Solent NHS Trust

We rated substance misuse services in Solent NHS Trust as requires improvement because:

• We had a range of concerns about the Southampton service despite the Portsmouth service performing well.

• Recruitment and retention to the Southampton service had been a significant challenge over the eighteen months before our inspection. Staffing levels were consistently low.

• Staff did not have clear, safe or consistent oversight of clients receiving substitute prescriptions. Caseloads were high and staff struggled to manage them. Staff had not carried out all home visits for clients with children living in or visiting the home so the service could not give assurances that medication was stored safely around children.

• Prescribers did not ensure a member of the prescribing team consistently monitored prescriptions, or that clients had clear prescribing care plans at commencement of treatment.

• Staff in did not consistently respond when clients repeatedly failed to attend appointments or engage in treatment. Staff in the Southampton service did not consistently document outcomes of reviews or interventions.

• The Southampton service was not meeting all waiting time targets set by commissioners. Caseloads remained high, as some clients did not have discharge plans. It was not always clear from records we looked at what the treatment pathway was for a client.

• Managers in Southampton had been aware the electronic system failed to identify clients with children who needed a home visit, but had not found other ways to access this information in a timely way. Managers had not ensured all problems identified were on the trust risk register.

• Staff had not completed all mandatory training.

However:

• There was emergency equipment that staff regularly checked and emergency procedures in place.

• Although staff in the Southampton service did not document interventions clearly, we did see some positive outcomes for clients in some of the care records.

• Clients in both services had good initial assessments, risk assessments, access to psychosocial interventions and social support in both locations.

• Most clients told us they felt respected and the teams were caring.

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. 

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.

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.

We gave an overall rating for specialist community mental health services for children and young people of requires improvement because:

• The performance of the Southampton team was of concern in many areas which was in contrast to the Portsmouth team.

• Risks assessments were not completed for all young people and there was not an effective system in place to assess the risks to young people. The staff team had not met all the recommendations from an investigation into a serious incident in July 2015 about review assessments and the introduction of crisis plans. Environmental risks to young people in the clinics were not always considered.

• In Southampton CAMHS, there were limited improvements or learning made following the serious incident involving the suicide of a young person in July 2015.

• There was no consistent approach to caseload management to assist access and discharge. The community CAMHS services did not meet all their targets for assessment or treatment in all areas. Waiting times for children on the autism pathway and cognitive behavioural therapy were long. Staff did not assess the risks to young people whilst they were waiting for assessment or treatment. There was not an effective system in place to ensure consistency in standards and work processes across the different community CAMHS teams.

• We found no evidence to show that young people were involved in decisions about the service including being able to recruit staff. Few young people had an advocate and both services stated this was an area for further development.

• Record keeping was inconsistent. In Southampton, 12 of the 23 care records we reviewed did not contain up to date care plans. In Portsmouth, all the seven reviewed did contain care plans. Staff members were inconsistent about the storage of the plans on the electronic records system so they were not easy to find. Information about a young person being under the care of the local authority or subject to safeguarding procedures was not clearly highlighted or readily accessible.

• Staff shortages and vacancies prevented the CAMHS community services from delivering all the psychological therapies recommended by National Institute for Health and Care Excellence. Not all young people had access to timely psychology input. Following recent integration of services, staff were expected to work with children of all ages. Staff trained in adolescent work did not feel competent to work with young children under the age of ten and vice versa. Training had not been provided for this change in roles.

However:

• All young people we spoke with said the staff they worked with were supportive. The foster carers and parents of young people who used the service gave us positive feedback regarding the service. The staff we met spoke respectfully of the young people and their carers and understood the individual needs of the young people who used the service.

• Comprehensive assessments were documented in each of the 30 care records we reviewed and had been carried out at the young person’s first appointment. In Portsmouth CAMHS, risk assessment, care plans and crisis plans were comprehensive and assisted staff deliver safe care and treatment to young people and children.

• There was good team working with regular meetings, supervision and work with outside agencies such as the community CAMHS teams and children’s learning disabilities team had built very good working relationships with the local schools.

