Dorset Healthcare University NHS Foundation Trust

We rated mental health crisis services and the health-based place of safety as requires improvement because:

• We found conflicting and contradictory evidence about staffing and sickness levels in the east Dorset crisis team. However, we found evidence to indicate that this had a marked adverse effect on the team’s ability to provide a robust home treatment service.
• The telephone call management systems, set up specifically to deal with calls at night, did not function effectively and patients experienced difficulties accessing the east Dorset crisis team if experiencing a crisis, posing a potential significant risk.
• There were poor relationships between the east Dorset crisis team and the community mental health teams. Communication was ineffective and as a result people using services could experience delays in receiving support from the most appropriate team.
• In the east Dorset crisis team not all contributions from the multidisciplinary teams’ members were considered equally valuable.
• There were several areas of concern related to poor morale, staff shortages and confusion about the crisis team model in the east Dorset crisis team. We found areas of good practice with clinicians delivering services in east Dorset but this was inconsistent. There was consistent examples of good and outstanding practice in the west Dorset crisis team.
• Both crisis teams fell well below the trusts target for completion of mandatory training in basic life support, breakaway techniques and the Mental Capacity Act.
• We had some concerns that the training needs of staff expected to work in the health based place of safety were not adequately met in relation to the application of section 136 of the Mental Health Act.
• Journey times to St. Ann’s hospital, for people living in west Dorset ranged from one hour through to over two hours, traffic dependant. Reports we looked at showed that 90% of transport was provided by the police, in either a car or van and not an ambulance. This meant comparatively long journeys, often in the back of a police van, for people from the West of Dorset.

However,

• It is important to state that we found areas of very good practice. The layout and furniture of the health based place of safety was designed to promote people’s safety, and privacy and dignity as far as possible. There was equipment available to deal with medical and psychiatric emergencies. All people had a risk assessment carried out when they were seen by the crisis teams, or were seen in the health based place of safety. People working with the crisis teams had their level of risk reviewed regularly. Staff knew how to identify and report safeguarding concerns. Staff knew how to report incidents. Staff were offered debriefing when serious incidents occurred.
• Peoples’ needs were assessed and care was delivered in line with their individual care plans. The street triage initiative had been effective in reducing the number of people detained under Section 136 of the Mental Health Act, and the number of people referred to the crisis response team. Within the first six months, peoples’ presentation at the health based place of safety reduced by 20% and in the following six months by 32%. There were strong and firmly established relationships between the provider and the police which were conducive to positive outcomes for people using services and the staff.
• Staff were caring, compassionate and motivated and there was good, professional and respectful interactions between staff and people using the crisis services, when we shadowed staff, during our inspection. Patients commented positively about how kind the staff were towards them.
• We noted all groups of people, including young people under 16 years of age are able to use the health based place of safety. We saw evidence that in all but one occurrence in May 2015, the police did not use police custody cells for people, once detained under section 136 of the Mental Health Act.
• In addition, people using the crisis services across Dorset had access to the recovery education centre which offered many courses to enable people to understand their experiences, manage their recovery and also how to support others with their journey. The west Dorset crisis service had a peer led carer’s project. There was availability of crisis house beds across Dorset which provided as an alternate to an inpatient admission.
• The senior management team was fully committed to making positive changes. We saw that the management team had put a robust plan in place to address deficiencies identified in order to develop and implement improvements to the service.

We did not provide a rating for 'safe' for mental health crisis and health based places of safety due to conflicting and contradictory evidence which meant a definitive, robust judgement could not be made.

• We rated the acute wards for adults of working age and psychiatric intensive care unit at Dorset Healthcare University Foundation Trust as outstanding because:

• We found very caring, compassionate and motivated staff, and, saw good, professional and respectful interactions between staff and patients during our inspection. Patients commented positively about how kind the staff were towards them. We found that staff promoted egalitarian relationships with patients and showed empathy consistently. We saw evidence of initiatives implemented to involve patients in their care and treatment. We saw that all of the acute wards used the Safe wards interventions to ensure they provided a contained and therapeutic environment for patients.

• A service model and acute care pathway which optimised patients’ recovery, comfort and dignity was in place. There was a varied, strong and recovery orientated programme of therapeutic activities, many of which were instigated at the suggestion of patients. People with lived experience of mental health conditions delivered a series of educational and skills based workshops and programmes, directly on the wards for patients in partnership with staff. We noted the service was responsive to listening to concerns or ideas made by patients and their relatives to improve services. Bed management processes were very effective and patients were able to access an acute and PICU bed when required.

• Wards were kept clean and well maintained and patients told us that they felt safe. There were enough, suitably qualified and trained staff to provide care to a good standard. We found that patients’ risk assessments and formulations were robust and person centred and that the service had strong mechanisms in place to report incidents and we saw evidence that the service learnt from when things had gone wrong. However, the provider should review the description of the word seclusion while describing de-escalation on RIO in order that the intervention is accurately described and review availability of outside space on Seaview ward for non-smokers.

• The assessment of patients’ needs and the planning of their care was individualised and had a strong focus on recovery. Most staff had a good understanding of the Mental Health Act 1983 (MHA), the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice. We saw throughout all of the wards that the multi-disciplinary teams were involved in assessing and delivering patient care. We found motivated and supportive ancillary staff on all of the wards. However, the provider should maximise use of the physical health teams, review input from psychology in order to offer patients a good selection of psychological therapies, review procedures for acquiring advance directives from patients and address training across all staff groups on the new Mental Health Act Code of Practice.
• Staff morale was good and they were well supported and engaged. There was visible and strong leadership team which includ ed both clinicians and managers. Governance structures were clear, well docum ented, adhered to by all of the wards and reported accu rate l y. Mana gers and t heir teams were fully committed to making positive chan ges. Each ma n ager had developed a ward business plan which included submissions to secure capital funds in order to develop and implement i mprovements to the serv ice.

