Northamptonshire Healthcare NHS Foundation Trust

We rated community-based mental health services for adults of working age as good because:

• Patient records contained comprehensive assessment and person centred care plans. There was evidence of patient involvement in planning treatment and care, and patients confirmed this during interviews.

• Staff adhered to the National Institute for Health and Care Excellence guidelines relating to medication management, physical health checks, perinatal services and treatment of patients with personality disorders.

• Staff supported patients, and gave choice and control in relation to medication options.

• The trust nurtured and encouraged service improvement and innovative practice. Teams provided groups and treatment programmes to aid patient recovery. These included patient led groups.

• Staff demonstrated knowledge and understanding of safeguarding processes, and were able to recognise types of abuse.

• Staff demonstrated a good understanding of the trust lone working policy to maintain personal safety while working in the community.

• Care and treatment environments were clean including clinic rooms and patient waiting areas.

• Patients consistently reported that their allocated workers were responsive to their needs in times of crisis, and that they could contact the team or out of hours services when needed for support.

• Staff were aware of the trust’s speak up guardian, and knew how to raise concerns without fear of reprisals. Staff consistently reported that team morale was good and that they enjoyed their roles.

However:

• At Campbell House the first floor waiting area did not have reception staff and patients did not sign in at the ground floor reception. There was the possibility for patients to be unaccounted for between entering the building and accessing the first floor waiting areas.

• Community teams did not complete environmental ligature risk audits for rooms and waiting areas accessed by patients.

• Emergency medication such as adrenaline was not stored in clinic rooms for use on site or when administering medication in the community.

• From the 37 patient records reviewed for PCRT South teams, some did not contain information as to the patients MHA status. This could affect entitlement to assistance with support with care and housing services

• Some patients told us they had not received a copy of their care plans. The electronic recording system did not indicate when this information had been offered to patients.

• Patient records contained variable levels of recording for crisis plans with these plans incorporated into their care programme approach (CPA) reviews, with apparent confusion between CPA reviews and care plans. Care plans in some records were not individualised document.

• PCRT South, Daventry and South Northamptonshire had closed access to the psychology waiting list for new referrals for those patients who required long term intervention. The psychologists were available for assessment and advice, short-term work, urgent referrals and joint casework. No indication of timescales was given for when the team would be able to accept new referrals for long term pieces of work.

Overall rating for this core service

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

• 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 in what they did.
• The community dental service was well led. We saw a service that had strong and effective clinical leadership at its heart and there were effective governance and risk management structures in place. We found a local operational management team that was effective and visible and the working culture appeared open and transparent.
• We saw that the way staff delivered care and organised the running of the service embodied the organisation’s overall vision of how care should be delivered. Staff told us they were well supported by the management team and that they could raise any concerns at any time and reported that their concerns were always dealt with in a timely manner.
• Staff protected patients from abuse and avoidable harm. We saw that there were effective systems in place for identifying, investigating and learning from patient safety incidents. Effective infection control procedures were in place and followed published guidance in relation to primary care dental services. We observed an environment and equipment that was clean and well maintained and medicines and emergency equipment were available at each site we inspected to deal with medical emergencies.
• The dental services were effective and focused on patients’ and their oral health care. The care provided followed current professional guidance in relation to special care dentistry, best practice prevention, general anaesthesia and conscious sedation.
• To help address the needs of more vulnerable members of the community in Northamptonshire we saw an effective and outward facing oral health promotion unit led by an enthusiastic and committed clinical lead. For example, this service reached out to vulnerable groups in care homes, adults with a learning difficulty, homeless, those with drug and alcohol dependence, those living with dementia and chronic obstructive pulmonary disease support groups. We saw a comprehensive package of training that had been developed by the clinical lead to assist care home workers in maintaining good oral health to the residents in the care home.
• Staff responded to patients’ needs at each clinic we inspected. The service kept treatment delays for routine dental treatment within reasonable limits through effective resource management. Effective multidisciplinary team working ensured the service provided patients with care that met their needs, at the right time and in the right place.
• Patients, relatives and carers reported that they had positive experiences of care within the service. We saw good examples of staff providing compassionate and effective care. We also saw effective interactions taking place between individual staff members which resulted in a happy yet calm working environment.

We rated end of life care services at this trust as good overall because:

• Patients were protected from avoidable harm. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. 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 and could describe what safeguarding was and the process to refer concerns.

• Patients received effective care and treatment that reflected current evidence-based guidance, standards and best practice.

• Patients had comprehensive assessments of their needs, which included nutrition and hydration and physical and emotional aspects of their care.

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

• Staff understood the 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 orders reviewed during our inspection.

• The care provided to patients in the end of life care service was good. Patients were truly respected and valued as individuals and were empowered partners in their care.

• Feedback from patients, relatives and carers was consistently positive and there were many examples of staff being caring, compassionate and providing dignity in a respectful manner.

