Solent NHS Trust

Updated 27 February 2019

Not used

Updated 27 February 2019

Our rating of the trust improved. We rated it as good because:

We rated safe, effective, responsive and well-led as good. The rating for caring improved from good to outstanding. We rated seven of the trust’s 16 services as good. In rating the trust, we considered the current ratings of the primary medical services for general practices rated separately to this report and eight other services not inspected this time.

We rated well-led for the trust overall as good.

• Leadership teams were visible and supportive to frontline staff and demonstrated good knowledge and understanding of the services they provided.
• There was a positive organisational culture, which supported openness and transparency. Staff were mostly very happy to be working for Solent NHS Trust and spoke highly of their leaders.
• Managers involved staff in changes to services.
• Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses and to report them internally and externally.

• Staffing levels, skill mix and caseloads were planned and reviewed so that people received safe care and treatment.

• Staff had access to necessary equipment and medicines; and had a range of policies and procedures based on national standards to support their practice.
• Medicines were appropriately prescribed and administered to people in line with the relevant legislation and current national guidance, and had improved since our last inspection.
• People’s physical, mental health and social needs were holistically assessed and their care and treatment delivered in line with legislation, standards and evidence-based guidance.
• Multidisciplinary working was strong across the services. Staff worked well together and with other organisations to deliver effective care and treatment.
• The services had clear arrangements for supporting and managing staff to deliver effective care and treatment.
• Staff had annual appraisals and managers encouraged staff and supported opportunities for development.
• Staff were kind caring and treated patients with dignity and respect. Patients spoke of the positive care they received from staff.
• Staff communicated with people so they understood their care, treatment and condition; and advice was given when required. Staff involved carers and families in the patient’s care, where appropriate.
• Services delivered were accessible and responsive to people with complex needs or in vulnerable circumstances.
• People with the most urgent needs had their care and treatment prioritised. Waiting times were within the trust target.

However,

In the community services we found:

• Equipment was not always available in a timely way. For adults as well as children and young people there were delays with the provision of or repairs to wheelchairs.
• Electronic recording systems could not provide assurance about staff completion of appraisals or mandatory training. The figures provided by the trust indicated that some staff were not meeting the statutory and mandatory training targets set by the trust. The trust set training to zero each business year but this did not show assurance that any staff overdue training had dates set in a timely manner.
• Although the service had systems for identifying risks, not all risks were formally identified which meant there were missed opportunities for escalation to plan to eliminate or reduce them.
• Staff in some teams had limited understanding about the Freedom to Speak up Guardian role
• Staff had variable understanding of their responsibilities towards the duty of candour legislation

Updated 6 January 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.

Updated 27 February 2019

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

• The service had enough medical and nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment
• Staff kept detailed electronic records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
• Community adults planned and provided services in a way that met the needs of local people. Services were delivered, made accessible and coordinated to take account of and meet the needs of different people, including those people in vulnerable circumstances.
• There was effective multidisciplinary working both across the community adults and with partner organisations. Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare and social care professionals supported each other to provide good care
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

However,

• Equipment was not always available in a timely way. Patients were subject to significant delays in the provision of or repairs to wheelchairs, which affected the safety and well-being of many patients receiving adult community services. Ordering procedures resulted in delays of equipment for some patients.
• While the service provided mandatory training in key skills for all staff the figures provided by the trust indicated that staff were not completing their training and were not compliant with statutory and mandatory training targets set by the trust.
• Staff we interviewed understood how to protect patients from abuse. The service provided staff with training on how to recognise and report abuse however,the data provided by the trust indicated that staff were not completing their training and were not compliant with statutory and mandatory training targets.

Updated 27 February 2019

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

• Children, young people and families were protected from poor care and abuse by staff who had the relevant skills and received appropriate support. This was by mandatory training, safeguarding awareness, competency assessments, supervision and appraisals. Where there were staff shortages the service took mitigating actions to reduce the level of risk to patients.
• The service had a culture of learning from where things had gone wrong, this included learning from incidents and complaints.
• The service mostly provided care and treatment based on national guidance. Staff followed processes to ensure management of medicines was carried out in a sure way that met national guidance.
• There was effective multidisciplinary working both across the trust and with partner organisations.
• The leadership of the service supported monitoring and improvements to the services they delivered. The service engaged well with patients, partner organisations and staff. Staff reported a supportive working environment that looked after their wellbeing as well as supporting them in their personal career development.