We rated long stay rehabilitation mental health wards for working age adults as requires improvement because; 

• We found patients were not protected against the risks associated with the unsafe use and management of medicines on Glendinning ward by ensuring the record of the administration of medication is accurate.
• The physical environments on two of the wards did not promote privacy for patients.
• We were concerned that the management of ligature risks in Nightingale House was not robust.
• Emergency equipment was not consistently maintained and the frequency of audits of controlled drugs was not in line with the trust's policy. There were also problems with the arrangements for the management of legal highs.
• Although there was a range of therapeutic activities available, on both an individual and a group basis, there were mixed views about whether there were enough activities on offer and about their quality. On some wards patients were unable to complete shopping or cooking tasks as part of their rehabilitation programme.

However;

• We found that patients were positive about the way staff treated them. We observed that patients were treated with compassion, respect and dignity. and involved in the planning of their care.
• Staff understood the trust’s vision and values and these were embedded into day to day working practices. The rehabilitation wards were well-led, ward managers were visible on the wards and there was good governance systems in place to manage the service and provide information to the trust's senior team.
• The ward layouts allowed for easy observation of patients and were clean.
• All three wards worked closely together to ensure that patients were admitted to the ward that best met their needs. Patients needs were assessed after admission. Care was then delivered in line with their individual care plans. Patients could access psychological therapies as part of their treatment. The wards had a wide range of staff from different professional backgrounds to support patients. These included nursing, medical, occupational therapy and psychologists.
• The wards used appropriate clinical outcome scores. The outcome measures were completed by the multidisciplinary team and allowed patients progress to be monitored by quantifiable measures. We saw evidence of regular, effective and well-staffed multi-disciplinary team meetings on all three wards.
• Staffing levels were in line with the levels and skill mix determined by the trust as safe.

We rated Dorset Healthcare University NHS Foundation Trust as good because:

The ward did not have robust processes for reducing the risks to patients and staff. This included risks in the environment, gaps in policies for and implementation of procedural security, and the unsafe use of sharps bins. However, all patients had a risk assessment carried out which was reviewed regularly by the multidisciplinary team. Medication was administered and managed safely. Incidents were reported and investigated. Recruitment was ongoing, and bank staff were used to cover nursing and support worker vacancies. Staff had completed most of their mandatory training but there were gaps.

Patients had their needs assessed, and care plans developed in response to this. Patients had their physical healthcare reviewed every three months by a dedicated physical healthcare team in the hospital. Records were stored securely and could be shared with the community team. There was a structured activity programme five days a week. Staff received supervision, appraisal and training. Detained patients had their rights under the Mental Health Act explained to them, and had access to an independent Mental Health Act advocate (IMHA). The Mental Health Act was implemented correctly in most cases, and any errors were rectified. Patients who received a service from the Pathfinder service had regular psychological support. For other patients there was limited access to psychologists and occupational therapists on the ward.

Patients were mostly positive about the staff and the service, and said they felt safe on the ward. Patients had their care discussed with them. Patients had access to an advocacy service. Patients had been involved in deciding on the decoration of the refurbished ward, and an open day had been held for patients’ relatives before it reopened. A patient on the ward was peer representative and attended ward and forensic service meetings, and was able to raise patients concerns. Although patients were mostly positive about their care, they were less certain about the blanket policy of locking doors during the day and what they saw as compulsory attendance at groups.

Patients had their own room, and a lockable draw and locker for valuable or contraband items. There was a kitchenette where patients could make their own drinks. There was a structured activity programme that ran five days a week. The service had a car to support patients to access services in the community. There were rooms on the ward for patient activities, and outdoor space. The service routinely reviewed the care, needs and risks of all inpatients. It also reviewed all referrals, people on its waiting list, and patients in services outside the trust team. With the exception of nursing staff and support workers all staff worked across both inpatient and community services. There were no delayed discharges at the time of our inspection. Patients were aware of the trust’s complaints policy. The trust had no secure inpatient facilities for women, so any woman requiring this would have to be admitted out of area.

Staff were mostly positive about their managers and the staff they worked with. They felt able to speak out and voice their concerns. The ward had participated in the Royal College of Psychiatrists’ quality network for forensic mental health services annual review cycle. The service had individual groups that focused on the three parts of the service: inpatient, community (which included referral and out of area patients) and the Pathfinder service. These fed into an overarching governance group that monitored the quality of the whole forensic service. All the groups included clinical and managerial staff. The inpatient group was attended by a peer representative, who was a patient on the ward. The forensic service used information from and fed into the governance systems within the trust.

We rated child and adolescent mental health wards as good because:

• The ward was a safe and clean environment. Environmental risks were assessed and managed appropriately.
• Staffing levels were appropriate to the need of the patients and additional staff could be used when necessary. All staff were up to date with their mandatory training. Staff had received safeguarding training and understood the trust’s safeguarding policy.
• There had been no serious incidents in the past six months.
• Care records were generally well documented, holistic and recovery oriented.
• Physical health examinations were carried out on admission and patients received ongoing physical health care.
• The trust is part of Reading University’s children and young people's improving access to psychological therapies (CYP-IAPT) programme.
• The ward had a full multi-disciplinary team. Staff had regular supervision and 80% had received appraisals in the last 12 months.
• Young people were treated with respect and dignity by staff. The young people we spoke with told us that staff were supportive and caring. Patients on the ward had access to specialist children’s advocacy and independent mental health advocacy.
• Average bed occupancy on Pebble Lodge over the past six months was 69% and beds were usually available when needed for young people in Dorset. There had been no delayed discharges from the ward in the past six months.
• The patients were able to attend regular education at the on-site school which had recently been rated outstanding by Ofsted. Age appropriate activities were available on the ward.
• The CAMHS service ran the Wave project which provided free surfing to young people with mental health problems.
• There was very positive feedback from stakeholders regarding the responsiveness of the unit to the needs of young people and commissioners of services.
• The ward had a strong multi-disciplinary leadership team which ensured that staff received mandatory training, regular supervision and appraisals and there were sufficient suitably trained staff in place. Systems were in place to ensure that staff were trained in and understood safeguarding, incident reporting and the requirements of the MHA and MCA.
• The ward was a member of the quality network for inpatient CAMHS (QNIC).

