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Inspection Summary


Overall summary & rating

Updated 1 June 2014

St James' Hospital is the registered location from where Solent NHS Trust provides all its mental health services. The Trust provides mental health services including Child and Adolescent Mental Health Services (CAMHS) for the 220,000 people residing in the City of Portsmouth and some CAMHS services in Southampton.

Overall we found that people received a safe and caring service. People reported feeling well cared for and receiving a compassionate service. People's physical health needs were well managed. We saw positive examples of collaborative working and active engagement with local black minority and ethnic (BME) groups through the community development workers employed by the trust in partnership with Portsmouth City Council. The evidence seen showed us that this had led to an increase in service engagement of these specific groups and demonstrated a pro-active approach to community engagement by the trust.

We found that improvements need to be made in respect of safety at the Kite Unit where there were a lack of specific male and female areas and some fixtures and fittings could present increased risks. In adult community services staffing levels may present risks to safety for people using the services. We also found that staffing levels within the adult community teams were low and improvements were needed to ensure access and safety was maintained.

Inspection areas

Safe

Updated 1 June 2014

Effective

Updated 1 June 2014

Caring

Updated 1 June 2014

Responsive

Updated 1 June 2014

Well-led

Updated 1 June 2014

Checks on specific services

Acute admission wards

Updated 1 June 2014

These services were provided in a safe way. The Trust had ensured that risk assessments had been completed upon initial admission to the service. We saw evidence that showed us the service reviewed, understood and managed the risk to people who used this service. Systems were in place to identify and investigate patient safety incidents with an emphasis in the organisation to reduce harm to patients. Action plans were monitored by local governance groups. The Trust had a risk register as a working document and informed the Trust where to make improvements.

The services were provided in an effective way. People were involved in their care treatment and management of their goals. The care and treatment was holistic and all their mental and physical needs were assessed and supported. The holistic care also applied to their money and benefit concerns and housing needs. Daily support from specialists was available in these areas.

The services provided were caring. This was confirmed by our observations of the care and treatment being provided by staff. We noted that staff actively engaged with people at a local level. Every person we spoke with told us that they were treated with respect and kindness by staff. They told us that they had their privacy and dignity respected and were provided with care or treatment choices wherever possible. Clinicians told us that they felt that people got a ‘good service’ from the Trust.

The services provided were responsive. We saw, and people told us, that they received care, treatment and support to meet their needs in a timely way. Their concerns were listened to and responded to with at least a verbal response and/or a written response where appropriate.

The service was well-led. For example the matron had asked people using the service, relatives, carers and staff their thoughts on weekly ward meetings and had responded with changes based on the feedback.

Adult solid tumours

Updated 1 June 2014

We found that whilst the provision of these community services was safe; some improvements were required. The trust had not always ensured that full risk assessments had been completed upon initial admission to the service. Examples were seen of large caseloads and staff shortages within two distinct teams. The evidence seen showed us that improvements were required by the trust to demonstrate that the services reviewed; understood and managed the risk to people who used this service.

Improvements were required to ensure that these services were effective. We noted that the trust amalgamation of the assertive outreach and early intervention psychosis team lacked clear clinical validation. This model had not been evaluated fully by the trust and yet further trust reconfiguration was due to take place shortly. Whilst we saw some good examples of collaborative partnership working, there was a lack of multi-disciplinary input into the crisis team. There was a need to review the levels of the consultant psychiatrist input into the access to intervention service based on the numbers of incoming referrals noted. These identified concerns meant that improvements were required by the trust to fully ensure the effective delivery of care and treatment to some patients.

The services provided were caring. This was confirmed by our observations of the care and treatment being provided by front line staff. We noted that staff actively engaged with people at a local level. Almost every person spoken with told us that they were treated with respect and kindness by staff. They told us that they had their privacy and dignity respected and were provided with care or treatment choices wherever possible. Clinicians told us that they felt that people got a ‘good service’ from the trust.

Improvements were required to ensure that these services were fully responsive to people’s needs. This was because we noted that the trust needed to review the evidence it had used to plan their services based on the needs of the local population. The trust was meeting the individual needs of people who used this service and we reviewed some good examples of responsive and patient centred care during the inspection. Examples were seen of effective complaints management. Some patients spoke highly of their own involvement and participation in their transition from hospital in-patient care to recovery in the community.

Whilst we found robust and well led local service provision; improvements were required to ensure that trust wide leadership was more visible and responsive to front line staff. Some staff told us that they didn’t feel listened to at the organisational level and that they felt the trust's risk register did not reflect the potential risks to the organisation. This showed us that improvements were required by the trust in order to review the existing trust risk register in the light of these concerns.

Child and adolescent mental health wards

Updated 1 June 2014

We found that whilst the provision of child and adolescent mental health services was safe some improvements were required. We saw that the service had assessed the mental and physical needs of children who were using these services and provided care accordingly. However, the records seen showed us that the Trust had not always ensured that full risk assessments had been completed upon initial admission to all the services provided.

