• Organisation

Somerset NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider

Our most recent report published 23 January 2023 on Somerset Partnership NHS Foundation Trust is available as a British sign language video.

Important: We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

All Inspections

06 September - 08 September 2022, 28 September and 29 September 2022

During a routine inspection

Somerset NHS Foundation Trust (SFT) is the first NHS trust on the English mainland to provide community, mental health, and acute hospital services. The trust was formed with the formal merger of Somerset Partnership NHS Foundation Trust and Taunton and Somerset NHS Foundation Trust which took place on 1 April 2020. At our last comprehensive inspection of the Taunton and Somerset trust in January 2020 (the report published in March 2020) we rated the trust overall as good, with a requires improvement rating for safe. Caring was rated as outstanding. The other key questions of effective, responsive well led were rated as good. At our last comprehensive inspection of Somerset Partnership in October 2018 (published in January 2019) we rated the trust overall as good, with a requires improvement rating for safe. Effective, caring responsive and well led were rated as good.

The trust is working towards a planned merger with Yeovil District Hospital NHS Foundation Trust (YDH) to bring the trusts together to create a new, single organisation which will be responsible for running Yeovil District Hospital and Musgrove Park Hospital, the community hospitals in Somerset, all community, mental health and learning disability services in the county with population coverage of 20% of GP practices in Somerset. The two trusts are overseen by a joint board. The merger is due to complete in April 2023.

We carried out this short notice announced inspection of acute wards for adults of working age and psychiatric intensive care unit (PICU), specialist community mental health services for children and young people and community end of life care services of this trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall. At our last inspection we rated the trust good overall.

During this inspection we inspected three of the Trust’s core services and rated one outstanding and two as good. We also undertook an inspection of how ‘well-led’ the trust was. We rated the trust as good overall. We rated each of the key questions. We rated safe as requires improvement; effective, responsive, and well-led as good, and we rated caring as outstanding.

The trust provides the following services:

Mental health services

Acute wards for adults of working age and psychiatric intensive care units (PICU's)

Long stay/rehabilitation mental health wards for working age adults

Forensic inpatient / secure wards

Child and adolescent mental health wards

Wards for older people with mental health problems

Community-based mental health services for adults of working age

Mental health crisis services and health-based places of safety

Specialist community mental health services for children and young people

Community-based mental health services for older people

Community mental health services for people with a learning disability or autism

Community health services

Community nursing services or integrated care teams, including district nursing, community matrons and specialist nursing service

Community health services for children, young people and families

Community health inpatient services

Community end of life care

Community dental services

Community sexual health services

Urgent Care

Acute hospital services

Urgent and emergency services

Medical care (including older people's care)


Critical care


Services for children and young people

End of life care


Our rating of the trust stayed the same. We rated them as good because:

  • We rated effective and responsive as good, caring as outstanding and safe as requires improvement. We rated ‘well-led’ for the trust overall as good. In rating the trust, we took into account the existing ratings of the 22 previously inspected services not inspected during this inspection.
  • We rated 1 of the 3 core services we inspected as outstanding and 2 as good.
  • We rated specialist community mental health services for children and young people as outstanding overall, with caring and responsive rated outstanding. This had improved from the overall rating of requires improvement given at our last inspection. We rated acute wards for adults of working age and psychiatric intensive care units as good. This rating was unchanged since our last inspection. We rated community end-of-life care as good in every domain, this was an improvement as we rated the safe domain as requires improvement at our last inspection.
  • During the core services inspections we saw that staff treated people with compassion and kindness, respected their privacy and dignity and understood people’s individual needs. Services were inclusive, took account of patients’ preferences and their individual needs. People had their communication needs met and information was shared in a way that could be understood.
  • The strategy provided a focus for the work being done by the trust to prepare for the merger with Yeovil District Hospital NHS Trust and to meet the needs of local populations.
  • We found that despite the challenges of the pandemic, the trust had adapted, learnt, and continued to make positive progress. We found that the trust had addressed all the areas where improvements were recommended in the specialist community mental health services for children and young people at the previous inspection. This had a positive impact for people who use services and staff working for the service.
  • Staff were well supported by supportive and competent leaders across the organisation. Leaders were well supported with their career development and the provider had improved its approach to succession planning for senior leadership posts.
  • We found a positive culture across the trust. Staff told us that they felt proud to work for the trust and we heard many examples of how they put the people who use services at the centre in their work. The senior leaders including the non-executive directors were open, friendly and approachable. They had worked hard during the pandemic to engage with services in person and remotely. People and teams were able to speak honestly and reflect on where improvements were needed and how this could be achieved.
  • The non-executive directors provided high quality, effective leadership and delivered support and appropriate challenge to the senior executives. They all had experience as senior leaders in a range of organisations and brought skills from other sectors including NHS acute care, health organisation directorships, social care, education and local government.
  • The senior leadership team demonstrated a high level of awareness of the priorities and challenges facing the trust and the local health environment, and how they could address these and influence change in the system. The trust had well embedded clinical leadership.
  • The trust’s governance system effectively provided assurance and helped keep patients safe. It helped the organisation deliver its key transformation programmes and priorities outlined in the annual business plan.


  • There were still outstanding maintenance, refurbishment and repair issues on acute wards for adults of working age and psychiatric intensive care units to ensure they provided a therapeutic environment. The outstanding issues had been logged on the trust system by staff, but repairs had not been completed. The specific issues are described in the core service reports.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Before the inspection we reviewed a range of information we held about the services.

During our inspection of the three core services, the inspection teams:

  • reviewed records held by the CQC relating to each service
  • visited seven wards and ten community team bases across Somerset. We looked at the quality of the ward environments, management of the clinic rooms, and observed how staff were caring for patients
  • interviewed the ward manager and/or matron for each ward or service
  • reviewed 69 patient care and treatment records
  • interviewed 31 patients and 13 relatives of patients
  • looked at a range of policies and procedures related to the running of the service
  • spoke with the Peer Support worker
  • spoke with an independent mental health advocate
  • looked at a range of policies, procedures and other documents relating to the running of each service
  • spoke with 46 staff members including nurses, clinical practice leads, end of life coordination team, district nursing teams, rapid response service, staff proving care on community inpatient ward. support workers, occupational therapists, occupational therapy students, clinical psychologists, associate psychologists, health care assistants, activities coordinator
  • spoke with 18 senior members of staff including the professional lead for the PMVA (Prevention Management of Violence and Aggression) team
  • spoke with medical teams across the services including the palliative consultant leadership team, consultant psychiatrists and doctors. We also spoke to members of the LARCH team and End of life education team
  • observed eight multi-disciplinary meetings, two home visits and one assessment.

The well led inspection team comprised one executive reviewer who was an executive of an NHS mental health and community health provider, two specialist advisors with professional experience in executive roles and board-level governance, one CQC head of hospital inspection, two CQC inspection managers and three colleagues from NHS England.

What people who use the service say

Acute wards for adults of working age and psychiatric intensive care units

Patients felt safe and their relatives confirmed their family member receiving care and treatment was safe.