However:

• The clinic room fridge was out of order and awaiting parts. The pharmacy medication history verification and reconciliation section had only been completed on one of the seven medication charts we reviewed.
• Clinical staff told us that outcome measures were not being used consistently and that there was poor compliance with recording.
• Clinical staff told us they were not currently doing any clinical audits.
• Patients detained under the Mental Health Act were not being informed of their rights in complete accordance with the Code of Practice.

We rated wards for older people with mental health problems as requires improvement because:

• On all wards, staff did not monitor safety and emergency equipment adequately. Although there was a system in place to do this, staff did not complete the checks consistently and there were gaps in the recording of the checks.
• The trust were not monitoring fire risk on Chalbury ward to ensure clear safe fire evacuation if needed. Although efforts were being made by ward management to ensure safety for patients, there were no completed fire evacuation procedures. The trust had drafted a fire evacuation procedure. However they had not completed it nor made it available to staff. Following the inspection the trust provided us with plans in progress. Training was being arranged for staff, however this was not imminent and due to on-going risks around the environment and position of this unit this meant the patients remained at risk.
• Staff did not always ensure that risks identified in risk assessments were reflected in the patients' care plans. This meant that, although regular staff understood the risks for their patients, this was not being communicated to new or temporary staff.
• Staff were not always protecting the privacy and dignity of patients on some wards, and were not making sure that privacy and dignity was a high priority.
• Due to two wards being on the first floor, patients had poor access to outside space and fresh air. Staff told us this had been escalated to the trust but had not been assured action would be taken.
• One ward had single sex dormitories, beds separated by curtains only. As some patients had been admitted longer than nine months ago, this sleeping environment did not provide adequate privacy.
• The layout of one ward allowed wheelchair access, and two rooms were identified as disabled bedrooms. However the doorframes were too narrow to allow access to these bedrooms by wheelchairs.
• We found ward managers were visible and supportive on the wards. However there was little engagement by senior trust managers in these services. There was no clear corporate strategy for older people with mental health problems.

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

• We found considerable variance in the quality and completeness of care plans and in how up-to-date they were. We identified safety concerns in relation to the standard of care planning and risk assessment and management at some teams. Allocation and management of caseloads varied between teams, and this meant that some staff held high caseloads.

• Some teams did not have the right numbers of staff or skill mix to safely meet all the requirements of the service. Variance in performance and quality across teams, and gaps in critical aspects of service provision, were issues which had been identified eighteen months previous to our inspection through the Trust’s own internal investigations, following serious incidents. These issues had not been addressed at the time of our inspection.

• We saw some good examples of learning from incidents and actions to to improve safety at a local team level. However, we were concerned that there was limited evidence of wider learning for the community teams to improve safety following serious incidents.

• Staff demonstrated good understanding of safeguarding processes and were able to give examples of when they had acted effectively to protect people in their care.Teams had robust lone working procedures, which helped to ensure staff safety when out in the community. However, not all staff were up to date with their mandatory training. This training included areas of learning essential for safe practice such as safeguarding vulnerable adults, basic life support, moving and handling, and fire training.

• The availability of different professional disciplines varied across teams. In some teams gaps in staffing potentially impacted on the effective running of those services. We identified widespread delays from assessment to treatment and long waiting times for people requiring essential psychological therapies as part of their treatment.

• We identified a number of concerns in relation to the Trust meeting its legal obligations under the Mental Capacity Act 2005 (MCA). Mental capacity assessments and best interest decisions were not always recorded. Consent to sharing information was not always clearly documented. The majority of front line staff had not had training in MCA.

• People using services and their carers were treated with kindness, dignity and respect. Without exception, the staff we met were conscientious, professional and committed to doing the best they could for the people in their care. Staff also supported each other well and treated colleagues with kindness, dignity and respect. Staff in different roles told us they felt valued and appreciated by their colleagues, and all staff spoke positively of their immediate peers and line managers. Carers told us they were kept up to date and involved in assessments and decision making processes concerning their family members who used services.

• We observed people were actively involved in planning their own care, during home visits we undertook with staff. People were supported to access independent advocacy services if and as needed. Teams took a proactive approach to engage with people who found it difficult or were reluctant to engage with mental health services. People were able to provide feedback on the service they received. There was a comprehensive range of information provided for people who used services, and staff were able to obtain information in different formats and languages to support people’s different communcation needs.

• Some of the staff we spoke to during our inspection could not tell us about the organisation’s values. Lack of shared focus and direction meant some of the community teams seemed to operate in isolation from other community teams and the wider organisation. High caseloads, disconnect from the senior management team and the wider Trust, and the effect of serious incidents and the subsequent investigation processes, had all contributed to low morale in some of the teams we visited.

• We identified examples of innovation in many teams and a commitment from all staff to deliver quality services, but saw insufficient evidence of best practice sharing across different community teams, which would have allowed for greater improvements in quality across those teams and the wider Trust. This was particularly evident in the response to and learning from serious incidents.

• We saw positive evidence of the integration of adult social care and health care in some teams, which were able to deliver a more effective, holistic service due to their shared knowledge and expertise. All non-management staff told us they got effective support and supervision from their team managers. Staff were well supported by their peers and spoke positively about ther immediate teams. We saw excellent examples of innovative projects and practice at many different teams, which demonstrated staff’s willingness to improve the quality of service they delivered.