We saw that children and their parents were involved wherever possible in their care treatment and management of their goals. However, some sites inspected could not demonstrate learning points from audits and were not able to provide action plans which were monitored on a regular basis.This meant that the monitoring of quality of the services provided by the Trust was inconsistent across those services inspected.The evidence we saw showed us that improvements were required to demonstrate fully that the Trust provided an effective service to children and their families.

The service provided by staff was caring. This was confirmed by our observations of the care and treatment being provided by staff. We observed a referral meeting in one team and saw staff accommodated the individual needs of the people referred and that staff worked together to ensure the most appropriate response to individual need. In feedback reports from people who used the service staff were described as caring, helpful and supportive.

Improvements were required by the Trust to ensure that these services were responsive. There were systems in place to monitor the quality of care provided and check it was meeting national standards. There was an effective process in place for responding to complaints. Outcome measures were used to check progress of people using the service. However, there was no evidence of higher levels of analysis to inform service development. Whilst there were arrangements in place for a person’s transfer to other services, for example adult mental health services, these arrangements were noted to be varied across sites as a result of different commissioning arrangements.

Staff told us they felt well supported by their manager and could raise any concerns they had and these would be addressed. However, we found that some improvements were required in the use and analysis of outcome measures in these services by the trust. We noted that improvements were required to ensure a consistent approach across all of these services. Staff were concerned about the impact of potential cost improvement plans upon these services, although these had not been finalised.

Wards for people with learning disabilities or autism

Updated 1 June 2014

Overall we found that the service was safe. Staff were aware of their responsibility to report incidents and safeguard people. Incidents were reported and learnt from. There were sufficient staff to provide for people’s care needs.

People’s care took account of clinical guidance and best practice. The quality of care delivered was monitored through audits, surveys and people’s feedback. The community team could demonstrate that there had been few admissions to inpatient units required for people with a learning disability.

People were provided with choices about their care and took part in reviews. Where people lacked the capacity to make specific decisions, their capacity had been assessed and best interest decisions made. We observed very positive interaction between staff and people using the service.

Care was tailored to people’s individual needs. The complaints policy was readily available to people. Advocacy was proactively promoted and there were a range of activities undertaken to involve people in their care planning and service design.

Staff received a good level of training. Staff had an understanding of the governance procedures and processes in place for risks to be identified and managed. Staff felt well supported by their team managers. Staff received regular supervision and an annual appraisal.

Specialist eating disorders service

Updated 1 June 2014

There were systems and processes in place to ensure the safety of people using the service and staff, although some improvements were required.

The service had not always ensured full risk assessments had been completed upon initial admission to the service. We saw that improvements were required to fully demonstrate the services understood and managed the risk to people who used this service.

People who used the service reported feeling safe and understood the approach used by staff. They told us staff were caring and responsive to their needs.

In feedback reports from people who used the service, staff were described as caring, helpful and supportive. Staff told us there had been no formal complaints and if an individual raised any concern it would be dealt with as part of their therapeutic intervention and recorded in their clinical record.

There were sufficient transfer arrangements for young people coming in to the service. For example we looked at records for a young person who was in the process of transferring and saw there was communication between both services.

However, there was poor communication between adult mental health and this service. For example the electronic system did not show the involvement of the eating disorder service for a person open to adult mental health services.

The record keeping required improvement, we found the care records did not contain all relevant information which staff retained; there was discrepancy between what was recorded on the electronic system and what was in the paper record.

Staff could not show us a record of when the equipment, for example weighing scales, had been checked and calibrated and there was no label on the equipment to show when this was last done. There were labels to show when the equipment had been tested for electrical safety. We later received assurance from the Trust the equipment had been calibrated. Improvement was required in local systems to monitor this.

There were effective processes in place for appraisal of staff and regular supervision to ensure safe and effective provision of care. Staff we spoke with told us they felt well supported by their manager and could raise any concerns they had and these would be addressed.

Some improvements were required to ensure safe record keeping which identified risk, care planning and in recording communication with other services. Improvement was required in the local monitoring of equipment checks.

Services for older people

Updated 1 June 2014

There were clear incident reporting processes and staff understood their reporting duties. Processes were in place to safeguard people. Risks to people had been assessed upon their admission or referral to community services and on an ongoing basis. Actions had been taken to manage the risk of people falling. There were sufficient staff to provide people’s care. There was a significant use of agency staff on The Limes but reasonable steps had been taken to manage the impact of this on people’s care.

People’s care took account of clinical guidance and best practice. There was close working with other services within the Trust to meet people’s needs. People could not currently access a psychologist on The Limes; however, the Trust was in the process of recruiting to this post. The quality of care delivered was monitored through audits, surveys and people’s feedback. Staff received a good level of training. We saw adherence to the requirements of the Mental Health Act (MHA) 1983 and the associated Code of Practice (CoP).

People were provided with choices about their care and took part in reviews. Where people lacked the capacity to make specific decisions their capacity had been assessed and best interest decisions made. Staff communicated effectively with people and they were treated with dignity and respect.

