisciplinary work. Care and treatment was evidence based, staff were competent and people using the service were protected from inappropriate care or treatment for which they had not given proper consent. There were policies and procedures in place to support staff and ensure that services were delivered effectively and efficiently. Parents and caregivers felt well supported and involved with their children’s treatment and told us that staff displayed compassion, kindness and respect.

Services delivered by the trust were caring. Staff were dedicated to their patients and worked hard to ensure that patients received the best treatment and support possible. Patients were involved in decisions and understood the services being delivered to them. Emotional support was available to patients who were dealing with difficult circumstances. Staff undertaking home visits were dedicated, flexible, hardworking, caring and committed.

We found the service was responsive to needs of children and families. Effective multidisciplinary team working, including external partners, ensured children and young people were provided with care that met their needs, at the right time and without avoidable delay. The service was in general well led with effective decision-making and strategic planning. The board and senior managers had oversight of the reported risks and had measures in place to manage these risks.

Updated 27 September 2016

We rated the community dental services at this trust as outstanding.

• Staff protected patients from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.
• Infection control procedures were in place. The environment and equipment were visibly clean and well maintained and medicines and emergency equipment was available at each site we visited.
• The dental services were effective and focused on patients and their oral health care.
• We found clinical staff delivered care according to best practice guidelines for dentistry; this included special care dentistry, conscious sedation for dentistry in primary care, paediatric dentistry and preventive dental care.
• Patients, relatives and carers said they had positive experiences of care within the service. We saw good examples of staff providing compassionate and effective care. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed their dedication to what they did.
• Staff responded to patients’ needs at each clinic we visited. The service kept treatment delays for routine and complex dental treatment within reasonable limits through effective resource management.
• The community dental service was well led. Organisational, governance and risk management structures were in place. The service’s operational management team was visible and the working culture appeared open and transparent. Staff were aware of the organisation’s vision and way forward and they said they felt well supported and they could raise any concerns.
• The service vision and strategy was an evolving one. This was because the service was being placed out for tender in the coming months which had brought a period of uncertainty. Despite this, we spoke to dentists and dental nurses who said the service had forward thinking and proactive clinical directors who were well supported by senior managers within the trust.
• The culture of the service was one of continuous learning and improvement. At each clinic we visited, we saw staff worked well together and there was respect between all members of the dental team.
• The morale of the staff appeared good at each clinic with staff adopting a positive ‘can do’ philosophy about their practice and the challenges they faced.

Updated 27 September 2016

Overall, we rated the community health inpatient service as good, with outstanding for caring.

We found:

The service protected patients from avoidable harm and abuse. There was an embedded system in place to keep people safe and a good level of staff knowledge on how to safeguard patients from abuse. There was evidence of an open and transparent culture in relation to the reporting of incidents and we saw evidence of staff learning from investigations. All of the areas that we visited were visibly clean and staff actively participated in keeping their patients safe from infections. There were well embedded systems in place to recognise a deteriorating patient and we saw evidence where escalation of treatment was correctly identified and acted upon. All wards had good staffing levels with proposed staffing always matching the planned staffing. On occasions where additional staffing was required, staff told us that they were supported to increase the staffing.

The trust participated in local and some national audits, and was also looking into participating in other national outcome audits. All local policies and guidance were evidence-based and followed National Institute for Health and Care Excellence (NICE) guidance. Staff comprehensively assessed patients to produce individualised care plans. Care plans accounted for patients’ physical, mental and clinical needs. Staff were competent to undertake their roles and responsibilities and the trust supported staff to continue their professional development. We saw evidence of staff providing a cohesive team approach to patient’’s care involving all members of the multi-disciplinary team, including discharge planning and transferring to other teams. Staff had knowledge and understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards.

We observed patients being treated with the upmost respect and dignity during their admissions. Staff valued patients as individuals and empowered them to become partners in their care. Feedback during the inspection was positive from patients with words including ‘excellent’ and ‘brilliant’ often being used. Staff welcomed the relatives of patients to also become involved in their care and we saw evidence of where the staff involved the relatives in decision making. Staff empowered the patients and their relatives to have a voice and realise their own potential.