We rated Community services for people with a learning disability provided by Dorset Healthcare University NHS Foundation Trust as good because:

• Infection control issues were discussed in team meetings and there are named staff to champion infection control.
• Most staff had caseloads within the levels set by the trust. Where staff had caseloads over the amount expected by the trust, this was being addressed.
• We found some examples of positive risk taking with people who use the service to improve their safety. Staff were aware of how to report incidents when they arose and we saw evidence of points of learning being discussed in team meetings.
• The majority of the records we reviewed contained up to date and holistic plans, but there were inconsistencies in the quality and presence of care plans in some care records.
• We observed the use of evidence based models of therapy being used during the inspection.
• Staff were skilled, qualified and worked together within multi-disciplinary teams to provide a caring service to people who use the service.
• We found evidence of staff helping to create resources for other health care providers to enable positive healthcare outcomes for the people who use their service.
• People who use the service and their carers reported that staff were caring and professional and  that they felt involved in their care and supported by staff. We found appropriate systems in place to ensure staff could respond effectively to changes in the needs of people who use the service.
• We found leaflets on a variety of relevant topics in the locations we visited as well as access for people with differing mobility needs.
• People we spoke with who used the service felt that they were aware of how to make complaints if necessary and the trust were creating an easy read complaints leaflet.
• Staff reported feeling supported by the local and senior management in their service and incorporated the values of the trust in their everyday work.
• We found examples of innovative practice that the teams were undertaking to help improve the care received by people who used the service within the trust, and with other healthcare providers.

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

• In two of the CAMHS services we visited we found that there was not an effective system in place to assess the risks to young people whilst they were waiting for assessment or treatment.

• Two of the community CAMHS teams were unable to provide a service to children and young people within target waiting times due to vacancies and staff sickness.

• We were told by the staff and service managers that caseloads were reviewed regularly at the weekly multi-disciplinary meetings. We reviewed the minutes of the multi-disciplinary meetings for May 2015 and could find little evidence that caseloads had been reviewed at these meetings in two of the teams we visited..

• Insufficient numbers of staff were up to date with their mandatory training. The trust had a target of 85% of staff to have completed mandatory training. No CAMHS team had reached 85% for all mandatory training and there were some mandatory training courses with very low levels of attendance.

• Fourteen of the 26 care records we reviewed did not contain up to date care plans.

• There were backlogs in administrative work in one service which had delayed referrals of young people to other services.

• Staff shortages and vacancies prevented the CAMHS community services from delivering all the psychological therapies recommended by NICE.

• The community CAMHS services did not meet their waiting list targets for assessment or treatment.

• The trust could not provide us with detailed information regarding the number of young people waiting for tier two assessment or treatment or how long they had waited.

• Feedback we received from local stakeholders was critical of the wait for treatment that young people had to experience after referral to community CAMHS and was also critical of delays in the crisis service responding to urgent assessments.

• Four of the seven parents of young people who used the community CAMHS services we spoke with told us that they were not satisfied with the amount of time their child had to wait for assessment and treatment after the initial referral.

• There were not effective systems in place to ensure staff received mandatory training, to manage the waiting lists and to ensure there were sufficient staff.

• There was not an effective system in place to 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.

However:

• safeguarding was good and we saw clear evidence of learning from incidents. All staff we spoke with received regular supervision. There were weekly team meetings and multi-disciplinary meetings. The community CAMHS teams and children’s learning disabilities team had built very good working relationships with the local schools. The consultant psychiatrist at the children’s learning disability service carried out regular joint clinics with a consultant paediatrician. The trust is part of Reading University’s CYP-IAPT (children and young people's improving access to psychological therapies) programme. The North Dorset community CAMHS team had set up a CAMHS advisory telephone service for professionals in North Dorset. Nine of the eleven young people or carers we spoke with said the staff they worked with were supportive. The three parents of young people who used the North Dorset service we spoke with gave us extremely positive feedback regarding the service. They praised the team psychiatrist and support workers and told us that both their children’s and their own support needs had been met by the service. The staff we spoke with spoke respectfully of the young people and their carers and were able to give us many examples to demonstrate their understanding of the individual needs of the young people who used the service. The trust produced age appropriate and accessible information leaflets. Toys and books were available in waiting rooms. The multi-disciplinary leadership teams at the children’s learning disability service and at North Dorset community CAMHS worked very well and enabled those teams to deliver high service standards. Staff generally were positive and engaged. 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 highest risks and has drawn up an action plan to review all the waiting lists, caseloads and the risk assessment process.

We rated Dorset Healthcare University NHS Foundation Trust as requires improvement because:

• There was limited access to psychological therapies. Patients who could have benefited from specialist psychological therapies were not always offered them. These included patients whose mental health difficulties were not responding to medication.

• Understanding and application of the Mental Capacity Act was variable and was not embedded in everyday practice in all teams.

• Caseload sizes varied between teams and in several teams they were very high.

• The quality of care plans was varied across the service. Some were not holistic, personalised or recovery orientated.

• The quality of risk assessments was varied across the service and not all risks identified fed through to the patients care plan.

• There was a lack of strategic oversight for older people’s mental health and patients did not receive an equitable service across the county. There was no clear strategy for older adults with functional illness.
• There was no formal structure to share good practice across older people’s mental health services.

However:

• The intermediate care service for dementia (ICSD) was a specialist crisis service for people with dementia in east Dorset. The team consisted of a team manager, nurses, a full time occupational therapist (OT), support workers and consultant psychiatrists. It was generally a nurse led service, operating 7am – 9pm, to prevent hospital admission, support discharge from hospital, support carers, families, residential and nursing homes and general hospital settings for up to six weeks. The team could provide intensive support up to four times per day, were able to access day hospital places and had an emergency social care budget to access emergency respite for up to two weeks. The ICSD provided very good crisis support for patients with dementia, although this was not available to patients in the west of Dorset.
• Deterioration in health was discussed as part of risk reviews at weekly multi-disciplinary team (MDT) meetings. This meant that all team members were aware of individual patients’ risks.
• None of the teams we visited had waiting lists. Assessments were carried out within the four week target in all teams, and new assessments were discussed at the weekly MDT meeting.
• There was little use of bank or agency staff.
• Patients were allocated a care co-ordinator within a week.
• There was good medicine management amongst the teams and safe lone-working procedures.
• NICE guidance was being adhered to.
• Staff were friendly, kind and respectful and the interactions we witnessed were patient-centred, collaborative and compassionate. Patients and carers told us that they felt involved and were asked for their opinions and feedback.

