Herefordshire and Worcestershire Health and Care NHS Trust

Updated 19 January 2024

We carried out this unannounced inspection of Herefordshire and Worcestershire Health and Care NHS Trust, of the mental health and community health services provided by this trust because since our previous inspection Worcestershire Health and Care NHS Trust, had taken on responsibility for providing mental health service to Herefordshire from Gloucestershire Health and Care Foundation Trust in April 2020.

We carried out this inspection because 2 services that had previously been inspected had been rated inadequate overall. This included acute wards for adults of working age which had been rated as inadequate in July 2022, and community-based mental health services for adults of working age had been rated inadequate in January 2020. We also inspected 2 services which had not been inspected since 2018, both which were previously rated as good. We also carried out this inspection because of concerns we had received about sexual safety of patients at Hillcrest ward.

We also inspected the well-led key question for the trust overall.

At this inspection, we visited 3 mental health services and 1 community health service. We also inspected the well-led question at provider level for the trust overall.

The trust provides the following services:

• Acute wards for adults of working age and psychiatric intensive care units
• Long stay or rehabilitation mental health wards for working age adults
• Wards for older people with mental health problems
• Mental health crisis services and health-based places of safety
• Community-based mental health services for adults of working age
• Specialist community mental health services for children and young people
• Community-based mental health services for older people
• Community mental health services for people with a learning disability or autism
• Community health services for adults
• Community health services for children, young people and families
• Community Health inpatient services
• Community end of life care
• Community dental services.

We inspected all key lines of enquiry in all domains (safe, effective, caring, responsive and well-led) in the 4 services inspected. These services were:

• Acute wards for adults of working age and psychiatric intensive care units
• Community-based mental health services for adults of working age
• Mental health crisis services and health-based places of safety
• Community health services for adults

We also assessed if the organisation is well-led and looked at areas of governance, culture, leadership capability and improvement. Our inspection approach allows us to make a judgement on how the trust’s senior leadership leads the organisation, and the provider level well-led rating is separate from the ratings of the services we inspected.

In rating the trust overall, we took into account the current ratings of the 10 services which were not inspected this time and therefore bought forward the most recent ratings.

At this inspection, the key questions were rated overall, as requires improvement for safe, and effective, good for caring and responsive and requires improvement for well-led.

The trust-wide well led rating is not aggregated with all the service ratings. The trust-wide well led rating went down. We rated the overall trust-wide well-led as requires improvement.

At this inspection, we rated all 3 of the mental health services we inspected as requires improvement overall. This was an improvement in rating for 2 services since the last inspection. The rating for 1 of the mental health services inspected went down to requires improvement. The rating for the community health service we inspected went down and was rated requires improvement.

Our overall rating of services went down. We rated the trust as requires improvement because:

• We found environmental risks at 2 of the services inspected. In acute wards for adults of working age, where accommodation was mixed sex, staff did not sufficiently monitor and observe single sex spaces. This resulted in sexual safety incidents. Two services did not ensure ligature risk assessments were up to date and identified risks were not effectively mitigated.
• Two services we inspected had not ensured that patient risk assessments were completed, reviewed, or updated. Not all services had mitigated risks to patients in relation to sexual safety in acute wards for adults of working age. In mental health crisis services, the safety of young people when admitted to a health-based place of safety was not always well managed.
• Safety was not a sufficient priority in all services. Staff did not manage sexual safety incidents well. Not all services escalated or reported sexual safety incidents. In acute wards for adults of working age, staff did not take action that was reasonably practicable to report, respond to or mitigate sexual safety risks.
• The systems and processes used to manage risks in the trust were not effectively managed. There was a lack of collaborative oversight, escalation or challenge. The trust board was not always sighted on all risks that could affect the delivery of strategy and provision of high-quality care.
• Across the trust, not all environments in services we inspected had been well maintained, clean or were fit for purpose. In mental health crisis services, the health-based place of safety in Worcestershire did not meet the standards on the use of Section 136 of the Mental Health Act 1983 (England and Wales July 2011 Royal College of Psychiatry CR159) and the guiding principles of the Code of Practice.
• Staff compliance with mandatory training fell below expected standards in 3 of the 4 services we inspected. This included training in basic life support, fire safety training and Mental Health Act training. Systems and processes to monitor training compliance were not effective in these services.
• Some services did not receive regular supervision or appraisals. In 2 services the service did not provide data on supervision compliance, and in a third service, compliance was as low as 20%. One service inspected had appraisal compliance at 66%. Systems and processes to monitor supervision and appraisal compliance were not effective in these services.
• Psychology waiting times prevented patients receiving interventions in a timely manner in community-based mental health services for adults of working age in Worcestershire. The number of patients on the waiting list had steadily increased each month, from 57 in March 2022 to 161 in February 2023.
• We had concerns about staffing in 2 services. In Neighbourhood mental health teams, the service did not have enough staff and some teams had patients who were waiting to be allocated to a caseworker. Vacancy rates were between 17% and 61% across both Herefordshire and Worcestershire. In the Worcestershire health-based place of safety, there were not always appropriate staff available to assess a young person outside working hours. This meant young people had to then stay overnight.
• In services we inspected, some systems and processes did not effectively provide managers with oversight or assurance of how services were delivered. Managers did not always have systems to be able to assess, monitor and review the quality of the service. For example, locking of doors, reporting of incidents, adherence to trust policies and procedures training and supervision and appraisal compliance.
• Whilst members of the board had the skills, knowledge and experience required, we were not assured that they worked in a cohesive and collaborative way to address areas of risk or concern. Leaders at all levels were not always visible.
• Systems of accountability for some areas of governance were not always clear, and not all senior leaders discharged their responsibility of active challenge to decisions and actions robustly. Learning from incidents, and previous inspections had not been shared across the trust or acted on swiftly enough to bring about improved, safe care.
• There was evidence of a closed culture within the trust with minimal actions at board level and in services to address equality, diversity and inclusion issues felt by staff. There was a lack of urgency to implement culture change initiatives across the organisation.
• We found a lack of evidence to support patient involvement in service development, redesign, and improvement. Whilst the trust published this was in place, there were few examples to show where this occurred.

However:

• The trust had a clear vision with values which were understood by all staff. All staff spoken with during our inspection knew the trust values and were able to relate them to their work within the team. Staff knew and understood the provider’s vision and how it applied to the work of their team.
• Three services had decreasing rates of bank and agency nurses and support workers. Managers limited their use of bank and agency staff and requested staff familiar with the service. They made sure all bank and agency staff had a full induction and understood the service before starting their shift.
• In 2 services we inspected, staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
• We were assured that trust safeguarding systems and processes were well managed and risks were mitigated. Staff in the trust were up to date with safeguarding training and knew how to recognise abuse and when to report it.
• Across services, medicines management was managed well. Physical healthcare was managed effectively, and staff encouraged patients to live healthier lives.
• We saw how staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. They had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
• Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
• The trust had been impacted by a national cyber security issue which had affected access to the patient recording system. Action taken around the failure of the electronic care record system appeared both positive and proactive. Whilst difficult and time consuming, this was well managed. Staff had been unable to update patient records on this system for several months. Staff told us they could still access the system to view historical records but could not add updates. The trust had developed an interim patient recording system. Staff told us that they had access to both systems and that managers had kept them updated about the system issues.
• Staff knew their responsibilities under the Mental Health Act and Mental Capacity Act. The trust had effective and embedded systems and processes for management of duties under the Mental Health Act.
• The trust was well positioned within the ICB to influence the health and social care system. We have heard how key Board members advocate and action the agenda with stakeholders. Service managers engaged actively with other local health and social care providers to ensure that an integrated health and care system was commissioned and provided to meet the needs of the local population.
• The trust had a clear focus and agenda within the research team with a positive plan to become self-sufficient. Quality improvement was actively encouraged from small local ideas to larger, more complex service improvements. The trust had an agenda to continue to develop their quality improvement approach.
• The trust had led on new integrated models of care to improve how people accessed and came into contact with services across Herefordshire and Worcestershire.