People’s individual needs and preferences were central to the planning and delivery of the services. The service was proactive in its approach to understanding the needs of different groups of people and delivered care in a way that met the needs of patients. We saw evidence during our inspection where staff made considerable efforts to meet the needs of vulnerable patients and those with complex needs. Waiting times and cancellations were minimal and staff took appropriate action to rebook procedures for patients in the event of cancellations. There was a well-established complaints procedure which was well publicised and patients felt comfortable in raising complaints and concerns.

There was a clear vision and set of values which was publicised by the trust. All staff we spoke with were aware of the ‘DCHS Way’ which reflects the vision and values. There was a good governance structure in the service and there was a flow of information that went both ways. Risk was assessed at all levels and residual risks were held on a trust risk register, which all staff had access to. There was positive leadership in the service and staff demonstrated high levels of satisfaction stating they felt appreciated and supported in their roles.

Updated 27 September 2016

End of life care services at this trust was rated as good overall.

Safety was rated as good. Patients were protected from avoidable harm; staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and, arrangements to minimise risks to patients were in place. Patients were protected from abuse; staff had an understanding of how to protect patients from abuse, could describe what safeguarding was, and the process to refer concerns.

We rated the effectiveness of this service as good. Patients received effective care and treatment that reflected current evidence-based guidance, standards and best practice. Patients had a comprehensive assessment of their needs, which included pain management, nutrition and hydration and physical and emotional aspects of their care.

Care from a range of different staff, teams and services was coordinated effectively; there was effective multidisciplinary working, with staff, teams and services at this trust and external organisations working in partnership to deliver effective care and treatment.

Staff understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005; this was reflected in the ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) orders reviewed during our inspection.

The care provided to patients in end of life care services was good. Patients were truly respected and valued as individuals and were empowered partners in their care. Feedback from patient’s, relatives and carers was consistently positive and there were many examples of staff going ‘above and beyond’ when delivering care.

We found the responsiveness of end of life care services to be good. Patients' needs were mostly met through the way end of life care was organised and delivered. However, the rapid discharge of those patients expressing a wish to die at home was not monitored. We could not therefore be assured this was happening in a timely way.

The leadership of end of life care services was good. This was an evolving service with a developing vision and a strong focus on patient centred care. There were robust mechanisms in place to share learning across end of life care services. However, not all incidents and complaints specific to end of life care had been identified and used to improve the quality and safety of end of life care services and, good practice was not always recognised and widely shared across end of life care services.

Updated 27 September 2016

Overall, we rated urgent care services provided by the minor injury units as outstanding.

Feedback from patients was continually positive about the way all staff treated them. There was a strong, visible person-centred culture; patients described being treated as “individuals” rather than a “number”. Patients and relatives told us all staff go the extra mile and the care they received exceeded their expectations. One relative of a child told us they chose to attend the unit with their child as staff “understand" the needs of children and their experiences have always been “positive”. They told us staff went “above and beyond” what was expected of them. Other patients described being treated like “family” describing the service as “absolutely brilliant” and said the care was more “attentive” than at bigger hospitals. Staff across all units were highly motivated to offer care that was kind, compassionate and promoted patient’s dignity. During our inspection we were particularly impressed with the interpersonal skills demonstrated by staff.

The services provided by the minor injury units (MIUs) were tailored to meet the needs of the individual patient and were delivered in a way to ensure flexibility, choice and continuity of care. Patients could access the service in a way and time to suit them. The units had set up nurse led fracture clinics to reduce the numbers of patients having to transfer to acute hospitals for the management of simple fractures. The MIUs also offered clinics for patients requiring follow up treatment or review of conditions such as burns, foreign body removal, eye problems and wounds. There was a proactive approach to understanding the different needs of people and delivering care to meet those needs. Waiting times and delays were minimal and managed appropriately if they did occur. The service exceeded targets in respect of time spent in MIUs and the time people waited for treatment.