• Patients’ needs were mostly met through the way end of life care was organised and delivered.

• The service was evolving, with a developing strategy. There were robust mechanisms in place to share learning across end of life services.

However,

• The trust did not collect data to establish how rapidly patients were discharged from inpatient services and how often delayed discharges occurred.

Overall rating for this core service Requires Improvement

We rated community health inpatient services as requires improvement because:

• Vacancies existed throughout the service and bank and agency staff were required to fill gaps in service provision. Active recruitment was ongoing but staff shortages remained on the service risk register. From November 2015 to December 2016, staff reported 23 incidents, which related to staff shortages, with one categorised as moderate harm and six low harms.The moderate harm incident was not attributable to the trust.
• The environment and room layout on some wards meant not all patients were easily observed. Some wards had significant health and safety hazards including leaking roofs, heating failures and trip hazards. There was insufficient storage space to store equipment safely.
• Prescribed medicine was not always signed for and staff were unsure if patients had received medicine as prescribed.
• Staff did not report all medicine related incidents in line with trust policy. There was no agreed training and assessment protocol for staff to undergo when they had made drug errors. Individual wards made their own decisions regarding staff competence following a drug error.
• Staff did not always review patients’ prescribed medicine at the correct time.
• Medicine was not always stored in line with best practice guidance or trust policy.
• The service did not partake in national audits and so there was no benchmarking against other similar services and improvements could not be measured and compared.
• There was a high number of delayed discharges. At the time of our inspection, 46% of all patients were medically fit to go home but were waiting for assessments by the NHS or waiting for care packages. On average, 30% of all discharges over the year were delayed.
• Stroke patients were treated on different wards despite an action plan from August 2016 to accommodate all stroke services on one site. Following our inspection, the trust provided evidence that it is was working with commissioners to move stroke services to one site only.

However:

• The service had a good safety record. There had been no reported serious incidents or never events from September 2015 to September 2016.
• The service met its target for mandatory staff training and staff appraisals.
• Additional training was available for therapy staff and healthcare assistants. These provided opportunities for staff to develop their role and take on more responsibility. This improved the staff skill mix on each shift.
• Quality of care was assessed and monitored through a quality dashboard. This involved several local audits and action plans. Audit results were discussed at governance meetings and action plans were in place to address issues identified.
• Multi-disciplinary working across the service was good. Therapy assistants worked seven days a week.
• Patients and their families were involved in planning care and setting rehabilitation goals and they told us that they were very happy with the care they received.
• Patients received a mental capacity assessment on admission. Patients living with dementia or other cognitive impairment were easily identifiable to staff. Some wards had adapted their environment to cater for patients with living dementia.
• A core group of doctors and GPs provided care during normal working hours. The doctors were visible and accessible to patients, relatives and staff.
• The service responded positively to our February 2015 inspection. Staff told us about the improvements made, and how they had addressed some of the issues we identified. Notice boards in public areas displayed the changes that had been made and highlighted work still in progress.
• There was visible leadership in each area. Staff we spoke with told us they knew who their service leaders were and that they were accessible to them. Staff said they felt supported in their roles.

Overall rating for this core service Good

Overall, we rated the children, young people and family service as good. We found that:

• Despite staffing pressures due to vacancies, staffing levels generally met patients’ needs at the time of the inspection.

• Staff understood their responsibilities to raise concerns and record and report safety incidents, concerns and near misses and adhered to safeguarding policies and procedures.

• For staff training, the overall compliance rate was 88% and this was comparable to the trust target of 90%.

• Individual care records were written in a way that kept patients safe from avoidable harm. For example, records were maintained on the trust’s electronic record system and staff were able to access the system and update records.

• Generally, arrangements for the handling of medicines kept people safe from avoidable harm. The servicing arrangements for equipment were generally effective.

• There were reliable systems in place to prevent and protect patients from healthcare associated infection.

• Care and treatment were planned and delivered in line with current evidence based guidelines, standards, best practice, and legislation.

• Clinical audits were undertaken and outcomes used to drive improvements in the service.

• The service delivered all aspects of NHS England’s Healthy Child Programme and had Baby Friendly Initiative breastfeeding stage 2 accreditation.

• Staff had the skills, knowledge, and experience to deliver effective care and treatment.

• There were suitable arrangements in place to enable staff to receive professional development, supervision and appraisal. Multiagency working across teams was positive and effective.

• Staff worked together to assess and plan ongoing care and treatment in a timely way when patients moved between teams or services, including referral, discharge and transition.

• Consent was obtained in line with legislation.

• Staff involved children, young people and those close to them in all aspects of their care and treatment.

• Staff were committed to empowering young people and provided them with appropriate information and support to enable them to make decisions around the care they received.

• The service reflected the needs of the local population and provided flexibility, choice and continuity of care to meet needs of the local community.

• Generally, patients had timely access to initial assessment, diagnosis or urgent treatment.