Patients knew the reasons for their admission and the conditions of their stay. They knew their rights and how they applied to them. For example, their right to leave.

Relatives felt informed of important events and where appropriate were invited to reviews. Some relatives raised concerns about the closure of St Andrews and how this would impact on their visiting

Patients overall gave positive feedback about the staff and relatives praised staff for their patience. Some relatives had observed staff shortages when they visited. Patients in Rydon 2 said there was a lack of meaningful activities, and the activities room was often closed.

Patients felt confident to approach the staff with complaints and gave us examples of complaints they made with support of their advocates.

Patients knew about their care and treatment but were not provided with copies of their care plan.

Patients knew the routines of the ward and said the meals were of a good standard

Specialist community mental health teams for children and young people

Parents and carers gave very positive feedback about CAMHS (Child and Adolescent Mental Health Services) services. Parents and carers said that every single service responded to them in a timely way, that their children were assessed, and appropriate therapy offered quickly.

Children and young people said their appointments were flexible; they could request a digital appointment and appointments always ran on time.

Parents and carers said that communication was good. They said that staff were supportive, kind, and caring. Parents and carers said that staff always made sure they understood what was happening, they had a very open dialogue with staff and that their opinion was always sought.

Parents and carers said they were reassured by staff and included in reviews and assessments. They said that care plans were done together as a family, and they received written copies regularly.

Young people said they were fully involved in their care and understood what was going on.

Community end of life care

Patients and families knew how to complain and felt they could raise concerns without fear of prejudice.

Patients and families described staff very positively. Some carers had fundraised following the death of patients as they had wanted to give something back to the services that they felt had cared for their loved ones very well.

Patients and families were positive about the support they received from staff, their religious and cultural needs were respected and supported.

Patients and families were supported to give feedback on their treatment and the service.

9 October 2018 - 31 October 2018

During an inspection of Community health inpatient services

  • The service worked closely with the local NHS acute trusts and developed care pathways for discharge. This supported rehabilitation services and reduced length of stay for patients. Staff, teams and services within and across different organisations worked together to deliver effective care, treatment and discharge arrangements for patients. The trust set up a project board to manage and monitor delayed transfers of care in order to take a system wide approach.
  • Patients’ care, treatment and support achieved good outcomes, promoted a good quality of life and was based on the best available evidence. Patients’ physical, mental health and social needs were holistically assessed and cared for. Staff gave patients enough food and drink to meet their needs and improve their health. Patients’ pain was assessed and managed including those with difficulties in communicating. Patients were empowered and supported to manage their own health, care and wellbeing and to maximise their independence.
  • All the community hospitals looked visibly clean, corridors were not cluttered with equipment and fire doors were not blocked. Equipment and the premises were kept clean and staff used control measures to prevent the spread of infection. The facilities and premises were appropriate for the services that were delivered. Colour schemes were ‘dementia friendly’ and there was good access for people using wheelchairs
  • Staff went above and beyond to provide exceptional care for patients. Patients were treated with respect, kindness, compassion and had their privacy protected by staff.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff recognised incidents and reported them appropriately. All staff had a good understanding of the duty of candour and could describe when it would be used.
  • The trust was working hard to ensure all hospitals were staffed safely and that good quality care could be delivered. Several different strategies were being implemented to overcome staffing issues.
  • Staff felt supported, respected and valued by the trust. The culture of the hospitals and teamwork was strong and staff were supportive of each other. The trust had found ways to support staff with new roles and the development of existing staff.
  • Strong leadership was demonstrated at the community hospitals. All members of the leadership team we spoke with showed skills, knowledge, passion and experience to lead the service in a collaborative working style.


  • Some medicines requiring disposal were not always stored securely. Some blank prescriptions were not monitored and we saw some patient group directions were out of date.
  • Clinical and management supervision was not embedded in community hospitals to support staff

9 October 2018 - 31 October 2018

During a routine inspection

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

  • The community health inpatient service moved up a rating from requires improvement to good. One rating remained the same (responsive remained ‘good’), all other ratings improved, three from ‘requires improvement’ to ‘good’ and one (caring) from ‘good’ to ‘outstanding’. Four of the mental health core services inspected remained rated good overall and one rating went down to requires improvement (specialist community mental health services for children and young people).
  • We rated the long stay/rehabilitation mental health wards for working age adults and community health inpatient services outstanding for the caring key question.
  • The Deaf CAMHS service, Enhanced Outreach team and Community Eating Disorders teams demonstrated good practice and positive outcomes.
  • There was a positive and passionate senior leadership team with the capability to ensure that the transition through the formal merger process had a positive impact on patient care, and this was the overall aim of the executive team. There was a wide range of experience and expertise throughout the organisation. Staff and stakeholders commented positively on the integrity of the board and senior leadership team. We were told there had been an ongoing improving picture around openness and honesty in the trust during the previous few years.
  • The trust had a vision and strategy which had been re-designed to align to the mission of both trusts in the alliance. Staff felt proud of their work within Somerset Partnership NHS Foundation Trust and were well supported by senior and directorate leaders.
  • The organisation had governance systems in place to provide an appropriate level of assurance to the trust board. The majority of services had robust processes to identify risks, report on and learn from incidents and respond to complaints.
  • The mental health services and community health services inspected had a range of suitably skilled healthcare workers which included registered nurses, occupational therapists, managers, healthcare support workers and medical staff. Staff were suitably skilled and trained. Staff were compassionate, respectful and supportive towards patients and each other. Staff were motivated to ensure the best outcomes for patients and carers.
  • Medicines were well managed in frontline services although we identified some minor issues around disposal of medication in some services. Some blank prescriptions were not monitored. An out of date patient group directive (PGD) was found on a community health inpatient ward, but we saw there was a reviewed and in-date PGD available
  • Appropriate arrangements were in place to ensure the trust executed its duties under the Mental Health Act (MHA) appropriately including good governance arrangements. Staff had access to support from the MHA lead in the trust who was described as visible and approachable.
  • The majority of facilities in the services we inspected were clean and well maintained.
  • The trust ensured services were accessible and took account of individual patient need. Staff ensured there was access to advocacy services.
  • Patients and carers provided positive feedback about how staff treated them or their relative. Staff involved patients and carers in decisions around their care and sought their views on how services could be improved.
  • We saw examples of outstanding practice in many of the services.


  • The trust found it difficult to recruit registered nurses. There were many vacancies across the trust. However, the trust had recruitment and retention strategies in place.
  • Although it was recognised that overall, the waiting times from referral to treatment for young people using CAMHS services remained in the top quartile nationally, waiting times in the east community CAMHS teams were too lengthy. The trust had recognised this and had implemented an action plan to address this issue prior to our inspection
  • We found that there was limited visibility of the medicines management function at a strategic level within the trust, and processes to consider medicines management as part of service development were not robust. Morale was low within some parts of the service, and pharmacy staff we spoke with did not feel visible within the trust. Pharmacy service provision was also not embedded into the clinical teams. Despite this, there was good medicines management practices and procedures within the core services.
  • Clinical and managerial supervision were not fully embedded or consistently implemented in some services.
  • Morale was low within some of the specialist community mental health services for children and young people services and community-based mental health services for older people.