Overall this core service was rated as ‘good’. We found that community health services for adults were ‘good’ for effective ,caring, responsive and well led but ‘required improvement’ to be ‘safe’.

Our key findings are:

• Process and procedures were followed to report incidents and monitor risks. Individual localities had quality dashboards which monitored safety information such as healthcare associated infections, avoidable pressure ulcers acquired in care, safety information related to workforce and patient experience Learning from risks, incidents, near misses was shared with staff.
• The environment was clean.Trust premises for community locations were well maintained. Equipment was available for patients in their homes and was usually delivered promptly Patients whose condition deteriorated were appropriately escalated and action was taken to ensure harm free care.
• There was a high vacancy rate for night nursing team staff. This team felt they were overworked with not enough capacity with one team to cover a very large geographical area.There were waiting lists for therapy and rehabilitation services due to staff shortages. The staffing across other teams were mostly safe.
• Care plans reviewed within district nursing teams were were not always person centred and did not demonstrate active involvement of the patients in risk assessments and goal planning.The information found in home notes was not always consistent. Staff told us that they did not receive any training or support on mobile working and it was not effective due to poor internet connectivity.
• Staff across all services described anticipated risks and how these were dealt with. Safeguarding protocols were in place and staff were familiar with these.

• Community services for adults took into account guidance from the National Institute for Health and Care Excellence (NICE). There was well established multidisciplinary team working across almost all the community services we visited, Staff had statutory and mandatory training, and described good access to professional development opportunities.
• Incidents of pressure ulcers varied throughout the period and a plan was in progress to reduce avoidable pressure ulcers.
• Discharges from the intermediate care and Integrated Community Rehabilitation teams ICRT were affected due to delays in transition to social care services for patients awaiting long term care package.Staff told us that these delays could sometimes be more than six weeks and this eventually affected the teams’ ability to accept new referrals.
• Staff spent much of their time in trying to obtain accurate information about patients from referrers including GPs and acute hospitals.They said that often the important information such as patient’s medical history, medication was not received and referral forms were not fully completed .
• Patient feedback was collected and used in planning many of the services we visited, most frequently through surveys or focus groups. Feedback from patient surveys was very positive. Lessons from incidents and complaints were usually shared within the staff.
• Patients received compassionate care that respected their privacy and dignity. Patients told us they felt involved in decision making about their care.We found staff were caring and compassionate. Without exception, patients we spoke with praised staff for their empathy, kindness and caring.
• There were effective governance arrangements and most of the staff felt supported by managers.The culture within community services was caring and supportive. Most staff were actively engaged and the service supported innovation and learning.
• Elements of the trust’s vision and strategic forward plan had been implemented in community services. Staff were focused on achieving key outcomes and these were linked to the trust’s vision and strategy.

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

Our key findings are:

• Staff did not demonstrate a consistent understanding or value of incident reporting. Some were not clear what should be reported and six staff from different professions said they were discouraged from using it. Incident analysis showed a high proportion of no or low harm incidents however which can indicate a safe reporting culture. There was evidence of high incident reporting rates in paediatric speech and language therapy, dentistry and sexual health services. Serious incidents were investigated to deliver improvements in practice.
• There were shortages of staff in school nursing, sexual health services and health visiting services. This was due to unfilled vacancies and, in some cases, high sickness levels.
• Medicines were not always checked or kept safe within sexual health services, which presented a risk to both patients and staff. There were clear procedures for the use of medicines for immunisation programmes however and for emergency medicines within dental services.
• There was low compliance with mandatory training in basic life support, adult safeguarding and fire safety. There were alert systems to prompt staff to attend updates training updates, but only a minority of teams had achieved over 85% compliance with all mandatory training.
• Patient records were comprehensive, clear and informative. They showed evidence staff addressed the needs of children and young people. Electronic records were used in all services, however with different systems used by services, there was variation in how safely they captured all the important information about children and young people’s care and treatment.
• Safe infection control practices were seen in most situations.
• Business continuity plans were not robust with clear guidance to help staff know when to implement escalation procedures.
• There were safe systems and practices to safeguard children and young people from abuse.
• There were effective systems for supporting prompt referrals and working collaboratively to deliver the care required when a child or young person needed additional health or welfare support.
• Staff delivered programmes of assessment, care and treatment in line with standards and evidence based guidance. Patient outcomes were monitored based primarily on contact-measures but satisfaction surveys were also used to find out if patients and people using the services thought they had been effective.
• There had been some delays in reviewing the health of children in care, but this had been identified and action taken to clear the backlog of assessments.
• Children, young people and families received care, treatment and support from competent staff, qualified and trained for their roles. Access to training was good and new staff felt supported in their roles. Staff worked well with colleagues and with professionals in other disciplines to deliver a joined up service.
• Care pathways were based on recommended best practice and new guidance was incorporated into updated ways of delivering care. Arrangements were in place to support children moving between services and parents told us these were helpful and effective.
• Patients were asked for their consent before treatment was delivered.
• People spoke highly of the caring and kind staff, and the way they listened to their concerns. They were involved in decisions about their care, given time to consider options and put at ease if they were anxious.
• Staff coordinated care for the whole family and were committed to helping meet people’s emotional, social and welfare needs as well as their health needs.
• Clinics and services were located in places where people could access them, and delivered at a range of times to accommodate people’s different preferences. Community health services delivered a timely service to children, young people and families.
• Locally, staff set up health and support groups required in their 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 school nursing service had reduced capacity to deliver public health improvement programmes, and some clinics and education sessions had been cancelled. This meant that some children and young people might not receive the support they needed at the right time.
• There had not been many complaints received by these services, but staff told us where complaints had resulted in changes to practice. Guidance on how to make complaints was not readily available however in the clinics we visited.
• Staff felt well supported in their teams and able to contribute to service development.
• There was a lack of clarity in the governance structures and staff were not sure that resources were adequately allocated to monitor and report on quality, safety and outcomes for people. The risk register was not consistent with staff concerns and there was not a strong culture for reporting and learning from all incidents and complaints. Services had carried out ad hoc audits, where they had identified a need, but there was no overall audit or service evaluation programme.
• Staff were committed to working together to provide a high quality of service. They were empowered to implement improvements in service delivery.

