Dorset Healthcare University NHS Foundation Trust

Updated 31 July 2019

Not used

Updated 31 July 2019

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

• We rated the trust outstanding overall because over the past four inspections we have seen a consistent pattern of progressive improvement in the quality of core services that is reflected in the ratings of these services.
• We rated the trust outstanding overall for the key question is the trust well-led due to the inspirational leadership provided by the senior team. In rating the trust overall, we took into account the current ratings for the services not inspected this time.
• At this comprehensive inspection (2019) we found the trust had made the required improvements in the safe key question to increase its rating to good.
• We rated the trust as outstanding overall for the key questions are services caring and are services well led. In addition, we rated the trust good for safe, effective and responsive. We rated one out of six core services that we inspected as outstanding overall which was community health services for adults.
• We were particularly impressed by the strength, knowledge and integrity of the leadership at the trust. They had a comprehensive knowledge of current priorities and challenges and took prompt action to address them. The board was visible and supportive to the wider health and social care system. Reports from external sources including NHS England/Improvement and commissioners were consistently positive. The trust had quality and sustainability as its top priorities.
• We were also impressed with the trust attitude towards and application of innovation and service improvement. The delivery of high-quality care was central to the trust values and all aspects of running the core services. We got a true sense of the trust’s main focus was on providing care that truly benefited patients and carers and supported the wider system. There was a dedicated quality improvement (QI) team which engaged frontline staff and empowered and inspired them to use innovative means of improving services.
• There was a strong learning culture within the trust and staff showed caring, compassionate attitudes, were proud to work for the trust and were involved in the development and improvements within the trust. Staff embraced and modelled the values and behaviours in both mental health and community health services. Throughout the trust staff treated patients and each other with dignity and respect. Staff morale was high in the services. Staff told us they felt respected, supported and valued by their managers and the trust. Staff used creativity to ensure patients were treat well and their care needs listened to.
• Staff, patients and carers were actively involved in the development of the services, and the trust were creative in engaging all the relevant people. Senior leadership in the trust had good relationships with partner organisations and were engaging positively in the wider health systems. The trust had a mixture of highly experienced and new senior leaders with the skills, abilities, and a commitment to provide high-quality services. The executives and non-executives presented as a strong unified board.
• Two of the wards for older people with mental health problems (Herm and St Brelades) had been awarded the Gold Standard Framework (GSF). These were the first older adult’s mental health unit in the country to receive this award. All community hospitals in the trust were GSF accredited. The GSF is a systematic evidence based approach to ensuring all patients approaching end of life receive the best possible compassionate care in the best possible place. This meant patients approaching the end of their lives on these wards could remain on the ward rather than be transferred to another place to receive this care.
• The trust had effective systems and processes in place for identifying risks and how to eliminate or reduce them. Staff had training in how to recognise and report abuse and applied it. The trust had an innovative focus on reducing incidents of falls and pressure ulcers and were committed to improving services by learning when things went well or wrong. The pharmacy management leadership team ensured patients were safe and good governance was in place. Medicines safety risks were identified, actioned and shared appropriately within the trust and with external partners. Learning actions from medicines incidents and audits were shared across the trust.
• Excellent governance arrangements were in place in relation to Mental Health Act (MHA) administration and compliance. One of the non-executive directors had a legal background and was highly experienced and chaired the MHA monitoring group. Minutes demonstrated that it covered an appropriate range of subjects including monitoring of MHA review report findings. The trust ensured they were responsive in their approach to issues raised within these reports. There was clear, robust and effective multi-agency working arrangements around the MHA. A regular programme of MHA audits took place. Where MHA audits had identified gaps in knowledge the MHA lead provided targeted training and support.
• Trust premises were clean and well maintained although several buildings were not fully fit for purpose. There was an estates strategy in place and the trust had a clear idea of what needed to be done but planning permission was required for many the changes which was proving difficult to get due to the nature of the buildings. We saw during our core service visit that the gardens in Herm and St Brelades wards were not dementia friendly and unsafe in some areas. However, this was addressed quickly and funding made available to improve these areas further. Staff were clear on their responsibility to mitigate safety and ensure dignity of patients in shared accommodation. During our well led inspection we saw many improvements had already been made to these areas.
• Staff at all levels worked well with each other and external organisations to provide care and treatment to patients based on national guidance. Staff generally kept clear records of patients’ care and treatment and confidentiality was maintained. Patients had access to psychological support and occupational therapy. The physical healthcare needs of patients within mental health services was excellent. Patients in community health services benefitted from outstanding care and support from staff.

