Derbyshire Healthcare NHS Foundation Trust

Updated 2 November 2023

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.

Updated 10 December 2025

Date of assessment: 20 and 21 January 2026

Derbyshire Healthcare NHS Foundation Trust provide long stay/rehabilitation inpatient mental health wards for working age adults. The service is located at Cherry Tree Close on the trusts Kingsway Hospital site in Derby. Care and treatment is provided for people who may be detained under the Mental Health Act 1983, and informal patients.

Cherry Tree Close is a mental health rehabilitation and recovery unit, providing assessment, care and treatment for up to 23 people. The accommodation is open which means patients could enter and leave of their own free will, and comprised of five single sex, self-contained bungalows for either four or five men or women. An administration office is located in the centre of the unit.

We assessed all 33 quality statements across the five key questions: safe, effective, caring, responsive, and well-led. The service had last been inspected in June 2016 and had been rated Good. Following this assessment, it has remained Good.

Cherry Tree Close provided a safe, therapeutic, and personalised environment focused on rehabilitation and community reintegration. The environment was clean, well-maintained, and appropriate for the care and support it provided.

Care and treatment were delivered to a high standard. Staff demonstrated skill and innovation, delivering a wide range of interventions, including psychological therapies, vocational and educational support, and structured activity programmes. Patients had made consistent progress towards independence and personal goals, with proactive risk assessments and an effective management structure in place.

Patients told us they had felt empowered, fully involved in decision-making, and supported to develop independence and control around their care. Were appropriate families were involved, and staff supported patients to maintain meaningful community connections and networks.

Leaders were visible, and focused on innovation, continuous improvement, and staff wellbeing. Staff felt enabled, valued, and supported to deliver high quality care.

Mental Health Act Mental Capacity Act Compliance Summary

During our assessment, we evaluated the service’s compliance with both the Mental Health Act (MHA) and the Mental Capacity Act (MCA). Staff demonstrated a strong understanding of the MHA and its Code of Practice, applying it confidently when admitting and managing detained patients to ensure care remained lawful and patients’ rights were respected. Governance and oversight of MHA use were robust, with clear escalation pathways, regular reviews, and effective monitoring arrangements. Patients detained under the MHA were supported to engage in decisions about their treatment, with access to independent advocacy and second opinion appointed doctors where required, providing safeguards for those who lacked capacity or were subject to treatment under legal frameworks. There was no evidence of systemic overuse or misuse of restrictive powers or practices, and leaders emphasised patient-centred decision-making when restrictions were necessary.

Staff consistently assessed patients’ capacity under the MCA to make specific decisions using the two-stage test and documented these assessments thoroughly. When patients lacked capacity, staff made decisions in their best interests after consulting the multidisciplinary team, families, and advocates. They clearly recorded the rationale, who was consulted, and what options had been considered. Reasonable adjustments were made to support patients in understanding and involvement in decision-making, including easy-read materials, interpreters, and adapted communication methods. Governance of the MCA practices were effective, with regular audits of capacity assessments and best-interest decisions. Staff received ongoing training in MCA, human rights, and equality to ensure decisions upheld patients’ rights and dignity.

Overall, the service demonstrated good compliance with both the MHA and MCA. Staff applied legal frameworks appropriately, maintained a balance between care, protection, and autonomy, and ensured patients were involved as much as possible. Governance systems supported compliance, and the service showed a clear commitment to respecting patient rights which ensured the delivery of safe, effective and person-centred care.

Updated 28 May 2025

Date of Assessment: 19 to 21 August 2025. This was a scheduled assessment.

The Kedleston Low Secure Unit provides a low secure service for male patients. Its purpose is to deliver intensive, comprehensive, multidisciplinary treatments and care by qualified staff and healthcare assistants. The service provides care for men aged 18 years and above who have a mental disorder and are detained under the Mental Health Act 1983. They require treatment in a specialist low secure service and usually have complex and challenging forensic and mental health needs. There are 2 wards at the Kedleston Unit: Curzon is the admission and assessment ward, and Scarsdale is the rehabilitation ward. Curzon Ward has 8 beds, and Scarsdale Ward has 12 beds. Bedrooms on Scarsdale Ward have ensuite shower, toilet and wash hand basin. Bedrooms are not ensuite on Curzon Ward and patients have access to multiple shared bathroom facilities.

Forensic inpatient or secure wards were last rated as Good (published September 2018). This was an unannounced assessment, which means the provider was not told an assessment was going to be taking place beforehand. During this assessment, we looked at all quality statements across all 5 key questions. As we assessed all quality statements at this visit, the current rating reflects the findings from this assessment. We rated this service as Good.

Updated 25 March 2025

Date of Assessment: 28 April to 14 May 2025. This was a scheduled assessment.
Derbyshire Healthcare NHS Foundation Trust provide wards for older people with mental health problems for people in Derbyshire at Bluebell Ward, Tissington House and Cubley Court. This was the first assessment for all three services for older people with mental health problems provided by Derbyshire Healthcare NHS Foundation Trust.

Bluebell Ward is purpose built 12-bed inpatient unit for older adults with functional mental health needs, such as depression or schizophrenia. The ward is a mixed-sex unit, with all bedrooms offering single occupancy and en-suite bathrooms. This ward was never inspected before.

Tissington House is an 18-bed assessment and treatment ward for individuals over the age of 65 with functional mental health problems, such as depression, schizophrenia, mood disorders, or anxiety. The ward is a mixed-sex unit with gender-specific sleeping areas, and all bedrooms are single rooms with en-suite facilities. This ward was never inspected before.

Cubley Court is a 36-bed assessment and treatment unit for both men and women with acute organic illnesses, such as dementia, who require inpatient care. The unit is divided into male and female wards, each offering single-sex accommodation and a shared lounge area. The service was last rated as Good (published September 2018). The report was published following Care Quality Commission’s (CQC) old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics.

This assessment has been completed following CQC new approach to assessment; Single Assessment Framework (SAF). This was an unannounced assessment, which means the provider was not told an assessment was going to be taking place beforehand. During this assessment we looked at all quality statements across all 5 key questions. As we assessed all quality statements at this visit the current rating reflects the findings from this assessment. We rated this service as good.

Updated 27 December 2024

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.

Updated 6 March 2020

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.

Updated 29 September 2016

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.

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Updated 6 March 2020

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.

Updated 28 September 2018

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.

Updated 6 March 2020

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.

Updated 6 March 2020

• 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.