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Provider: Solent NHS Trust Requires improvement

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 November 2016

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

Letter from the Chief Inspector of Hospitals

Solent NHS Trust is a specialist provider of community and mental health services. The trust formed in April 2011 a year after the merger of two PCTs. The trust employs over 3,400 staff and services are provided to a population of over a million people living in Southampton, Portsmouth, South East and South West Hampshire. Some services extend across the whole of Hampshire, including specialist dentists and sexual health services. Solent NHS Trust is the main provider of community services to people living in Portsmouth, Southampton and to parts of Hampshire. The trust is also the main provider of mental health services to people living in Portsmouth

Our inspection took place on 27-30 June 2016 and unannounced visits up until the 14 July 2016. We inspected the trust as part comprehensive inspection of community NHS trusts. We inspected 17 core services. This included five community services and nine mental health services and three primary medical services.

The community core services inspected were: community inpatients, adult services, end of life care services, sexual health services, and care of the child and young person services. We did not at this time inspect the dental core service.

The mental health core services inspected were: substance misuse services, acute wards for adults of working age and psychiatric intensive care units, community mental health services for people with learning disabilities, specialist community mental health services for children and young people, long stay/rehabilitation mental health wards for working age adults, mental health crisis services and health-based places of safety, wards for older people with mental health problems, and community-based mental health services for older people.

The primary medical services (PMS) were general practice and health centres. Please review the specific reports on Portswood Solent GP, Adelaide Health Centre and Royal South Hants – Nicholstown. For information on the PMS inspection please review the specific location reports.

Overall, we rated the trust as ‘requires improvement’. We rated the trust’s services as ‘requires improvement’ for safe, effective and well led services. The trust was ‘good’ for providing caring and responsive services.

Community based services for adults were good overall but needed to improve safety, community based services for children and young people and families required improvement.

Mental health services for adults were good overall but needed to improve safety. Services for older people, children and young people, and substance misuse services required improvement.

Learning disability services were outstanding.

Our key findings were as follows:

  • Staff were reporting incidents. The trust had a strong culture for reporting incidents and there was evidence of learning and action taken to improve services. However, the process was inconsistent and some community and mental health teams did not recognise what should be reported or take actions on incidents.
  • Staff followed the Duty of Candour although staff understanding of the regulation, for example, the requirement to formally write to patients, needed to improve.
  • Some staff were working with children and vulnerable adults without the appropriate level of training, including safeguarding training. Risks were not always managed or recognised to safeguard patients.

  • Staff did not always store, prescribe or administer medicines appropriately or monitor their use.

  • The trust had completed a ligature audit programme although it had not identified all ligature points, including assessments of outside areas. Identified risks were not always mitigated. However, the trust responded quickly to concerns we raised at the time of the inspection. .

  • Staff did not always check equipment before use.

  • There were delays in the wheelchair provision and repair service commissioned by the Clinical Commissioning Group and provided by an external provider. This affected the safety and well-being of some patients who received adult community services.

  • Staff completed risk assessments for patients but these were not always appropriately completed for children and young people in community and mental health services.

  • Some services had staff shortages and had difficulty coping with demand. There were some missed and shortened appointment times in community and bed closures on mental health acute inpatient wards. Staffing levels did not meet planned levels in some services and there was an impact on patient care and outcome. In Portsmouth, community nursing staff had high workloads and there were missed patient visits. Children’s health visitors had higher than recommended caseloads In the Southampton CAMHS, children’s needs were not being fully met, and patients were not always appropriately monitored in Southampton substance misuse service

  • In some instances, care was not fully delivered or took account of national and evidence based guidelines.

  • The trust did participate in national and local audits, and nationally was identified as the top community trust involved in research.

  • Patient outcomes varied. Some were similar to the England average for long term conditions; some indicators and performance targets were not being met, such as the Healthy Child Programme.

  • Staff had appraisal and supervision. In one team, they reported that they did not always have training specific to their role.

  • There was limited evidence in several mental health services that patients were involved in care planning and the standard of care planned varied.

  • There were many examples of integrated multidisciplinary teams working well together particularly for patients with long-term chronic conditions. These often included team members from other organisations such as the local acute trusts, the local authority and a neighbouring community trust. The teams worked well together for the benefit of the patients.

  • Staff were caring and compassionate and treated patients with dignity and respect.

  • There was an outstanding patient centred culture in the learning disability services.

  • Patients were involved in their care and treatment, although the CAMHS service did not have appropriate advocacy support to involve children and young people. Not all patients had care plans for older people in community mental health services and care was inconsistent because staff did not communicate with other agencies involved in their family member’s care.

  • Many services were focused on bringing care closer to people’s homes, supporting early interventions, avoiding hospital admission and promoting self-management. There was evidence of integrated and collaborative working although this varied across geographical areas based on commissioning and strategic planning arrangements.

