Hampshire and Isle of Wight Healthcare NHS Foundation Trust

• Sufficient numbers of suitably trained staff were deployed to meet patients’ needs. Further training opportunities were provided by the trust to allow staff to expand their skills and professional knowledge.

• Staff followed professional guidance and applied this in their treatment to provide safe and effective care to patients.

• Patients received outstanding care delivered by staff who took exceptional care to ensure their emotional and wellbeing needs were met.

• Staff recognised and acknowledged patients who had additional support needs associated with their illness or long-term health condition. Patients were supported by staff who understood how to meet these additional needs.

• The trust was led by a strong executive team who demonstrated a visible presence to staff. Staff spoke positively of the service leadership saying they promoted a patient centred culture which was focused on improving the lives of the patients they supported.

However:

• One team did not have access to the trust’s ‘Store and Forward’ record keeping system on their laptops. This meant not all patients had up to date information available in their homes for other health and social care professionals to follow.

• The investigation of complaints did not take place in a timely way leading to delays in responding to the complainant. The service did not complete investigation of, respond to, and close complaints within agreed timescales.

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

• The Care Quality Commission issued a warning notice due immediate concerns of the safety of young people using the service. We required the trust to make significant improvements to the quality of care delivered in the service by 16 July 2018.
• At Bluebird House there were insufficient levels of staff on the wards to ensure that young people were protected from avoidable harm. There had been an increase in the number of prone restraints, there was a high number of incidents and observations and physical health monitoring, including physical health monitoring following rapid tranquilisation were not always being conducted as needed. Bluebird House was dealing with some extremely challenging situations at the time of the inspection which CQC escalated to NHS England as the commissioners of the service. NHS England recognised that it needed to support the service to help resolve and/or deal with the challenges (which are still ongoing) and made further funding available to increase staffing levels to help the service to deal with the challenges.
• We found a significant number of ligature risks at Leigh House that were not being managed appropriately.
• The risk register was not being used effectively to escalate the seriousness of the staffing problems to the executive team and trust board. The data about the use of restraint and seclusion was unreliable so could not provide robust information about restraint and seclusion practice and prevalence.
• Staff and young people felt that there were often too few activities being offered and young people said there was often little to occupy them.
• At Bluebird House staff told us that there were times when they felt unsupported and experienced significant stress.
• Individual supervision was not in line with the expected completion rate set by the trust.
• Staff, across the two sites, had varying knowledge of the Mental Capacity Act (MCA) and Gillick competency.

However:

• The trust responded immediately to the concerns we raised and voluntarily agreed to suspend admissions until it had addressed the safety issues. The trust provided an action plan that set out how it would make the improvements required by the warning notice. We undertook an unannounced, focussed inspection on 18 July 2018 to check that the trust had taken the actions identified in its action plan. We found the trust had reconfigured the wards at Bluebird House and had increased staffing levels on each shift; no shifts were left uncovered and as such there were always sufficient, suitably qualified and competent staff on duty at all times. Observations were being conducted appropriately although some further work was needed to ensure these were always recorded. Environmental work to address the ligature risks at Leigh House were nearing completion and staff had detailed knowledge of the management of the risks. Staff and young people told us that they now felt safe. As such we lifted the warning notice.
• Young people had their mental health needs assessed prior to admission. Admissions to the wards were discussed and screened to review risks. Staff completed comprehensive risk assessments and recorded these in the patient care record.
• Care plans across both sites consistently demonstrated a holistic approach to care.
• There were consistently good outcomes for young people. Staff planned care in conjunction with young people focussing on recovery from their mental health problems.
• The service provided a number of psychological therapies recommended by the National Institute for Health and Care Excellence (NICE).
• Discharge was planned in advance.
• Young people said that the staff were caring and treated them with dignity and respect. Both sites had service user forums and young people were involved in decisions about the service. Families and carers received regular updates from the wards when appropriate.
• Staff were aware of how to recognise and report incidents. Managers refused admission if the wards were unsettled.
• Young people admitted to the wards had their own bedrooms. There was a range of facilities at both sites and there were disabled adaptations. The school at Leigh House supported young people to gain outstanding academic results.. Young people knew how to complain and staff responded well to concerns and complaints.
• The buildings were in good order, clean throughout and well maintained. Clinic rooms were well equipped, including with resuscitation and emergency drugs.
• Young people on the eating disorder programme had their meal plans monitored to ensure treatment was effective.
• The teams appropriately inducted new staff into the service. Staff received specialist training to work within the service. Multi-disciplinary teams met weekly with young people to review progress and treatment
• Staff were trained in the Mental Health Act and they conducted seclusion reviews in line with guidance.