• There were positive adjustments in place when monitoring and responding to patients with a learning disability.

• Complaints’ processes were effective.

• Front line staff described their senior managers as being supportive, visible and approachable and provided an open door policy.

• Staff were aware of the vision and strategy for children and young people’s services and supported the changes to provide a more child centred service.

However, we also found that:

• Arrangements for storing some medicines, such as vaccines storage in cool boxes, did not always keep people safe. Staff took immediate action to address this concern.
• The service undertook child protection medical assessments but had no standard operating procedure for these assessments.

There were 233 children waiting on the attention deficit hyperactivity disorder waiting list and 127 patients on the autism spectrum disorder waiting list. However, the number of children on the waiting list had reduced and there was an action plan in place to monitor the waiting list.

Overall, we rated this service as good because:

• There were processes in place to measure safety performance. The majority of patients that used community health services for adults received harm free care.
• There was a good reporting culture across most services. Staff were encouraged to report incidents and always received feedback from incidents they had reported.
• Medicines were stored securely and there were robust arrangements to manage medicines across services.
• Care was provided in accordance with evidence based guidance, standards, best practice and legislation.
• We observed effective multidisciplinary working to provide co-ordinated patients care.
• The service reported good performance in a number of national audits such as podiatric surgery.
• Services were planned and delivered to meet the needs of patients and those of the local health economy.

• Staff morale was good. Senior nurses were visible to staff and staff said they felt respected and supported by their managers and colleagues.

• The service scored highly in the trusts “I want great care” questionnaires with 94% of patients saying they would recommend the service to their family and friends.
• Staff competencies were based on best practice guidance.
• Most staff had received an appraisal.
• The intermediate care team facilitated early discharge from hospital where a health monitoring or rehabilitation need had been identified.
• Patients were treated with respect and kindness, and their privacy and dignity was protected. Patients understood their care and were involved in making decisions about their care.
• Patients were seen for an initial assessment in a timely manner once they had been referred.

However:

• Not all risks to patients and staff had been identified, assessed, monitored and mitigated. We found out of date equipment and medical consumables in storage cupboards and treatment rooms within the phlebotomy service.
• Infection prevention and control processes were not always being followed. We found a visibly dirty treatment room within the phlebotomy service and dedicated hand-washing basins contained personal items.
• Community nursing teams did not routinely monitor patients for signs of deterioration.
• Not all staff had the appropriate level of safeguarding training. Some staff were treating children within the physiotherapy and tuberculosis services without the level of safeguarding training required.
• Not all staff had received mandatory training. Mandatory training compliance did not meet the trust target of 90%.

• Not all staff had received Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training.
• The podiatric surgery service did not audit the five steps to safer surgery World Health Organisation checklist.

• The phlebotomy service was not assessed or monitored. There was a lack of oversight of the service and it had not been delivered in line with the service level agreement with commissioners.
• There was no overarching strategy for planned and unplanned care. Staff had not been involved in the development of the trust strategy and not all staff were aware of the trusts visions and values.
• Some services had a high number of patients that did not attend their appointment without informing the service prior to their appointment time.
• Complaints were not always responded to within a timely manner.

We rated community-based services for people with learning disability and autism as good because:

• The trust employed sufficient numbers and disciplines of staff including psychiatrists, nurses, psychologists, occupational therapists, physiotherapists and speech and language therapists to meet the needs of people who used services.

• The trust had policies in place to assess and manage risk to staff, a risk register was in place and clinical and safety audits were completed monthly.

• Teams were able to offer a wide range of therapies across a number of disciplines.

• Teams worked closely together and with other departments and external agencies.

• People who used services and carers were consistently positive about staff and the support they had received from the service.

• Staff were highly motivated and regularly went the extra mile to support people who used services.

• People who used services were fully involved in writing their care plans and action plans. Staff provided care plans and treatment information in easy read and visual formats.

• People referred to the service were assessed within the timeframe set by the trust and the intensive support team were able to respond quickly to urgent referrals.

• The trust encouraged involvement and feedback from people who used service and their carers including recruitment of staff.

However:

• Staff reported 46 people were waiting for access to psychological therapies, some of whom had been waiting for over 40 weeks.

We rated Community-based mental health services for older people as requires improvement because:

• There was no system in place to ensure that patients received the required annual health checks, including blood tests. Staff did not know whether this was the responsibility of the service or of the GP.

• Staff were not supervised and appraised in line with trust policy. When we visited the service the compliance rate for supervision was 43%. The compliance rate for appraisals was 75%. However, the trust submitted data following the inspection and these figures had improved.

• Compliance with mandatory training for the service was 78%, which fell below the trust target of 90%.

• Sixty-seven per cent of staff were trained in the Mental Capacity Act. This fell below the trust’s target of 90%. Staff did not consistently document mental capacity assessments and best interest decisions in care records when they were required.