However,

• Equipment was not always available in a timely way. Children and young people were subject to delays with the provision of or repairs to wheelchairs. Ordering procedures resulted in delays of equipment for some children.
• Electronic recording systems could not provide assurance about staff completion of mandatory training.
• Health visiting performance was below the national average
• Although the service had systems for identifying risks, not all risks were formally identified which meant there was no plan to eliminate or reduce them.
• Staff had limited understanding about the Freedom to Speak up Guardian role and their responsibilities towards the Duty of Candour legislation.

Updated 15 November 2016

Staff understood their responsibilities to raise concerns and report incidents, and evidence learning occurred as a result. Staffing levels were sufficient to provide safe care. The trust employed regular agency and bank staff to mitigate risks to patients when wards were short of staff. Risks to patients were monitored, and arrangement were in place and followed access to medical advice and support when needed.

Staff provided care and treatment that took account of nationally recognised evidence based guidelines and standards. Patient pain was managed effectively, and patient’s varied dietary and nutritional needs were met. The trust took part in national and local audits to measure and promote improved outcomes for patients. Staff had a good understanding of their responsibilities to the Mental Capacity Act and applied it appropriately when caring for patients who had reduced capacity and cognition. There was a strong emphasis on multidisciplinary working across all inpatient wards.

Nursing and medical staff were caring, compassionate and patient centred in their approach. We observed staff maintained patient’s respect and dignity at all times. Patients were involved in making decisions about their care and treatment.

Admission criteria supported patients to be admitted to the ward that met their individual needs. There was evidence the trust used learning from complaints to improve the quality of care.

There was a clear governance framework to monitor quality, performance and risk at ward level. Staff knew the risks and mitigating actions for their individual wards. Staff felt respected and valued by their immediate and senior managers.

However:

The admission criteria for Spinnaker ward was not always adhered to. Staff told us that at times the local acute trust overruled the admission criteria and sent patients to Spinnaker ward before assessments were completed. Difficulties in accessing social care services resulted in delayed discharged from the wards. Some wards had difficulties in accessing interpreting services, which affected the care and treatment patients received.  On some wards medicines were not always stored at the correct temperature: this had the potential to reduce the effectiveness of medicines.

Updated 15 November 2016

Overall rating for this core service

End of life care services at this trust was rated as good overall.

• Safety was rated as good. Patients were protected from avoidable harm; staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and arrangements to minimise risks to patients were in place. Patients were protected from abuse. Staff had an understanding of how to protect patients from abuse, could describe what safeguarding was, and the process to follow if they suspected a patient was at risk of avoidable harm or abuse.

• We rated the effectiveness of this service as good. Patients received effective care and treatment that took account of current evidence-based guidance, standards and best practice. Patients had a comprehensive assessment of their needs, which included pain management, nutrition and hydration, and physical and emotional aspects of their care.

• Care from a range of different staff, teams and services was co-ordinated effectively. There was effective multidisciplinary working, with staff, teams and services at this trust and external organisations working in partnership to deliver effective care and treatment.

• Staff understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005; this was reflected in the ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) orders reviewed during our inspection.

• The care provided to patients in end of life care services was good. Patients were truly respected and valued as individuals and were empowered partners in their care. Feedback from patients, relatives and carers was consistently positive and there were many examples of staff going ‘above and beyond’ when delivering care.

• We found the responsiveness of end of life care services to be good. Patient’s needs were mostly met through the way end of life care was organised and delivered. However, the rapid discharge of those patients expressing a wish to die at home was not monitored. We could not therefore be assured this was happening in a timely way.

• We found the leadership of end of life care services was good . This was an evolving service which had diffently commissioned service models across the two cities it served (Portsmouth and Southampton). There was a strong vision and a strong focus on patient-centred care. There were robust mechanisms in place to share learning locally across end of life care services.

Updated 3 January 2014

Patients and their relatives commented favourably on the care and treatment they or their relative received on the wards. Patients (and/or relatives where appropriate) were involved in decisions about their care and their plans for discharge.

We found the wards delivered safe care and people were protected from abuse and avoidable harm. There were systems and processes in place for identifying, investigating and learning from incidents. Patients’ needs were assessed and records indicated that treatment, care and support was provided to meet those needs. There was effective multi-disciplinary and multi-agency working to ensure that people received care that met their needs, at the right time and without delay. Discharge planning was comprehensive and consistent.