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

• Staff were caring, respectful and compassionate. Patients and carers gave consistently positive feedback about staff. Staff understood patients’ needs and preferences and found creative ways to communicate with patients and involve them in their care.
• Carers felt supported by the staff teams and felt staff helped them solve problems and were available for additional support. An intensive support team created tailored care programmes for carers and ensured they could implement the plans.
• There were active service user groups in each locality. Staff offered patients training and coaching to enable them to be on interview panels, chair meetings and review documents relating to the service.
• Staff were motivated to provide high quality care. Access to the service was efficient and waiting lists were short. Staff supported patients to access physical health care from other services and developed documents with patients to help them express their physical and mental health needs. They supported patients during transitions between placements.
• Teams were well led. There were enough staff with the appropriate skills to deliver a safe and effective service. Staff told us managers were available and approachable. Managers praised staff for doing a good job. Managers monitored staff performance. They ensured staff were well trained, appraised and supervised. They enabled staff to develop their skills and pursue special interests. Morale was good.
• There was an open culture and a willingness to learn. Staff developed the service in response to learning from complaints and incidents. Staff welcomed feedback from patients and carers. There was a good structure of meetings for staff to discuss the safety and quality of the service. There were processes for escalating and monitoring service risks and staff were involved in the process.

However:

• Staff did not monitor if patients had been offered a copy of their care plan.
• Staff did not always document a Mental Capacity Act assessment when they needed to, such as when making best interest decisions about patients’ treatment.
• Some staff were stressed by frequent change and demands from the trust. Staff described having to respond to directives from senior management which they felt were sometimes risk aversive and less relevant than local issues.
• There were information technology connectivity issues at two of the team bases that was causing stress to staff.

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

• All the environments we visited were comfortable, clean and welcoming. Environments had disabled access and toilets. Conversations could not be heard from outside interview rooms and staff were aware of issues around privacy and dignity during confidential interviews. Clinic rooms were well equipped and maintained. Staff made sure equipment was checked regularly.
• There were no waiting lists at the service due to the efficiency with which referrals were handled and caseloads were manageable within the teams. Staff completed risk assessments on admission and ensured regular monitoring of patients’ physical and mental health.
• All patients had care plans in place which contained risks and interventions. Staff were focussed on the health and wellbeing of patients. Staff involved carers in assessment and treatment and offered support and advice on issues and services. Patients, families and carers told us they were happy with the care received.
• Teams discussed clinical and managerial issues in weekly multidisciplinary meetings. Staff attended mandatory training and knew how to raise a concern. There were seven serious incidents reported in the previous 12 months. Reporting systems were in place and staff across the trust learned from incidents.
• There was evidence of good leadership in all teams. Managers were visible and supportive, and motivated their teams to create a positive culture. Staff morale was generally good and vacancy rates were low across the teams. Sickness was monitored and managed well in most teams.
• Staff were positive about the leadership in the trust. Staff were also aware of the senior management team, and told us that senior managers were visible and accessible.

However:

• Clinic rooms did not have alarm systems fitted and staff did not carry personal alarms.
• Although risk assessments were completed on admission, they were not always updated in the patient records. The quality of risk assessments varied across the service.
• Staff did not always report incidents that should have been reported.
• Some medicines that required storage below certain temperatures were not stored in a temperature controlled environment.
• Staff did not always make a safeguarding referral when they had identified potential safeguarding concerns.
• Patients did not always get offered their care plans and patient records did not show that staff offered care plans.
• Some teams did not keep records of staff clinical and managerial supervision.
• The provision of psychological therapy varied across the service, with one team having no access to psychological therapy.
• The provision of office space in New Forest East, Parklands and Gosport was not sufficient to allow staff to complete their roles adequately.

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

• The service did not ensure that staff from the health based place of safety service collected and used information well to support all its activities. Senior trust members did not have full access to information concerning the 24 breaches where the maximum detention period in the health based place of safety had been exceeded (It is a requirement that patients, who have been not been given an extension by an approved person must not be detained more than 24 hours in the health based place of safety). Staff did not follow the trust policy of monitoring patients held in the section 136 suite hourly and the trust did not monitor this.