Dorset Healthcare University NHS Foundation Trust provides community health services for babies, children, young people and their families in Dorset, Bournemouth and Poole. These services include health visiting, school nursing, therapy services, services for looked-after children, sexual health services and services for children and young people with long term conditions, disabilities or complex needs. As part of this inspection we included the dental urgent care service and the intermediate minor oral surgery service.

We spoke with 108 staff for this inspection, reviewed 37 sets of care records and an extensive range of service documents. We received feedback forms from three people using the service and spoke with, or observed care and treatment for 53 parents, children, young people or carers.

We rated this service as requires improvement. Improvements were required to ensure safe, responsive, effective and well-led inpatient services for patients. We found staff were caring and compassionate and treated patients with respect. We rated caring as good.

We found that there were variations in the quality of services across the 11 locations we visited. The services at Swanage, Blandford, Wimborne and Alderney were a better standard but we had concerns about inpatient services at other locations, particularly at St Leonard’s and Bridport hospitals. Surgical services were good across all locations, where provided, including Bridport hospital.

• There were processes and procedures which were followed to report incidents and monitor risks. All locations had quality dashboards which recorded healthcare associated infections, avoidable pressure ulcers acquired in care, and safety information related to staffing numbers.

• Essential and emergency equipment such as resuscitation trolleys and suction facilities were available and overall managed safely. However at Bridport and Westminster hospitals, improvement was needed to ensure these were fit for purpose.
• The overall standards of cleanliness and infection control were good in eight of the 11 hospitals where infection control procedures were followed. There were significant shortfalls in these locations where staff did not follow infection control procedures and the management of infected materials.
• There were clear procedures for the management of medicines. Medicines were managed safely most of the time. Although we found issues with safe storage of some medicines including those on the resuscitation trolleys.
• The process for assessing risks such as pressure ulcers, falls and malnutrition were completed and care plans developed to manage them effectively.
• All hospitals used a recognised tool to determine if patients were at risk of deterioration of their health. This system had been used appropriately such as advice from doctors was sought appropriately.
• The trust had effective systems in place to gather information from patients, and used these to improve patients’ care. We found staff were caring and willing to go the ‘extra mile’ in supporting patients with their emotional needs.
• Patients’ feedback was consistently positive about their care, treatment and the community was keen to retain this local service.
• There were not always adequate staff to meet the needs of patients in a safe and consistent way and this could impact on patients’ care.
• The quality of patient records was variable. Records were securely stored on an electronic patients’ record system, but not all agency staff had access and trust staff had limited access to records as patients moved across services.
• Staff followed guidance from the National Institute for Health and Care Excellence (NICE). This included the five steps to safer surgery to ensure surgical procedures were undertaken safely and effectively.
• Staff recognised the equality and diversity of patients when providing care, although written information was only available in English.
• Therapists carried out thorough assessments of patients, however due to shortage of therapists; patients did not always receive therapy in a timely way such as out of hours and weekends.
• We found there was strong ethos of multi-disciplinary working. Multi- disciplinary team meetings were held and led by a consultant, where patients and their relatives were involved in decision about their care and discharge planning.
• Although there were some internal audits, these were not always linked to improvement in quality and safety or patient outcomes.
• Governance across the service was not robust, not all risks were identified or managed appropriately.
• There was a process which staff followed in dealing with concerns and complaints and responses were sent to patients.

We rated end of life care as requires improvement because:

We found improvements were required in the responsiveness and strategic leadership of end of life care services. The safety and effectiveness of services were good and staff providing end of life care across the trust were compassionate and caring.

• We found planning and delivery of end of life care was inconsistent across the geography of the trust, based upon historical commissioning arrangements.
• The generalist palliative care service, commissioned in Bournemouth and Poole, was more responsive than the community nursing service in West and North Dorset as they could support both health and social care needs of patients. If personal care services were not available to support a discharge in rural Dorset these patients did not have timely access to end of life care in their preferred place of care.
• The generalist palliative care teams did not use an objective tool to measure its daily capacity to support patients. The team had a waiting list, and so patients were sometimes waiting to access the end of life care to meet their needs.
• The strategy, and strategic objectives, for end of life services was still in development. Service leads articulated a vision and priorities for end of life care services across the trust, but this had not been shared with staff.
• There was no evidence of regular reporting on the quality of end of life services to the board.
• Priorities for improvement focused on achieving the Gold Standard Award standards, but progress had been slow.
• Staff in end of life care services were aware of their responsibilities. They raised concerns and reported incidents and used the systems were in place for reporting and learning. They had received mandatory training to support safe care and were aware of safeguarding and how recognise and respond to concerns.
• Appropriate equipment was available to support the delivery of safe end of life care.
• Facilities for end of life care in community hospitals were a good standard, and where they fell short of this, plans were in place to make improvements. Mortuary viewing rooms were not used by staff, because they were not fit for purpose.
• There were processes in place for the safe management of medicines. All staff were trained in the use of one model of syringe driver. There was a palliative care drug administration chart available, but this was not used across all services.
• Patient records were stored securely on electronic patient records and an end of life assessment proforma was used as part of the Gold Standard Framework. There were some inconsistencies in the records reviewed.
• Staffing in end of life care services was adequate and staff across teams prioritised end of life care. There was limited medical cover for patients admitted to a community hospital out of hours.
• End of life care was planned and delivered in line with best practice guidance. The trust had responded to the withdrawal of the Liverpool Care Pathway by introducing a new communication care plan around end of life care.
• We found that pain assessment took place on a continual basis and staff were responsive to this.
• Staff had access to relevant training and support. All the teams we spoke with valued the expertise of the specialist palliative care team and used this service often as a learning resource and for referrals where patients had complex symptoms that were difficult to manage.
• Our observation of practice, review of records and discussion with staff confirmed there was effective multidisciplinary team (MDT) working practices. Staff worked collaboratively to understand and meet the range and complexity of people’s needs
• A combination of electronic patient records and paper forms in patient homes were used. There were some inconsistencies in the information recorded, such as preferred place of death. The trust had audited Do not attempt cardio-pulmonary resuscitation and found they were well completed. However, at inspection we found that almost half those reviewed did not include a clear explanation as to why patient or relative was not involved in the decision.
• Staff had a good understanding of Mental Capacity Act (2005). However, some were still awaiting formal training. Recording of decisions needed to be more detailed.
• Staff treated patients with dignity, respect and kindness. Relatives we spoke to told us that staff delivered compassionate care and that staff were very attentive to their needs and that of the dying person.
• Care plans had been developed to be used with patients in vulnerable circumstances, such as people with a learning disability.
• People felt confident to raise complaints and concerns and these were dealt with in a timely way.
• There was an open and supportive culture with staff being very engaged, open to new ideas and interested in sharing best practice in end of life care.

