Dorset Healthcare University NHS Foundation Trust

Updated 31 July 2019

Not used

Updated 31 July 2019

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

• We rated the trust outstanding overall because over the past four inspections we have seen a consistent pattern of progressive improvement in the quality of core services that is reflected in the ratings of these services.
• We rated the trust outstanding overall for the key question is the trust well-led due to the inspirational leadership provided by the senior team. In rating the trust overall, we took into account the current ratings for the services not inspected this time.
• At this comprehensive inspection (2019) we found the trust had made the required improvements in the safe key question to increase its rating to good.
• We rated the trust as outstanding overall for the key questions are services caring and are services well led. In addition, we rated the trust good for safe, effective and responsive. We rated one out of six core services that we inspected as outstanding overall which was community health services for adults.
• We were particularly impressed by the strength, knowledge and integrity of the leadership at the trust. They had a comprehensive knowledge of current priorities and challenges and took prompt action to address them. The board was visible and supportive to the wider health and social care system. Reports from external sources including NHS England/Improvement and commissioners were consistently positive. The trust had quality and sustainability as its top priorities.
• We were also impressed with the trust attitude towards and application of innovation and service improvement. The delivery of high-quality care was central to the trust values and all aspects of running the core services. We got a true sense of the trust’s main focus was on providing care that truly benefited patients and carers and supported the wider system. There was a dedicated quality improvement (QI) team which engaged frontline staff and empowered and inspired them to use innovative means of improving services.
• There was a strong learning culture within the trust and staff showed caring, compassionate attitudes, were proud to work for the trust and were involved in the development and improvements within the trust. Staff embraced and modelled the values and behaviours in both mental health and community health services. Throughout the trust staff treated patients and each other with dignity and respect. Staff morale was high in the services. Staff told us they felt respected, supported and valued by their managers and the trust. Staff used creativity to ensure patients were treat well and their care needs listened to.
• Staff, patients and carers were actively involved in the development of the services, and the trust were creative in engaging all the relevant people. Senior leadership in the trust had good relationships with partner organisations and were engaging positively in the wider health systems. The trust had a mixture of highly experienced and new senior leaders with the skills, abilities, and a commitment to provide high-quality services. The executives and non-executives presented as a strong unified board.
• Two of the wards for older people with mental health problems (Herm and St Brelades) had been awarded the Gold Standard Framework (GSF). These were the first older adult’s mental health unit in the country to receive this award. All community hospitals in the trust were GSF accredited. The GSF is a systematic evidence based approach to ensuring all patients approaching end of life receive the best possible compassionate care in the best possible place. This meant patients approaching the end of their lives on these wards could remain on the ward rather than be transferred to another place to receive this care.
• The trust had effective systems and processes in place for identifying risks and how to eliminate or reduce them. Staff had training in how to recognise and report abuse and applied it. The trust had an innovative focus on reducing incidents of falls and pressure ulcers and were committed to improving services by learning when things went well or wrong. The pharmacy management leadership team ensured patients were safe and good governance was in place. Medicines safety risks were identified, actioned and shared appropriately within the trust and with external partners. Learning actions from medicines incidents and audits were shared across the trust.
• Excellent governance arrangements were in place in relation to Mental Health Act (MHA) administration and compliance. One of the non-executive directors had a legal background and was highly experienced and chaired the MHA monitoring group. Minutes demonstrated that it covered an appropriate range of subjects including monitoring of MHA review report findings. The trust ensured they were responsive in their approach to issues raised within these reports. There was clear, robust and effective multi-agency working arrangements around the MHA. A regular programme of MHA audits took place. Where MHA audits had identified gaps in knowledge the MHA lead provided targeted training and support.
• Trust premises were clean and well maintained although several buildings were not fully fit for purpose. There was an estates strategy in place and the trust had a clear idea of what needed to be done but planning permission was required for many the changes which was proving difficult to get due to the nature of the buildings. We saw during our core service visit that the gardens in Herm and St Brelades wards were not dementia friendly and unsafe in some areas. However, this was addressed quickly and funding made available to improve these areas further. Staff were clear on their responsibility to mitigate safety and ensure dignity of patients in shared accommodation. During our well led inspection we saw many improvements had already been made to these areas.
• Staff at all levels worked well with each other and external organisations to provide care and treatment to patients based on national guidance. Staff generally kept clear records of patients’ care and treatment and confidentiality was maintained. Patients had access to psychological support and occupational therapy. The physical healthcare needs of patients within mental health services was excellent. Patients in community health services benefitted from outstanding care and support from staff.