  • Waiting times varied but overall were being met. For example, patients were being seen for cardiac and stroke care following discharge and patients had early intervention for psychosis. However, some services had long waiting times (over 18 weeks) for treatment, such as cognitive behaviour therapy for CAMHS. There was some variation in waiting times across Portsmouth, Southampton and Hampshire for the same type of services.

  • The trust had considerable and ongoing IT connectivity problems and this sometimes directly impacted on patient care. Some staff could not access systems, some staff could not update systems in a timely way, and staff reported electronic information was sometimes missing.
  • The operations model of two chief operating officers was developing. The model was based on the different strategic and commissioning approaches for the cities of Portsmouth and Southampton. However, the operational teams described feeling quite separate across the two cities, with different working practices across Portsmouth and Southampton. There was less evidence of shared learning, resources and staffing across the two cities. This had resulted in staff working under pressure in places and having varying impact on patient care delivery for the equivalent services across the two cities. Substance misuse services in Southampton and community nursing services in Portsmouth identified more risks to patients.
  • The trust was developing a five year strategy, and was working with an operational plan to focus on prevention and early intervention to promote healthy lifestyles and reduce the risk of ill-health through better management of long-term conditions and an increasing emphasis on self-management, choice and personalisation of care.
  • The trust has identified equal priority for physical and mental health and to work with partners across social care, primary care and other services to deliver more joined up services and care closer to home and avoid acute hospital admissions.
  • The leadership team was relatively new and showed commitment, enthusiasm and pragmatism to develop and continuously improve services. There had been rapid pace of change to transform and sustain services, and this had meant uncertainty and some confusion with staff about local leadership and support. Some staff expressed feelings of isolation and an inability to contribute to changes and quality improvement at work.
  • Governance arrangements were inconsistently developed and needed to improve to properly provide assurance around quality and risks. Services had quality dashboards but the quality of clinical and performance information needed to improve. Risks needed to be appropriately escalated to the board through the care group structure. Some risks were not known and some mitigating actions were not well developed or timely or had not led to improvements.

  • There was insufficient quality monitoring oversight of contracts with external providers. This included an independent ambulance provider transporting mental health and s136 patients to a place of safety. This put patients at risk.
  • Staff were positive about working for the trust and recognised the value of their service. However, morale was low across some areas due the uncertainty of reorganisation. The trust was worse than other similar trusts for its level of staff engagement. However, many staff reported the open and accessible culture that the new CEO was working to promote. Many service lines had action plans in response to the staff survey.
  • Public engagement took place through a variety of means, such as surveys, patient forums community groups.
  • There were many examples of innovation and improvement within the trust and staff were involved in quality improvement projects, new models of care, research and audit. The trust was developing a programme approach to ensure quality improvement was being managed effectively based on national models of best practice.
  • The trust was in a position of financial deficit, and was working towards a financial recovery plan. Cost improvement programmes were challenging, and focused on the transformation of services and improving efficiency and management costs. Cost improvement programmes needed to have better monitoring information to determine the impact on service delivery.

We saw several areas of outstanding practice including:

  • The trust was listed as the most research active trust in 2015/16 in the National Institute for Health Research National League Tables. There were many examples across community services of integrated working, new models of care, therapy based initiatives and early intervention projects to promote public health
  • The trust had developed innovative processes for learning from mortality in community and mental health settings. A range of appropriate approaches had been developed which enabled a review or investigation into deaths across high priority settings (mental health, learning disability, children services & community services), as well as in primary care, dental and sexual health – areas that are often ‘hard to reach’ in terms of investigating mortality in the NHS. Learning was shared within the trust and with its commissioners and stakeholders. The trust was developing its approach across Hampshire and Isle of Wight and was working with national organisations to further develop the process.
  • We observed areas of good and innovative practices in some community services. This included  ‘The Trache’ bus’ within the children and young people’s community service and COAST, the paediatric specialist care service.
  • Tulip Clinic in particular for sex industry workers and exploited children was noted for its very good practice.
  • Community mental health services for people with a learning disability were an excellent inclusive service; service users were at the centre of the service and were very involved in their care.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must take action to improve the following services:

The main actions identified are to ensure:

Community services

  • There are sufficient numbers of suitably qualified staff in all community adult teams to ensure consistently safe and timely care is given as planned to meet patient’s needs.

  • Patients are protected against the risks of unsafe or inappropriate care and treatment arising from incomplete patient records or an inability to access electronic patient records when required by staff, including bank staff.

  • The trusts works with the external provider of wheelchairs and commissioners to provide wheelchairs in a more responsive and timely way. The safety and well-being of patients was currently at risk because of the long waiting times for wheelchairs.

  • Medicines are safely managed in community children, young people and families services, specifically the school services, staff receive appropriate training, supervision and competency assessments, and staffing levels are as planned to deliver appropriate levels of care.