Patients attending MIU were protected from avoidable harm and abuse. We saw effective and reliable systems and processes in place for infection control, medicines management, patient records and assessing and responding to patient risk. The systems and processes were sufficient to protect patients from avoidable harm. We saw an effective system in place to ensure patients received appropriate initial assessment by appropriately qualified clinical staff within 15 minutes of arrival to MIU in line with best practice. Staff across all MIUs were up to date with mandatory training. Staffing levels and skill mix were appropriate to keep patients protected from avoidable harm. The safeguarding of vulnerable adults, children and young people was given sufficient priority. Staff were actively engaged in local safeguarding procedures and worked effectively with other relevant organisations.

Patients’ care and treatment was planned and delivered in line with current evidence based guidance and standards. Staff were qualified and had the skills they needed to carry out their roles effectively. Patients had a comprehensive assessment of their needs, which included clinical needs, mental health, physical health and wellbeing needs.

There was a clear statement of vision and values, driven by quality and safety, staff knew and understood the trust vision and values. Unit managers had the experience, capacity and capability to lead the services and prioritised safe, high quality, compassionate care. There was a high level of staff satisfaction. Staff said they were encouraged and supported to develop, were proud of the teamwork within the units and the willingness to help and support each other and said there was a positive regard for their welfare. Over 30% of the compliments received by the trust related to the positive care and experiences of people attending the MIUs.     

Updated 12 September 2019

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

• We rated responsive and well led as outstanding and safe, effective and caring as good.
• Since our last inspection a comprehensive Derbyshire Integrated Sexual Health handbook containing guidance including termination of pregnancy, screening policy, HIV (human immunodeficiency virus) and PEP (post exposure prophylaxis) was in use in all areas. The handbook complied with BASHH standards and current evidence-based practice.
• The service had made improvements to the results management system and all patients now received their results within eight days of having a test taken. All staff told us that protected time had been given to them to ensure results were managed correctly, this was monitored weekly to ensure the British Association for Sexual Health and HIV (BASHH) standards had been met.
• The service now had systems in place to ensure incidents were reported, investigated and learnt from. Complaints and significant events were discussed at team meetings, meetings, training sessions and clinical governance meetings. Imbedded in the service was protected time for all staff to allow them to attend monthly meetings. Staff told us this was regular practice and if they attended a meeting while off duty they would be paid to do so
• All staff working with children and young people now completed level 3 safeguarding training.
• Since our last inspection young people who booked in to the service but did not wait for a consultation were followed up by clinical staff if they were assessed as vulnerable or if there were any safeguarding concerns. Any young people that attended the clinic when it was closed to bookings at that time were offered an appointment for an alternative date or referred to an alternative service.
• During extremely busy times staff told us the clinic would close to new arrivals (walk ins) and any service users who could not be seen following triage would be offered an appointment to return or referred to another appropriate provider. This action was documented by staff on a Clinic Monitoring Form, which was submitted weekly to the nurse manager and service manager.
• A new system of call monitoring was implemented that allowed information to be collected and audited
• Staff at all levels described leaders as visible, approachable and responsive. They told us managers responded quickly to emails and phone calls if they were not on site, each hub had a senior sister who was responsible for the hub and the peripheral clinics attached to the individual hub. All staff spoken to could identify who was their line manager
• The service now employed a full time Service improvement and Training Lead who was in the process of reviewing audits, developing peer review for all grades of staff and liaising with quality governance teams to support improvement and innovation within the service. The service provided the audit plan for 2019 to 2020 which shows plans to carry out, local and national audits covering a wide range of subjects.
• The service met the internal Appraisal rate of 96% of staff having an appraisal from February 2018 to January 2019. All staff we spoke to, confirmed they had received a meaningful appraisal within the past year and they valued the appraisal process to aid their development
• Service users were able to access care and treatment at a time suitable for them. For example, they could order a test kit and book appointments on line, clinics had walk in slots, there were evening clinics and clinics on a Saturday morning.
• In 2018 the service won clinical team of the year, which is a DCHS initiative.