However:

• Recruitment in some areas (e.g. community CAMHS) remained a struggle. The trust was working creatively with commissioners to resolve this and the implementation of a new care model in CAMHS services should ease some staffing pressures.

• A bed was not always available when needed on return to the acute mental health wards. There had been some inappropriate placements on the wards, due to the wards not having control over bed management.

• There remained shared accommodation on one acute mental health ward and some of the older people’s mental health inpatient wards. Bedrooms and shared accommodation did have lockable storage facilities for clothing and possessions and the provider had taken action to mitigate the adverse effects of privacy or safety. Capital funding had been secured with a plan in place to remove all shared accommodation.

Updated 31 July 2019

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

• The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.
• Individual care records were electronic, integrated and consistently managed. Patients were protected against the risks of unsafe or inappropriate care and treatment arising from incomplete patient records or inability to access electronic patient records. This was a marked improvement following the inspection in October 2015
• Staff understood their responsibilities to raise concerns, record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate. There was evidence following incident investigations that duty of candour had been applied. Therefore, patients were protected by a strong comprehensive safety system with the focus on openness, transparency and learning when things went wrong.
• Health and social care were truly integrated. Services were planned and met patient’s needs as care pathways were person-centred especially for patients with complex health and social care needs. Referral criteria to community services was clear and managed through a health and social care single point of access. This was a marked improvement on the last inspection in October 2015.
• Leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Managers made sure they had staff with a range of skills needed to provide this and staff had appropriate training to meet their learning needs to cover their scope of work.
• There was a drive to increase skills of staff to provide effective care and treatment for patients. This included volunteers who were recruited where required and trained and supported for the role they undertook.
• There were good arrangements for supporting and managing staff to deliver effective care and treatment. The trust provided comprehensive clinical supervision for staff which they undertook regularly.
• Staff from different health and social care disciplines worked together as a team to benefit patients. This multidisciplinary working supported effective care planning and delivery especially for adults with long term conditions and complex needs.
• Staff understood and respected the personal, cultural, social and religious needs of patients. There was a strong patient-centred culture. We observed kind, compassionate and respectful interactions with patients and their relatives in both trust clinics and in their own home.
• Feedback from people who used the service was continually positive. Patients, their relatives and carers we spoke with told us, without exception, that the staff were always kind. Staff looked for ways to communicate with patients and those close to them to reduce and remove barriers to communication.
• Staff made efforts to involve patients and those close to them in decisions about their care and treatment through personalised care planning. Staff communicated well with patients so that they understood their care, treatment and condition, and any advice given. Staff took time to interact with relatives and carers. The home visit appointments and rehabilitation fitness sessions we observed did not feel rushed. Staff said that it is about “what is important” to patients and that patients had “ownership” of their care plan.
• Services were tailored to meet the needs of individual patients and delivered in a way to ensure flexibility, choice and continuity of care. Patients received personalised care that was responsive to their needs. Patient records contained assessments that were carried out with the patient and those important to them.
• The service worked with other health and social care providers to meet the needs of patients, particularly those with complex needs, long term conditions or life limiting conditions. The involvement of other services was integral to how services were planned and met patient’s needs.
• Advanced care planning was well established in the community services.
• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers held, or were studying for, management qualifications and had community and primary care experience.
• The trust had systems and processes to ensure staff met the duty of candour. Duty of candour was included in the trust's induction programme which ensured all new starters were provided with relevant information. Duty of candour has been integrated into the Root Cause Analysis and pressure ulcer training packages. This was a noticeable improvement from the last inspection in October 2015.
• There were high levels of staff satisfaction. Staff felt positive and proud to work for the trust and spoke highly of the culture. Staff felt they were in a much better position since the last inspection in October 2015.
• The trust was very proactive in supporting development opportunities for staff. There was also a strong emphasis on the safety and well-being of staff.
• Staff were engaged so that their views were reflected in the planning and delivery of services. At the last inspection in October 2015, staff had felt that changes were made without consultation and without being made aware that changes were happening. At this inspection, staff were much more positive.