• Care plans and crisis plans were not all up to date or comprehensive and so did not support the team’s delivery of safe care and treatment to patients. Staff members from the ambulance service who stayed with patients brought into the section 136 suite until the trust had completed the assessments did not have access to up to date, accurate and comprehensive information about patients in their care and treatment plans.

• Both the crisis teams and the health based place of safety staff did not ensure crisis plans were consistently completed. The trust monitored completion monthly. Data showed that compliance was mixed across the teams. In the south team, on average 60% of patients had crisis plans. In the east, the average was between 48% and 72% compliance. However, each team had a plan in place to address this.

• There were delays in patients being able to see a psychiatrist in the crisis teams. For some patients this mean that there were delays to them starting on the appropriate medication and others had not received a medical review when needed. Patients receiving care from the south crisis team had easy access to a psychology team who provided a wide range of psychological therapies and groups but in the north and east teams patients had to be referred to a psychologist.
• Staff did not fully understand their roles and responsibilities under the Mental Health Act 1983 Code of Practise 2015 because patient’s ethnicity was not included in the monitoring form in line with the Code.
• Managers of the service did not consistently monitor the number of safeguarding referrals sent to the local authority.
• The trust did not have a process to obtain feedback from patients who had used the health based place of safety.
• There was no toilet door in the section 136 suite at Antelope house which compromised patients’ privacy when using the facilities

However:

• Patients were seen quickly by the crisis service. Patients could access the service when they needed it. There was an out of hours provision for patients. Patients had access to a crisis lounge in Antelope House all day and night.
• Patients were quickly assessed by the crisis team and the staff in the health based place of safety.
• The crisis team took a proactive approach to monitoring and re-engaging with patients who did not attend appointments
• The trust was monitoring incidents in relation to the new ambulance provider and there was learning from each incident.
• Staff treated patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• The managers across all teams ensured that staff had access to regular team meetings to share information and develop learning.
• The managers promoted a positive culture that supported and valued staff.
• Staff morale was mostly good and staff felt positive about working in their teams.

Our rating of this service went down. We rated it as requires improvement because:

• Female patients did not have a female-only designated day area that was not used by male patients. Some wards had female only lounges but these were often used for de-escalation and on Elmwood ward, a male patient was present in the female lounge during the day of our inspection. Staff told us this patient spent every day in the female lounge
• Medication across all wards was not stored at a safe temperature. The trust was aware but this had not been acted upon.
• A patient on Beechwood ward had been detained informally without any legal safeguards. Staff believed the patient did not have capacity to consent to admission, however, they had not assessed his capacity and he was frequently trying to leave.
• Staff on Beaulieu and Berrywood ward were not reporting safeguarding concerns in line with trust policy or legislation.
• There was no provision for psychological therapies.
• We had concerns of patients’ privacy and dignity. Staff told us patients did not always have access to private telephone calls. Female patients on Rose ward had to walk past communal areas to get to the washing facilities.
• The trust did not have a good overview of some of the governance issues occurring on some of the wards. The trust did not have a procedure for monitoring the use of the Mental Capacity Act. There was no oversight of the safeguarding referral process on Beaulieu ward and Berrywood ward. The trust did not have oversight of the use of the Mental Health Act on Beechwood ward.

However:

• Staff on all wards undertook the required mandatory training. Any new starters were quickly booked on to future training sessions.
• Care records were mostly detailed, holistic and person centred. Records were updated as necessary and regularly reviewed.
• Staff were routinely holding best interest meetings for patients that lacked capacity to make specific decisions. Patients’ relatives were involved where appropriate, as were Lasting Powers of Attorney for health and welfare.
• Staff monitored patients’ physical health well. Staff used a range of tools and scales to assess and review patients’ physical well-being.
• Patients felt respected, cared for and involved in their care and treatment. Patients were involved in their care planning process and decisions about improvements that could be made on the wards.
• Staff planned patients’ discharges early on in their admission. Relationships with the local authority had been strengthened which contributed to a smoother discharge process for patients.
• Staff felt supported by leadership across the wards. The executive team had become more visible at ward level and staff felt there had been improvements in culture.