• The trust responded very positively and quickly when we raised concerns about the risk assessment process for cases on the waiting lists following our visits. The trust took prompt action to review and reduce the high and medium risks and developed a crisis plan. They developed a new risk assessment format and an action plan to review all the waiting lists, caseloads and the risk assessment process. We saw immediate improvements evident when we visited unannounced eight working days after our formal inspection ended.

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.

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.

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.

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.

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.

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.

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.

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.

Overall rating for this core service Requires improvement

Overall, this core service was rated as ‘requires improvement’. We found that community health services for children, young people and their families were inadequate in the area for safe. Requires improvement for effective, responsive and well led, and caring was rated as good.

We rated the service as requires improvement because:

• Medicines were not always managed safely or consistently. This was noted in the special schools, and this posed risks to the health and safety of children and young people. Staff practices and processes in schools did not follow regulatory guidelines for the safe management of medicines. This included medicines which were not stored, dispensed and administered safely. There were limited updates and competency assessments undertaken in the schools to ensure this was delivered effectively and safely where non clinical staff undertook clinical duties.
• A piece of emergency equipment was not available in one school which could impact on the immediate safety of children with profound disability. Maintenance of equipment was not entirely robust as some essential equipment had not been serviced in line with the trust’s policy.
• Staffing levels and skill mix were planned, and reviewed to meet the level of need. However, staff vacancies meant there were sometimes insufficient staff such as health visitors, school nurses and therapists to deliver care in a consistent manner and to meet the needs of children and their families
• New births visits and development checks were not always completed within the recommended timescale and this impacted on the delivery of the Healthy Child Programme. This was due to unfilled health visitors’ posts. The school nursing service and therapy service had reduced capacity, due to staff shortage in order to deliver public health improvement programmes, and some clinics and education sessions had been cancelled.
• Staff reported incidents about safety although this was not entirely consistent. Incidents were investigated and, following root cause analysis, practices were reviewed and lessons learned shared.
• Care and treatment took account of best practice and evidence based guidelines when delivering care across the services.
• All staff including bank staff were provided with induction and training, to support them in their role. Clinical staff were supported with revalidation.
• Feedback from children and their families was complimentary and highly positive about the care and treatment they received. Care was provided in a respectful and compassionate manner at all times. People were treated with dignity and respect by staff and relationships were viewed positively.
• Parents and children were involved in their care and treatment, and consent obtained appropriately with age and ability to consent taken into account prior to providing care.
• The referral to treatment time of 18 weeks was not consistently achieved in the Hampshire therapy service due to unfilled posts which impacted on care delivery.
• The issues with IT connectivity meant that staff could not always update patients’ records in a timely way.
• Alerts were not put onto the system routinely to immediately advise practitioners and managers to the presence of children in a case and this clearly elevated risk that child welfare may not be prioritised.
• There had been many recent changes in the staff’s structure and there was a mixed view of the visibility of senior managers and the executive team. Staff felt the level of changes which had resulted in the loss of experienced staff had not been well communicated and managed.
• The governance process was not sufficiently robust in order for action to be taken and mitigate the risks. The quality assessment system was not always able to appropriately measure outcomes due to unassessed risk and the management process had not identified an area of substantial risk which we raised with the trust.
• Action taken following the staff’s survey included the increased visibility of senior management staff. Although staff felt they received support from their immediate managers, they viewed management overall as top down with too many changes occurring at the same time. These included new IT system, locality and team changes and inadequate access and support
• The public health nurses in Southampton were working collaboratively with the No Limits service to deliver integrated health and emotional wellbeing to children in school.
• Staff set up links with health and support groups in their local areas, for example to meet the needs of minority groups. Systems were in place to identify those who may be vulnerable and to provide targeted care. The needs of different people, in different localities, were taken into account when planning services.
• There was a service strategy for paediatric, health visiting and therapy services which included development of carers’ surveys and improving nutritional and breast feeding initiatives.
• There was a low level of complaints across children services, complaints were investigated and cascaded at staff’s meetings for shared learning.
• There were some examples of outstanding care such as the COAST team supporting children at home. The interactive “Trachey bus” which supported children with a tracheostomy (an artificial opening in the windpipe enabling to assist with breathing) to attend school.

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