Updated 27 September 2016

We rated Derbyshire Community Health Services C community learning disability service as good because:

• Patients and carers told us the service was excellent. They told us that staff treated them with respect and compassion. They told us that nothing was too much trouble for staff in the service.
• Staff compliance with mandatory training in the Mental Health Act and Mental Capacity Act was 100%.
• Staff supervision rates were 100%.
• Staff appraisal rates were 100%.
• Staff lone working practices were safe and well embedded within each team .
• Staff sickness rates in the 12 months prior to our inspection was 6%.
• There were no staff vacancies in any of the teams.
• Managers were supportive of staff with difficulties. We spoke with a member of staff who had received support and access to specialist equipment to help him do his job when managers discovered he had dyslexia.
• Managers supported staff in accessing education and training relevant to the service.
• Teams were well-led at a local level and at a senior management level.
• The service had received no complaints in the 12 months prior to our inspection.
• The service had received 33 compliments in the 12 months prior to our inspection.
• Teams could respond the same day to patients in crisis.
• Staff conducted a risk assessment of every patient at initial triage of the patient.
• We saw an excellent example of an adapted ABC chart which a nurse in the Darley Dales team had created. How information is gathered may be different for each person collecting the data and depending on the complexity of the situation. One format involves directly observing and recording situational factors surrounding a problem behaviour using an assessment tool called an ABC chart. An ABC chart is an assessment tool used to gather information that should evolve into a positive behaviour support plan. ABC refers to: antecedent - the events, action, or circumstances that occur before a behaviour; behaviour - the behaviour. Consequences - the action or response that follows the behaviour. The adapted document made it simple for carers to complete by ticking boxes when the patient was at home on leave. This meant that the information staff were gathering from the document was more accurate and detailed.
• Patients had positive behaviour support plans (PBS plans). A PBS plan is a document created to help understand and manage behaviour in patients who have learning disabilities and display behaviour that others find challenging. A PBS plan provides carers with a step by step guide to making sure the patient not only has a good quality of life, but also enables carers to identify when they need to intervene to prevent an episode of challenging behaviour. A PBS plan is based on the results of a functional assessment and uses positive behaviour support (PBS) approaches. A formulation summarises the patient’s core problems and shows how the patient’s difficulties may relate to one another by drawing on psychological theories and principles. The plan contains a range of strategies which not only focus on the challenging behaviour, but also include ways to ensure the person has access to things that are important to them.
• Care records contained up to date, personalised, holistic, recovery-oriented care plans. Patients had contributed to their care plans. Care plans were available in easy-read format if the patient required. There was a reasonable adjustments section in the care record which allowed for the adaptation of documents, such as pictorially.
• Patients had health action plans and communication passports which they could take with them to other services or accommodation providers.
• Staff adhered to relevant national institute for health and care excellence (NICE) guidelines.
• The multidisciplinary teams communicated effectively with each other.
• Patients could self refer to the service as well as be referred by other professionals such as the GP.
• The Quality Always programme provided a robust audit strategy with RAG (red, amber, green) rated outcomes.
• There had been no serious incidents in the 12 months prior to our inspection.
• There had been no never-events in the 12 months prior to our inspection.
• There was clear evidence of learning from when things go wrong.
• The trust scored above the England average for staff who would recommend the trust as a place to work (70% compared to 62% England average) whilst also having a lower number of staff who would not recommend the trust (13% compared to 19% England average).
• The trust scored 12% above the England average for staff who would recommend the trust as a place to receive care (91% against 79%).

However;

• Signage in reception areas was not always available in accessible formats.
• Safeguarding children training was at 48% staff compliance. This was because the trust had initially identified the incorrect safeguarding children training for staff so staff were having to re-attend the training.

