Dorset Healthcare University NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.
At our last assessment we rated this key question good. At this assessment the rating has remained the same.
Patients received care, treatment and support that was based on a comprehensive assessment of their needs, strengths and preferences. Staff delivered care in line with current legislation, standards and evidence-based guidance and worked collaboratively with patients, carers and partner organisations to achieve positive outcomes. Patients were supported to maintain and improve their physical and mental health and wellbeing, and staff regularly reviewed care, treatment and outcomes to ensure support remained effective. Where required, staff applied the Mental Capacity Act appropriately and supported patients to make decisions about their care.
 

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.
We reviewed nine care records. Care plans were generally detailed, personalised and reflected people's individual needs, strengths, preferences and circumstances.
Staff demonstrated detailed knowledge of the people they supported and were able to describe changes in presentation, risks and support needs. Discussions evidenced a strong understanding of the individual's history, current circumstances and factors influencing their wellbeing.
For example, one care record demonstrated a detailed assessment of a person with autism and moderate learning disability who had transitioned from living with elderly parents into supported accommodation. Staff demonstrated a clear understanding of communication needs, mental health presentation, social inclusion, family involvement and the impact of this significant life transition.
Care plans demonstrated consistent use of first-person language, detailed life histories, comprehensive risk formulations, person-centred interventions, strong understanding of communication needs and clear evidence of family involvement.
Records reviewed included wellbeing plans, care passports, "All About Me" documentation, Occupational Therapy intervention plans and annual reviews. These documents supported a holistic understanding of the person and provided clear guidance for staff.
Staff demonstrated detailed knowledge of the people they supported and were able to clearly explain support arrangements, risks, progress and future plans. This reflected continuity of care and strong therapeutic relationships.
However, there were some areas for improvement in relation to record keeping. For example ,one patient’s annual review had not been uploaded to Rio ( their electronic recording system) and one Speech and Language Therapy (SALT) plan was not available within the electronic record system. In another case, a Best Interest (BI) risk meeting was referenced within notes but supporting documentation could not be located and an outdated COVID-19 alert remained active on a person's record and required removal.
Staff acknowledged that information could occasionally be difficult to locate within Rio due to the way documentation was stored and recorded.
Despite these recording issues, which were resolved during the assessment the care plans reviewed demonstrated that people's needs were understood, regularly reviewed and responded to appropriately.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.
Care plans demonstrated use of recognised evidence-based approaches including Positive Behaviour Support (PBS), Occupational Therapy (OT) interventions, Speech and Language Therapy (SALT), specialist dentistry services, mental health pathways and person-centred planning.
Staff described specialist pathways developed to support people with autism, forensic learning disability needs, personality disorder, complex trauma and mental health needs within learning disability services. Staff demonstrated confidence and expertise when discussing these pathways.
The Intensive Support Team (IST) undertook behavioural analysis and worked alongside care providers to improve support arrangements. Staff described using behavioural understanding to identify triggers, reduce distress and improve outcomes for people receiving support.
Staff provided examples of supporting acute hospital staff to better understand the needs of people with learning disabilities. This included education around communication, routines, environmental adaptations and individual support needs.
One Occupational Therapy intervention plan reviewed used strengths-based language throughout and clearly identified practical support needs. The plan focused on promoting independence whilst ensuring support remained personalised and appropriate.
The service had developed a specialist bloods pathway for people who lacked capacity, or had limited capacity, to consent to blood tests. Staff described this as an individually tailored approach which used Mental Capacity Act (MCA) principles and Best Interest (BI) decision-making to facilitate access to essential healthcare.
Staff advised the specialist bloods pathway had been recognised as good practice, shared with other services and had received an award. Staff were proud of this initiative and described positive outcomes for people who may otherwise have struggled to access important investigations.
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.
Staff had access to administrative support and legal advice on 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 and 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.
 