However:

• The single point of access was triaged by a trained healthcare professional. In contrast, calls to the night nursing team are taken and collated by a healthcare assistant. Staff felt a trained member of staff at night to triage would provide a more comparable service to the single point of access team.

Updated 13 April 2018

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

• The three services inspected improved from a rating of requires improvement to good overall.

However:

• We also found areas for improvement in each of the services we inspected this time. See areas for improvement section above for details.

Updated 13 April 2018

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

Updated 13 April 2018

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

Updated 31 July 2019

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

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• There were effective systems to protect patients from harm. Incidents were discussed regularly in team and governance meetings. There was an open culture of reporting, and learning was shared with staff to make improvements.
• Infection risks were well controlled, and there was enough suitable equipment which staff were trained to use.
• Staff worked together as a team to deliver effective, patient-centred care and improve patient outcomes. Treatment was planned and delivered in line with current evidence-based guidance.
• Staff treated patients with kindness, dignity and respect. Patients were involved as partners in their care and were supported by staff to make decisions about their treatment.
• The needs and preferences of different people, including the local population, were considered when designing and delivering services.
• Patients were monitored to maintain their safety and meet their health needs. The trust aimed for all patients to be seen and assessed as fit to wait or, in the case of the urgent treatment centre, triaged within 15 minutes. The trust monitored performance against this 15-minute standard and it was consistently met.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• The leadership team was knowledgeable about quality issues and priorities, understood what the challenges were and acted to address them.
• There was a strong culture of openness, transparency and teamwork within the organisation. Staff felt well supported by managers and told us that they encouraged effective team working across the hospital. Senior staff were visible, approachable and supportive.

However:

• Unplanned lone practitioner working was not always recorded as an incident.
• Not all patient waiting areas gave practitioners a clear view of patients.
• Clinical audits were not done to demonstrate that care and treatment was provided in line with evidence-based guidance, standards and recent best practice guidance.

Updated 13 April 2018

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

A summary of our findings about this service appears in the overall summary.

Updated 13 April 2018

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

A summary of our findings about this service appears in the overall summary.

Updated 13 April 2018

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

• Services were safe. There were effective policies and procedures in place to ensure the safety of both staff and patients.

• Staff had the skills, knowledge and experience to deliver effective care and treatment. Care and treatment followed current evidence based guidance.

• Staff were caring. Patients were treated with kindness, dignity and respect and were involved as partners in their care where possible.

• Services met the individual needs of patients.

• There were effective systems in place to support the delivery of good quality care.

However:

• Access to some treatments, for example, speech and language therapy, was sometimes delayed due to shortages of these staff.

• There was a lack of involvement of patients, carers and their representatives in decision making about, and within, the learning disability service.

Updated 13 April 2018

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

• The core service improved overall from requires improvement to good.

Updated 31 July 2019

• The service provided safe care. Clinical premises where patients were seen were safe and clean, and the physical environment of the health-based place 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 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.
• The mental health crisis service and the health-based place 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.
• Staff working in the mental health crisis teams developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The mental health crisis teams included or had access to a 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 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 service was well-led and the governance processes ensured that procedures ran smoothly.

Updated 13 April 2018

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

A summary of our findings about this service appears in the overall summary.

Updated 31 July 2019

Our rating of this service stayed the same. The rating for safe improved from requires improvement to good. We rated the service as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough staff. Staff assessed and managed risks well. Staff minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented and personalised care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to a range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• 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 planned and managed discharge well and liaised well with services that would provide aftercare.
• The service worked to a recognised model of mental health rehabilitation. There was strong leadership in place and the governance processes ensured that ward procedures ran smoothly.

Updated 31 July 2019

Our overall rating of the service stayed the same. The rating for safe improved from requires improvement to good and the rating for caring improved from good to outstanding.

We rated it as good because:

• The service provided safe care. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance on best practice. 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 patients on the wards. Managers ensured that staff received training and appraisal. The staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
• Herm and St Brelades wards had been awarded the Gold Standard Framework accreditation due to their excellence in end of life care. These wards were the first older people mental health wards in the country to be awarded this. The service met high standards of patient and carer involvement, meeting the wishes of the patients and providing peace of mind to carers and patients.
• The service met all the needs of patients, including those under protected characteristics. Staff treated complaints and concerns seriously and investigated appropriately. Lessons were learned and shared across the teams.
• The service was well-led and the governance processes ensured that service procedures ran smoothly. Leaders were visible on the wards and knew the patients well. Leaders were innovative, and where challenges presented themselves leaders were resilient and able to make positive changes.