9 October 2018 - 31 October 2018

During an inspection of Mental health crisis services and health-based places of safety

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

  • There were sufficient staff with the right training, knowledge and skills to provide safe care and treatment; staff received appropriate supervision. Staff completed thorough risk assessments and had a good awareness of safeguarding issues. There were robust incident reporting processes and managers ensured any lessons learned were cascaded to staff.
  • Staff used best practice and national guidance to complete comprehensive assessments of patients, and communicated patient need well within the multidisciplinary team, the wider trust and with their external partners as appropriate.
  • Patients told us that staff treated them with respect and that they were involved in their own care planning. They felt listened to and both patients and carers were provided with relevant information and support to manage their condition.
  • The service had a positive patient-centred culture which was demonstrated consistently throughout the treatment period.
  • At our last inspection in September 2015, admission into the health based places of safety out of hours sometimes resulted in a lengthy wait for assessment. By the time of this inspection, this had improved and people were being assessed in a timely manner. From 1st January 2018 to 10th October 2018, assessments were consistently completed within 24 hours regardless of the time of day that the person was admitted.
  • At our last inspection in September 2015, staff at the places of safety were not always confident or clear on provision of support out of hours, or around the joint working arrangements under the Section 136 joint protocol. By the time of this inspection, this was no longer the case and staff were well informed of the procedures and protocols specific to the places of safety.

  • The home treatment teams responded to patient need quickly and managed their caseloads effectively to ensure they could respond to concerns in a timely way. The teams were meeting their expected targets and had effective complaints procedures in place. None of the home treatment teams had waiting lists, and the risk of patients on the caseload was discussed informally, and formally at daily handovers.

  • Governance arrangements were in place and robust. Leaders had clear oversight of their services. Managers and staff monitored the quality and effectiveness of the service through feedback and key performance indicators. Morale was high and staff were innovative.


  • The trust lone working policy was inconsistently applied across the home treatment teams, which meant staff could be at risk if colleagues did not know of their whereabouts. We raised this at the time of our inspection and the trust assured us they would take action.
  • Medical staff did not always receive clinical supervision as per trust policy.

9 October 2018 - 31 October 2018

During an inspection of Specialist community mental health services for children and young people

Our rating of this service went down. We rated it as requires improvement because:

  • Community CAMHS teams had not improved documentation around risk since our last inspection and still did not meet these requirements. Risk assessments were not updated regularly and lacked important detail about the young person. Crisis plans were generic and not specific to the young person.
  • The service did not have sufficient staffing numbers to help keep young people consistently safe from avoidable harm at all times. The team struggled with staff vacancies and safe caseload management. Staffing issues had been highlighted on the service risk register since 2015, although the trust were trying to recruit and ensure safe staffing numbers.
  • The physical environment in the east CAMHS team in Yeovil required some updating and refurbishment. The environment was not clean and was not fit for purpose. in places. Some of the equipment and furnishings were of poor quality. Staff were not regularly using a cleaning rota for toys or the environment.
  • Community CAMHS teams did not keep up to date records of care, records were not always person centred or holistic and consent was not always documented well. Staff in the east and west community CAMHS did not assess the physical health of all patients on admission unless they were taking prescribed medication.
  • The east CAMHS team had a long waiting list, the average being 18 weeks and the longest wait time being 45 weeks. The west team were managing to keep within the provider’s target of six weeks to see a new referral for treatment.
  • Complaints were not logged, documented or investigated in the east team due to workload pressure and time capacity.
  • Staff morale in the community CAMHS teams was generally low and staff felt fragmented from their teams due to sudden changes in their management structure.


  • The service had improved the environment at the east team in Wells since the 2015 inspection and it was now safe, clean, well equipped, and fit for purpose. The clinical environment at Foundation House was well maintained and had child friendly environments.
  • Staff in the specialised CAMHS service teams assessed the physical and mental health of all young people during their initial assessment. They developed individual care plans and updated them when needed. They provided a range of treatment and care for patients based on national guidance and best practice.
  • Staff received high quality safeguarding training and supervision.
  • Multidisciplinary team worked effectively with internal and external professionals. Staff worked hard on creating smooth transitions of care for young people.
  • Staff involved young people and their families in their care by offering them the opportunity to join the young people’s participation group. The staff also offered volunteer programmes for young people and had feedback systems in place for young people and their families.
  • The trust provided individualised and considerate communication support to staff, young people using the service and their families.
  • Senior management teams responded to concerns about the east team’s waiting list. They devised an action plan which they updated weekly to demonstrate progress made against their current regulatory breach.
  • Managers created learning events after serious incidents which allowed the teams time to reflect and recover.

9 October 2018 - 31 October 2018

During an inspection of Child and adolescent mental health wards

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

  • Staff and young people worked together to identify and manage risks and develop risk assessments. Staff had detailed knowledge of the risks and the care needs of the young people and where skilled and experienced in working with them. There were sufficient staff to carry out physical interventions safely. The team had a local risk register that had items so that risks could be identified, escalated and addressed.
  • Environmental risks, including some fixed ligature points, had been assessed and were managed appropriately by staff. The environment was clean and tidy. Alarms were on hand to call for an assistance. Young people were searched appropriately on return from unescorted leave. Young people’s rooms were searched when warranted, for example after an incident of self-harm, by staff to maintain a safe environment. Staff were trained in safeguarding and knew how identify, manage and report safeguarding issues.
  • Care plans were holistic and created with the young people on the ward. There was a variety of treatment and interventions on offer that were in line with national guidance and best practice. Consent and capacity was recorded appropriately in the young person’s notes. There was a skilled multidisciplinary team that met regularly for meetings to discuss young people’s care. Mental Health Act rights had been explained regularly to those young people detained under the Mental Health Act.
  • Staff were caring and demonstrated respectful attitudes towards the young people and were knowledgeable around their care plans. Throughout the admission process, staff reassured and helped young people settle into the ward.
  • Young people were involved in decisions about the service and there were meetings to collect feedback from the young people admitted to the ward. Advocacy services were readily available. Staff ensured young people had good access to education.
  • Young people had their own bedroom with an ensuite bathroom. There was a full range of facilities available.
  • Carers were included and consulted in the care provided. Young people and their families knew how to raise concerns or complaints.
  • Managers understood and knew their ward and the challenges they faced. Staff were aware of the trust values and how they applied in the work of their team. Staff we spoke with felt respected, supported and valued by their team.
  • Staff felt able to raise concerns and were supported in the process. Staff had implemented recommendations from events such as incidents, deaths and complaints.
  • The trust provided specific Mental Health Act training however this was not mandatory for staff and managers found it difficult to release staff for training. Despite this, we found that knowledge of the Mental Health Act was good.