• Managers did not have assurance systems in place to monitor and audit the quality and performance of the service.

• The consultant post at Corby and Kettering had been vacant for over two years. Locums covered this post but changed every few weeks. This meant that appointments were not always available when needed.

• The service did not have information leaflets readily available in other languages. Staff told us they had to request these from the trust communications team.

However:

• Ninety per cent of staff were trained in safeguarding and knew how to respond to any safeguarding concerns.

• Staff responded promptly to deterioration in patients’ health. Staff worked flexibly to respond to changes in patients’ needs.

• The service mostly followed National Institute for Health and Care Excellence (NICE) guidelines for the treatment of Alzheimer’s and dementia. The service offered psychological therapies recommended by NICE.

• Patients told use that staff treated them with respect and were kind and caring. Patients felt that staff listened to them and were helpful.

• The service was meeting their referral to assessment targets. Staff discussed new referrals in the weekly multi-disciplinary meetings and prioritised patients who needed seeing urgently.

• Managers ensured staff reported all incidents, safeguarding, and complaints.

• Managers and staff had the ability to submit items to the risk register.

We rated specialist community mental health services for children and young people as good because:

• All patients using the service had a comprehensive risk assessment and care plan, which was regularly reviewed and updated.

• The service protected children and young people from abuse through clear safeguarding policies and procedures.

• The service complied with local safeguarding children board procedures and appropriate national guidance.

• Staff, including temporary staff, had undergone a Disclosure and Barring Service check (or local equivalent) and were checked against the Protection of Children Act register before appointment.

• Staff used nationally recognised assessment tools.For example, the child and young people self-harm pathway, and completed integrated assessments with acute hospital staff.

• Staff provided a range of therapeutic interventions in line with National Institute for Health and Care Excellence (NICE). For example cognitive behaviour therapy provided by Improved Access to Psychological Therapies training practitioners.

• Regular team meetings took place, and staff told us they felt supported by colleagues.

• Young people and their carers reported they were treated with dignity and respect and gave positive feedback about staff.

However:

• Interview rooms were not fitted with alarms at any of the locations we visited. Staff mitigated this by always telling colleagues where they were and who they were with. Managers had not completed ligature audits in any of the locations we visited.

• Two of the first aid boxes we inspected at Isebrook Hospital and Sudborough House had out of date materials in them, such as bandages.

• One patient we spoke with told us they were kept waiting for an hour for an appointment

• Interview rooms appeared to have adequate sound proofing for normal rate and volume speech, but if voices were raised this could be heard outside of the interview room, meaning that in those cases confidentiality may not be maintained.

We rated mental health crisis services and health-based places of safety as good because:

• Records showed that staff had completed a risk assessment during initial assessment and risk assessments were updated regularly, following an incident or prior to transfer to another team. Risk levels for patients accessing the CRHTT were discussed at daily handover meetings in order to detect any increase in risk.

• CRHTT staff completed crisis plans for all patients after each contact and discussed individual patients crisis plans at team meetings.

• Learning was fed back to staff during team meetings. Staff received feedback from incidents both internal and external to their core service. We saw evidence of change having been made within teams as a result of feedback from incidents.

• Care plans for patients using the CRHTT were person centred, holistic and reviewed weekly during team meetings. Staff ensured that all patients who were assessed by the AMHLS were given a leaflet with an individualised crisis plan and details of who to contact in a crisis.

• All mental health crisis and health-based place of safety teams reported good working relationships, both within the trust and with external organisations.

• Patients were routinely transferred to the HBPoS by ambulance.

• Staff were observed to be caring, warm, empathic and respectful towards patients. We observed a home assessment where we saw a good relationship between staff and the patient, including joint working and collaborative discussions.

• Patients fed back positively about the care they received from staff. Patients told us that staff were willing to help and treated them with consideration and dignity.

• Staff could request literature in different languages if there was a need. Staff had access to translation services and interpreters and were able to access hearing loops and sign language interpreters if required.

• All patients we spoke with were aware how to make a complaint if they were not satisfied with the care they received.

• Staff had regular contact with their immediate managers. All staff we spoke with reported that their managers supported them to carry out their roles and they felt able to raise concerns with their manager.

• Overall, the average compliance rate for mandatory training across mental health crisis services and health-based places of safety was 93%, the average supervision rate was 99% and the average appraisal rate was 93%.

• Staff said they felt supported to take part in further training, were given the opportunity to give feedback on services and input into service development and had opportunities for career progression.

• The trust led on the crisis care concordat and close partnership working across commissioning and partner provider agencies. The trust reported it resulted in a range of service improvements and ensured strong leadership, working for the benefit of service users and carers using the pathways. Much of this work was co-produced with service user sand carers.

• The trust led on the crisis care concordat and close partnership working across commissioning and partner provider agencies. The trust reported it resulted in a range of service improvements and ensured strong leadership, working for the benefit of service users and carers using the pathways. Much of this work was co-produced with service user sand carers.