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

• All patients had a risk management plan, and a crisis plan where appropriate. Most patients had next of kin details recorded and consent to share information details had been completed.
• Staff responded promptly to a deterioration in a patient’s mental health. Patients were placed on ‘shared care’ when their mental health deteriorated. Patients would receive extra home visits from a care co-ordinator to provide additional support on weekdays, evenings and weekends.
• Some teams had physical health leads responsible for ensuring patients’ physical health was monitored and their needs were met.
• Teams learnt from incidents and shared learning across teams and the trust.
• Caseloads sizes were continually being monitored and caseload sizes had reduced since the last inspection.
• Staff provided a range of care and treatment interventions suitable to the patient group, for example, running dialectical behavioural therapy groups for those with a personality disorder diagnosis.
• Staff were passionate, compassionate, knowledgeable and proud of their work. Teams were cohesive and supported one another.
• All teams proactively tried to contact patients who had missed scheduled appointments and who were reluctant to engage in the service. Staff made phone calls, sent letters and did cold calls to follow-up with patients who had not made contact with the service following a missed appointment.
• Managers ensured staff were regularly supervised and appraised. Teams held regular structured and effective meetings such as team, shared care, multidisciplinary and business meetings. Teams were well-led.
• Managers had clear action plans and were continually working towards improving the service provided to patients.
• There was an emphasis on improving involvement from patients and carers in the development of the service.

However:

• Not all of the teams were adhering to the trust’s safeguarding policy and making safeguarding referrals directly to the local authority. Procedures for making referrals to the local authority differed across teams. The procedure was particularly unclear at the Southampton teams.
• Patients on clozapine, an anti-psychotic medication which requires regular physical health monitoring, did not always have a relevant medication care plan.
• Care plans were not always person-centred, holistic and recovery-orientated. Some patients did not have a care plan.
• Care plans were difficult to access on the electronic patient record system as staff did not save the document in the correct place and used various formats.
• We could not find evidence that patients had always been offered a copy of their care plan or were involved in their care planning. Some patients we spoke to were not aware of their care plan.
• Managers were not using supervision sessions to ensure staff improve the quality of patient’s’ care plans.

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

• Patients were at the centre of all the care provided on the wards. Staff made a holistic assessment of the patient’s needs and capabilities and built this into a care plan centred around the patient’s goals. Staff listened to the patient’s views and reflected these in their plans. They also explained the care plan to patients in a meaningful and clear way.
• This spirit of inclusion and communication was echoed in the wards’ safe practices of observation, ensuring that patients’ views and wishes were considered while keeping them safe. The layout of the wards was designed to give staff unrestricted views of the ward, and used mirrors where needed to accomplish this. The trust had included patients and carers in designing a new build for the Ashford unit, and this was due for completion in October 2019.
• There were good systems in place to ensure that staff logged and reported information such as incidents, and the use of restraint. There was high reporting of restraint on Willow ward. When we looked into this, we found that the staff were reporting all instances of de-escalation and low-level restraint, such as a ‘guiding hand’ as an incident of restraint. We concluded that staff were committed to using least restrictive practices where possible and all staff had been trained in how to use restraint.
• There had been a reduction in the number of vacancies on the wards, but the forensic outreach team still had some vacancies.
• Staff were experienced and had received specialist training from the trust to enable them to do their jobs effectively. Patients had access to therapies recommended by National Institute for Health and Care Excellence and national guidance about the use of antipsychotic medicine was followed. Staff regularly met as a group to discuss patients, and changes in national guidance was highlighted to them.
• From the time that patients were admitted, staff were focused on helping them to recover enough to be discharged. This was well-planned and staff helped prepare patients for discharge by ensuring they kept in contact with the people they valued and engage in activities and groups in the community. Where patients were waiting for discharge this was because of a lack of suitable placements in the community.

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

• The wards calculated the required numbers of staff within safer staffing guidelines but these numbers were not always met. Staff told us that this impacted on patient care due to a reduction in patient one to ones and escorted leave having to be cancelled occasionally, not always having enough staff to hand to deliver safe interventions with patients and therefore a higher level of incidents taking place.
• The lack of staff also impacted on the ability of managers to provide adequate supervision to all staff. However, most staff members informed us that they were able to raise concerns, share information and gain development through other means, such as reflective group sessions attended by psychologists, peer support and handovers.
• Not all wards held regular team meetings. This impacted on staff support and patient care, as concerns are not raised, learning is not shared with ward staff and may affect morale. For example, Hamtun Ward had very low staff morale, due to inconsistent leadership and lack of staff meetings.