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.
We observed one discharge planning meeting involving the Community Learning Disability Team, Consultant Psychiatrist, inpatient ward staff, Adult Social Care (ASC), provider representatives, Police Offender Manager, Independent Mental Health Advocate (IMHA) and the person receiving care. The meeting was well structured and demonstrated effective multidisciplinary working.
Risks, legal restrictions, previous discharge attempts and future support arrangements were discussed openly and clearly. Participants demonstrated a shared understanding of the person's needs and responsibilities within the discharge plan.
The person was given opportunities to contribute throughout the meeting. Information was explained clearly, and the person was supported to understand the plans being discussed. The meeting demonstrated a person-centred approach to discharge planning.
Weekly Multidisciplinary Team (MDT) meetings were held every Wednesday. Staff described these meetings as an opportunity to review risks, discuss complex cases and coordinate care across disciplines.
Additional MDT reviews occurred on the second Wednesday of each month for people subject to Community Treatment Orders (CTOs) and Mental Health Act (MHA) restrictions. This provided additional oversight for individuals with more complex legal and clinical needs.
Staff described use of Community Treatment Reviews (CTRs), Local Area Emergency Protocol (LEAP) meetings, Continuing Healthcare (CHC) reviews and Circle of Support meetings every six weeks for people with complex needs. These arrangements supported coordinated and responsive care.
Staff worked collaboratively with acute hospitals, Continuing Healthcare (CHC), Adult Social Care (ASC), care providers, families, police services and advocacy organisations. Discussions demonstrated positive working relationships across agencies. The service provided evidence of co-production with people with lived experience being included in co-facilitating forums and participating in decision-making.
The Senior Clinical Lead described strong relationships between east and west locality services and reported good multidisciplinary engagement across teams and partner organisations.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.
Care records demonstrated involvement from a range of specialist services including Cardiology, Endocrinology, Gastroenterology, Haematology, Speech and Language Therapy (SALT), Occupational Therapy (OT) and Specialist Dentistry. This demonstrated a holistic approach to meeting people's health needs.
The Senior Clinical Lead described a workforce consisting predominantly of Learning Disability Nurses supported by Registered Mental Health Nurses (RMNs) and Adult Nurses. Leaders described how this skill mix enabled the service to respond effectively to both physical and mental health needs.
Staff demonstrated a strong understanding of significant physical health risks alongside mental health and learning disability needs. Physical health considerations were integrated into assessment, care planning and review processes.
One care record included structured oral care plans, specialist dental care involvement and reviews every six to eight weeks. Staff demonstrated awareness of the importance of maintaining oral health and making reasonable adjustments to support access to treatment.
Staff supported people to access healthcare appointments and specialist services where required. Examples were provided of staff working alongside families, providers and healthcare professionals to overcome barriers to healthcare access.
Staff also described supporting people to access meaningful activities and community opportunities. Examples included swimming, travelling on public transport and participation in social activities that promoted wellbeing and independence.
One care record demonstrated a reduction in hospital admissions following implementation of a structured support package and relapse prevention planning. Staff described this as a positive outcome resulting from consistent multidisciplinary support.
Staff described collaborative working with Continuing Healthcare (CHC) and care providers to monitor health needs and ensure support arrangements remained appropriate and responsive to changes in presentation.
 

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.
We saw that staff used recognised tools to assess and record risk, symptom severity, and clinical outcomes.
Staff we spoke with demonstrated a clear focus on achieving positive outcomes for people. Outcomes were monitored through a range of review and oversight processes like Health of the Nation Outcome Scales (HoNOS)
Staff described a structured approach to monitoring outcomes through annual reviews, Continuing Healthcare (CHC) reviews, Section 117 aftercare reviews, multidisciplinary team (MDT) meetings, Community Treatment Reviews (CTRs) and Circle of Support meetings. These processes enabled professionals to review whether support remained effective, identify changes in need and agree actions where outcomes were not being achieved.
Care records evidenced ongoing review of wellbeing plans, risk assessments and support arrangements. Records demonstrated that outcomes were monitored through changes in presentation, levels of support required, placement stability, risk management, physical health oversight and engagement with services. Staff were able to articulate progress, deterioration and changing needs during case discussions, indicating that outcomes were being considered as part of routine clinical practice.
There was evidence of regular oversight for people with more complex needs. Staff described reviews taking place every three months for people receiving Section 117 aftercare and every six months for Continuing Healthcare funded packages, alongside annual reviews and additional reviews where concerns arose. This provided opportunities to evaluate whether care remained effective and whether interventions continued to meet identified needs.

The service told people about their rights around consent and respected these when delivering person centred care and treatment.
Care records demonstrated consideration of the Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS) and Best Interest (BI) decision-making processes. Legal frameworks were clearly reflected within records reviewed.
Community DoLS applications were evidenced within records and staff demonstrated understanding of their responsibilities in relation to legal restrictions and safeguarding people's rights.
Staff demonstrated a good understanding of capacity assessment and least restrictive practice. Discussions reflected an emphasis on supporting people to make their own decisions wherever possible.
Family members, advocates and relevant professionals were involved in Best Interest decision-making processes where appropriate. Staff recognised the importance of collaborative decision-making when people lacked capacity to make specific decisions.
Staff described multidisciplinary Best Interest processes for people requiring healthcare interventions where capacity was lacking. Examples included support for blood tests and other physical healthcare procedures.
The specialist bloods pathway provided evidence of practical application of Mental Capacity Act principles to support access to healthcare whilst ensuring decisions remained lawful and person-centred.