We rated caring as good but found safety inadequate and the effectiveness, responsiveness and leadership of urgent care services/minor injury units required improvement.

• The quality of clinical leadership needed to improve in most of the minor injury units (MIU), and there was insufficient leadership of urgent care services across the trust. We found visible and positive clinical leadership at Blandford and Swanage MIUs which resulted in a locally well led and organised service. However, at Weymouth, Portland and Bridport MIUs we found some serious issues.
• The trust governance frameworks did not always operate effectively for MIUs. There were insufficient processes for proactively identifying, assessing and managing risks and seeking staff views. There was insufficient auditing of quality or learning across the service.
• There was no clearly defined system for ensuring timely clinical assessment of patients arriving at the MIUs. This meant the service was not assessing and responding to potential risks, and patients could be waiting for some time without clinical assessment, when possibly needing urgent or more acute care and treatment. This was not in line with the trust’s service operational policy or national guidance.
• There were staff shortages across the service and on occasions agency staff were lone working without adequate support or induction. There was variation in the experience and skills of staff employed in the units and the required qualifications and competency checks were unclear and inconsistent, particularly for lone workers.
• There was an electronic incident reporting system in place, and some evidence of learning from incidents, but the process was not clearly understood or used by staff at all units.
• Not all staff were up to date with safeguarding training and some staff did not know about, or respond appropriately to, the child protection flags on the electronic patient records system.
• Resuscitation equipment was not always regularly checked or fit for use and not all staff had completed updated training on intermediate life support. Maintenance and testing of some pieces of electrical equipment was out of date.
• Medicines were well managed in many units, and there was monitoring of storage of refrigerated medicines. However, the service had identified insufficient pharmacy support and some medicines were not stored securely. Although recently updated on electronic systems, some staff were using out of date patient group directions to administer medicines to patients.
• We observed staff following infection control policies and procedures, but there was little evidence of auditing of the environment and staff practice to ensure this was implemented consistently.
• We found some out of date NICE guidance but some updated treatment protocols were available for use in some of the MIUs. We were told of up to date guidelines held electronically, but these were not always accessible or used by staff, particularly agency staff. There was little auditing of adherence to guidance or monitoring of patient outcomes.
• There were inconsistencies in clinical supervision and continuous professional development with some staff receiving more support and funding than others, depending on their location.

• The environments of some minor injury units were cramped and reception areas compromised privacy and confidentiality. The poor signage to some units potentially led to patients attending acute hospital when not needed.

• MIUs achieved the government’s four hour waiting targets but they did not provide clinical assessments on patients arriving in the department within the 15 minute timescale. Some MIUs had to close when there was insufficient staff to provide the service, and there was little or no xray services at some of the locations.
• There was limited understanding of, or adjustments for, the needs of people with a learning disability and staff had not attended dementia training.
• MIU staff had a variety of managers, some had no specific knowledge or experience in emergency nursing, and accountabilities were sometimes unclear to staff. Although staff enjoyed their jobs in MIU, some felt isolated and undervalued by the trust.
• The MIU staff were unclear about the vision and strategy for the service. They were aware of a clinical services review being undertaken across Dorset, but did not feel informed or consulted.
• The service specification was outdated and not being followed as it did not reflect the current service provided by the MIUs.
• There was a clear process for patients to raise complaints and some, but not always, evidence of learning and improvement in the service as a result of complaints.
• There were good links with acute services and appropriate referrals. There were examples of close working with GPs but some inconsistencies.
• Verbal consent was obtained for care and treatment and this was sometimes recorded in patient records. Staff demonstrated understanding of the Mental Capacity Act (2005).

• Nurses were caring and compassionate across all MIUs we visited. Patients spoke highly about the staff and were involved in decisions about their care and treatment.

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.