However:

• The HBPoS suite at St Mary’s Hospital and The HBPoS suite at Berrywood Hospital did not comply with Royal College of Psychiatrists’ guidance. Furniture was not sufficiently weighted and ligature risks were present.

• AMHLS had two interview rooms at Northampton General Hospital, one of these rooms did not comply with PLAN accreditation standards. The AMHLS Team at Kettering General Hospital had a designated room in the accident and emergency department. The trust had identified the room did not meet PLAN accreditation standards.The trust had an action plan in place for rooms which did not meet PLAN standards.

• The HBPoS at St Mary’s Hospital was not visibly clean and did not have access to a dedicated clinic room.

• There was no record available of blank prescriptions held in the CRHTT south team. Staff did not carry out any audits with regard to unopened boxes held in the storage area, meaning that they would not know if any prescriptions went missing.

• The HBPoS at St Mary’s Hospital did offer patients access to fresh air within a safe setting, however this was on another ward and could only be used when patients from that ward were not using it.

We rated child and adolescent inpatient wards as outstanding because:

• Patients’ care, treatment and support achieved good outcomes, promoted a good quality of life and was based on best practice. Staff actively monitored and reviewed consent practices to ensure that patients were involved in making decisions about their care and treatment.
• Staff identified ligature points on an environmental audit and took actions to reduce the risk to patients. These included enhanced observation levels. Wards complied with the Department of Health’s guidance of eliminating mixed sex accommodation, which meant that the privacy and dignity of patients was upheld.
• Staffing levels were appropriate to meet the needs of patients. Staff said leave and activities were very rarely cancelled or rearranged because of staff shortages.
• Staff completed comprehensive assessments for patients, which they completed in a timely manner in collaboration with the patient and their families where appropriate. We looked at 12 care plans, the patient, reviewed and signed them, they were up to date, personalised, holistic, recovery orientated and included physical health checks. Specialist training was available to staff and supported by the trust, this included two members of staff undertaking a master’s degree in working with patients with eating disorders and two support workers who were advanced apprentices. Staff said they felt supported to maintain their continuing professional development.
• The service held a yearly “rivers of experience” event. Patients and parents who had used the service over the preceding 12 months were invited to attend a meeting whereby they were encouraged to share their experience, contribute to developing the service and to look at where things could have been done differently.
• Patients told us that they had good relationships with staff and they were very helpful, understood their problems and were always available. They said they felt safe and staff took the time to listen to them when they had a problem.
• The service held a yearly “rivers of experience” event. Patients and parents who had used the service over the preceding 12 months were invited to attend a meeting whereby they were encouraged to share their experience, contribute to developing the service and to look at where things could have been done differently.
• Staff gave patients information on how to make a complaint. We saw information around the units about how to make a complaint. Patients said they felt they could make a complaint if they wanted.
• Staff reported extremely positive morale and job satisfaction. They reported good relationships with managers and felt empowered in their roles.
• The trust was supporting the service, in collaboration with Northampton University with a poster presentation at a conference in Geneva in 2017.

However:

• Staff had secluded a patient for a prolonged period of time. The patients’ notes showed that staff had reviewed the episode of seclusion as per the trust policy. However, we could not establish what the outcome of the review was or why the decision was made to continue the seclusion.
• Patients did not have a lockable cupboard in their room.

We rated wards for older people with mental health problems as good because:

• The ward environments were clean and tidy, which patients confirmed was always the case.

• Patients confirmed that staff were available to them on the wards. Leave or activities were not cancelled due to staffing shortages.

• Patients said that they felt safe.

• Staff completed detailed risk assessments for patients on admission and reviewed them regularly.

• Staff monitored patients’ physical health regularly from the point of admission.

• Staff were warm in their interactions, quick to respond in a kind and caring manner.

• Patients and carers were encouraged to be involved in their care and they knew how to complain if needed.

• There was a range of treatments and activity delivered by skilled and experienced staff.

• Staff reported good morale, felt they were supported by managers and were happy in their roles.

• We reviewed 39 prescription charts and saw generally good management of medication on Brookview, Spinney and Orchard wards. Medication was prescribed within recommended guidance and most documentation was present and in date.

However:

• On Riverside ward we found a number of missed medication doses and staff did not always report using the incident reporting system.

• Not all care plans were recovery focused or personalised and some paperwork had gaps.

• Mental capacity assessments were not documented in detail and lacked evidence of family or Independent Mental Capacity Act Advocate involvement.

• Some patients reported that they would like a television in their bedrooms.

We rated forensic inpatient/secure wards as good because :

• Patients had a positive experience of care and told us they felt safe on the unit. Patients attended community meetings daily, raised issues, and gave feedback to staff both at the meeting and through ‘I want great care’. The service ensured patients and their carers knew how to make a complaint and patients had access to advocacy services.