However:

• The garden at Herm and St Brelades had presented a hazard, so staff did not allow patients to use it. They had made requests to have the garden maintained but this had not been completed at the time of the inspection. We raised this with the trust leadership team who took immediate action to prioritise this. The lounge at Herm ward was not dementia friendly and patients did not always have their own bedrooms on Alumhurst ward, and there was limited private space for patients. The trust was aware of these issues and looking to eradicate shared sleeping arrangements and improve access to private space in the longer term.
• The service did not always have enough nurses and doctors available. There were problems with the recruitment of registered nurses, particularly on night shifts, and doctors were not always immediately available out of hours.
• Staff did not always manage medicines robustly. There were some missing checks of controlled drugs and emergency medications and gaps in the auditing process of medications on some wards. The trust did however provide assurance that systems were being improved and new electronic prescribing would rectify these issues.
• Female patient accommodation on Alumhurst ward was composed of shared accommodation. Bedrooms and shared accommodation did have lockable storage facilities for clothing and possessions and the provider had taken action to mitigate the adverse effects of privacy or safety. Capital funding had been secured with a plan in place to remove all shared accommodation.

Updated 31 July 2019

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

• The service provided safe care and the ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
• During our previous inspection we identified many ligature risks across the wards which had not been identified or mitigated effectively. During this inspection we found that ligature risks had been addressed and managed. The large garden was labelled as ‘yellow’ which meant patients had to request outside access due to increased risk. If individual patients’ risks were low they could access the garden on their own, but staff would accompany other patients as needed.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
• 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 well-led and the governance processes ensured that ward procedures ran smoothly. Leaders were visible on the wards and knew the patients well. Leaders were innovative, and where challenges presented themselves leaders were resilient and able to make positive changes.

However:

• Staff did not always ensure emergency medicines were consistently checked. We raised this at the time of the inspection and this was rectified immediately.
• When patients were transferred to the seclusion suite on Haven ward from the other wards at St Ann`s hospital, they were escorted through the female corridor on Haven ward. The staff knew this could potentially compromise privacy and dignity at times and staff managed this very well. The trust monitored this each occasion that a patient had to be transferred through this route. This was due to the layout of the ward, and no alternative access was available.
• Sometimes beds were used when patients went on leave and there were no beds for them on their return. The trust told us they were working hard to secure additional estates to create more beds to address this.
• Patient accommodation on Chine ward was composed of shared accommodation. However, staff used good relational security, observations and risk assessments to keep patients safe (relational security is the knowledge and understanding that staff have of a patient and of the environment) and if a patient was assessed as high risk they would be admitted to a single room where possible.

Updated 24 February 2017

We rated substance misuse services in Dorset NHS Trust as Good because:

• Staffing levels were good and there was managerial and team oversight of the safe management of caseloads.

• Staff had visited the homes of all clients with children living at or visiting their home to ensure that the client had safe storage facilities for their medication. Staff in the prescribing teams reviewed prescriptions regularly.

• Staff held multi-disciplinary meetings to discuss referrals, discharge, safeguarding and complaints. Assessments, reviews and interventions were well documented in all care records.

• The teams responded quickly if patients phoned into the service to ensure they received a timely service from both teams in line with the requirements of the Commissioners. Staff members were proactive in contacting clients who did not attend their appointments. Staff held multi-disciplinary meetings to discuss referrals, discharge, safeguarding and complaints.
• In CADAS west, there were a variety of rooms available for staff to see clients. Staff were able to call on interpreters if required, leaflets were available in different languages. There was good disabled access.
• There were managerial systems in place to audit clinical notes to ensure risk assessments and care plans were updated and completed correctly, ensure staff received training and yearly appraisals.

However :

• Managers did not ensure all staff had recorded staff managerial supervision sessions.

• All clients had the opportunity to provide feedback about the services. Clients did not receive written feedback about the outcome of their complaint.

• Clients in the CADAS east did not receive the same service as clients in CADAS west as there was no central hub where they could receive treatment.

Updated 13 April 2018

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

A summary of our findings about this service appears in the overall summary.