How we carried out the inspection

During the inspection, our inspection teams carried out the following activities across 5 wards and 7 community-based mental health service and community health services and 2 health-based places of safety:

• spoke with 65 patients and 18 family members or carers of patients
• accompanied staff on 2 visits to patients in the community
• viewed clinic rooms and reviewed 70 medication charts
• spoke with 134 members of staff including senior leaders and managers, consultants, doctors, registered nurses, healthcare assistants, ward clerks, independent mental health advocates, occupational therapists, and physiotherapists
• reviewed staff rosters
• reviewed 63 sets of patient care records
• undertook 14 incident reviews where we looked at information relating to incidents across all 5 wards we visited
• observed shift handover meetings, a ward round, a reflective practice group and an occupational therapy patient session
• reviewed CCTV footage and the digital images log
• observed a Mental Capacity Act training session
• attended 14 community visits to observe care and treatment
• reviewed a range of policies, procedures and other documents related to the running of the service.

During our well-led inspection, we spoke with senior leaders of the organisation and reviewed a range of policies, procedures, and other governance documents relating to the running of the trust.

What people who use the service say

Community-based mental health services for adults of working age

We spoke with 15 patients who were pleased overall with the service they had received. Most patients told us that staff were kind, respectful and polite and had involved them in decisions about their care and treatment. Patients told us that staff gave them information and advice about medicines and healthy lifestyles. However, 5 patients told us that they had not been given a copy of their care plan.

We spoke with 3 carers, who told us that staff were responsive and caring. However, 2 carers told us they had not been as involved as they would have liked and that they had not been given information on how to access a carers assessment.

Mental health crisis services and health-based places of safety

We spoke with 11 patients and 3 carers. Feedback from patients, family and carers was positive. They described staff as kind and supportive. They told us staff communicated well with them and they received effective and high-quality care and treatment.

Staff made sure patients understood their care and treatment. Patients said staff supported them with their immediate mental health crisis and their recovery by referring them to longer term interventions such as psychological therapies.

Staff involved patients in decisions about the service. Patients could give feedback on the service and their treatment and staff supported them to do this.

Patients told us they felt listened to and staff responded quickly to their views and wishes. Patients were particularly positive about being able to talk directly to consultants and with staff day and night. Patients described the service as life changing.

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

We spoke with 15 patients and 4 carers. Overall, the 15 patients that we spoke with were positive about the service and complimentary of the staff. We received some comments relating to agency staff. Some patients felt that they did not engage with them as well as substantive staff and felt that they were more difficult to work with.

We spoke with 4 patients on Mortimer ward. They told us temporary staff were kind and caring and responsive to their needs. Patients were complementary about the meals provided and said there was lots of choice. Patients told us they heard the loud building work noises during the week due to ongoing building work but had become used to the level of noise and frequency.

One patient said regular staff were very good and they felt comfortable to speak with them. They enjoyed planned walks to Churchill gardens with the occupational therapist and said walking helped them to feel better. They liked regular sessions with the Art therapist on Fridays. Another patient said they enjoyed chatting with staff and felt safe to a certain degree. There were regular staff at night who met their needs.

However, patients did not always feel safe in relation to sexual safety. One patient told us male and female patients usually walked around single sex spaces. Another patient told us about a sexual safety incident they reported to the police as they did not feel staff had taken their concerns seriously.

Community health services for adults

We spoke with 27 patients and 8 carers in this service. Feedback from patients, family and carers was overwhelmingly positive. They described staff as caring, friendly, and supportive. They told us they felt involved in their care and reported good communication from staff. Patients all felt they received effective and high-quality care and treatment.

Patients told us they felt staff listened to them and were responsive to their views and wishes. They said staff gave them advice on their care and treatment in an accessible and clear manner. This included explaining the nature, purpose, and side effects of medicines.

Patients spoke positively about occupational therapy. They said they were provided with appropriate specialist equipment and that staff made sure they were explained how to use it.

Patients, carers and family said they observed good communication with teams within the wider trust and also external teams. For example, they felt that staff regularly liaised with GP practices and were jointly aware of care and treatment decisions.

Despite some staffing issues, particularly within the therapy teams, patients, carers and family mostly fed back that appointments were rarely cancelled or delayed.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 19 January 2024

Updated 21 January 2020

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

• The service had enough staff to care for children, young people and families and keep them safe. Staff had training in key skills, understood how to protect children, young people and families from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to children and young people, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care, treatment, advice and support. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children, young people and families, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated children, young people and families with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children, young people, families and carers.
• The service planned care to meet the needs of local people, took account of children and young people’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of children, young people and families receiving care. Staff were clear about their roles and accountabilities. The service engaged well with children, young people, their families and the community to plan and manage services and all staff were committed to improving services continually.