  • The quality of mental capacity assessments in community wards improves and patient records and care plans are completed fully, in a timely manner and used appropriately in community end of life care services

Mental Health

  • Patients with potential safeguarding issues are managed safely on the acute ward, Hawthorn ward, and the psychiatric intensive care unit Maple ward. There was no clear segregation of male and female bedrooms in one corridor on Maple Ward (PICU) which was in breach of Department of Health guidance on mixed sex accommodation.

  • Long stay/rehabilitation mental health wards for working age adults, the Oakdene unit: remove non-collapsible curtain rails, and ensure other anti-ligature work identified in its audit is completed

  • The ward for older people with mental health problems, Brooker Unit , will assess, monitor and manage risks appropriately, including staff competence and training, resuscitation procedures, safeguarding procedures, managing mixed sex environments and the administration of medicines.

  • Community-based mental health services for older people take reasonable steps to provide opportunities to involve people in making decisions about their care and treatment, and support them to do this, and ensure that physical health checks are carried out in line with the national guidelines.

  • Staff have appropriate training, and there are appropriate governance systems to monitor mental health crisis services and the health-based places of safety. This includes appropriate governance of the private ambulance provider for the health-based place of safety.

  • Risks assessments are completed for all children and young people in specialist community mental health services, and there is an effective system in place to assess the risks to young people whilst they were waiting for assessment or treatment. Crisis plans are completed for all young people who are assessed as requiring them to keep them safe. Staffing levels are as planned and staff have appropriate training.

  • There is appropriate monitoring of prescribing, and staffing levels are as planned to be able to manage caseloads in Southampton substance misuse services.

The trust MUST also ensure

  • The trust is to work with NHS England to agree a formal escalation policy for patients who require mental health forensic services.
  • All serious incidents are investigated so that wider lessons are learnt and human factors understood.
  • Complaints are handled in a timely manner.
  • Governance arrangements are effective and identify, assess, monitor and manage risk and quality issues appropriately.
  • Staff engagement continues to improve.
  • Cost improvement programmes are effectively monitored and managed in terms of impact on staff and patients.

Professor Sir Mike RichardsChief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 November 2016

Overall we rated the trust as ‘requires improvement’ for safe. For specific information, please refer to the core service reports for community health services and mental health services at Solent NHS Trust

We rated the trust as requires improvement for safe because

  • Staff were not consistently reporting incidents across some community and mental health teams and did not always recognise what should be reported as an incident.
  • Not all staff we spoke to understood the full requirements of the Duty of Candour and the trust policy needed to be updated to comply with the NHS contract standard.
  • Incidents and patients’ records were not always recorded and updated in a timely way due to IT connectivity issues and pressure on staff’s time. This posed a risk to patient care.
  • Most bank nurses did not have password access to electronic patient record systems, and were dependent on access via substantive staff. This contravened information governance principles and nursing and midwifery code of practice.
  • Compliance with safeguarding training was below the trust target: the relevant staff had not all completed level 3 training as needed when working with children and young adults. Risks were not always managed or recognised to safeguard vulnerable adults on mental health inpatient wards.
  • Medicines were not always stored, prescribed or administered or monitored appropriately in children’s and young people (school) services, substance misuse services, mental health long stay rehabilitation services, older peoples mental health wards or on the Jubilee Ward.
  • Ligature points were assessed. However, potential ligature points had been not fully identified on the mental health inpatient wards. Action had not been taken to remove ligature points on the mental health long stay rehabilitation ward
  • Risks associated with mixed sex wards on older people mental health ward were not being managed in line with current DH guidelines.
  • The environment and cleanliness at Bitterne Health Centre did not fully support safe care.
  • The delays in wheelchair provision and repair service through an external provider affected the safety and well-being of some patients who received adult community services.
  • Some equipment was not checked and tested to ensure it was safe to use and fit for purpose. Not all staff were aware of the process to order and obtain essential patient safety equipment, particularly out of hours and weekends.
  • Staff did not always have appropriate levels of mandatory training, and staff on the older people mental health wards did not have access to appropriate training in medication management and violence and aggression.
  • Staffing levels did not meet planned levels in some services and there was an impact on patient care and outcome. In Portsmouth, community nursing staff had high workloads and there were missed patient visits. In children’s and young people’s services there were higher than recommended health visitor caseloads in deprived areas. In the Southampton CAMHS service children needs were not always being fully met.
  • There was unequal care delivery across Southampton and Portsmouth when staff shortages affected teams offering the same type of trust service. For example, patients were at higher risks in Southampton substance misuse service than in Portsmouth, and in community nursing in Portsmouth than in Southampton. Staff were not shared across teams.
  • Risks assessments were not always appropriately completed for children and young people in community and mental health services.