Care was tailored to people’s individual needs. The Intermediate Care Team (ICT) had been responsive in reducing the need for people to be readmitted. This service did not operate overnight; however, there was a care pathway in place for people who required overnight admission. The complaints policy was readily available to people.

Staff had an understanding of the governance procedures and processes were in place for risks to be identified and managed. Staff felt well supported by their team managers. Staff received regular supervision and an annual appraisal.

Other specialist services

Updated 1 June 2014

Overall we found that the service was safe but improvements are required in respect of the environment and the risks that this poses to patients, in particular female patients. Staff were aware of their responsibility to report incidents and safeguard patients. Incidents were reported and learnt from. There were sufficient staff to provide for people’s care needs. We judged that the lack of gender separation on the Kite Unit was not safe and was in breach of Department of Health guidelines and Mental Health Act code of practice.

Care was provided with account of clinical guidance and best practice. We saw adherence to the requirements of the Mental Health Act, however some improvement is required to deliver care in line with the Code of Practice. The quality of care delivered was monitored through audits, surveys and people’s feedback. Staff received a good level of training.

People were provided with choices about their care and took part in reviews. Where people lacked the capacity to make specific decisions, their capacity had been assessed and best interest decisions made. We observed very positive interaction between staff and patients.

Care was tailored to people’s individual needs. The complaints policy was readily available to people. Advocacy was proactively promoted at the service.

Staff had an understanding of the governance procedures and processes in place for risks to be identified and managed. Staff felt well supported by their team managers. Staff received regular supervision and an annual appraisal.

Acute wards for adults of working age and psychiatric intensive care units

Updated 1 June 2014

PICU

The PICU services were provided in a safe way. The Trust had ensured that risk assessments had been completed upon initial admission to the service. The evidence we saw showed us that the service reviewed, understood and managed the risk to people who used this service. Systems were in place to identify and investigate patient safety incidents with an emphasis in the organisation to reduce harm to patients. Action plans were monitored by local governance groups. The Trust had a risk register as a working document and informed the Trust where to make improvements

The PICU services were provided in an effective way. We saw that people were involved in their care treatment and management of their goals. The care and treatment was holistic with all patients' mental and physical needs assessed and supported. The holistic care also applied to money and benefit concerns and housing needs with daily support from specialists in these areas.

The PICU services were provided in a caring way. This was confirmed by our observations of the care and treatment being provided by staff. Staff actively engaged with people at a local level. Every person we spoke with told us that they were treated with respect and kindness by staff. They told us they had their privacy and dignity respected and were provided with care or treatment choices wherever possible. Clinicians told us they felt that people got a ‘good service’ from the Trust.

The PICU services were provided in a responsive way. People told us, and we observed that they received care, treatment and support to meet their needs, in a timely way. Their concerns were listened to and responded to with at least a verbal response and/or a written response where appropriate.

We found the PICU service to be robust and well-led at the local level. Previously the matron had asked people who used the service, relatives and carers, and staff their thoughts on weekly ward meetings and had responded with changes based on the feedback.

Place of safety

The environment and location of the section 136 suite meant that there were risks to the safety and dignity of patients and could not ensure that this service was safe.

Whilst the Trust had the capacity to respond appropriately to clinical need there was a lack of joint and collaborative working around the use of the section 136 suite which compromised responsiveness.

We noted that the interface with Hampshire Police was not working as well as it should and was, therefore, not as effective as it could be.

We found that the current arrangements did not ensure coordinated working with the police around Section 135 and 136 of the Mental Health Act and this need to be more robustly led to ensure better liaison.

However, the services provided were caring. The records and other policies seen showed us that there were robust operational protocols in place. This was supported by our discussions with patients and staff. Patients were being made aware of their rights and staff supported people in a caring manner.

Mental Health Act responsibilities

Updated 1 June 2014

We found that patients were lawfully detained, however there was room for improvement in the recording of procedures required under the Mental Health Act and Code of Practice. This included the recording of conditions associated with section 17 leave.

We were told about delays in the process for Mental Health Act assessment due to the availability of key staff.

Mostly people’s rights were being upheld. However we did find some practices that were restrictive within adult mental health services. These included the admittance of people detained under the Mental Health Act directly to psychiatric intensive care even if the individual's risk assessment did not specify this action and routine body searches for people returning from leave.

Care planning and risk assessments were fully completed and usually inclusive of the people's views. People generally felt involved in their care and well supported by staff. Advocacy support was available and community meetings took place.

We found issues regarding the privacy and safety of patients at the Kite Unit. Gender separation was not in line with the Mental Health Act Code of Practice and the environment provided challenges regarding potential self-harm. We also found that the environment within the seclusion facility required improvement.

We found that arrangements with the police regarding the management of places of safety were not clear and the health based place of safety suite was not always used as the preferred place of safety as required by the Mental Health Act Code of Practice.

We found that there was a programme of audit and a governance process in place to consider how well the Mental Health Act is being implemented at the hospital.

Other CQC inspections of services

Community & mental health inspection reports for St James Hospital can be found at Solent NHS Trust.