• Staff described the electronic system to report incidents, how learning was shared and knew their role in the reporting process.

• Staff undertook comprehensive assessments and reflected patients’ needs and goals. They completed individualised risk assessments at or before admission and updated them regularly according to need.

• All staff were trained in and had a good understanding of the MHA and MCA.

• Staff told us they felt supported to carry out their role and had regular appraisals. Some staff had undertaken specialist training relevant to the patients’ needs.

• The trust had built a new seclusion room away from the main patient area. This helped to promote patient dignity. Ligature risk assessments helped staff to manage risk along with the use of anti-ligature fittings.

• Staff treated patients and their families with care, compassion and respect. The multi-disciplinary team worked well together and focused on patient recovery.

• Patients gave feedback through “I want great care.” Patients scored on a variety of headings by using a computer tablet, which generated an overall score out of five. This was done every three months and at the time of inspection, the score was 4.6 out of 5. This process also enabled patients to raise individual issues.

However:

• Data provided by the trust indicated that prior to the inspection there had been four vacancies for qualified nurses and five vacancies for healthcare assistants, and the manager told us the service found it difficult to recruit male nurses.

• Staff were not able to see all areas of the ward and outside area as there were blind spots and CCTV cameras were not switched on, although staff mitigated this risk by zonal observations.

• It was not clear that supervision meant dedicated individual time for staff to reflect and learn.

• Medical staff felt that the trust had made decisions without adequate consultation, particularly over the changes to bed numbers on Wheatfield and Meadowbank. Medical staff felt that medical management was under-resourced, with the associate medical director and clinical director very thinly stretched.

We rated Long stay/r ehabilitation on mental health wards for working age adults as good because:

• Patients had a positive experience of care and told us they felt safe on the unit. Patients attended community meetings daily, raised issues, and gave feedback to staff both at the meeting and through the trusts’ own feedback system called ‘I want great care’. Staff ensured that patients and their carers knew how to make a complaint and patients had access to advocacy services.

• Staff treated patients and their families with care, compassion and respect.

• The multi-disciplinary team worked well together and focused on patient recovery. Most staff described the electronic system to report incidents, how learning was shared and knew their role in the reporting process.

• Staff undertook comprehensive assessments and reflected patients’ needs and goals. They completed individualised risk assessments at or before admission and updated them regularly according to need.

• All staff were trained in and had a good understanding of the MHA and MCA.

• Staff told us they felt supported to carry out their role and had regular appraisals. Some staff had undertaken specialist training relevant to the patients’ needs.

However:

• Medical staff told us that the trust had made decisions without adequate consultation, particularly over the changes to bed numbers on Meadowbank. Medical staff told us that medical staffing was under-resourced.

• Staff were unclear about whether a patient for whom a DoLS application had been made should be considered as detained or as informal.

• One patient told us that one member of staff was unhelpful, negative and did not engage in meaningful conversation with them.

We rated acute wards for adults of working age and psychiatric intensive care units as good because:

• The trust had completed ligature risk assessments across all wards, detailing where risks were located and how these should be managed. Staff maintained a presence in clinical areas to observe and support patients.

• There were sufficient staffing levels on all wards. On all wards there were skilled staff to deliver care. Staff were experienced and qualified. Ward matrons made effective and immediate arrangements to cover vacant posts. Ward matrons provided appraisals, personal development planning training, supervisions and support to all staff.

• Harbour ward did not fully comply with the Department of Health guidance on eliminating mixed sex accommodation. However, there was mitigation with additional staffing provided in key areas.

• Wards had protocols on searching, code of conduct for ward behaviour and police liaison.

• Patients had good access to psychology, dietician, physiotherapy, and occupational therapist on wards and effective pharmacy input on Avocet and Sandpiper wards. The trust employed a registered nurse to assist with assessment and management of physical healthcare needs for patients on Marina ward. The nurse worked across the acute wards also. Patient’s admissions included effective physical health checks, and monitoring of physical health care.

• Staff completed comprehensive care plans. Patients on all wards were involved in care planning. We saw occupational therapist plans for individual patients.

• We observed effective handovers on all wards.

• Health care support workers received appropriate induction using the care certificate standards. Staff were trained in safeguarding and know how to make a safeguarding alert and to do this when appropriate.

• On all wards, staff enabled patients to give feedback on the service they received and reviewed and acted on this information. Patients knew how to complain and receive feedback.

• Staff were caring, compassionate and kind towards patients. We saw staff engage with patients in a kind and respectful manner on all of the wards. However on Kingfisher ward one staff member showed a disrespectful attitude towards a patient. This was addressed with the staff member on the day of inspection.

• On Sandpiper ward, we observed that a patient and their family and carers were involved in care decisions in a multidisciplinary meeting. On Kingfisher, we observed three patients preparing a hot meal with the occupational therapist as part of a therapeutic programme. On Sandpiper, activities and therapy programmes were available seven days a week.