  • Staff felt that from the wider trust communication could be improved as they didn’t always know why changes were being made. There were no clear frameworks of what must be discussed at a ward, team or directorate level in team meetings.
  • There was no dedicated specific dietetic support for the ward and staff stated that it was difficult to access from other areas of the trust. This had been raised with the managers and escalated to the trust.
  • The service did not regularly collect feedback from families and carers.
  • The ward applied some blanket restrictions, for example young people always had to request access to the outside areas and were observed by staff. Staff discussed blanket restrictions at team meetings and a positive and proactive best practice meeting.

9 October 2018 - 31 October 2018

During an inspection of Long stay or rehabilitation mental health wards for working age adults

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

  • The ward was clean, spacious, and well maintained. It was a positive environment which focused clearly on rehabilitation needs and enabling patients to move out of hospital and live in the community. The atmosphere was warm and friendly and the environment comfortable and welcoming.
  • Staff completed thorough environmental risk assessments and mitigated identified risks on an ongoing basis. Staff knew, assessed, managed and communicated individual risks well.
  • The staff team were knowledgeable, skilled and cohesive. Staff demonstrated effective application of relevant legislation and good practice; in line with national guidance. Staff provided a range of care and treatment within the therapeutic rehabilitation service. Patients had access to a range of multidisciplinary staff to meet their mental and physical health needs. Patients were supported to reintegrate into their community and independent living.
  • Documentation was complete and assessments were comprehensive, holistic and thorough.
  • Care plans were kept up to date, personalised with clear outcomes and goals identified which included plans for discharge, and clearly evidenced the involvement of patients throughout.
  • The ward had a progressive ethos and the team were constantly looking at innovative ways to engage and use the patient voice and experience to develop staff competence and improve rehabilitative outcomes. For example, a patient was supported to deliver a training session to staff following some work with the ward psychologist on how best to meet their needs.
  • Staff encouraged and supported patients and carers to be involved in their care as much as practically able and ensured clear discharge planning took place with the patients.
  • Staff were respectful, supportive and responsive to patients’ needs.
  • The service was well led, leaders and managers had the skills and knowledge to provide good quality leadership, were visible and accessible. The trust senior directors and board members visited the service regularly.


  • Not all staff had completed Mental Capacity Act and health and safety awareness training.

9 October 2018 - 31 October 2018

During an inspection of Community-based mental health services for older people

  • Staff completed risk assessments for patients when they initially met them. Staff knew how to keep patients safe. Staff made appropriate safeguarding alerts and were appropriately trained to identify safeguarding concerns. Staff were trained in safeguarding and they accessed support of the trust’s safeguarding team. Staff completed mandatory and specialist training.
  • Patients and carers gave good feedback about the service and said that staff were supportive, understanding, reliable, kind, caring and communicated well with them. Staff enabled patients to give feedback on the service and they followed a nationally recommended approach to working in partnership with carers to support patient care.
  • Teams had effective working relationships with other teams within the organisation and with other agencies such as primary care and social services. They met with other agencies to look at patients’ holistic needs. Staff encouraged patients to develop links with other agencies that could help them and gave them support and advice about their conditions, medicines, treatments, services and about how to live a healthier life.
  • The service was responsive to patients’ needs. All the teams were meeting the targets for referral to assessment which were six weeks for routine referrals and five working days for urgent referrals. Emergency referrals were seen the same day. Emergency referrals were seen the same day and all teams had a member of staff on duty each day to respond to calls from or about patients and carers.
  • A full range of specialists provided care and treatment interventions suitable for the patient group that were in line with national best practice guidance.
  • The trust communicated well with staff through the intranet, bulletins and newsletters. Staff met regularly to discuss the service and the patients they were treating. They discussed learning from complaints, incidents and from audits. They used these meetings to plan improvements to the service. Team managers held regular meetings with each other to improve the service and develop a consistent service across the county.
  • The provider recognised staff success within the service with certificates of recognition and appreciation for making a positive difference in the workplace. The Burnham-on-sea manager and memory service had received these.
  • We saw some positive, committed leadership in teams and some staff were complimentary about their managers and felt supported.


  • There were delays in getting approval to advertise vacant posts that meant posts could remain vacant for up to six months. This put additional pressure on staff who covered the work. Staff across the service said they were pressured and stressed by their workloads at times.
  • Managers provided staff with line management supervision, but it was not always provided regularly. Some staff had access to additional clinical supervision and other staff did not.
  • There were variations in the quality of care records. According to 43 care records we reviewed of patients across the whole service, a small number had not been given a copy of their care plan, some care plans lacked personalisation, and a holistic and recovery-oriented approach.
  • The Yeovil team told us they felt unappreciated, stressed and morale was low. They complained of a lack of positive feedback. Some staff felt ‘done to’ rather than ‘done with’. Some staff said they felt disconnected from senior management. Staff did not know who the speak up guardian was for the trust or how to contact them. The trust had already recognised this and had put in place an action place to address this.

27,28 February and 1, 2 March 2017

During an inspection of esb.services_rated.community health (sexual health services)

We rerated sexual health services as Good overall because:

  • During this inspection we found the service had addressed the issues that had caused us to rate responsive and well-led as requires improvement following our September 2015 inspection. The ratings for safe, effective and caring all remained unchanged from 2015 (good). The ratings for responsive and well-led have changed from requires improvement to good.
  • We found strong safeguarding procedures were in place which staff adhered to and followed to protect children, young people and vulnerable adults. The trust encouraged staff to report incidents. Staff we spoke with were confident in this system and said they received feedback following reported incidents of the action taken and lessons learnt were shared amongst the staff team.
  • The care and treatment provided to patients was planned and delivered in line with current evidence based guidance, standards, best practice and legislation. Staff liaised with other professionals, both within the organisation and with professionals outside of the organisation to provide a service to patients.
  • Staffing levels were appropriate and there were no vacancies in the last 12 month period. The majority of staff we spoke with were content in their role and felt motivated to provide an excellent service.


  • The provision to cater for bariatric patients (people with a high body weight) was limited. Patients who fell into the bariatric category will have to travel across the region to access a clinic that had suitable equipment such as examination couches.
  • The limited phone service available to patients was criticized by the patients themselves, often calls were abandoned or callers found the line engaged for long periods. This has been identified by SWISH and a more suitable system is being sourced.
  • Patients stated they found the reception areas of some of the clinics a little exposed and felt as though they could be overheard when talking to reception staff.