Staff followed best practice guidelines when treating and supporting people.There were audit systems in place to check on the quality of care, including the prevention of infections. We saw staff using good hand washing techniques and there were sufficient hand washing facilities throughout the wards.

We found that the care was delivered by caring and compassionate staff.We observed staff treating patients with dignity and respect. The service was responsive to the views and needs of people who used the service. Staff gave us examples of how services had been developed in response to patient feedback.

The two wards at the Royal South Hants Hospital were well-led. Staff told us they felt able to raise concerns and were supported to carry out their job role. Staff were very passionate and proud to work at the service and aware of the vision and values of the organisation. We saw evidence of good integrated team work and regular monitoring of the quality of the service being delivered.

Updated 6 January 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.

Updated 6 January 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.

Updated 5 September 2017

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

• By the time of this inspection, the services had completed the actions we required it to take following the inspection in June 2016. The specialist community mental health services for children and young people were now meeting Regulations 9, 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

• Staff understood how to assess and manage the risk to young people. Clinicians in the service had designed a new bespoke risk assessment appropriate to young people’s needs. All young people had a risk assessment and staff completed risk management plans if it was appropriate to do so. Managers had made adjustments to manage environmental risks in the team bases. Staff understood how to make safeguarding referrals and felt confident to do so.

• Staff completed care plans to support the safe and effective care of young people on their caseload. Staff had received appropriate training to enable them to assess young people and work with those on their caseload.

• Staff demonstrated empathy, kindness and caring when working with young people. Staff actively encouraged young people and their carers to be engaged in making plans of care and to provide feedback on the service they received. This included training for young people to interview new staff. Staff were highly motivated and offered care that is kind and promotes young people’s independence. We rated caring as outstanding.

• There were robust governance structures in place to ensure the quality and safety of the care young people received. We saw closer working relationships between the teams in Southampton and Portsmouth. This ensured consistency in the delivery of care with teams sharing ideas and training opportunities.

However:

• We found that waiting list times between assessment and receiving treatment were still long. However, the trust had made changes and recruited more staff to reduce these as quickly as possible.

• Staff in Southampton did not routinely record capacity or consent in an easily accessible manner. None of the 20 records in Southampton had it recorded. In Portsmouth, all records had a form that recorded consent and considered Gillick capacity. The trust confirmed that they would implement this form in Southampton when we raised this with them.

Updated 15 November 2016

We rated community mental health services for people with learning disabilities as outstanding because:

• Staff truly respected and valued service users as individuals and aimed to empower them to achieve what they wanted to. All staff had a focus on the individual in what they did, with an ethos of enabling service users'. The service was focussed on the needs of the people using it and valued their participation in their care. Leadership within the service drove a positive, valuing and learning culture that staff thrived in.

• The service was innovative in developing new approaches to care and was responsive to the needs of service users. These were developed collaboratively with people using the service.

• Capacity and consent were carefully considered in all interventions. Interventions followed best practice guidance and latest research which the service regularly reviewed.
• Governance arrangements were exemplary. The service had excellent learning from complaints and incidents The service continually reviewed best practice and national guidance and how it could be applied to the service. The service worked hard to gain feedback from people using the services in different ways and then acted on it.

Updated 27 February 2019

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

• All environments we visited were clean and comfortable. The team base had disabled access and toilets. Appropriate equipment was available to staff and regular checks were in place.
• All patients had high quality care plans in place with well documented patient and carer involvement. There was regular assessment of mental and physical health needs.
• Patients and carers told us they were happy with the care they received from the team.
• The team was proactive in its approach to quality improvement and undertook regular audits to ensure quality of care. The team was also involved in quality improvement projects.
• There was a proactive approach to managing risk. Each patient had a high-quality risk assessment and the team held weekly risk meetings.
• There was evidence of good leadership within the team. The manager was visible and supportive and created a positive culture with good staff morale.

However;

• Ligature points identified in a risk assessment did not feature on the risk register. There was no mitigation in place for the ligature points which meant that staff may not be aware if a patient tied a ligature.
• Staff did not offer independent mental health advocates or independent mental capacity advocates to patients.
• There was no access to neuropsychology for patients.
• There was no clear discharge procedure or maximum caseload size for the memory monitoring service. This caseload number could potentially become risky in the future unless staffing levels are closely managed.