Updated 30 March 2022

Hillside ward is an assessment and treatment unit for adults with a learning disability or autism. To meet urgent local need, in September 2021, the service was reconfigured to meet the needs of people with a learning disability from Derbyshire awaiting longer term placements. One person was admitted from a secure environment at very short notice meaning not all the adaptations could be completed before admission. Bespoke, personalised staff teams had been deployed by the trust, Clinical Commissioning Group and Mental Health trust to meet the needs of the people using the service. At the time of our visit, the ward had three people with very high levels of need who were all being nursed in long-term segregation, in isolation from each other. The ward was not accepting further admissions. We carried out this unannounced focused inspection because we had received information raising concerns about the safety and quality of services.

We inspected parts of the safe and well led domains to gain assurance that people were being cared for safely. We did not fully rate this service at this inspection. The previous overall rating of good remains. However, we did re-rate the safe domain as requires improvement.

We found:

• Staff completed personalised care plans, positive behaviour support plans and risk assessments for people using the service. Staff had completed and kept up to date with mandatory training.
• Managers had increased available funds to purchase suitable resources and had agreed a full time occupational therapist for a time limited period.
• Although the service had experienced a loss of staff, existing staff and managers ensured the unit was adequately staffed.
• Managers had effective oversight of the care of all the people on the ward. Managers had put systems in place to manage the three separate staff teams. Agency staff worked to Hillside ward’s risk assessments and care plans and saw the ward manager as having overall responsibility for care.
• Staff cared for people with respect and kindness. Staff ensured they applied the safeguards from the Mental Health Act Code of Practice to all three persons in long-term segregation.

However:

• The ward environments were not always clean and well maintained. The ward was not designed to meet the needs of people who required a secure environment. Making structural alterations to the layout of living areas was difficult due to the nature of each person’s presentation.
• Staff supporting people using the service were not all trained in the same techniques for restrictive interventions. There were insufficient alarms for all the agency staff on the ward.
• People who used the service had different multidisciplinary arrangements in place as the service was short of permanent learning disability doctors and had to arrange cover from other services.
• The morale of some of the trust staff was low at the time of the inspection.

How we carried out the inspection

Hillside is an assessment and treatment ward on the Ash Green learning disability hospital site. It is commissioned to look after six people from the age of 18 upwards, with expressing distress and/or agitation. At the time of our inspection, all three people were detained under the Mental Health Act. Both detained people and informal people can be admitted to the ward.

The ward had recently admitted two people who had previously been accommodated in secure wards outside of Derbyshire. When we inspected, the ward had three people, each nursed in long-term segregation. Managers had made changes to the layout of the ward to facilitate this. Managers had also decided there would be no further admissions until the three people using the service had moved to new placements.

Due to the high levels of need of the current people, there were separate arrangements for each person. Staff from Hillside ward supported one of the people while staff from two separate agencies supported the other two. These arrangements had been supported by the local Clinical Commissioning Group (CCG) as part of a system response to the urgent need to provide placements for vulnerable people with learning disabilities.

We carried out this inspection because we received concerns relating to staffing, care planning, restraint and staff engagement. We interviewed five managers, 14 staff and one advocate and reviewed all three care records.

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

We were able to speak to one person using the service on the day of our inspection and were able to get feedback from the advocate for the other two people. We spoke briefly whilst the person was interacting with staff.

Updated 27 September 2016

We rated Derbyshire Community Health Services NHS Foundation Trust as good because:

• Patients and carers were positive about the standard of care and described the care as excellent.
• Wards were clean, clutter free and safe.
• De-escalation techniques such as distraction, talking and guiding patients to quiet areas were widely used to manage patient behaviours.
• Staff undertook both physical and mental health assessments on admission. Staff updated assessments frequently as patient needs changed.
• There was a range of mental health professionals available to patients. All wards had access to psychological therapies and social work input.
• Patients and carers were able to give feedback on the service they received via comment boxes and meetings.
• Access to advocacy was available to all patients on all wards
• Effective and detailed handovers took place on all wards. Handover meetings gave staff the understanding of current patient need.

However:

• Patients were not given copies of their care plans.
• On all four wards there was no systematic recording relating to section 17 leave. We noticed old section 17 leave forms not crossed through.
• Staff did not have access to the computer care recording system used by Derbyshire Healthcare NHS Foundation Trust, therefore did not have access to all patient information.