However:

• All the wards were well-maintained, clean and had appropriate furnishings. The wards were undergoing renovations to ensure there were appropriate anti-ligature fittings.
• The wards shared learning from incidents. The environmental risk of patients absconding from Kingsley ward via the garden roof had been resolved and the trust had added anti-ligature and anti-climb rollers on the roof-ends. These measures had also been installed at Elmleigh ward.
• Staff were caring and compassionate. Staff communicated well with patients and introduced new initiatives such as the ‘normalised care’ on Hawthorn which aimed at making the environment as non-clinical as possible. All items presenting risk were not necessarily locked away (such as television cables) but rather managed effectively through staff and patient engagement, observations, activities and relational security on the ward. Patients praised staff for this initiative.
• Patient risks were assessed, monitored, updated and managed appropriately. Risk changes were identified immediately and discussed in weekly multi-disciplinary team meetings. Patients were involved in the risk updating process, as seen by audits ensuring the patients signed the risk assessments. The risk and patient assessments were comprehensive enough that the wards did not have to apply blanket restrictions.
• We saw evidence of good physical healthcare of patients on all the wards. Patients were regularly assessed in weekly or fortnightly physical health checks. All the wards had access to dedicated staff leading physical health clinics and providing general care.
• There was good multi-disciplinary work among nurses and other professionals on all the wards. All staff, including healthcare support workers, peer support workers, advocates and social workers felt involved in patient care and were invited to the patient review meetings.
• Effective clinical audits were taking place on all the wards. Staff were involved in a number of audits, including hand hygiene, care planning, physical health assessments and wound audit. However, there were some inaccuracies in the Mental Health Act paperwork on Hamtun ward. This was raised with the managers on the ward at the time of the inspection and they informed us that they would carry out further audits of all MHA paperwork to ensure compliance.
• There was considerable improvement in the care records on all the wards (since our last inspection). Care records were comprehensive, holistic and personalised.
• We saw good examples of patient and carer involvement. On Kingsley ward staff were very passionate about ensuring that carers felt involved in their loved ones’ care and had introduced a number of support groups and sessions for carers.
• The trust had introduced some training and development workstreams in care planning and effective team meetings on the wards to wards in delivering the best outcomes for staff and patients.
• Staff felt that they had good opportunities for personal and professional development and that the trust encouraged career progression.
• Most staff spoke highly of their managers and management teams, and felt supported and listened to.

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

• Staff had built good relationships with patients. Staff gave patients information about the service and the treatments available. The information was provided in different formats and was freely available.
• The service had regular fortnightly ward rounds that focused patient care, outcomes and on working with multidisciplinary teams.
• New staff were provided with induction and a personal development program with regular reviews from managers and supervisors.
• Staff assessed the needs of patients. Assessments were updated regularly by the multi-disciplinary team.
• Staff assessed and managed physical health through weekly monitoring.
• Patients said staff were kind and caring. They felt safe on the wards.
• Staff had access to services in the trust and external services to meet patients’ needs. These included regular visits by an independent Mental Health Act advocate.
• Staff understood safeguarding, what to report and how to seek advice on safeguarding issues. Staff followed the trusts safeguarding policy.
• Staff received supervision and yearly appraisal but this was not always documented in line with trust policy.
• There was good leadership from ward managers.

However:

• There was no adapted bathroom or toilet facilities for people with physical disabilities at either site.
• Patients’ care plans did not contain patients views and although staff told us patients were involved in planning their care this wasn’t always clear in care plans at Ravenswood House.
• Some patients told us that there was little variety in the food served and that portion sizes where small.
• Some staff at Ravenswood Medium Secure Unit said that they had experienced bullying. This was escalated to senior management and immediate actions were taken.