However,

  • Overall, the trust was a consistent reporter of incidents nationally and was in the top 25% compared with other similar trusts. Many staff reported incidents and there was evidence of lessons learnt.
  • The trust had commissioned a review of serious incidents and mortality management and recommendations were being used to ensure a more consistent approach.
  • The trust followed the Duty of Candour where appropriate.
  • Relational security in the mental health ward environments was good.
  • Across the trust most environments were visibly clean.
  • Most medicines were secured and stored safety.
  • Risk assessments were holistic and comprehensive for most adult patients both in community and mental health services.
  • Staffing levels met planned levels in some areas, including community and mental health inpatient areas. Recruitment was ongoing and vacancy levels were decreasing.
  • In the learning disability service, service users were actively encouraged to manage their own risks.

Effective

Requires improvement

Updated 15 November 2016

Overall we rated the trust as ‘requires improvement’ for effective. For specific information, please refer to the core service reports for community health services and mental health services at Solent NHS Trust

We rated the trust as requires improvement for effective because

  • Some mental health services did not use nationally recognised standards or good practice including HoNOS and National Institute for Health and Care Excellence (NICE) guidelines. For example, psychological therapies were not provided in long stay rehabilitation or CAMHS services as recommended by NICE. National guidelines were not followed in substance misuse services.

  • Some mental health services could not demonstrate that patients were involved in care planning and the standard of care planned varied.
  • Some audits had not led to the development of local action plans and improvements.
  • Some staff could not access training because of workload and some staff were not always provided with training specific for their role, for example, dementia training in older people’s service and training in dealing with younger people in CAMHS.
  • Clinical supervision was ineffectual in some of the school services of the children and young people community services where clinical practice was not always up to date.
  • Some performance targets in children and young people services and sexual health services were not achieved.
  • Staff in some mental health services did not have training or did not appropriately assess patient’s mental capacity.

However,

  • In community services, most care was delivered that took account of national guidance. There was participation in national and local audits and patient outcomes, where known, were broadly similar to other trusts.
  • Patients had their pain assessed and monitored depending on their needs. There were processes for obtaining pain relief for patients out of hours in the community and for end of life care patients.
  • Patients had their nutritional needs assessed and there were appropriate referrals to specialists.
  • The trust had an innovative approach to review the learning from unexpected deaths across services. Over the last six months, all unexpected deaths had had a mortality review or serious incident/ high risk investigation.
  • Most staff had appraisal and supervision and access to training and development
  • There were many examples of integrated multidisciplinary teams working well together particularly for patients with long-term chronic conditions. These often included team members from other organisations such as the local acute trusts, the local authority and a neighbouring community trust. These teams worked well together for the benefit of the patients.
  • Patient consent was appropriately obtained and most staff understood their roles and responsibilities regarding the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
  • Portsmouth CAMHS service had achieved accreditation and CAMHS learning disability services accreditation for excellence by the quality network for community CAMHS.

Caring

Good

Updated 15 November 2016

Overall we rated the trust as ‘good’ for caring. For specific information, please refer to the core service reports for community health services and mental health services at Solent NHS Trust

We rated the trust as good for caring because

  • Staff provided compassionate care and treated patients with dignity and respect. Feedback from patients, carers and family members was consistently positive.
  • Patients were involved in their care and treatment and staff took time to explain care and treatment and services in ways patients could understand.
  • We observed staff supporting patients with care and kindness, including ancillary and non-clinical staff, within busy service environments. For example, this was evidenced in Jubilee Ward at Jubilee House, Portsmouth, and Fanshawe Ward, Southampton.
  • Caring in the Mental Health Learning Disability unit was outstanding. All staff had a focus on enabling and empowering service users to achieve their goals. Service users had an active voice in how the service was delivered through a well-run participation group, seeking of service user’s views, and service users working in the service as volunteer trainers.
  • Patients told us staff met their emotional needs by listening to them, by providing advice when required, and responding appropriately to their concerns. There were many examples where staff were working to support patients’ and their carers’ wellbeing, spiritual and psychological needs. This included setting up support groups and working with the voluntary sector.

However:

  • Some clinic receptionist staff did not always display compassion, respect and consideration to patients.
  • In the specialist MH children’s and young people’s service, there was no evidence of patient advocacy, and no evidence of the young person’s involvement in their care and treatment.
  • In community mental health services for older people, not all patients had care plans and these were not routinely given to patients. The patients did not know how to get involved in their care, and carers said care was inconsistent because staff did not communicate with other agencies involved in their family member’s care.
  • There was variation in the provision of spiritual and pastoral support for community inpatients and teams. Some wards and teams did not have direct access to a chaplaincy service although a spiritual strategy was being developed.