However:

• It was not clear if there were cleaning records to document when cleaning had occurred at all locations. Cleaning records we observed were not always up-to-date and did not always demonstrate that all clinical areas were cleaned regularly.
• Not all equipment was serviced and calibrated in line with trust policy.
• Safeguarding adults level 3 training module compliance rates were low. Some staff that were required to complete the module had not completed it.
• Safeguarding supervision timeframes were not consistent across the workforce and timeframes stated in the policy were not in line with NHS England National Health Visiting Service Specification 2014/2015.

Updated 21 January 2020

This service had not previously been inspected or rated. We rated it as good because:

• The service had comprehensive systems to help them manage risk to patients and staff. There were processes for the reporting and shared learning when significant events occurred within the service. Incidents were reported, acted on and learning was shared across the service.
• Staff were qualified and competent to carry out their roles. They were encouraged to complete mandatory training, and this was actively monitored. There were clear lines and support for staff to be further developed into extended duty roles by completing postgraduate courses.
• Staff followed infection control procedures which mostly reflected published guidance.
• Staff provided treatment, advice and care in line with nationally recognised guidance. There was an effective skill mix at the service to assist with the ever-increasing complexity of patient.
• Staff worked together as a team and with other healthcare professionals in the best interest of patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental health issues and those who lacked the capacity to make decisions about their care.
• The service had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Staff treated patients with compassion. We observed staff treating patients with dignity and respect. We observed clinicians working collaboratively to ensure one patients specific needs were met.
• The service took into account patients’ individual needs. Clinics had been adapted to ensure they were accessible for all patients. Staff visited a local day centre where they provided a contact session once month to offer basic oral health screening including soft tissue examination to “hard to reach patients” such as those experiencing homelessness.
• The dental health educator actively provided preventative advice, support and training within the local community to support vulnerable groups in various settings. They had delivered several Dental Health Education sessions at a local school under special measures, attended several school readiness events to support parents and families with children who were about to start school and had worked collaboratively with the learning disabilities team and hospital wards to train staff to complete oral health care assessments and to assist people to carry out basic daily oral hygiene procedures.
• The service dealt with complaints positively and efficiently.
• The service asked patients for feedback about the services they provided. Results of patient feedback were analysed and displayed throughout the clinics for patients to read.

However:

• The clinical waste bin at the Dental Anxiety Management Service in Malvern was not locked and was accessible to the public. This was locked during the inspection.
• Weekly protein residue tests were not completed on instruments when using the ultrasonic baths at any of the dental services we inspected.
• There was no receptionist at the Dental Anxiety Management Service in Malvern and therefore this role was covered by the dental nurses when they were available. This meant that patients were not always greeted at the reception desk if the nurses were in surgery. But this was a small service and a sign and bell was in place to attract the attention of staff.
• Paediatric patient wait times from being assigned to the community dental service to receiving treatment under general anaesthesia averaged 25 weeks. A working group had been developed to improve efficiency and reduce the wait times. Although the overall wait was beyond the control of the trust.

Updated 1 June 2018

• Our rating of this service stayed the same. We rated it as good because:
• We rated well-led as outstanding, safe, caring and responsive as good, and effective as requires improvement.
• The service kept people safe by ensuring sufficient staff with the right training, supervision, knowledge and skills were in place. Risk assessments to patients were thorough and staff planned care accordingly. Staff followed infection control procedures and wards were clean. Medicines management was effective. Incidents were investigated and managers ensured that staff learning was in place.
• Staff used best practice and national guidance to complete comprehensive assessments of their patients. Staff were suitably skilled and worked well within multidisciplinary teams. Patients physical health and hydration needs were appropriately met. Measures were in place to effectively monitor treatment outcomes.
• Patients’ told us staff treated them respectfully and they were involved in their own care. Staff provided emotional support to patients.
• The trust planned and provided services in a way that met the needs of local people and were delivered where possible in a way to ensure flexibility, choice and continuity of care. The service took account of patients’ individual needs. Waiting times for treatment and arrangements to admit, treat and discharge patients were in line with good practice. The service treated concerns and complaints seriously and lessons learnt were shared with all staff.
• Quality improvement initiatives were evident across this core service. This has led to improvements in the quality of care and the leadership managers offered to therapy staff. Staff reflected the vision and values of the trust, and there was a positive culture of support and involvement for patients, carers and staff. The trust had effective systems for identifying risks and planned to eliminate or reduce them. The trust was committed to improving services by learning from when things go well and when they do go wrong, promoting training, research and innovation.