To Be Confirmed

During an inspection of Community-based mental health services for adults of working age

We rated Somerset Partnership Foundation Trust as good because

  • During this most recent inspection, we found that the service had addressed the issues that had caused us to rate safe responsive and well led as requires improvement following the 2015 inspection. We found at the previous inspection in 2015 that there had been issues with the management of patients on the waiting list for allocation of a care coordinator. This had resulted in a breach of a regulation resulting in a requirement notice. By the time we revisited in March 2017, four of the five sites had made improvements to how staff managed waiting lists. At the Mendip site there had been continuing issues that the trust had identified and responded to with a temporary change of management. We found that there was a positive air within the service despite there being an extended period of change over the past year with more change proposed through the review of the community mental health service.
  • The service had some excellent areas of practice particularly at the wellbeing clinic at the Taunton site. The management of the clozapine blood clinic at the Taunton site used pharmacy technicians, which meant that staff could administer medication without patients having to wait for an extended amount of time.
  • Staff were risk aware and had worked with patients to assess risk, create crisis plans and to plan care that was meaningful to them. There were practices in place to protect patients from abuse with the staff being knowledgeable of the safeguarding policy and process within the trust. There was a safeguarding lead in place to provide staff with support when they needed to escalate a safeguarding incident. Staff had use of an electronic incident reporting system to escalate incidents that occurred within the service. We found that there was a positive approach to incident reporting and that when there were serious incidents the trusts’ investigations were effective and lessons learnt were cascaded amongst the staff.
  • Staff comprehensively assessed patients on first contact. We observed assessments and found that staff were caring and treated patients with respect within the assessments. Assessments covered a number of areas to do with the patient’s life and were holistic in their nature. Staff followed national guidance to inform their practice. Staff provided both therapies and medicines according to National Institute for Health and Care Excellence (NICE) guidance. Staff recorded outcomes and used nationally recognised rating scales in order gauge the severity of a particular condition.
  • Staff used supervision to review their caseloads and get support from their line managers and we found that there was good interagency working within the teams. Staff supported each other and used the different skills within the team to inform their practice, for example a joint assessment of a patient with a suspected eating disorder.
  • We reviewed Mental Health Act paperwork and found that staff completed it in line with guidance. Staff had completed capacity assessments when appropriate.
  • We observed episodes of care that showed how staff worked with patients to create a plan of care. Staff worked with patients to look at options around areas such as work and housing. They treated patients with dignity and respect in their interactions.
  • Care coordinators within the service assessed patients within the set referral to assessment time of six weeks. There were arrangements in place for when staff needed to see a patient more urgently. Managers determined the size of the caseload that staff carried and ensured that these were consistent across the service according to the hours that each staff member worked. Staff demonstrated how they followed up patients that did not attend their appointments. We reviewed the environment at all of the community sites and we found that there was good access for patients with a physical disability. There were also examples of how staff worked with patients that did not speak English. There was a clear complaints process in place and we found that staff responded to complaints within the team as well as directing patients to the trusts patient advice and liaison service (PALS).
  • Staff were aware of the values set by the trust. We heard of positive change made to the trust from the appointment of a new chief executive, he was responsive to staff emails. There was generally good local leadership and local management were able to show how they had responded to the requirement notice from the previous inspection. Managers within the service were visible and supportive to staff. Managers demonstrated how they used the risk register to escalate issues, for example, the clinic room at the Taunton site was not fit for purpose so was placed on the risk register to initiate a change. Staff were aware of how to raise concerns within the trust and felt confident in using the whistleblowing policy as well as raising concerns locally.


  • The environment at the Yeovil site appeared tired and in need of updating. There was no local log of complaints made to the community mental health teams. While there was a record of formal complaints, there was no oversight and recording of informal complaints, this meant that managers did not have a record of potential trends. Staff told us that the extended period of change that they had experienced through the changes to the social worker provision had affected the morale of the teams.

27 February- 02 March 2017

During an inspection of Community mental health services with learning disabilities or autism

We rated community mental health services for people with learning disabilities as good because:

During this most recent inspection, we found that the service had addressed the issues that had caused us to rate it as inadequate following the September 2015 inspection. The community mental health services for people with learning disabilities were now meeting Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

  • Staffing levels were good and there was managerial and team oversight of the safe management of caseloads.
  • The staff team had worked hard to develop new systems to ensure that all service users had holistic and detailed care plans that addressed known risks and areas of treatment that service users required. They were available in a format that people who used the service could understand.
  • Interactions between staff and service users and their carers were warm, good humoured, and professional. The staff team ensured service users were included in the development of new accessible templates and care plans.
  • 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.
  • We rated well led as outstanding because of the dramatic improvements in the service since our September 2015 inspection. This was due to the leadership of the divisional manager who had just been appointed at the time of our last inspection and the service manager who had been appointed by the trust to complete the transformation. The team leaders had also embraced the need for change and worked to support their teams in the process. Staff morale was high and staff were keen to show us the improvements to the service. Staff were fully involved in the improvements and changes to the service, with groups of staff from each team reviewing how the service worked for patients and asking is the service safe, effective, caring, responsive and well led. The trust had supported this change with a no blame approach to the staff team following the previous rating of inadequate. The trust had requested support from another NHS organisation with a good learning disability service to help with the improvement plan and there was visible senior management support for the service development, including the chief executive attending meetings in the service and shadowing visits.


  • Staff did not have access to alarms in Yeovil.
  • The service did not have sufficient systems in place to ensure that all clinicians completed their reviews of patients. This was addressed when we brought it to the services attention.
  • Staff did not always update risk assessments after they had completed a piece of work with the patient which had resulted in the risk lowering.

27 February – 2 March 2017

During an inspection of Forensic inpatient or secure wards

We rated Somerset Partnership NHS Foundation Trust as good because:

  • The trust had addressed the problems that had caused us to rate effective as requires improvement when we last inspected in September 2015. These included ensuring that patients were aware of their section 132 rights when detained under the Mental Health Act, that staff documented patients’ consent to medicines and that patients received feedback from second opinion appointed doctors.
  • The wards were clean, and staff were managing risks within the ward environment. These included checking medical devices and ensuring that staff levels met the needs of patients.  Staff had risk assessed patients in their care and had systems in place to ensure that learning was shared from any incidents on the ward.
  • We spoke with three patients and they provided positive feedback on the activities on the ward. Patients we spoke with said that staff treated them with respect and dignity and we saw that this was the case on our inspection visit. Staff encouraged patients to give feedback on the service and ensured that they had access to advocacy. Staff took care to involve patients’ family and carers as appropriate and according to the patient’s wishes.
  • Staff had a focus on discharge. They planned for discharge for all of their patients and they tracked patients’ progress towards discharge. Staff liaised with other services to help ensure rapid but appropriate discharge when patients needed either more or less intensive care than they could receive on the ward. The facilities of the ward allowed patients a range of rooms to use for activities and therapies. The ward also had access for people requiring mobility aids. Staff ensured that patents could continue to practice their different cultural and religious beliefs.
  • The ward had strong local leadership, and this had helped staff to develop a good working team. NHS England commissioned the ward and required them to provide a range of performance data. This meant that in the majority of cases, governance systems were embedded and worked well. The ward was also part of a peer led quality network – the Royal College of Psychiatrists’ quality network for forensic mental health services.


  • The trust had not fully rolled out its training programme on the Mental Health and Mental Capacity Acts.
  • While seclusion was rare on the ward, it was only used six times in the year before this inspection, staff did not always documented the checks they were supposed to make in line with the trust’s policy. Seclusion is where a patient is contained and supervised in a room that may be locked because they are highly agitated and their behaviour is likely to present a risk of harm to others.