Responsive

Good

Updated 15 November 2016

Overall we rated the trust as ‘good’ for responding to people’s needs. For specific information, please refer to the core service reports for community health services and mental health services at Solent NHS Trust

We rated the trust as good for responding to people’s needs because

  • The learning disability service was outstandingly responsive to the needs of its’ patient group

  • Many services were focused on bringing care closer to people’s homes, supporting early interventions, avoiding hospital admission and promoting self-management. There was evidence of integrated and collaborative working, although this varied across geographical areas based on commissioning and strategic planning arrangements.
  • Many services were responsive and waiting times were being met. For example, patients were being seen for cardiac and stroke care following discharge, and patients had early intervention for psychosis. The CAMHS service met targets to assess children for mental health conditions.
  • Staff had good awareness of equality and diversity and action was taken to improve access to services and people’s understanding about their care.
  • Action was being taken to support vulnerable people using the service.
  • Access to sexual health services had improved since the inspection in 2014
  • There was good access for the acute mental health inpatient wards to transfer patients quickly to the psychiatric intensive care unit

However:

  • Some services had staff shortages and had difficulty coping with demand. There were missed and shortened appointment times in community services, and bed closures on mental health acute inpatient wards.
  • Patients had long waiting times of over 18 week’s treatment in some services. There was variation in waiting times across Portsmouth, Southampton and Hampshire for the same type of services.
  • The Healthy Child Programme was not meeting its targets. Waiting times for some CAMHS services such as cognitive behaviour and autism were lengthy.
  • Patients had limited access to therapy service in rehabilitation services and to psychology services.
  • Some services could not be sustained, and the trust had made the decision to withdraw contracts. However, patients had not been adequately informed of service changes in podiatric surgical services, and patients still travelled to clinic appointments with surgical expectations.
  • There were long delays in wheelchair provision which affected the ability of community staff’s responsiveness; some patients had waited up to two years for a suitable wheelchair. The demand for the service was greater than the level of commissioning. However, the monitoring arrangements and actions that trust had taken had yet to improve the responsiveness of the service or the risk to patient safety and well-being.
  • There was evidence of learning and improvement as a result of responding to complaints. However, the trust was not always meeting national and local trust target response times.
  • On the mental health long stay rehabilitation ward, the use of the bathroom was supervised to ensure safety but this impacted on patient’s privacy and dignity.

Well-led

Requires improvement

Updated 15 November 2016

Overall we rated the trust as ‘requires improvement’ for well-led. For specific information, please refer to the core service reports for community health services and mental health services at Solent NHS Trust

We rated the trust as requires improvement for well-led because

  • Governance arrangements were not well developed and needed to improve to properly provide assurance around quality and risks. Services had quality dashboards but the quality of clinical and performance information needed to improve. Risks needed to be appropriately escalated to the board through the care group structure. Some risks were not known to senior staff, and some mitigating actions were not well developed or timely or had not led to improvements.
  • There had been rapid pace of change to transform and sustain trust services, and this has meant uncertainty and some confusion with staff about local leadership and support. Some staff expressed feelings of isolation and an inability to contribute to changes and quality improvement at work.
  • Staff were positive about working for the trust and recognised the value of their service. However, morale was low across some areas due to the uncertainty of re-organisation and some staff groups working under pressure. The trust was worse than other trust for staff engagement based on the NHS staff survey 2015. However, many staff reported the open and accessible culture that the new CEO was working to promote.
  • Cost-improvement programmes needed better monitoring information to determine the impact on services.

However,

  • The trust was developing a five year strategy and was working with an operational plan to focus on prevention and early intervention to promote healthy lifestyles, and reduce the risk of ill-health through better management of long-term conditions and an increasing emphasis on self-management, choice and personalisation of care.
  • The trust has identified equal priority for physical and mental health, and works with partners across social care, primary care and other services to deliver more joined up services and care closer to home and avoid acute hospital admissions.
  • The leadership team showed commitment, enthusiasm and pragmatism to develop and continuously improve services.
  • Public engagement took place through a variety of means, such as surveys, patient forums and community groups.
  • There were many examples of innovation and improvement within the trust, and staff were involved in quality improvement projects, new models of care, research and audit. The trust was developing a programme approach to ensure quality improvement was being managed effectively based on national models of best practice.
  • The trust had a historical financial deficit and was working towards a financial recovery plan. Cost improvement programmes were challenging and focused on the transformation of services and improving efficiency and management costs.
Checks on specific services

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 15 November 2016

We rated long stay/rehabilitation mental health wards for working age adults as good because:

  • Staffing levels were good and there was a good sense of relational security.

  • We noted good morale amongst the staff, and a sense of team spirit. Leadership and development were encouraged and there was a team approach to service development.

  • The ward was clean. Furnishings were in good order and the ward was well maintained.

  • Staff used de-escalation techniques to reduce the need for restraint.
  • Patients had a comprehensive assessment on admission, which included mental and physical health. On-going assessment was evident.
  • Staff received management and clinical supervision, staff appraisals were carried out.
  • There were good working relationships with the community teams and the acute and PICU wards that were located on site.
  • All patients we spoke with told us that staff were caring and kind.