• Staff responded to the needs of people from different ethnic groups and to those for whom English is not the first language.

• On all wards there was effective leadership. Staff reported being well led and supported.

  Ward matron was the point of contact for all ward operational matters. This person had the authority and administrative support to lead the ward team.

However:

• There were environmental issues identified. These included heating problems on Harbour, poor drainage in shower floor. On Bay ward one patient was involved in an incident of self-harm in the garden where there were poor lines of sight. Some measures were put in place to mitigate the blind spots. On Bay ward some staff told us there was no de- brief for staff after local incidents to consider whether improvements could be made to ward safety. On Cove ward some aspects of the ward environment were in disrepair and not addressed. The garden was dirty and strewn with litter. The adapted bathroom was used as a storage room. On Kingfisher, Avocet, Cove and Bay some parts of the wards and garden areas were over looked by nearby houses. There were no screens or frosted glass provided.

• We saw on Avocet ward large numbers of staples used on patient noticeboards. The staples were a risk to patient safety. Staff told us all the noticeboards were due to be covered with laminate, and the staples would no longer be used. However, the ward matron did not feel the risk required immediate action.

• Senior managers failed to consistently assess all health and safety risks to the premises, which impacted on the safety and wellbeing of patients.

• On Kingfisher ward one patient out of six care records examined did not demonstrate alternatives to restraint and efforts to de-escalate.

• Patients on Cove and Harbour wards did not have input from psychology services.

• Marina and Kingfisher seclusion rooms were compliant with the Mental Health Act Code of Practice. However, in the Kingfisher ward staff area outside the seclusion room, staff could not easily view a part of the seclusion room as a desk blocked the view.

• There were three out of area placements on Marina ward. Bay ward had 17 beds, however three patients were on leave and they had been filled with three other patients. This meant that the ward had 20 patients allocated to the 17 bedded ward. If a patient needed to return early to the ward, there may not be a bed available. Seven patients on Avocet ward were ready for discharge, but placements were not available.

• On Bay ward two T2’s were inaccurate and on Marina ward one T2’s was missing one medicine. The ward matron took immediate action with the consultant. There were some medication errors on Harbour and Cove ward with gaps in signatures. Harbour, Bay and cove clinical room temperatures were tested each day but, not recorded.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We rated the trust overall as good because:

• The trust responded in a very positive way to the improvements we asked them to make following our inspection in February 2015. At this inspection, we have seen improvements in most core services across the trust.The senior leadership team have been instrumental in delivering quality improvement within the trust.
• Throughout the trust, in both mental health and community health services, staff treated patients with kindness, dignity and respect.Consistently, staff attitudes were helpful, understanding and staff used kind and supportive language that patients would understand. The style and nature of communication was kind, respectful and compassionate.Staff showed strong therapeutic relationships with their patients and clearly understood their needs. Staff offered guidance and caring reassurance in situations where patients felt unwell or distressed, confused or agitated.
• Staff encouraged patients to give feedback about their care.Staff offered patients the chance to give feedback in a variety of ways. A feedback system had been introduced across the trust called I Want Great Care. This received feedback from carers, patients and staff about the care of patients and other issues. The trust received 61,000 reviews since the system began.
• Patients were involved in projects across the organisation and we saw evidence of this in the core services.This included reviewing documents, delivering training, and recruiting and interviewing staff.The trust had a patient involvement group that was well attended by patients from the mental health pathway.
• Information leaflets were available in easy read formats and we saw evidence of information available to patients on how to access interpreters should they need one.
• The trust had a robust governance structure in place to manage, review and give feedback from complaints. Staff consistently knew how to handle complaints, and managers investigated complaints promptly and gave feedback to patients, carers and staff about outcomes of complaints.
• The trust had a clear vision and set of values.The vision and values had been widely communicated across the trust through posters, presentations, and the intranet page called the staff room, screen savers and board members visits to wards. Staff in mental health services and community health services were, for the majority, aware of the trust’s vision and values.
• The trust had safeguarding policies and robust safeguarding reporting systems in place and described how they worked with partner agencies to protect vulnerable adults and children.
• An operational management tool was in place which recorded data for 40 areas of patient safety and areas of compliance for the trust.The trust board had oversight of this.
• The trust had developed and invested in an extensive range of well-being schemes for the staff.They told us about physical fitness classes, recruitment and retention rewards, counselling, and support groups available.
• The trust ensured staffing levels and skill mix across 15 core services was planned and reviewed so that people who used services received safe care and treatment. The majority of services across the trust increased staffing based on clinical need or made arrangements to cover leave, sickness and absence. Managers had authority to make these decisions.
• Physical environments across most services in mental health and community services were clean and well maintained. Across most services staff had completed environmental risk assessments. Where issues had been identified, staff mitigated these risks by carrying out additional checks or had taken other actions to resolve the issues.
• Emergency medicines and equipment were available in all of the inpatient clinical areas that we visited. All emergency equipment was in date and staff checked them daily. Antipsychotic medication was prescribed within the British National Formulary (BNF) limits and monitoring was in place.
• The trust was meeting Department of Health guidance for eliminating mixed sex accommodation.
• Staff completed detailed and clear risk assessments at seven of the 10 mental health core services and at all community health services.Staff involved patients in their care plans and risk assessments and where possible, staff gave copies to patients.Staff across mental health services completed comprehensive assessments and person centred care plans in a timely manner, and in collaboration with the patients.
• The trust used an electronic system for reporting incidents. At all services staff knew what incidents needed to be reported and how to report them. Managers monitored the reporting and recording of incidents.The trust had robust systems for sharing lessons learned from incidents.
• The majority of mental health services and used best practice to influence treatment and care offered to patients. Staff used a wide range of outcome measures within their practice, across most mental health services. The trust monitored and audited outcomes using rating scales, best practice and a range of audit.
• All mental health services had access to psychological therapies. All teams within mental health services and described effective and collaborative team working and had effective working relationships external agencies.Core services reported effective handovers between teams.
• Physical healthcare needs had been addressed at inpatient mental health settings. Information needed to deliver care was stored securely on an electronic record system which the GP also had access to, this improved continuity of care.The trust was nominated for a health service award following their work to introduce this system.
• The trust made available and supported specialist training and induction. Staff felt this training helped them in delivering services to patients.Both registered and non-registered staff had access to further training.
• The trust average compliance for supervision was 93% but this varied across services.
• The trust provided information that overall MHA training compliance was 92%.Most services showed compliance in adhering to the MHA and MCA. In all services we visited, staff told us about how patients could access independent mental health advocacy services
• The BME group had reconvened and had made progress in highlighting their goals for the year ahead.The trust supported the agenda and provided opportunity for meetings, projects and feedback and had a Workforce Race Equality Standard (WRES) action plan in place.
• The trust board encouraged candour, openness and honesty from staff. Staff knew how to whistle-blow and the majority of staff felt able to raise concerns without fear of victimisation.
• Senior managers told us frequently that there had been much organisational change and transformation of care within the trust. Staff told us they accepted change but they positively embraced the opportunity it provided. They felt supported by the board to work with change and felt able to provide feedback about their experiences.

