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Provider: Solent NHS Trust Good

Reports


Inspection carried out on 09 Oct to 18 Oct 2018

During a routine inspection

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


CQC inspections of services

Service reports published 27 February 2019
Inspection carried out on 09 Oct to 18 Oct 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 495.69 KB (opens in a new tab)Download report PDF | 2.42 MB (opens in a new tab)
Inspection carried out on 09 Oct to 18 Oct 2018 During an inspection of Community health services for adults Download report PDF | 495.69 KB (opens in a new tab)Download report PDF | 2.42 MB (opens in a new tab)
Inspection carried out on 09 Oct to 18 Oct 2018 During an inspection of Community-based mental health services for older people Download report PDF | 495.69 KB (opens in a new tab)Download report PDF | 2.42 MB (opens in a new tab)
Inspection carried out on 09 Oct to 18 Oct 2018 During an inspection of Community health services for children, young people and families Download report PDF | 495.69 KB (opens in a new tab)Download report PDF | 2.42 MB (opens in a new tab)
Inspection carried out on 09 Oct to 18 Oct 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 495.69 KB (opens in a new tab)Download report PDF | 2.42 MB (opens in a new tab)
Inspection carried out on 09 Oct to 18 Oct 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 495.69 KB (opens in a new tab)Download report PDF | 2.42 MB (opens in a new tab)
Inspection carried out on 09 Oct to 18 Oct 2018 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 495.69 KB (opens in a new tab)Download report PDF | 2.42 MB (opens in a new tab)
See more service reports published 27 February 2019
Service reports published 30 November 2017
Inspection carried out on 11 and 18 October 2017 During an inspection of Community health services for children, young people and families Download report PDF | 285.33 KB (opens in a new tab)
Service reports published 5 September 2017
Inspection carried out on 23-24 May 2017 During an inspection of Substance misuse services Download report PDF | 282.2 KB (opens in a new tab)
Inspection carried out on 22 May 2017 – 24 May 2017 During an inspection of Specialist community mental health services for children and young people Download report PDF | 332.69 KB (opens in a new tab)
Service reports published 15 November 2016
Inspection carried out on 27 - 30 June 2016 During an inspection of Community health services for adults Download report PDF | 501.89 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Community health inpatient services Download report PDF | 353.53 KB (opens in a new tab)
Inspection carried out on 28-29 June 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 287.37 KB (opens in a new tab)
Inspection carried out on 27 -30 June 2016 During an inspection of End of life care Download report PDF | 332.65 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Community-based mental health services for older people Download report PDF | 308.83 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 310.22 KB (opens in a new tab)
Inspection carried out on 28-29 June 2016 During an inspection of Wards for older people with mental health problems Download report PDF | 318.28 KB (opens in a new tab)
Inspection carried out on 27th – 30th June 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 285.37 KB (opens in a new tab)
Inspection carried out on 27 - 30 June 2016 During an inspection of Community health services for children, young people and families Download report PDF | 449.66 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Specialist community mental health services for children and young people Download report PDF | 345.42 KB (opens in a new tab)
Inspection carried out on 27 - 30 June 2016 During an inspection of Community health sexual health services Download report PDF | 372.63 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Community-based mental health services for adults of working age Download report PDF | 294.14 KB (opens in a new tab)
Inspection carried out on 30 June 2016 and unannounced 5 July 2016 During an inspection of Substance misuse services Download report PDF | 302.09 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 329.38 KB (opens in a new tab)
See more service reports published 15 November 2016
Inspection carried out on 27 - 30 June 2016

During a routine inspection

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 carried out on 17 - 21 March 2014

During a routine inspection

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. It serves a population of over a million people living in Southampton, Portsmouth, South East and South West Hampshire and provides community and mental health services from over 120 locations.

Overall we judged that community and mental health services were safe. Staff were confident and willing to raise concerns, we found high reporting levels. The Trust had systems for collating and investigating incidents and there was evidence of improvements made to services through sharing of lessons learned. However the environment of Kite Unit needs to be improved to protect people against the risks of receiving treatment that is inappropriate or unsafe. Most people working at the service said that they felt there were enough staff and the Trust was taking a proactive approach to check that there were enough staff to keep people safe and meet people’s needs. However we found some community teams were finding it hard to meet demand. We found the leadership and sharing of productive ways of working across the Trust could be improved.

Staff used pathways of care to treat patients, based on nationally agreed best practice. There was evidence of very good multi-disciplinary team work taking place across the Trust, in both inpatient and community services. We found examples of innovative practice and excellent care.The Solent recovery college and the day treatment centre were innovative developments in supporting and in maintaining people’s mental health recovery in the community.The Children’s Outreach Assessment and Support Team (“COAST”), and the Portsmouth specialist palliative care services were also notable as exceptional services.

We found a highly committed and caring workforce and there was evidence that the Trust strategy and values were embedded in the organisation. Patients commented on the caring and compassionate approach of staff across the organisation. We saw staff treating patients with kindness, compassion, dignity and respect. Services sought patient feedback, which was generally positive, and feedback was used to make changes and improve services where possible. But the environment of the Kite Unit does not reflect the requirements of published expert guidance to ensure privacy and dignity.

Generally services we reviewed were accessible and responsive to the needs of the patients. Multi-disciplinary teams were working to make sure patients avoided unnecessary admission to either mental health wards or acute hospitals and that patients were discharged effectively. An excellent service was provided to homeless people in Southampton, and the special care dental service provided exceptional care to patients, children and young people with special needs. The children care services were centred on the needs of families. However, in some geographical areas sexual health services were struggling to meet demand and patients did not always receive treatment as the clinics were full. There was a risk that some patients may not receive thesexual health treatment they needed.

Overall we found that services were well-led both locally and at trust level. The Trust has a clear vision and objectives which focused on the delivery of high quality, patient centred care. The reorganisation into eight divisions, over the past year, had strengthened clinical leadership and accountability at all levels of the Trust. There were developing governance and risk management structures in place. The recently formed Assurance Committee had strengthened communication of quality and risk issues to the Trust Board.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.