  • Patients told us they were included in discussions and decisions relating to their care and treatment, and we observed a strong culture of promoting independence and rehabilitation.
  • The ward had had a sufficient number of beds to meet the needs of patients from the catchment area. Discharge was well planned.

  • Staff told us they felt supported by their immediate managers.

  • Morale was high, with a low turnover of staff. There were opportunities for staff to develop their skills.

However:

  • Ligature points had been identified on the ward, an action plan identified action to mitigate these, however at the time of our inspection final plans from the estates department were still to be completed. The large patient garden was locked due to a ligature risk presented by a large tree. However, this is the only non-smoking outdoor space.

  • The trust has a list of training that was mandatory for staff. The list did not include some training that would be expected of a ward of this type such as medication management and the management of violent and aggressive patients.

Community mental health services with learning disabilities or autism

Outstanding

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.

Community health sexual health services

Good

Updated 15 November 2016

Overall rating for this core service Good

We rated sexual health services as good because:

Staffing levels and skill mix were planned, implemented and reviewed by the matrons to meet the level of need for the service/ needs of patients. All staff including bank staff were provided with induction, including competencies, to ensure they could safely and effectively undertake their role.

Where patients received care from a range of different staff, teams or services this was co-ordinated. All relevant staff, teams and services were involved in assessing, planning and delivering patients care and treatment. Staff worked collaboratively to understand and meet the range and complexity of patients’ needs.

Feedback from patients who used the service and other stakeholders was positive about the way staff cared for them. Staff treated patients with dignity and respect, and patients told us they felt supported and said staff cared about them.

Evidence based practice was being followed for care and treatment. Patients had appropriate and timely notifications but there were delays in the diagnosis time for Chlamydia patients and for testing times for children with HIV parents.

Services were planned in a way that met the needs of the local population. The importance of flexibility, choice and continuity of care was reflected in the services. The needs of all patients were taken into account when planning and delivering services. For example, the trust provided clinics for young people at locations and times when they could access them. Patients were offered appointments within 48 hours.

Information and data were used proactively to identify opportunities to drive improvements in care, for example, same day access clinics. Service changes were developed with input from doctors, nurses and patients who used the service, to understand their impact on the quality of patient care.

There was a culture of continuous learning, and sharing knowledge nationally, to achieve good patient outcomes.

Since the last inspection of the service in March 2014, there have been improvements in timely access to the clinics. This has included same day access clinics. Patients were now not being turned away from clinics without being assessed and prioritised, and given a plan that took account of their sexual health needs. Although delays meant some patients did not wait for treatment.

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

Good

Updated 15 November 2016

We rated acute wards for adults of working age and psychiatric intensive care units as good because:

  • Staff completed comprehensive and mostly person-centred assessments on admission. Physical health assessments took place on admission. There was good multidisciplinary team input in to patient care from a number of professionals across both wards.

  • Mental Health Act documentation was complete across both wards. Staff adhered to the principles of the Code of Practice.

  • Patients told us staff were caring. They had access to advocacy and information on their rights. We observed warm and professional actions on both wards despite the staff being under pressure.

  • Patients could access information easily about treatment and support. Patients’ needs were respected with regard to food, cultural and their spiritual needs. There was good access to interpreters

  • Managers were available to staff. Despite the high acuity of patients and increased risks in previous months, staff had maintained fairly good morale and told us they felt supported by their leaders. The modern matron provided robust oversight of both wards and worked well with the ward managers.

However:

  • We found potential ligature points in the enclosed gardens of both wards. These were not recorded on the ligature risk audit and were not always mitigated by staff.

  • On Maple ward there was no clear segregation of male and female bedrooms. This was in breach of Department of Health guidance on mixed sex accommodation.

  • Staff did not put a high priority on reporting safeguarding concerns on Maple ward (PICU). We saw examples of risks around safeguarding issues not transferred to care plans and found that there were not always clear management plans in place.

Community health inpatient services

Good

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.

Community health services for adults

Good

Updated 15 November 2016

Overall rating for this core service Good 

We found that the ‘caring’ in community services for adults was found to be ‘good’, ‘good’ for ‘effective, responsive and well led’ and ‘requires improvement’ for ‘safe domains because:-

  • The trust had many examples of responsive teams working collaboratively to meet their patients’ needs. They provided care close to or within the patients’ home environment, thus reducing hospital admissions. Staff used comprehensive holistic patient risk and care assessments, to identify and respond to risks including the safety, health and wellbeing of patients in the community within their care.

  • The trust staff followed process and set procedures to report safety incidents and manage risks. The teams used a ‘governance tracker’ dashboard to monitor serious incidents, staffing information and patient feedback. Most staff had learning from incidents shared with them. There was a pro-active approach to following patient safeguarding procedures. The staff, however, did not understand or follow the full requirements of the Duty of Candour, and this was not carried out appropriately.