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

• The wards were tailored to meet the needs of individual patients. Both wards were recovery orientated and planned discharge from the point of admission.
• The wards were clean and well maintained. Environmental risks were identified and managed. Clinic rooms were clean, contained sufficient equipment and had access to emergency medication.
• Staff were caring and compassionate towards patients. Patients told us staff were respectful towards them and supportive. Staff were experienced in rehabilitation and understood the needs of patients well. Staff completed risk assessments and updated these regularly. Staff were knowledgeable about how to identify a vulnerable person was at risk and how to raise a safeguarding alert.
• We saw evidence of good physical healthcare of patients on both wards. Patients were assessed on admission and monitored regularly. The wards operated a staged self-administration of patient medication.
• Staff knew how to report incidents and provided examples where learning from incidents had been implemented. Learning from incidents was disseminated to teams in meetings.
• Care records were holistic, recovery orientated and discharge focused. Care plans covered all areas of well-being. Patients were involved in the development of their care plans from admission, could contribute their views and preferences and had copies of the plan.
• The wards both had a good multi-disciplinary team and worked collaboratively. Staff were experienced in rehabilitation and understood the needs of patients. Staff were up to date with mandatory training.
• The wards actively engaged with families and carers. Families and carers were invited to meetings, provided with detailed information and told us they were involved in the care of their relatives.
• Patients could access meaningful activities on the ward and were encouraged and supported to engage in activities in the local community. Activities were available seven days a week.
• Patients were provided with vast amounts of information. Patients received a welcome pack on admission and there was lots of other information leaflets available on the wards.
• Both wards had clear admission criteria and worked with patients towards discharge planning. The average length of stay on the wards was between six and nine months. Patients were rarely readmitted to the service.
• The wards had clear admission criteria and completed initial assessments to measure a patient’s suitability for the service. The wards were tailored to meet the needs of individual patients.
• The wards had strong local leadership which provided stability and consistency in the quality of care. Staff felt supported in their roles and received regular supervision and appraisals. Morale among staff was high and they described the culture as open and transparent. Staff knew how to raise concerns and felt able to do so.
• There were good governance arrangements in place to monitor the quality of care provided. Governance and performance management arrangements were proactively reviewed and reflected best practice.

However;

• There was limited input from clinical psychologists available to patients on both wards.

• Patients at both MIUs were seen quickly, assessed, treated and discharged within the national set target of 4 hours.
• The service had enough staff with the right qualifications and experience to keep patients safe from avoidable harm and abuse and to provide the right care and treatment.
• Staff treated patients and those close to them with dignity and respect. Patients felt supported and provided positive feedback.
• Staff responded compassionately to pain, discomfort and emotional distress in a timely and appropriate way.
• The trust board had determined and kept under review the information it required to monitor performance, set priorities and make decisions through a local reporting system.
• Safety was a priority at all levels. Staff took an active role in delivering and promoting safety, learning and improvement.
• Safety performance included waiting times for assessment and treatment, adverse incidents, complaints and compliments, which were monitored continuously and were reported to the board. We reviewed safety data from April 2017 to March 2018 and found no serious issues.
• There was a positive culture and a very good supportive team working amongst staff. Staff at both MIU spoke enthusiastically about their department and the support they received.

However:

• The Petersfield MIU was small with two clinical areas and was not fit for purpose due to the workload and this had been acknowledged by the trust. There were plans in place to reconfigure the area to increase to five clinical spaces. The present arrangements did not breech the privacy or dignity of patients.

• There were sufficient numbers of skilled staff to deliver the service and staff had regular appraisals and training.
• Staff completed and updated records of people’s care and treatment, and delivered care based on best practice guidance.
• The service had systems for reporting incidents, complaints and risks and staff used these to improve care and practices.
• Staff showed kindness and compassion and were committed to providing a good service to children, young people and families in the community.
• There was an effective leadership and governance structure and a positive culture within the service. Staff understood the service aims, priorities and performances.
• Staff understood the needs of the families in the local areas where they worked. They monitored non-attendance at appointments and acted to engage people who might to vulnerable.

• We rated three of the key questions, ‘are services safe, effective and well-led’ as requires improvement. We rated two of the key questions, 'are service caring and responsive' as good.

• We issued a warning notice due to immediate concerns about the safety of young people on the child and adolescent mental health wards. There were not always sufficient levels of staff on the Bluebird House to ensure young people were protected from avoidable harm and not all shifts were covered and fell below the safer staffing level. This had resulted in observations, including physical observation not being carried out as needed and section 17 leave being cancelled. Ligature reduction work in Leigh House did not go far enough to ensure that young people were protected from the risk of unavoidable harm. We undertook an unannounced, focussed inspection on 18 July 2018 and found the trust had addressed all of the actions required, as such we lifted the warning notice.

• The trust faced significant financial challenges. The cost improvement programme was off track with the trust still having to find a £2 million saving. At the time of the inspection the trust had been concentrating on engaging staff, changing the culture and improving the quality of care. The trust were taking steps to reduce the financial risk posed by the slippage of the cost improvement programme.