Updated 27 February 2019

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

• There were robust systems in place to keep staff safe, including personal alarms. All staff knew how to report incidents on the electronic system and made safeguarding referrals as needed. The teams learnt from incidents and could show changes they had made to prevent similar incidents happening. Staff assessed and reviewed patient risk regularly.
• Staff completed assessments promptly after admission and developed treatment plans that were recovery focused. The teams followed national guidance and the crisis team offered appropriate psychological therapies.
• Staff were compassionate towards patients. Patients and carers were involved in decisions about their care and the development of the service. Staff signposted patients to other services that could support them and encouraged families to have carers assessments.
• Staff in the crisis team offered appointment times to suit patients, were flexible and actively worked to engage with patients. The teams worked to meet patients’ needs; offering food and lifts home to patients.
• Managers were supportive, approachable and encouraged staff to review and improve their practice. The teams’ vision reflected the trust’s values. Senior trust managers supported the development of team manger’s leadership skills. Team leaders encouraged staff to work towards improving quality. There were effective governance systems in place and managers acted to address any identified concerns.

However:

• The crisis team had low compliance with mandatory training and the manager did not keep a record of safeguarding referrals made by the team. The health-based place of safety did not follow the trust’s seclusion pathway.
• The crisis team’s care plans were not always up to date.
• Managers did not monitor when there was no health-based place of safety available to patients.

Updated 27 February 2019

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

• Staff had built good relationships with patients. Staff gave patients information about the service and what treatments were available. The information was provided in a number of formats and was available to patients and upon their request at any later date.
• The service had regular fortnightly ward rounds that focused on multi-disciplinary and multi-agency working. There had been recruitment on the ward to improve staffing numbers since our last inspection in 2016. New staff were provided with induction and a personal development program with regular reviews with managers and supervisors.
• The ward used regular bank and agency staff to cover sickness and vacancies. These shifts were block booked ahead with same bank or agency staff to provide continuity of care and familiarity for patients.
• Staff assessed the needs of patients. Assessments were comprehensive and updated regularly in fortnightly reviews.
• Patient care plans were holistic and patient centred. Staff sought patients` views and involvement in their care plans.

• Staff assessed and managed physical health through weekly monitoring.
• Staff carried out risk assessments of the care environment. The team risk register included a comprehensive record of environmental risks and how they were mitigated.
• Staff completed a comprehensive risk assessment for all patients on admission and updated them regularly in fortnightly multi-disciplinary meetings.
• Patients said that staff were kind and caring. They said they felt safe on the ward.
• Staff had access to services in the trust and external services to help meet patients’ needs. These included regular visits by an independent advocacy service.
• Staff understood and knew when to report safeguarding. Staff were familiar with and followed the trust’s safeguarding policy.
• There was good leadership from the ward manager, the modern matron and the ward psychiatrist.

However:

• Provision of psychological therapies and intervention were limited. For example, specialised risk assessment such Historical, Clinical, Risk Management-20 (HCR-20) which were usually completed by the psychologist were not always done for patients who required these specific risk assessments.
• Staff supervision was not documented and recorded every month in line with trust policy.
• Staff appraisals were not documented and recorded yearly in line with trust policy.
• Staff did not routinely check T2 and T3 forms when administrating prescribed medicines.
• Sterile equipment was not managed safely as we found a number of products that had passed their expiry date.

Updated 27 February 2019

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

• Staff assessed and managed risk well. Staff regularly risk assessed the care environment and gave strong consideration to observation of patients, potential ligature points and blind spots. Staff worked to reduce incidents on the ward including falls. Staff communicated information relating to risk effectively to the oncoming shift and wider multidisciplinary team. Staff made safeguarding referrals when incidents met the safeguarding threshold.
• Staff monitored patients’ physical health. Staff used a range of tools and scales to assess and review patients’ physical well-being. Staff supported patients to live healthier lives through education and well-being groups. Care records were mostly detailed, holistic and person centred.
• The trust had invested in creating a dementia friendly environment. Doors and walls had been painted with appropriate colours. There was pictorial signage with wording on doors and there was an orientation board for patients in communal areas.
• Staff received an effective induction and supernumerary period. Managers supervised staff and completed a yearly appraisal. Staff were encouraged to professionally develop and had access to additional internal or external training courses.
• Staff complied with the Mental Health Act and Mental Capacity Act. Detained patients received their rights in line with trust policy and were written up for section 17 leave. Staff assessed patients’ mental capacity when there was doubt about their capacity to make a particular decision and made applications to the local authority to deprive patients of their liberty under the Deprivation of Liberty Safeguards when necessary. Staff had support and advice from the Mental Health Act administrator within the trust for issues relating to the Mental Health Act and Mental Capacity Act.
• Patients said staff were kind to them and treated them with dignity and respect. Patients were well orientated to the ward environment. Patients felt involved in their care.
• Patients were respected and valued as individuals and empowered as partners in their care.
• Patients were active partners and felt involved in their care. Staff were committed to working in partnership with people.
• Patients emotional and social needs were highly valued by staff and were embedded in their care and treatment.
• There was strong leadership on the ward and staff felt senior leaders were visible and approachable. Staff felt valued and respected and the trust supported them to develop within their role.