  • Patient and their families received compassionate, focused care, which respected their privacy and dignity. They told us they were involved in planning their care and without exception, patients we spoke with praised staff for their kindness, caring and empathy. Most formal patient feedback was positive, although where there were complaints; clear action plans were in place.

  • Community services for adults provided care based upon the latest national guidance from the National Institute for Health and Care Excellence (NICE). There was well-established multidisciplinary team (MDT) working across all the teams we visited. Staff had mandatory training and most had had appraisals and access to personal development.

  • The trust had actively engaged staff in agreeing values to support the trust vision and strategy.

  • The trust environments were generally clean with the exception of the Bitterne Health Centre, which had numerous cleanliness and environmental concerns some of which did not support safe patient care.

However

  • The geographical differences in the location of services and in their commissioning and delivery meant that there were differences in the delivery of care across both areas, with some staff feeling there were also inequities in opportunities and learning.

  • The teams described feeling quite separate across the two cities; staff described different working practices across Portsmouth and Southampton for example; the management of pressure ulcers affected patients, with Southampton’s incident rates improving and Portsmouth’s incident rates worsening.

  • Community nursing teams particularly in Portsmouth had significant registered nurse vacancies that the trust told us had recently reduced to19% from much higher. The safety of patients could be affected while they were waiting for visits and staff were concerned that their workload was too high to care for patients properly. We observed the frequent overflow of unmet visits to the following nursing shift.
  • The trust staff did not always manage to update patient records in a way that kept patients safe. IT connectivity problems and pressures on staff time meant there were risks of delayed recording and a possibility for incomplete records. Bank nurses we spoke with did not have access to the electronic patient record system, and were dependent on access via substantive staff colleagues to record patient information.

  • There were significant delays in the provision of wheelchairs and repair service through an external provider, which affected the safety and well-being of many patients receiving adult community services in different localities. We were told of vulnerable patients being kept in bed at home because of a lack of appropriate seating. There had been an increase in referrals to the psychology service for those patients waiting for wheelchairs due to their low mood and depression caused by the wait.

  • Some specialist services such as bladder and bowel were not achieving the 18 week referral to treatment targets pathway. Whilst the podiatry pathway had been changed in conjunction with the local commissioners, the service aimed to meet with individual patients to explain the circumstances and to offer support and signposting for onward treatment. However, some patients were still travelling to clinic appointments with expectations of potential surgery. They appeared unaware that surgery would be available from other providers. Therapist staffing shortages in some teams had also extended the waits for services for example, Speech and Language Therapy (SALT) and the community independence teams in Southampton.

Community health services for children, young people and families

Requires improvement

Updated 30 November 2017

Overall, this core service was rated as ‘requires improvement’.

A comprehensive inspection of Solent NHS Community Trust was carried out from 27 to 30 June 2016, and the subsequent report was published on 15 November 2016.

Community Health Services for children, young people and families was rated as ‘Requires Improvement’ with safe rated as ‘Inadequate’. There were significant concerns within two of the specialist schools we inspected at that time, Mary Rose Academy and Rosewood Free School.

Due to the inadequate rating in safe, we conducted an unannounced focused inspection of the safe domain on 11 and 18 October 2017. The inspection team focused on Mary Rose Academy and Rosewood Free School due to the significant concerns found at the last inspection. The team also visited the Highpoint Centre to review documents relating to governance arrangements, records and staffing. The focus of this inspection was to review whether the concerns we raised during the 2016 comprehensive inspection of the Community CYP service had been fully addressed.

This inspection only covered the inadequate domain rating for safety, so any new rating for Safe will not address or affect the other domain ratings for this core service.

At this inspection, we rated the safety of the service as 'requires improvement’ and although this is an improvement for that domain, it does not change the overall rating of ‘requires improvement’ for the whole core service rating.

We visited and inspected two specialist schools, which cater predominantly for pupils with severe and complex needs such as cognitive difficulty, physical disabilities, medical conditions and autistic spectrum disorder. The schools are state schools run by local government, but the nursing care is supplied by qualified nurses employed by Solent NHS Trust.

At this inspection, we rated the safety of the service as 'requires improvement’ because:

  • Medicines management processes, although showing improvements, were not yet fully embedded for safe practice. Because processes and guidelines were not consistently followed, this had resulted in an uneven provision of practice, and a mismatch across the two specialist school services. This did not completely ensure the quality and safety of the care children and young people received. Medicine stock numbers were not always fully reconciled, and this continued to pose potential risk to the health and safety of children and young people.
  • Records were mainly stored safely and securely, although records management was not yet fully secure in one location. Some records held inaccurate or out of date information, and had been used by teaching assistants to deliver care. This had the potential to pose potential risk to the health and safety of children and young people.