However:

• We could not find evidence that decision specific mental capacity assessments were always fulfilled when staff completed do not attempt cardio-pulmonary resuscitation (DNACPR) forms.

Updated 21 January 2020

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

• Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff managed infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Primrose ward did not have a dedicated area for preparing medication including controlled drugs. Staff completed this task in an area open to patients and visitors. This meant staff could be easily distracted from completing this which could lead to errors.
• The visitors viewing area in the mortuary was not fit for purpose. It was not designed to make visitors as comfortable as possible at a very difficult and distressing time for them. Staff did what they could to mitigate this but were not able to change the way the room was set out or the equipment used
• The lack of an end of life care strategy for the trust meant that there was an overall lack of audits and evaluation for end of life care. This affected the governance of the service at a more senior level. However, the trust participated in the national audit of at the end of life, which is a NHS benchmarking audit, and Primrose hospice used a metrics tool to measure quality.
• Staffing levels on Primrose Ward meant that at times staff did not feel able to take breaks as they needed to focus on patient care and keep them safe.

Updated 21 January 2020

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

• The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff treated patients with compassion and kindness and respected their privacy and dignity. They were passionate about working with the patient group and supported them to manage their care and treatment in ways in which they would understand. Staff were highly motivated to develop and adapt treatments that met patients individual needs. Staff had excellent knowledge of their patients, which meant they understood their individual needs. They actively involved patients and families in their care decisions from the start of their treatment.
• The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait longer than expected targets to start treatment. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
• The service was extremely well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly and effectively.
• Staff were innovative and were proactive. There were several examples of innovations taking place across the service with a view to enhancing the experience of care patient’s received.

Updated 21 January 2020

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

• The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was easy to access and staff and managers managed waiting lists and caseloads well. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly and those who did not require urgent care did not wait too long to receive help.
• The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

Updated 21 January 2020

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

• There were sufficient trained, skilled and experienced staff to meet patient needs. Staff had a wide range of clinical and professional skills and worked together well for the benefit of patients and were sufficiently resourced and skilled to be able to respond to changing circumstances in a patient’s well-being.
• The service had a good safety record, with few incidents. Good clear care records were maintained, supporting staff to be informed and inform relevant agencies about patient need and vulnerabilities.
• The service worked effectively with other teams and agencies and were able to support and signpost patients and carers to relevant outside support.
• Staff morale was good and staff were very positive about colleagues, team support, and managers, and resilient enough to work effectively in the faces of challenges presented by a recently reconfigured service.

Updated 19 January 2024

Updated 18 June 2015

The overall rating for wards for people with learning disabilities was that these services were good.

• The staff we interviewed were able to demonstrate to us that they had an understanding of the Mental Capacity Act 2005 (MCA) and also the Deprivation of Liberty Safeguards (DoLS).

• We saw that there were policies and procedures in relation to the MCA and DoLS to ensure that people who could not make decisions for themselves were protected. We saw from the records we looked at that where people lacked the capacity to make decisions about something, that best interest meetings were held.

• Care records covered a range of needs and had been regularly reviewed to ensure staff had up to date information. There were also detailed assessments about the person's health that included specific care plans.

• We observed that staff were able to support people with dignity and respect in a safe and caring manner. We found that people who needed help to manage their anxiety were effectively supported by staff. We saw that when required other health professionals had been involved to help develop strategies for doing this.

• All of the people we spoke with were positive about the care provided and how the services were managed. Systems were in place to monitor and review people’s experiences and complaints which ensured improvements were made where necessary.

• Staff were trained and experienced and showed high levels of motivation and commitment. We saw that staff were warm, friendly and supportive in the way that they spoke with and cared for the people using the service.