27 February – 2 March 2017

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We rated acute wards for adults of working age and psychiatric intensive care units as good overall because:

  • By the time of this inspection, the services had taken the action we required it to take following the inspection in September 2015. The wards for adults of working age and psychiatric intensive care units were now meeting Regulations 11, 12, 13 and 15 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
  • Staff had a good understanding of how to keep patients safe. They understood how to make safeguarding referrals and did so when appropriate. Staff completed comprehensive risk assessments to enable them to identify issues of concern. Staff used observation levels to maintain patient safety and they reviewed these regularly. Staff on Holford ward worked with patients to identify effective ways for them to manage escalating behaviour.
  • Staff completed comprehensive assessments at admission. The assessments identified areas of concern and staff formulated and used care plans to manage these. Staff used appropriate rating tools such as the malnutrition universal screening tool (MUST) to support the assessment process. They completed health of the nation outcome scores to assess the severity of the patient’s condition and the treatment outcome at discharge.
  • The trust provided a wide range of facilities to enable staff to support patients and help them to recover. Staff organised activities and ensured that patients had access to appropriate religious support and independent advocacy services.
  • We saw evidence of effective multi-disciplinary working with staff focussed on helping patients recover from their illness. This included working with external agencies. Staff engaged in active discharge planning to ensure that they supported patients to return to the community.
  • Most patients were positive about the care they received from staff. They reported that the food was good, activities were helpful and we observed warm and kind interactions between patients and staff. Patients had access to a weekly meeting to raise concerns and issues with staff.


  • Staff members had not followed the trust’s seclusion policy. This meant that staff completed seclusion paperwork inconsistently including patient seclusion reviews. There was confusion about what incidents qualified as seclusion and needed appropriate recording.
  • Staff did not manage medicines well. Staff had not signed when they had administered medicine and staff had given patients more medicine than had been prescribed. Managers were not able to act promptly on errors of this type, as there was no process in place to identify these problems regularly.
  • Wards had a number of blanket restrictions in place. These were contradictory, unnecessarily restrictive and not routinely reviewed to assess if they were appropriate.

27, 28 February and 1, 2, 13 March 2017

During an inspection of Community health inpatient services

During this inspection we found the service had addressed the Requirement Notices following our September 2015 inspection. However, we found some areas where further improvements were required.

The ratings for the community health inpatients service remain the same in safe (requires improvement), caring (good) and well-led (requires improvement). Effective has changed from good in 2015 to requires improvement, while responsive has changed from requires improvement in 2015 to good.

Overall, we rated the community inpatients service as requires improvement because:

  • The procedure for the application of duty of candour was not followed according to the regulation and medicines were not managed or stored correctly across the community hospitals in line with the trust’s medicine management policy.
  • Staffing was considered a risk for the trust due to the high number of vacancies, staff sickness turnover and the lack of matrons to have oversight of the hospitals. Safe staffing levels at three of the hospitals had not been met in January 2017.
  • There were inconsistencies between how the hospitals monitored and recorded pain. There were multiple pain scoring systems in use which had led to confusion and inaccurate recording of pain. This had remained an issue from the previous inspection in September 2015.
  • Staff did not understand or feel confident with the relevant consent and decision making requirements and guidance, including the Mental Capacity Act 2005 and there were inconsistencies about the recording of consent across the community hospitals.
  • The governance framework did not always support the delivery good quality care and there was a lack of leadership to ensure actions from audits to improve compliance with trust policies were implemented into practice.


  • The safety performance within the trust was good and demonstrated a commitment to patient safety. Staff understood and were aware of their responsibilities to report incidents and were knowledgeable about the systems and processes in place for safeguarding patients.
  • There was effective multidisciplinary working both within the trust and with other external organisations and the organisation participated in delayed transfer of care calls with local NHS trusts to overcome barriers to patient discharge.
  • Staff demonstrated compassion to all patients and respected their privacy and dignity and staff ensured patients understanding of their care and treatment. Those close to them were involved in the planning of their care.
  • There was a positive patient centred culture across the community inpatient service and the trust worked to engage both staff and the public.

27, 28 February and 1, 2 March 2017

During an inspection of Community health services for adults

During this inspection, we found that the services had addressed the issues that had caused us to rate safe, effective and well led as requires improvement following the September 2015 inspection. The rating for community health services for adults in caring remains the same as in 2015 (good). Effective, responsive and well-led have all changed from requires improvement to good. Safe has changed from inadequate to requires improvement.

Community health services for adults were now meeting Regulations 9, 17 and 18 of the Health and Social Care Act (regulated Activities) Regulations 2014.

We rated community health services for adults as good because:

  • There were effective incident reporting systems in place and staff reported they received feedback and learning from these.
  • The duty of candour regulation was understood by staff and we saw evidence which supported this.
  • Staff had good knowledge of safeguarding procedures and felt supported in raising any safeguarding concerns.
  • Good medicine management protocols were in place to keep patients and staff safe.
  • There was access to equipment for clinic settings and for patients in their own homes. We saw equipment was maintained/serviced as required.
  • All clinical areas we visited were clean and tidy and free from clutter.
  • Staff reported good access to mandatory training.
  • In the patient records we reviewed we found in most cases, risk assessments for example, frailty scale, falls risk, malnutrition universal screening tool (MUST), and skin assessments had been completed and reviewed.
  • We found multidisciplinary working was embedded in practice across the adult community services.
  • The lone working systems in place kept staff safe. Staff were very aware of the policy and adhered to it.
  • Patients’ needs were assessed and care and treatment delivered in line with relevant legislation, standards and evidence-based guidance.
  • Staff were knowledgeable about assessing patient’s mental capacity and cared for patients in a non-judgemental manner, respecting the rights of individuals.
  • Some services collected information about patient outcomes and could demonstrate the effectiveness of their service
  • The service participated in national audits, audits requested by commissioners and internal audits. The service used the results to review and improve services
  • Staff were qualified and had the skills to carry out their roles effectively. Staff had regular appraisal and supervision, including out of hours and overnight staff.
  • Multidisciplinary team working was embedded throughout the service and referrals to different healthcare professionals were coordinated and efficient.
  • Consent was obtained for care and treatment interventions in line with policy and guidance.
  • Feedback from patients was consistently positive, patients went to great lengths to tell us about their positive experiences.
  • We saw patients who were active partners in their care, and were encouraged to give their opinions of their planned treatment.
  • Care that we observed was person centred, with patient’s wellbeing at the heart of care.
  • Patients received care from staff who treated them with dignity and respect.
  • Staff involved patients in exploring their options, and respected the patient’s wishes and requests.
  • The needs of patients were taken into account when planning and delivering services. Staff were flexible to meet the needs of patients.
  • Reasonable adjustments were made for people with disabilities, learning difficulties and those living in vulnerable circumstances.
  • Teams worked very well together to provide the most appropriate care at the most appropriate time for patients.
  • Patients were given information about how to make a complaint or raise a concern. There were systems in place to evaluate and investigate complaints.
  • Staff were aware of the organisations values and strategy.
  • There was strong local leadership in place. Most staff felt able to approach their managers.
  • Staff were positive about the executive team and found them visible and approachable.
  • There were governance and risk management systems in place.
  • There was a positive, supportive culture across all staff groups we spoke with.
  • Patients were asked for their views of the service and how it could be improved.
  • The trust worked with local commissioners to ensure the needs of the local population were being considered.
  • Staff were innovative and worked with external organisations to examine where local improvements could be made.