However:

• Recruitment in some areas (e.g. community CAMHS) remained a struggle. The trust was working creatively with commissioners to resolve this and the implementation of a new care model in CAMHS services should ease some staffing pressures.

• A bed was not always available when needed on return to the acute mental health wards. There had been some inappropriate placements on the wards, due to the wards not having control over bed management.

• There remained shared accommodation on one acute mental health ward and some of the older people’s mental health inpatient wards. Bedrooms and shared accommodation did have lockable storage facilities for clothing and possessions and the provider had taken action to mitigate the adverse effects of privacy or safety. Capital funding had been secured with a plan in place to remove all shared accommodation.

Updated 14 April 2026

The Community Learning Disability Service forms part of Dorset HealthCare University NHS Foundation Trust and provides specialist multidisciplinary assessment, treatment and support for adults with learning disabilities across Dorset. The service is delivered through Community Learning Disability Teams. We visited sites in Bournemouth and Dorchester. The West service includes teams covering Bridport, North Dorset, and Weymouth and Portland, while the East service covers Bournemouth, Christchurch and Poole. Care is predominantly delivered in people's own homes and community settings by multidisciplinary teams comprising learning disability nurses, psychiatrists, psychologists, occupational therapists, physiotherapists and speech and language therapists.
The service also includes a countywide Intensive Support Team, based in Dorchester and Poole, which provides rapid assessment and short-term intensive intervention for adults with learning disabilities experiencing deteriorating mental health, behaviours of concern or an increased risk of placement breakdown or hospital admission. The Community Learning Disability Teams and Intensive Support Team operated between 8am and 8pm, seven days a week, with a target response time of two hours. They worked closely with primary care, acute hospitals, social care, commissioners, care providers and families to deliver coordinated, person-centred care, promote independence and support people to remain safely within their local communities wherever possible.
Staff described responding quickly to changes in risk and working alongside community teams, Adult Social Care, providers and commissioners to help people remain safely within their communities wherever possible.

CQC last inspected this service in 2017 under the previous inspection framework. The service was rated as good.

This was an unannounced comprehensive inspection as part of our planned schedule of assessments and in response to the aged rating of this service.

The services are registered to provide the regulated activities:
• Assessment or medical treatment for persons detained under the Mental Health Act 1983
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury.

We inspected the service on19 and 20 May 2026. Our inspection team comprised of 3 Inspectors and an Expert by Experience.

Before the inspection visit, we reviewed information that we held about the trust.

During and after the inspection visit, the inspection team:
• visited sites in the West and East of Dorset
• interviewed 2 managers
• interviewed the service manager
• interviewed and spoke with 12 staff members in two focus groups
• reviewed 9 care and treatment records
• and reviewed a range of policies, procedures and other documents relating to the running of the service.
• Attended a patients discharge meeting

After this inspection, we rated the service as good. The Community Learning Disability Service continued to provide safe, effective, caring, responsive and well-led care. Patients received person-centred assessment, treatment and support that reflected their individual needs, strengths and preferences. Staff worked collaboratively with patients, carers and partner organisations to promote positive outcomes, maintain independence and ensure continuity of care. Risks were appropriately assessed and managed, safeguarding responsibilities were well understood, and patients received safe care in relation to the environment, medicines and infection prevention and control.
Patients, families and carers were actively involved in care planning and decision-making, with information provided in accessible formats and reasonable adjustments made to support equitable access to services. The service demonstrated a positive and inclusive culture, supported by visible leadership, effective governance and a commitment to continuous learning, partnership working and service improvement. The service was able to demonstrate how they were meeting the underpinning principles of Right Support, Right Care, Right Culture.