• All staff were able to tell us about people’s needs, and were positive about how the service was managed.

• The carers and relatives we spoke with were very happy with the service provided and all felt that people were provided with safe and effective care.

• When people’s needs changed all of the locations inspected were able to demonstrate that they responded and where necessary work with other professionals to ensure that needs were met.

Updated 1 June 2018

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

• We rated caring, responsive and well-led as outstanding, and safe and effective as good.
• Since the last inspection, the wards had acted on our feedback and there had been significant improvement in the quality of patient care. The wards had comprehensive ligature risk assessments and action plans in place. The self-administration of medicines policy was being followed. The wards completed clinical audits and regularly monitored the quality and effectiveness of the wards.
• All staff had received training on the Mental Health Act and the Code of Practice and systems were in place to monitor and check all MHA documentation adhered to the requirements of the MHA. All staff had received training in the effective use of the Mental Capacity Act and Deprivation of Liberty Safeguards. 
• Safety was managed well on the wards; systems in place to monitor safe and the quality of the wards. The wards met safe staffing levels to keep patients safe. All patients had comprehensive risk assessments and management plans in place, which were reviewed and updated regularly. Staff raised safeguarding concerns and reported incidents. The fire alarm system at Keith Winter House was audible throughout the building.

• All patients had care plans, which were recovery focussed, personalised, holistic and updated regularly. Rating scales and outcome tools were used to measure and monitor a patient’s progress in treatment. Staff had the skills and competencies to deliver effective care and received regular supervision and annual appraisals.
• Staff treated patients with dignity and respect, were kind and compassionate and support the patient to understand and manage their care and treatment. Staff had built a very good rapport with patients, supported the patients to achieve their goals and ensured all their needs were met.
• Patients were encouraged and supported to develop skills to prepare them to live independently in the community. Each patient had discharge plans in place that involved other agencies and providers, who engaged with the patients to achieve the plan. Patients engaged with a range of activities on the wards and in the community to build on the skills needed to live independently and had access to volunteering schemes, education and employment.
• Managers demonstrated strong leadership of the wards. The staff respected the managers, felt supported and were given the opportunities for career and professional development. The wards developed a culture of openness and staff were encouraged to raise concerns, and were fully involved in developing and delivering improvements to practice.

Updated 1 June 2018

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

• We rated safe, caring, responsive and well-led as good and effective as requires improvement.
• Staff identified and appropriately managed environmental risks. The wards had access to emergency and medical equipment that was regularly checked and well maintained. The level of cleanliness in all three wards was of exceptionally high standard.
• The wards had enough staff that were experienced and qualified, and had the right skills and knowledge to provide safe patient care. Staff reported incidents appropriately and shared lessons learnt from the investigations. The wards had regular and effective multidisciplinary team meetings and worked well with other external organisations.
• All patients had up-to-date, comprehensive risk, physical health and mental health assessments that informed risk management and care plans. Staff regularly reviewed and updated care plans that were personalised, holistic and recovery orientated.
• Staff followed good practice in medicines management and monitored and reviewed the effectiveness of the medicines prescribed in line with the national guidance. Patients had good access to physical healthcare, including access to specialists, and their nutritional and hydration needs were met.
• Staff treated patients with kindness, dignity and respect. Staff understood the needs of individual patients and involved them and their relatives in their care and treatment. Staff enabled patients and families to give feedback about the service.
• The service had plans to escalate discharges and avoid unnecessary delays. Patients had access to information about their care and treatment and could be provided in an accessible format or different languages. Staff knew how to protect patients who raised concerns from discrimination and harassment.
• The service had robust governance processes to manage quality and safety. The managers had the skills, knowledge and experience to perform their roles and supported and valued staff to contribute to the strategy of the trust.

However:

• In our last inspection in January 2015, we asked the trust that this service should ensure that managers give regular formal supervision to staff. When we inspected this time we found staff were still not receiving regular supervision.
• Athelon ward was an old design building with a mixture of single beds and small bed-bays which meant that privacy and dignity for patients in the bed-bays could be compromised.
• Staff did not give patients copies of their care plans and not all patients could make a call in private.

Updated 19 January 2024

Updated 19 January 2024