• Staffing levels on the acute wards for working age and psychiatric intensive care units, and wards for people with mental health problems were not always being met.

• Care plans in the community based mental health services for adults of working age and the mental health crisis services and health based places of safety were not always person centred, holistic, recovery orientated and up to date. Care plans were not always stored correctly in either service.

• Supervision for staff on the wards for older people with mental health problems and the mental health crisis services and health based places of safety was not always being completed frequently or consistently.
• Medicines were not always appropriately managed in the community health services. In the inpatient services medicines were not always stored safely and in line with the manufacturers guidelines.

• Governance systems in the mental health crisis services and health based places of safety were not collating and using information to support the services activity. There were issues with the reliability of data used to provide assurance of the safety of services in the child and adolescent mental health services.

However:

• Within the trust, 29 core service domain ratings improved. We rated three of the core services as outstanding in the caring domain, and the remaining 12 as good.
• We rated long stay and rehabilitation wards for adults of working age and wards for people with a learning disability or autism as outstanding overall. We rated community health services as good overall.
• There was a positive, strong senior leadership team with the capability and integrity to continue to build on developments and improvements that had been progressively made over the last 12 to 18 months. The board was relatively new, including a new chief executive officer. There was now a wide range of experience and expertise and a clear programme of board and executive team development coupled with specific development for individuals.

• There were examples of positive leadership throughout the organisation. Leaders identified areas of improvement and had strategies in place to action these.
• The trust had clear vision and values. Staff are clear about the vision and signed up to it. The values are generally reflected throughout the organisation.
• The trust had developed a new governance system to provide assurance although some refinements was still required to ensure the trust board could be assured about the quality of care across the trusts.

• Staff felt respected, supported and valued and reported significant change in the culture and a developing sense of optimism over the previous 18 months. Frontline staff felt positive and proud of their work and said the trust was heading in the right direction.

• The majority of wards and facilities in the services we inspected in the mental health and community services were clean and well maintained.
• All the mental health services and community health services inspected had a range of suitably skilled healthcare professionals.
• Staff in the mental health services and community health services were knowledgeable about the needs of patients, patient risks and completed comprehensive assessments. The majority of care plans were holistic with patients and families having been involved in decisions about the care they received.
• Staff were respectful, compassionate and supportive towards patients. Staff demonstrated high levels of motivation towards patients and their families and carers.

• Patients and carers gave positive feedback about the care received. The trust had significantly improved how it used patients and families the views about their experience to improve care and services.

• There was a comprehensive serious incident reporting and investigation process in place and a culture of detailed examination and challenge over serious incidents and deaths. The appointment of a family liaison officer was a positive step in supporting family involvement in investigations.
• The trust had embarked on a significant programme of quality improvement (QI) training for staff. There was high profile given to research and development which complimented the trusts focus of wanting to be a centre of excellence.

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

• Staff across all sites followed professional guidance and applied this in their treatment to provide safe and effective care to patients.
• The trust was taking action to recruit and retain staff to ensure sufficient numbers of suitably trained staff were either employed or about to start at the trust to meet patients’ needs. There were effective selection, deployment and support processes in place along with succession planning.
• Staff had completed training and were knowledgeable about responding to and treating risk. There were effective handovers at shift changes and safety briefings to ensure that staff could manage risks to people who used the services.
• Safeguarding adults, children and young people at risk was given sufficient priority.
• People’s care and treatment was planned, delivered and monitored in line with current evidence-based guidance, standards, best practice, legislation and technologies. People had assessments of their needs, which included pain relief, mental health, physical health and wellbeing, and nutrition and hydration needs.
• Expected outcomes were identified and care and treatment reviewed and updated. Appropriate referral pathways were in place to make sure patients’ needs were addressed. The service monitored the effectiveness of care and treatment and used the findings to improve.
• Staff were consistent and proactive in supporting people to live healthier lives. There was a focus on early identification and prevention and on supporting people to improve their health and wellbeing.
• The leadership, governance and culture promoted the delivery of high-quality person-centred care.