Updated 3 February 2026

The date of assessment: 06/05/2026 – 18/05/2026
We carried out this comprehensive assessment as we had not assessed this service since July 2019. At our last assessment, the service was rated good overall and good for all key questions.
We visited 2 Minor Injury Units (MIUs) as part of this assessment, based at The Blandford Community Hospital and Victoria Hospital in Wimborne. The Trust also provided urgent care services at the following MIUs: Bridport Hospital; Swanage Hospital; Weymouth Hospital; Westminster Hospital in Shaftesbury and Yeatman Hospital in Sherborne. MIUs offer an alternative to using emergency departments. They can treat minor injuries and illness that are not emergencies but are urgent.
Both the Blandford Community Hospital MIU and the Victoria Hospital MIU are nurse-led services, supported by a combined team covering both sites. These services operated as a walk-in service for non-life-threatening injuries. Since December 2020, the MIUs have been fully integrated with the Dorset Integrated Urgent Care Service, which includes 111, Clinical Assessment Service (CAS), Out of Hours visiting services (including GPs and Night Nurses), Single Point of Access (SPoA), and Out of Hours Treatment Centres. The shared management structure allows for seamless transfers of care between local services with people receiving a tailored response to their needs and the application of governance processes which monitor performance. The Blandford Community Hospital MIU is open Monday and Wednesday between 9am and 5pm. Victoria Hospital MIU is open Monday to Sunday between 8am and 8pm.
The service made improvements which were recommended from the last assessment in July 2019. In particular, staff rotas were designed to prevent lone practitioner working with processes to record lone working as incidents. All waiting areas gave practitioners a clear view of people waiting to be treated to identify risks and early deterioration of symptoms. A clinical audit programme had been introduced which was regularly reviewed to demonstrate care and treatment was provided in line with evidence-based guidance.

Updated 23 October 2025

Dorset Healthcare University NHS Foundation Trust provides forensic/secure inpatient services for adults with mental health conditions. Patients are detained under the Mental Health Act 1983. The trust provides 15 inpatient beds on Twynham Ward at the St Ann's Hospital site in Poole.
We visited Twynham Ward on 18 and 19 November 2025. Twynham Ward is a low secure forensic ward for male offenders with mental health problems. This inspection was in response to concerns raised by external stakeholders about relational security, professional boundaries, the level of oversight on the ward and whether the team culture supported openness and staff confidence in raising concerns.
During this inspection, we inspected and rated safe and well led. Ratings for effective, caring and responsive have been pulled through from the previous inspection. The service is rated as good overall.
The staff team was in the process of developing the culture and leadership on the ward. Staff, including managers and members of the multidisciplinary team (MDT), had taken steps to strengthen team cohesion and psychological safety, including reflective practice sessions and a staff development day focused on professional boundaries, team bonding and psychological safety. Incident and seclusion rates were low.
However, we found some environmental and infection control issues that required improvement. Patients in seclusion could not access outside space, and some cleaning and audit processes were not consistently followed. Privacy screens were not in place in all areas, and aspects of medicines management, including equipment checks and clinic room organisation, did not always support safe practice. Infection control arrangements, such as bathroom cleaning schedules and waste management, were not always robust. The ward also lacked some adaptations for patients with mobility needs, and there was no clear log of blanket restrictions to support consistent review and communication with patients.

Mental Health Act and Mental Capacity Act Compliance
Mental Health Act
Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. The average compliance of staff across the forensic directorate was 95%.
Staff had access to administrative support and legal advice on the implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were in the trust.
Patients had easy access to information about independent mental health advocacy.
Staff members had relevant policies and procedures that reflected the most recent guidance.
Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it. Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.
Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly so that they were available to all staff that needed access to them.
Staff did regular audits to ensure that the Mental Health Act was being applied correctly.

Mental Capacity Act
Staff demonstrated good understanding of the Mental Capacity Act. They had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. They knew where to get advice regarding the Mental Capacity Act, including deprivation of liberty safeguards. They took all practical steps to enable patients to make their own decisions whenever possible.
The trust had arrangements to monitor adherence to the Mental Capacity Act and staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

Updated 12 November 2025

Pebble Lodge is an inpatient mental health ward for children and young people, provided by Dorset Healthcare University NHS Foundation Trust. It is located at Alumhurst Road in Bournemouth. Pebble Lodge is within a site that includes inpatient mental health services for adults and a mother and baby unit.

Pebble Lodge has 10 bedrooms, consists of one mixed-sex ward and offers care and treatment to young people aged between 12 and 18 years old. It provides 24-hour specialist care and treatment for those with mental health conditions. Young people can be admitted with their consent or detained under the Mental Health Act 1983.

Pebble Lodge has an on-site school, which is registered with Ofsted.

CQC last inspected Pebble Lodge in March 2019. The service was rated as outstanding.

This was an unannounced comprehensive inspection. We carried it out because it had been 6 years since the last inspection.

Pebble Lodge is registered to provide the regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury.

We inspected Pebble Lodge on 3 December 2025. Our inspection team comprised:

• 3 CQC inspectors
• a CQC national professional advisor
• a CQC senior specialist
• and an expert by experience.

Before the inspection visit, we reviewed information that we held about the trust.