However:

  • We noted substantial improvements in the service delivered through the specialist schools we inspected on this occasion, and evidenced through the pre-inspection presentation.
  • Medicines were now stored, dispensed and administered safely, although not always with best practice guidelines. Following a discussion with the trust about our concerns with medicine stock checking, an immediate action plan was developed. This outlined areas for improvement with leads identified and clear timescales for actions to be completed.
  • We noted some highly personalised care, record keeping and process assurance at one of the schools. This wholly supported the safe care of children and young people within this school environment.
  • 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 services for children and young people were now meeting Regulations 12 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Community-based mental health services for adults of working age

Good

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.

Community-based mental health services for older people

Requires improvement

Updated 15 November 2016

We rated older people’s community mental health services as requires improvement because:

  • The staff member who managed the memory service had a caseload of over 600 patients. Therefore, patients did not receive six monthly reviews of their medication in line with national guidance.

  • Staff did not follow the trust’s policies and procedures when managing medicines. Therefore, staff did not manage medicines in line with current legislation and guidance, including those related to storage and transportation.

  • Staff told us that they managed risk and investigated incidents. However, at the time of the inspection staff could not provide any records of risk assessments, incident reports or audits of these records. Therefore, it was difficult to see how staff reported incidents, what action they took and whether staff learnt any lessons as a result.

  • Electronic care records were of inconsistent quality. We viewed 10 records which had no evidence of patient involvement, capacity assessments that were incomplete and no evidence that the patients had received copies of their care plans

  • Care records did not describe how staff involved patients in making decisions about their care

  • Seventy Eight percent of staff in this service had completed statutory and mandatory training. However, the trusts target for completion was 85%

  • The clinic did not have hand-washing sinks in the consultation rooms so that they could wash their hands between consultations.

However:

  • The service had access to administrative support and legal advice on implementation of the Mental Health Act and the Code of Practice from a central team.
  • Staff were aware of the Mental Capacity Act and how to report Deprivation of Liberty Safeguards (DoLs). Although at the time of the inspection, nobody was subject to a DoLs.
  • We observed a patient assessment and saw that staff treated the patient and their carer with kindness. 

Mental health crisis services and health-based places of safety

Good

Updated 15 November 2016

We rated

mental health crisis services and health-based places

of

safety services

as good because:

  • There was a range of psychological therapies available to patients using the crisis and home treatment service.

  • Staff of the crisis and home treatment service told us they were well supported and had a good induction to the services. Patients we spoke with told us that the staff were respectful and staff reported morale as high.

  • The crisis team had daily multidisciplinary meetings (Monday to Friday) to discuss patients and update risk assessments. Detail and quality was good in most of the care records we reviewed.

  • The crisis team had access to a full range of mental health professionals and had non-medical prescribers.

  • The crisis team had capacity to respond to routine and urgent referrals and all patients were visited within target times.

  • The crisis teams were available 24 hours a day; seven days a week and staff gave patients known to the team a direct contact number.

However:

  • The trust did not receive comprehensive data from the private ambulance service that served the health-based place of safety in a way that assured them of the safety and quality of care in the health-based place of safety. There was a lack of oversight by the trust of the service that they commissioned.

  • Care records did not indicate that staff in the crisis and home treatment team gave patients copies of their care plans. The patients we spoke with and their carers told us they had not received copies of their care plans.

  • No staff in the crisis team had undertaken recent training in the Mental Health Act training the number of staff with Mental Capacity Act and safeguarding adults training was low. There was no day to day monitoring of the use of the health-based places of safety.

Specialist community mental health services for children and young people

Good

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.

Substance misuse services

Good

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.

Wards for older people with mental health problems

Requires improvement

Updated 15 November 2016

We rated wards for older peoples mental health as requires improvement because:

  • Safeguarding procedures were not always being adhered to with regards to patient on patient assaults. Staff did not consider any patient on patient assaults as a safeguarding events.
  • Staff did not know where the ligature cutters were or what they were used for. Some ligature risk and control measures were missing from the annual audit tool.
  • Staff were not adhering to best practice with regards to mixed sex environments or following local safety procedures. There was no separate female lounge in the smaller eight bedded area.
  • Confidential information was not stored securely.
  • Statutory and mandatory training was limited and did not include medication management and the management of violent and aggressive patients. Staff were not trained in the management of violence and aggression.
  • There was a lack of oversight by senior staff on the ward with regards to resuscitation procedures, safeguard reporting and managing mixed sex environments. Staff were not trained in restraint procedures and staff did not know how to respond to an incident involving the use of ligature cutters.

However:

  • Staff were caring and committed to delivering a positive patient experience. Patients told us that they felt safe on the ward.
  • Physical health monitoring was completed on admission and routinely thereafter. Care plans were up to date, comprehensive and patient focused.
  • Best practice with regards to prescribing was being adhered to. Covert medication was being managed well.

End of life care

Good

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.