  • The wound assessment tool available on the electronic patient record system was being reviewed by the specialist nurses for tissue viability and the leg ulcer service, district nursing lead and the clinical lead for the electronic patient record system. However we saw inconsistent practice in how wounds were assessed and recorded into paper based documentation in patients homes and on the electronic patient record system.
  • Some cupboards used for storing dressings and medicines were not always within the expected temperature ranges. This meant that staff may be using items that were not safe.
  • Sharps bins in use were not always labelled with hospital details and specific area in which they were being used. This meant they would not be traceable to an area if there was an issue when being disposed of.
  • Not all the emergency trolleys we saw had in date equipment stored on them. In some areas, a systematic check of the trolleys was not documented as having being carried out on a daily basis.
  • Not all staff in clinic settings washed their hands between patients or cleaned the examination couch between patients.
  • There was not yet an acuity (dependency) tool in place across the trust to enable senior staff to see each team’s dependency ratings and assure staff were deployed to the area’s most in need of help.
  • Mobile phone coverage remained patchy meaning staff did not always receive messages in a timely way.
  • Staffing levels remained an issue for some teams and specialities. Recruitment was ongoing.
  • Community nurses were able to photograph wounds to assess progress or deterioration of wound healing with their current mobile phones. However there were some ongoing issues with information governance and storing photographs on mobile telephones.
  • We did not see a corporate chaperone policy. We did see information in patient leaflets and on the organisations website that a chaperone could be requested when attending outpatient facilities.
  • Waiting lists for some services were long. Staff had waiting list initiatives in place to reduce waiting times for patients.           

27, 28 February and 1, 2 March 2017

During an inspection of esb.services_rated.urgent care services

During this inspection, we found that the services had addressed the issues that had caused us to rate safe, effective and well led as requires improvement following the September 2015 inspection. Urgent care services were now meeting Regulations 15 and 17 of the Health and Social Care Act (regulated Activities) Regulations 2014. The ratings for urgent care services in caring and responsive remain the same as in 2015 (good). Safe, effective and well-led have all changed from requires improvement to good.

We rated urgent care services for adults as good because:

  • Staff understood their responsibilities to raise concerns and recorded safety incidents, concerns and near misses. We saw that when things went wrong, there were thorough and robust reviews or investigations carried out.
  • There were systems and practices in place that were essential to protect people from abuse and avoidable harm and staff were aware of these.
  • The design, maintenance and use of facilities and premises kept people safe. All examination rooms we inspected were, clean and well equipped. The maintenance and appropriate use of equipment kept people safe. There were reliable systems in place to prevent and protect people from a healthcare-associated infection related to cleanliness of buildings. All minor injury units we visited were clean, tidy and well maintained.
  • Staffing levels and skill mix were planned and reviewed to support safe practice.
  • Patients’ needs were assessed and care and treatment was able to be delivered in line with legislation, national standards and evidence-based guidance. Emergency nurse practitioners had access to paper and online National Institute of Health and Care Excellence (NICE) guidelines
  • Information about the outcomes of patients’ care and treatment was collected and monitored. During 2015/16 there were 210 unplanned re-attendances within 7 days of treatment, for 158 patients. This was less than 1% of the annual minor injury unit (MIU) attendance rate. Most patients who used the service were empowered and supported to manage their own health, care and wellbeing and to maximise their independence. For example over 97% of patients who were treated did not return for further treatment. The average waiting time for patients in one of the trust’s MIUs was only 40 minutes and considerably less than the national average of 63 minutes and around 99.8% of patients waited under 4 hours for treatment.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. There was liaison with local emergency departments, with social services and general practitioners. There was a working relationship with ambulance service providers.
  • Patients were treated with kindness, dignity, respect and compassion while they received care and treatment in the minor injury units (MIUs). We saw that staff took the time to interact with patients who used the service and those close to them in a respectful and considerate manner.
  • Staff respected patients’ dignity and privacy. For example, they closed doors when they left clinic rooms and drew curtains where a curtain was provided in the MIU to provide privacy (Shepton Mallet, Chard).
  • Patients who used the service and those close to them were involved as partners in their care. Staff we observed communicated well with patients and those close to them so that they understood their care, treatment and condition. Staff made sure that people who used the service and those close to them were able to find further information or ask questions about their care and treatment. Staff we observed assessing and treating patients demonstrated an understanding of and respected patient’s personal, cultural, social and religious needs, and took them into account.
  • Services were planned and delivered to meet the needs of patients who used the service. Information about the needs of the local population were used to inform how services were planned and delivered.
  • Staff understood where people might have different needs, and adjustments may be needed to the care and treatment they were given
  • There was a comprehensive local strategy to deliver good quality care and to develop the service to be able to respond to any changes in the needs of the local community in respect of urgent care. The trust had developed a mission statement and a set of values with staff who worked for the organisation.
  • The governance framework for minor injury units (MIUs) ensured that responsibilities were clear and that quality, and risks were understood and managed. The risk register was effective for identifying, recording and managing risks, issues and mitigating actions.
  • Leaders of the MIUs had the skills, knowledge, experience and capacity needed to lead and manage the service. Leaders were visible and approachable. The service manager and nurse consultant worked as emergency nurse practitioners for a proportion of their time.
  • The culture centred on the needs and experience of patients, who used the service, and those close to them. Patients and those close to them who used the service and the public were engaged and involved. Patients’ views and experiences were gathered. Most staff felt actively engaged so that their views were reflected in the planning and delivery of services and in shaping the culture. Staff attended regular best practice groups and operational group meetings with the nurse consultant and the service manager.
  • The service had continuously improved in a range of areas since the previous inspection.


  • Not all staff were up-to-date with mandatory training, including safeguarding.
  • The monitoring of systems in place to prevent cross infection from practitioners was not reliable. We saw a small number of staff who did not wash their hands immediately before and after every episode of direct patient contact or care or for the length of time recommend by trust policy. We saw some staff not bare below the elbow.
  • Audits of infection prevention and control for MIU completed by community hospital staff did not include handwashing technique. The trust had completed only two separate audits in two of the seven minor injury units for handwashing in 2015/16.
  • Record keeping quality within minor injury units was variable.
  • The arrangements for managing medicines did not always keep people safe. We saw that there were some out of date drugs in two MIUs and a number of the PGDs we reviewed were out of date. These were approved documents permitting authorised members of staff to supply or use prescription-only medicines.
  • Arrangements for gaining and recording consent were not clear. The consent checklist in MIU included the phrase: Fraser competent when it should refer only to Fraser guidelines and Gillick competences. Fraser guidelines are only suitable for contraceptive advice while Gillick competent refers to the capacity to make specific decisions
  • One MIU reception desk was not suitable for wheelchair users to communicate easily with reception staff due to a printer situated on it.
  • Patients could not be seen directly by staff in some MIU waiting areas.