Overall, we rated the trust as requires improvement because:

• The services that the trust provided varied in their quality. We had particular concerns about the child and adolescent mental health services, minor injuries units, and mental health crisis and rehabilitation services. We found some significant variance in the quality of care delivered between teams and across the trust.
• The child and adolescent mental health services (CAMHS) in Weymouth and Portland and in Bournemouth and Christchurch did not assess risks to young people waiting for assessment or treatment effectively. Also, the teams were unable to meet the waiting time targets because of the number of vacant posts and staff who were on sick leave.
• At Weymouth, Portland and Bridport minor injuries units there was a lack of clinical leadership. There was no clearly defined system for triage and clinical assessment of patients arriving at the units. This meant that the service was not assessing and responding to potential risks, and patients could be waiting for some time without clinical assessment, when possibly needing urgent or more acute care and treatment. This was not in line with the trust’s service operational policy or national guidance. In addition, there were staff shortages and a lack of an appropriate skill mix across the service, and on occasions agency staff were working alone without adequate support or induction.
• We found conflicting and contradictory evidence about staffing and sickness levels in the east Dorset crisis team. However, we found evidence to indicate that staffing issues had a marked adverse effect on the team’s ability to provide a robust home treatment service.
• The telephone call management systems, set up specifically to deal with calls at night, did not function effectively and patients experienced difficulties accessing the east Dorset crisis team if experiencing a crisis, posing a potential significant risk.
• At Nightingale House and Nightingale Court patients were not able access comprehensive rehabilitation programmes in the community; they were unable to do their weekly shopping and cooking. During the inspection we saw that some patients on these rehabilitation wards spent much of their time smoking rather than engaging in meaningful activities. There were high levels of detention under the Mental Health Act on all rehabilitation wards and some patients had been detained on the wards for a considerable length of time which is unusual on rehabilitation wards.
• We found inconsistencies in the planning and delivery of a number of services across the trust.
• There were deficiencies in monitoring and checking safety and emergency equipment across older people’s mental health services and in inpatient wards in community hospitals
• The quality of patient records in community health services was variable. A combination of electronic and paper patient records were in use where care was delivered in patients’ homes. In community health care inpatient services, records were stored securely on SystmOne. However, there were inconsistencies within SystmOne due to how it had been set up, which meant that staff had limited access to some parts of the system as patients moved across services and not all agency staff had access it.
• The governance frameworks did not always operate effectively for minor injuries units. There were insufficient processes for proactively identifying, assessing and managing risks and seeking staff views. There was insufficient auditing of quality or learning across the service.

However:

• The trust responded very quickly and positively when we raised concerns about the risk assessment process for children and young people on waiting lists in the Weymouth and Portland and Bournemouth and Christchurch child and adolescent mental health services and took prompt action to review and reduce the highest risks. The trust drew up an action plan to review all waiting lists, caseloads and the risk assessment process, and has kept us updated on the positive progress with this.
• The trust responded quickly and positively when we raised concerns about the safety of services delivered in Weymouth and Portland minor injuries units. It assured us that only experienced clinicians would work at these units and that if safe cover could not be found the units would close. All units would have a band six nurse at all times as a minimum. The trust also told us that it is considering how it could provide band 7 shift leaders in each unit. The opening hours at Portland would be changed, with no weekend working, and there would be receptionist cover during opening hours.
• There was visible and positive clinical leadership at Blandford and Swanage minor injuries units, which resulted in a locally well led and well organised service.

In addition:

• We observed outstanding care and treatment in both inpatient mental health services and the forensic community services.
• In inpatient mental health services we found that the model of care and acute care pathway optimised patients’ recovery and that there was a strong emphasis on recovery-orientated therapeutic programmes, many of which were instigated by patients.
• The forensic community Pathfinder service worked with patients with a personality disorder who were at risk of offending to improve their outcomes and at significantly lower cost than being in hospital. The service was psychology led and worked with patients around their risk behaviour. The staff within the community forensic services went out of their way maintain contact with patients placed on wards out of the area and worked hard to bring patients back into the area as soon as they could, including supporting the maintenance of relationships with relatives.
• The trust had a relatively new board (executives and non-executives), with the majority having been appointed only since the arrival of the chief executive in 2013. The director of nursing had been in post for ten months before our inspection and a new medical director was due to take up post immediately after our inspection. The leadership team was positive, passionate, energetic and open and transparent. We concluded that they were a cohesive team who respected one another and shared a common purpose.
• The executive team, along with the senior managers, were aware that the trust needed to improve and we found that, despite many of them only recently coming into post, they had been very active in working quickly to address and identify issues. They had engaged well with staff, developing a new vision, ‘to lead and inspire through excellence, compassion and expertise in all we do’, which was underpinned by the principle of doing ‘better every day’. In addition, they had engaged positively with stakeholders, an aspect for which the chief executive had taken specific responsibility.  This included creating active relationships with the clinical commissioning groups (CCGs), NHS England, local authorities, and visiting groups of GP's.  They had been successful in changing attitudes and fostering positive relationships – so much so that commissioners and other stakeholders now held the trust in high regard and were positive about the future, whereas previously they had held a very different view. It was clear that there was a cohesive strategy based around driving improvements in clinical practice and working in partnership with patients, staff and stakeholders; we saw clear evidence of this in several areas across the trust.
• We found that the trust had developed an impressive, high quality and detailed governance system to support it to achieve its vision and this was in the process of being rolled out, although it was not yet fully embedded across all services. We found those systems were robust and we were confident that, given time, areas of concern could be identified speedily and managed well.
• In addition, the trust had recently moved to a locality-based delivery model to promote integration of both physical health and mental health services. This model was in the early stages and was developing well for some services but not so well for others, resulting in some variation in the quality of services and some services feeling fragmented as a result. For example, staff felt there was now a lack of strategic focus for people with functional illness across older people’s community services. Staff questioned whether the child and adolescent mental health service was too small to be split across localities and they felt that there was insufficient leadership of urgent care services.
• We found good practice across the services that we inspected, with a caring, enthusiastic and committed workforce that in the main treated patients in their care with dignity and respect.
• Although we found some care that gave us cause for concern, as identified above, throughout the inspection the trust was very receptive to any comments that we made and we saw immediate and appropriate action taken when we raised a concern.
• We have not taken any enforcement action and are confident that the trust will quickly address all areas of concern identified in the requirement notices detailed in this report.

We did not provide a rating for the 'safe' domain for the mental health crisis and health based places of safety core service due to conflicting and contradictory evidence which meant a definitive, robust judgement could not be made.

Dorset HealthCare University NHS Foundation Trust requires improvement. However, we saw that it was well led by its new leadership team and was in the process of deploying effective systems that we were confident would result in the delivery of improved, high quality services for the patients it serves in the future.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.