During and after the inspection visit, the inspection team:

• visited Pebble Lodge and specifically checked the environment
• interviewed 2 ward managers
• interviewed the service manager
• interviewed 2 responsible clinicians
• interviewed and spoke with 11 staff members a social worker, nurses and support workers
• spoke with 6 young people who were using the service and 5 family members
• reviewed 5 care and treatment records
• carried out a specific check of the medication management and prescribing processes
• and reviewed a range of policies, procedures and other documents relating to the running of the service.

After this inspection, we rated the service as good.

Mental Health Act and Mental Capacity Act Compliance Summary

We include our assessment of the trust’s compliance with the Mental Health Act and Mental Capacity Act in our overall inspection of the core service.

We do not give a rating for Mental Health Act or Mental Capacity Act. However, we do use our findings to determine the overall rating for the service.

Updated 21 November 2024

Date of on-site assessment 08 and 09 August 2024. Dates of desktop assessment between 28 February to 08 August 2024.



We carried out a responsive assessment of Dorset HealthCare University NHS Foundation Trust in response to concerns shared with Care Quality Commission (CQC) regarding patient care and treatment in Waterston Ward. We also reviewed evidence submitted from staff at the trust.

Waterston Ward is an acute assessment unit (AAU), which is part of the wards for adults of working age and psychiatric intensive care units. At the last inspection in April 2019, we rated the trust as outstanding overall and this service as good.



We also reviewed evidence submitted from staff at the trust. We reviewed 2 key questions safe and well-led.

Patients said they were safe and well cared for on the ward and it helped their recovery.

There were enough well trained and skilled staff to provide a range of therapeutic treatments to meet individual needs.

The ward was welcoming and had few incidents of violence and aggression as staff used effective descalation techniques.

Staff said they worked well together as a team and felt valued by managers.

Updated 21 November 2024

Date of on-site assessment 07 and 08 August 2024.

We carried out a responsive assessment of Dorset HealthCare University NHS Foundation Trust in response to concerns we received regarding patient care and treatment in St Brelades Ward and Herm Ward.

Both wards are wards for older people with mental health problems. At the last inspection in April 2019, the overall rating for trust was outstanding with the older people wards in the trust rated good in safe, effective, responsive and well led and outstanding in caring.

We reviewed 2 key questions: safe and well-led and we reviewed evidence submitted from staff at the trust.

We rated the key questions and rated the service overall as good. We found two breaches of the legal regulations in relation to safe care and treatment and governance.

Improvements were evident across all wards including reducing patient capacity on St Brelades ward, which has helped staff adapt, attend training and support patients and each other. The Executive team now reviewed all admissions and change in patient flow with robust plans to not just accept everybody

However, there were still concerns about medication management, the documentation around the use of covert cameras including best interests meetings and risk assessments. Staff on Herm Ward could not always access information about risk easily as it was recorded in many places. Risk assessments and care plans did not always include consistent risk information.

There were policies about the use of shared rooms but apart from the initial risk assessment, there was little evidence of patient consent.

New governance systems were in place following the recent death of a patient but needed to be further developed.