However:

• Some environments were not clean and well maintained and furniture was not sufficiently weighted. On acute wards and in some CHS hospitals, there were environmental issues identified.These included heating problems, drainage issues, and observation blind spots, areas of disrepair and privacy issues.
• There were no ligature audit assessments in place for any of the locations inspected within community-based mental health services for adults. Managers on community-based mental health services for children and young people had not completed ligature audits for the sites we visited.
• Weston Favell Health Centre (CHS Adults) had out of date equipment in a treatment room used by phlebotomists. In CHS Adults at Weston Favell and CHS for Inpatients, infection prevention and control processes were not always being followed.
• Medication was not being managed safely at Danetre Hospital and Corby Community Hospital.
• The trust did not meet compliance target for non-medical staff supervision in all core services.Systems used to record supervision were inconsistent across the trust.Some services used 1:1 supervision, group supervision or team meetings as a way of carrying out this task.Clinical and managerial supervision data was not collected separately.The trust wide average appraisal compliance rate was 65% at September 2016. During the inspection data showed there had been an increase in average compliance from 65% to 90%.The difference in this data suggested that data collection required a review by the trust.
• Staff compliance with MCA and MHA training was 67% for community-based mental health services for older people, below the trust compliance target of 90%. Staff did not consistently document mental capacity assessments and best interest decisions in care records where they were required. Some staff were not able to tell us how they would put the Mental Capacity Act into practice in their work.
• There was a high number of delayed discharges from CHS Inpatient hospitals. Data showed 46% of all patients across the service were medically fit to be discharged home but remained in hospital because there were no care packages available or the patients were waiting to be assessed.
• The trust did not meet its target for mandatory training compliance of 90%.At the time of inspection, mandatory training compliance was 89% with the lowest compliance for a core service at 62%.
• CHS for Adults had waiting lists and no way to monitor deteriorating patients.Some acute mental health services used beds for new admissions that were already allocated to patients on leave.Discharges from forensic inpatient services were affected by a reduced number of beds on the rehabilitation ward.
• CHS for Inpatients had high vacancy and sickness rates which put additional pressure on substantive staff. The strategy to move all stroke patients to one hospital site was delayed. Plans started in August 2016had not been completed. However, the trust provided evidence that they are now working on this strategy. Not all risks had been identified on the risk register and some risks had not been recognised or responded to.
• The trust did not assess or monitor the phlebotomy service in CHS for Adults. There was a lack of oversight of the service and it had not been delivered in line with the service level agreement with commissioners.