The Limes

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – This means we looked for evidence that patient care, treatment and support achieved good outcomes and promoted a good quality of life, based on the best available evidence. At our last assessment we rated this key question Good. At this assessment, the rating has remained Good. This meant that patients outcomes were consistent, and care was delivered in a personalised, recovery-focused, and proactive way.

Patients and their families described the service as excellent and one that encouraged and supported independence, and sustainable rehabilitation and recovery. Staff assessed the physical and mental health needs of every patient prior to admission and developed personalised care plans that were reviewed regularly through multidisciplinary discussions. Care and treatment outcomes were monitored.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

Patients felt confident that their individual needs had been fully assessed, understood, and staff had taken the time to listen to, and involve them in their care and treatment planning. One patient told us, “I have regular time with my named nurse, and keyworker. We talk about lots of things, medicine being one of them. They keep me in the loop.”

We reviewed 6 care records which evidenced staff had completed comprehensive and timely assessments of patient’s physical, mental, emotional and communication needs. Assessments were person-centred and reviewed regularly with the patient and their families if appropriate. Staff used clinical tools alongside professional judgment to build a comprehensive understanding of each patient’s individual needs. If a patient lacked capacity to make decisions, staff adhered to legislation and best practice which ensured decisions were made lawfully, and in their best interests.

Staff used a range of clinical assessment tools, for example, occupational therapists used the model of human occupation screening Tool (MOHOST) to assess capability, and need, this was used as a baseline and to track patients progress, the results were shared with the multidisciplinary team to ensure progress was being made, and the patients’ needs were being met. Occupational therapists also completed assessments of patients daily living skills, for example, road safety awareness, public transport use, shopping and budgeting, washing and dressing and kitchen use and cooking. Staff also used the health of the nation outcome scales (HoNOS), and national early warning score 2 (NEWS2).

The appropriate referrals were made to external services to support patients’ wider health needs, including GP’s, dentists, national screening programmes and specialist physical health clinics. Patient’s needs were also reviewed and amended through regular multi-disciplinary meetings.

Families were also supported and had the appropriate information and resources available to them. For example, carers assessments and signposting to numerous external resources of support. Staff facilitated carer drop-in groups either face to face or virtually. A staff member was also the carers lead and available to offer support when required.

Staff applied their learning effectively, leading to positive outcomes and enhancing patients’ independence and quality of life. They also considered carers’ needs during assessments, helping carers stay well and providing them with safe, effective support.

Staff planned and delivered care and treatment which was in line with legislation, best practice and co-produced with patients, and focused on individual need. Staff demonstrated a thorough understanding of their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice, applying this knowledge confidently, consistently, and effectively.

The service delivered a comprehensive range of interventions which were person centred, including medication management and psychological therapies, such as Cognitive Behavioural Therapy, Compassion Focused Therapy, Mindfulness, and Psychoeducational interventions around emotions, difficulties and strengths. Staff also networked with patient’s families and carers and signposted them to psychological aftercare and support. All interventions were delivered in line with guidance from the National Institute for Health and Care Excellence, ensuring care was effective and safe. This contributed to, and reinforced a therapeutic, person-centred environment.

Staff delivered care, and treatment through a clearly defined and structured model for mental health inpatient rehabilitation and trauma informed care, which supported patients from assessment throughout their rehabilitation and discharge. Care was delivered through a multi-disciplinary approach, with coordinated input from a psychiatrist, a physical health speciality doctor, mental and physical health nurses, a psychologist, an assistant psychologist and an assistant forensic psychologist, occupational therapy teams across staged phases of assessment, engagement and rehabilitation, speech and language therapists, dieticians and healthcare assistants. Patients developed insight, built practical and social skills, managed risks positively, and increased independence at a pace aligned with discharge and their preparedness for change.

Patients accessed physical healthcare intervention when required. Staff completed comprehensive physical health assessments on admission and maintained monitoring through regular observations, such as nutrition and hydration. Staff supported patients to attend GP appointments, specialist hospital appointments and national screening programmes, such as, prostate and bowel screening. Effective record-keeping and monitoring systems ensured that physical health checks were attended, and patients felt confident and reassured that their physical health was effectively managed alongside their mental health.

Innovation was embedded throughout practice. Staff supported a patient led quality improvement project which focused on streamlining diagnosis specific training for staff. A patient diagnosed with schizophrenia was supported by the psychology team to formulate a training package for staff which included a PowerPoint presentation based on their lived experience of mental health services. The training covered topics such as, potential presentations, triggers, and effective techniques for managing episodes of changing behaviour. Pre and post feedback was collected and demonstrated the value of the training, not only had it enhanced staff’s understanding and practice, but it provided an invaluable insight into the illness from the perspective of the person living with the condition.

Patient’s felt that everyone involved in their care and treatment worked well together and encouraged them and where appropriate their families to be as involved as possible. Patients consistently described joint working as smooth and well organised. One patient told us, “Everyone that I need comes to my meetings. We talk about how things are going and what things I need, the staff are on it.”