Updated 31 July 2019

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

• The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.
• Individual care records were electronic, integrated and consistently managed. Patients were protected against the risks of unsafe or inappropriate care and treatment arising from incomplete patient records or inability to access electronic patient records. This was a marked improvement following the inspection in October 2015
• Staff understood their responsibilities to raise concerns, record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate. There was evidence following incident investigations that duty of candour had been applied. Therefore, patients were protected by a strong comprehensive safety system with the focus on openness, transparency and learning when things went wrong.
• Health and social care were truly integrated. Services were planned and met patient’s needs as care pathways were person-centred especially for patients with complex health and social care needs. Referral criteria to community services was clear and managed through a health and social care single point of access. This was a marked improvement on the last inspection in October 2015.
• Leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Managers made sure they had staff with a range of skills needed to provide this and staff had appropriate training to meet their learning needs to cover their scope of work.
• There was a drive to increase skills of staff to provide effective care and treatment for patients. This included volunteers who were recruited where required and trained and supported for the role they undertook.
• There were good arrangements for supporting and managing staff to deliver effective care and treatment. The trust provided comprehensive clinical supervision for staff which they undertook regularly.
• Staff from different health and social care disciplines worked together as a team to benefit patients. This multidisciplinary working supported effective care planning and delivery especially for adults with long term conditions and complex needs.
• Staff understood and respected the personal, cultural, social and religious needs of patients. There was a strong patient-centred culture. We observed kind, compassionate and respectful interactions with patients and their relatives in both trust clinics and in their own home.
• Feedback from people who used the service was continually positive. Patients, their relatives and carers we spoke with told us, without exception, that the staff were always kind. Staff looked for ways to communicate with patients and those close to them to reduce and remove barriers to communication.
• Staff made efforts to involve patients and those close to them in decisions about their care and treatment through personalised care planning. Staff communicated well with patients so that they understood their care, treatment and condition, and any advice given. Staff took time to interact with relatives and carers. The home visit appointments and rehabilitation fitness sessions we observed did not feel rushed. Staff said that it is about “what is important” to patients and that patients had “ownership” of their care plan.
• Services were tailored to meet the needs of individual patients and delivered in a way to ensure flexibility, choice and continuity of care. Patients received personalised care that was responsive to their needs. Patient records contained assessments that were carried out with the patient and those important to them.
• The service worked with other health and social care providers to meet the needs of patients, particularly those with complex needs, long term conditions or life limiting conditions. The involvement of other services was integral to how services were planned and met patient’s needs.
• Advanced care planning was well established in the community services.
• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers held, or were studying for, management qualifications and had community and primary care experience.
• The trust had systems and processes to ensure staff met the duty of candour. Duty of candour was included in the trust's induction programme which ensured all new starters were provided with relevant information. Duty of candour has been integrated into the Root Cause Analysis and pressure ulcer training packages. This was a noticeable improvement from the last inspection in October 2015.
• There were high levels of staff satisfaction. Staff felt positive and proud to work for the trust and spoke highly of the culture. Staff felt they were in a much better position since the last inspection in October 2015.
• The trust was very proactive in supporting development opportunities for staff. There was also a strong emphasis on the safety and well-being of staff.
• Staff were engaged so that their views were reflected in the planning and delivery of services. At the last inspection in October 2015, staff had felt that changes were made without consultation and without being made aware that changes were happening. At this inspection, staff were much more positive.

However:

• The single point of access was triaged by a trained healthcare professional. In contrast, calls to the night nursing team are taken and collated by a healthcare assistant. Staff felt a trained member of staff at night to triage would provide a more comparable service to the single point of access team.

Updated 13 April 2018

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

• The three services inspected improved from a rating of requires improvement to good overall.

However:

• We also found areas for improvement in each of the services we inspected this time. See areas for improvement section above for details.

Updated 13 April 2018

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

Updated 13 April 2018

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

Updated 13 April 2018

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

A summary of our findings about this service appears in the overall summary.

Updated 13 April 2018

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

• The core service improved overall from requires improvement to good.

Updated 31 July 2019

• The service provided safe care. Clinical premises where patients were seen were safe and clean, and the physical environment of the health-based place of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• The mental health crisis service and the health-based place of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
• Staff working in the mental health crisis teams developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The mental health crisis teams included or had access to a range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was well-led and the governance processes ensured that procedures ran smoothly.

Updated 31 July 2019

Our rating of this service stayed the same. The rating for safe improved from requires improvement to good. We rated the service as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough staff. Staff assessed and managed risks well. Staff minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented and personalised care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to a range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare.
• The service worked to a recognised model of mental health rehabilitation. There was strong leadership in place and the governance processes ensured that ward procedures ran smoothly.

Updated 24 February 2017

We rated substance misuse services in Dorset NHS Trust as Good because:

• Staffing levels were good and there was managerial and team oversight of the safe management of caseloads.

• Staff had visited the homes of all clients with children living at or visiting their home to ensure that the client had safe storage facilities for their medication. Staff in the prescribing teams reviewed prescriptions regularly.

• Staff held multi-disciplinary meetings to discuss referrals, discharge, safeguarding and complaints. Assessments, reviews and interventions were well documented in all care records.

• The teams responded quickly if patients phoned into the service to ensure they received a timely service from both teams in line with the requirements of the Commissioners. Staff members were proactive in contacting clients who did not attend their appointments. Staff held multi-disciplinary meetings to discuss referrals, discharge, safeguarding and complaints.
• In CADAS west, there were a variety of rooms available for staff to see clients. Staff were able to call on interpreters if required, leaflets were available in different languages. There was good disabled access.
• There were managerial systems in place to audit clinical notes to ensure risk assessments and care plans were updated and completed correctly, ensure staff received training and yearly appraisals.

However :

• Managers did not ensure all staff had recorded staff managerial supervision sessions.

• All clients had the opportunity to provide feedback about the services. Clients did not receive written feedback about the outcome of their complaint.

• Clients in the CADAS east did not receive the same service as clients in CADAS west as there was no central hub where they could receive treatment.

Updated 13 April 2018

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

A summary of our findings about this service appears in the overall summary.