However:

• At Romsey hospital the geography of the wards did not facilitate the delivery of safe care and treatment at night time.
• At Romsey hospital the privacy and dignity of patients was not always maintained as bed spaces were less than the recommended guidelines.
• Safe records management was not consistent across all the hospitals. In some ward areas at Lymington hospital records were stored in an unlockable drawer.
• Medicines management was not always provided safely. In some areas medicines were not stored safely in line with the manufactures guidelines and in some cases reused which was not in line with hospital policy

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

• Staff providing end of life and palliative care were appropriately trained and understood their responsibilities to keep people safe and what to do if they needed to raise a concern. There was improved oversight of end of life training and competencies.
• Caseloads in the specialist palliative care team were planned and reviewed to ensure people received safe care and treatment at all times.
• Risk assessments for care and treatment were used for patients receiving end of life and palliative care. There was timely access to advice, initial assessment care and treatment and, diagnosis or urgent treatment. Advice could be accessed at different times of the day.
• Staff prioritised care for vulnerable patients with the most urgent care needs.
• All wards and buildings we inspected were visibly clean. Staff followed infection prevention and control procedures and routine standards of cleanliness and hygiene were maintained.
• The trust had improved the quality of patient records since the last inspection in 2017 to ensure information was included in a person centred manner.
• There was a positive reporting culture within the trust, themes from patient safety incidents were identified monthly through the patient safety group and quality and safety committee.
• Policies and procedures were developed in line with national guidance, and were accessible to staff to support their practice. The trust had recently commenced The National Audit of Care at the End of Life a three-year internal audit, specific to end of life and palliative care.
• Improvements had been made in the use of individualised end of life care plans since our previous inspection and there were systems to record patients preferred place of death and to monitor outcomes.
• Staff worked together to deliver effective care and treatment through multi-disciplinary teams.
• Patients and those close to them told us they were treated with kindness, dignity and respect while they received care and treatment including during physical or intimate care. We saw staff show an encouraging, sensitive and supportive attitude to patients and those close to them who used the services.
• Staff communicated clearly and knowledgably with patients so that they understood their care, treatment and condition.
• Staff ensured that when a person was in the last days and hours of life they had an individual plan of care, which included food and drink and symptom control.
• The trust worked with several clinical commissioning groups to understand and plan end of life and palliative care.
• Some community hospitals had side rooms that could be used when available for patients at end of life such as Anstey ward at Alton community hospital.
• The trust had an interpreter system and sign language specialists available. All community hospital wards had ‘dementia link’ nurses and had undertaken dementia awareness training.
• Wherever possible, the trust ensured the same nurses visited the same patients to provide continuity of care to enable easier identification of changes in a patient’s wellbeing.
• People who used the service knew how to make a complaint or raise concerns, and they were encouraged to do so.
• The leadership and culture of staff reflected the vision and values of the organisation. The trust had a vision to provide high quality, safe end of life care. The governance framework was clear. Quality, performance and risk was, managed and leaders could identify the actions needed to address challenges to quality care.
• The strategy was aligned to the National Palliative and End of Life Partnership’s Ambitions for palliative and end of life care and the values of the trust.
• Services had continuously improved since the last inspection. The trust had reviewed progress of the implementation of the four-year end of life strategy (2017).
• Staff felt respected and measures were taken to ensure staff were safe when lone working. Staff received support after working in distressing situations.
• Leaders we spoke with at all levels of the organisation described staff as passionate about end of life care and said staff provided high levels of care.
• Leaders prioritised the participation and involvement of most staff. Staff views and experiences were gathered by a series of ‘your voice’ staff engagement events.

However:

• When we reviewed seven sets of records we saw that do not attempt cardio pulmonary resuscitation or DNACPR decisions were still not always recorded appropriately and in line with national guidance.
• A number of improvements were still required for the recording of patient information in patient records, particularly related to timings of entries and level of detail in medical notes and clear rationale for prescribing decision.
• At May 2018 there were three community teams still below the 60% target set for syringe driver training and competence.
• Complaints received by the trust were not routinely able to be recorded under end of life care. The introduction to the electronic system for incidents of a means to do so was under review.
• The availability of information for patients and those close to them had been the subject of a thematic review which identified improvements were required in this area.
• There was no non-executive director lead for end of life and palliative care and the roles of leaders for end of life care were not clear from the intranet.
• Not all relevant staff felt engaged in creating the strategy for end of life care.
• The trust did not have a mechanism to explicitly gather experiences and opinions from those who had experienced the trust’s end of life care provision.
• The trust did not participate in the Gold Standards Framework (GSF) Accreditation process.