However:

• Patients did not receive psychological treatments to meet their needs. A psychologist had been employed by the trust but had not yet started. Patients who needed psychological therapy were referred to improving access to psychological therapies (IAPT) or supported by the occupational therapists with low level therapies such as mindfulness and breathing exercises.
• The local ligature audit did not update staff on the actions that had been taken to reduce ligature risks.
• Sterile equipment was not managed safely as we found a number of products that had dates expired.
• Capacity to consent to restrictive interventions such as bed sensors and sensor mats were not clearly recorded on the new care panning system.
• Patients could only make a private telephone call if they had their own mobile telephone. Patients could access the ward phone but had to do this under supervision.

Updated 27 February 2019

• 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.
• Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

• Staff told us that they learn from incidents on the ward and hold regular debriefs Staff received feedback for investigations of incidents through individual supervision.

However;

• The service did not ensure that the management of patient’s medicines was safe.

• The governance systems in relation to prescribing and medicine management did not pick up polypharmacy (many medications) prescribing for patients that may be detrimental to their health and wellbeing. They did not also pick up or patients on doses of medications that were higher than the recommended in BNF (British National Formulary that provides advise on prescribing and pharmacology).

Updated 5 September 2017

We rated Solent NHS trust substance misuse services good overall because:

• During this inspection, we found that the services had addressed the issues that had caused us to rate safe as inadequate and effective, responsive and well-led as requires improvement following the June 2016 inspection.

• The substance misuse services were now meeting Regulations 9, 12, and 17 and of the Health and Social Care Act (regulated activities) Regulations 2014.

• Staff ensured that they reviewed prescriptions regularly. There were clear policies in place identifying individual responsibilities and that all clients had a prescribing care plan in place. Both services had signed Patient Group Directions (PGDs) for Hepatitis B injections.

• Staff were supported to monitor and manage caseloads safely and effectively and there were sufficient staffing levels to safely manage and review clients in receipt of prescriptions.

• Staff had carried out necessary home visits for clients on prescribed medication and who had children. The services had an embedded process in place to monitor this.

• Managers ensured the trust risk register reflected all identified service risk issues.

• Staff ensured they discussed discharge plans for all clients who accessed the service, and there were clear protocols in place for those who regularly did not attend appointments or disengaged from the service.

• There was clear and visible leadership and oversight across both services. Managers ensured staff attended mandatory training and received supervision and appraisals. Local and senior managers worked together to ensure the staff were supported in their roles to achieve positive outcomes.

Updated 15 November 2016

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

• Managers were aware of staff caseloads and adjustments were made to take account of the complexity of patients. Recovery teams were piloting a case load tool which looks at risks, care coordination and time spent on cases, assigning scores of one to five depending on seriousness of risk.

• Patients who required regular blood checks to ensure maintenance of therapeutic levels of medicines and to detect any signs of serious side-effects, attended clinics run by the “wellbeing” staff. The trust had introduced point of care haematology testing for clozapine.

• Care records we reviewed showed care plans were up to date, personalised, holistic, recovery orientated and included evidence of ongoing physical care, informed consent and appropriate consideration of mental capacity.

• Staff had a very good understanding of the needs of their individual patients. Staff were committed to patient care and care was patient centred. Staff were responsive to patients’ needs and able to demonstrate how they could draw on increased support from colleagues if required.

• There were clear care pathways dealing with access and discharge to the community teams.

• Staff were overwhelmingly positive about the culture of the teams which they described as mature, supportive and very open. They also felt supported by line managers and colleagues.

However,

• The Trust should within the main base of the community mental health teams risk assess the three interview rooms which are L shaped. This is because when staff were sat at the desk with patients, they could not be observed through the door.

• The Trust should consider providing prevention of violence and aggression or breakaway techniques training for staff.