All staff worked effectively across their teams, handovers were concise and effective and took place before the start of every shift, with accurate information shared consistently. This ensured patients experienced coordinated care that supported their rehabilitation, and recovery goals. Staff shared all assessment outcomes, and care plans promptly when patients moved between services or transitioned to community living, reducing the need for patients to repeat themselves and reliving potential unnecessary trauma.

Multi-disciplinary meetings were held regularly and attended by the full multi-disciplinary team, and external partners when required. Meetings were well structured and covered areas such as, risks, physical health, patient goals, activity engagement, and progress toward discharge, which reflected the focus on rehabilitation and recovery. Minutes were shared electronically which ensured a cohesive approach, and effective collaborative working throughout the patient’s care and treatment journey.

Systems ensured patients were supported by multiple rehabilitation teams, including occupational therapy, psychology, nursing, activity coordinators, speech and language therapists and community mental health teams, Care remained coordinated, recovery-focused, and centred on individual recovery goals.

Patients felt supported and empowered to take control of their health. They described staff as proactive, encouraging, and skilled at advising and supporting them to make positive changes. They valued practical support with sleep, diet, exercise, and general wellbeing, and told us the interventions improved their confidence, independence, and quality of life. One patient told us, “My nurse and keyworker are great. They support me and give me sound advice; nothing is ever too much trouble.”

Staff effectively supported patients to manage their health and wellbeing and focused on promoting independence, which prepared patients for community living. Staff supported patients to develop personalised approaches to health that reflected their goals, preferences, and level of independence. Patients were fully involved in health assessments, progress reviews, and physical health monitoring.

Multi-disciplinary meetings ensured patients accessed the right health and social care support at the right time. Staff encouraged patients to make meaningful and sustainable lifestyle changes through group programmes, and 1 2 1 sessions which covered motivation, physical health awareness and promotion, and substance misuse awareness and education. Staff promoted healthier living through practical initiatives such as smoking cessation, sleep hygiene support and diet and nutrition advice. Staff were trained in relevant physical health monitoring tools and used these in line with rehabilitation goals. Staff also encouraged and supported patients to attend GP and dentist appointments, health support groups and national screening programmes.

Staff supported and delivered a wide range of patient led service and community activities, which supported their recovery and promoted long-term health, including walking groups, gardening groups, swimming and gymnasium visits, and relaxation sessions. Activities promoted independence, improved physical health, and prepared patients for successful community reintegration. Participation and outcomes were monitored to ensure progress was sustained and support remained tailored to individual goals.

Staff monitored patients’ progress and used data to continuously improve the quality and effectiveness of care. Staff ensured that outcomes were positive and aligned with both clinical expectations and individual goals.

The service was aligned with and participated in NHS national rehabilitation benchmarking. This was used by both providers and NHS commissioners of rehabilitation services. Services were assessed independently of each other and then compared nationally which ensured outcomes were consistent, and expectations were being met. Staff attended a regional mental health rehabilitation group which was a joint NHS and Independent sector meeting, where benchmarking was undertaken, and good practice shared. Any recommendations or actions needed were considered and completed via the organisations clinical network benchmarking framework.

Staff promoted improving independence, autonomy, and wellbeing alongside clinical outcomes. Work to reduce restrictive practice increased opportunities for extended periods of leave, participation in structured group work, in preparation for community living. The service was accredited with the triangle of care (ToC), which was a quality improvement scheme that certified health providers for effectively engaging, identifying, and supporting unpaid carers. It used a star-based system to assess compliance with six key standards and primarily focused on creating a collaborative partnership between patients, staff, and carers in mental health settings.

Shared learning from benchmarking against other rehabilitation services regionally and nationally supported staff to adapt practice and continue to improve outcomes. This ensured patients received consistent outcomes, and effective rehabilitation and recovery-focused care. Staff actively participated in clinical audits, benchmarking, and quality improvement initiatives, ensuring care was consistently measured against national standards and aligned with best practice.

Staff helped patients understand their rights and treatment options, using different communication methods to ensure information was clear and understood.

Staff informed patients about their rights around consent when delivering person-centred care and treatment. They took practical steps to enable patients to make their own decisions, promoting independence and choice in line with the principles of rehabilitation. Where patients might have impaired mental capacity, we saw evidence that staff had completed and recorded decision-specific capacity assessments appropriately, and in accordance with the Mental Capacity Act 2005.

If a patient lacked capacity to make certain decisions, staff held meetings with other professionals and made decisions in their best interests, considering their wishes, feelings, cultural background, and personal history. Staff used accessible formats, including easy read information and regular advocacy support, which promoted understanding and inclusion.

Staff followed the correct legal processes and ensured patients were kept informed of their rights. Staff supported patients to express their views and encouraged them to be involved in planning and reviewing their care as much as possible, maintaining a strong focus on recovery, rehabilitation and empowerment.