28 February – 2 March 2017

During an inspection of Wards for older people with mental health problems

We rated wards for older people with mental health problems as good overall because:

  • During this inspection, we found that the services had addressed the issues that had caused us to rate safe, effective and well led as requires improvement following the September 2015 inspection. The wards for older people with mental health problems were now meeting Regulations 12 and 11 of the Health and Social Care Act (regulated Activities) Regulations 2014.
  • Staff assessed and addressed risks associated with the physical environment and implemented appropriate measures to mitigate the risks to people using the services. Staff received training and support to manage patients with challenging behaviours and the teams managed risk well. Staff completed thorough risk screens and communicated risk throughout different forums. Safeguarding was a high priority and staff completed mandatory training. The environments were very clean and hygienic and managers had closed some beds in order to support safety due to staffing shortages.
  • Staff demonstrated they provided care and treatment with the consent of each patient, demonstrated good understanding and application of the Mental Capacity Act (MCA), and associated Best Interest decisions. Staff acted in accordance with the MCA in instances where there was a formal instruction of do not attempt cardiopulmonary resuscitation in place.
  • Patient care records were complete and up to date, and each patient had a care plan outlining risks and day to day needs. All care records contained complete information, including medication. All physical health monitoring was taking place. There was good multidisciplinary and multi-agency communication.
  • There were good examples and evidence of learning from incidents and changes made following incidents. Staff felt supported around incidents.
  • Staff treated patients with kindness and respect. We observed excellent examples of good quality care and positive and supportive staff attitudes. Without exception, the staff were professional, courteous and committed to providing the best level of care possible. The trust had nominated and given staff awards around dignity and care of patients.
  • The wards had good local bed management systems and were creative in managing the pressures around demand and discharge problems out of their control.
  • Local governance systems were good and managers ensured they supported staff. Staff had good morale and demonstrated openness and transparency. There was strong local leadership. The ward managers were visible and staff told us they were approachable and supportive.


  • The majority of care plans or records were person centred but did not always demonstrate patient involvement. We did not find clear evidence in the care records to show that staff had discussed or offered patients their care plan, even if they had refused it.
  • Staff did not feel fully confident or skilled in managing specific mental health problems such as schizophrenia, particularly the nursing assistants on the wards. The trust did not provide specific training to develop these skills.
  • Managers did not ensure staff received regular supervision as per their own trust supervision policy.

27 February – 2 March 2017 8 – 9 March 2017

During an inspection looking at part of the service

Following the inspection in March 2017, we have changed the overall rating for the trust from requires improvement to good because:

  • The trust had made significant progress in addressing the concerns we raised following our inspection in September 2015. We have changed the overall trust ratings in the key questions of effective, responsive and well-led from requires improvement to good.
  • In the services we inspected, the trust had acted to meet the requirement notices we issued after our inspection in September 2015. Out of 17 core services provided by the trust, 15 are now rated good overall.
  • In response to our March 2017 findings, we have changed the rating for community mental health services for people with learning disabilities or autism from inadequate to good. Because of the dramatic improvement to these services and the way they had been implemented by managers and the trust, we rated the key question of well-led in these services as outstanding.
  • Following the inspection in March 2017 we have changed the ratings for six core services from requires improvement to good: community based mental health services for adults of working age; wards for older people with mental health problems; acute wards for adults of working age and psychiatric intensive care units; community health services for adults; MIU/urgent care; and sexual health.
  • In September 2015, we rated eight of the 17 core services as good. Since that inspection we have received no information that would cause us to question those ratings. In March 2017, we sampled one of those eight services, forensic inpatient/secure wards to check if it had maintained the rating of good, which it had.
  • We completed a ‘well-led’ review and found the trust’s new chief executive had provided positive and proactive leadership which had enabled its senior leadership team to address the issues we identified in our last inspection visit in September 2015. This had led to an improvement in the trust governance processes.


  • Despite improvements across all the services that we inspected, the key question of safe for the trust remains requires improvement.
  • Despite seeing improvements in five core services in the key question of safe, there continued to be concerns in community health inpatient units and acute wards for adults of working age and psychiatric intensive care units and community health services for adults. This meant that we have again rated the trust overall as requires improvement for safe.
  • We still had concerns about the core service of community health inpatient units. We have again rated this core service as requires improvement overall.
  • In the key question of effective we found concerns surrounding the recording of capacity and consent in a number of areas.

The full report of the inspection carried out in September 2015 can be found here at http://www.cqc.org.uk/provider/RH5

At the inspection in March 2017, we did not reinspect the community dental services that we had rated requires improvement in September 2015. CQC will reinspect this core service as part of its ongoing dental inspection programme.

10 May 2016

During an inspection of Community mental health services with learning disabilities or autism

We carried out this unannounced focussed inspection to see if the trust had met the concerns we raised in a warning notice following our comprehensive inspection of the trust on 8-11 September 2015.

We found Somerset Partnership NHS Foundation Trust had met the requirements of the warning notice because:

  • There was a positive culture of considering risk in the service.

  • Care records had comprehensive risk assessments and care plans that were detailed and met patients’ needs.

  • Staff were positive about the changes and committed to making them work.

  • There was clear leadership in place. Senior managers had provided good oversight of the changes and supported staff well.

  • The changes were being introduced in a no blame, learning culture.


  • Care plans were not available in a format that people who used the service could understand.

8 - 11 September 2015

During an inspection of Community end of life care

Overall rating for this core service Good l

We rated community end of life care overall as good. We rated the service as ‘Good’ for being effective, caring, responsive to people’s needs and well led at local levels. Safety was rated as requires improvement.

Somerset Partnership NHS Foundation Trust did not solely employ its own team of palliative care nurses or doctors. They had no one member of staff whose sole responsibility was to lead end of life care. Community nurses provided end of life care to patients in their own home with support from palliative care nurses from the local hospices. Staff in community hospitals provided end of life care to inpatients. The trust hosted the palliative care medical team that had existed for just over a year at the time of our inspection. This trust, two acute trusts and local hospices funded this team. Its remit was to provide advice and support across the majority of Somerset and all the providers who funded their posts. The palliative care medical team felt this had improved the continuity of care for end of life patients. However, there was no lead consultant among this group appointed by the trust to lead the team.

Not all staff were reporting medication prescribing errors on the trust incident-reporting system. Patients’ care records were not always up to date with their current needs and care plans did not always cover all assessed needs. We found patients’ wishes about their end of life care and treatment were not documented in their care records.

We also found references to the Liverpool Care Pathway in some trust forms and the trust end of life policy dated 2015. References to this should have been removed in 2014.

The service had a continuous improvement plan but the dates for completion of the vast majority of the actions were after our inspection so we could not assess its impact.

We observed patients being cared for with dignity, respect and compassion. Patients and their relatives told us how good the care was and that staff were kind, caring and considered the patients’ dignity. At the End of Life Care Coordination centre, (This is a nurse-led telephone centre that has an overview of health and social care services available in Somerset. Staff were able to tailor a package of care to meet the patient's needs at the end of life), staff worked effectively with other health and social care professionals to set up care packages and provide equipment quickly for end of life patients who wanted to die at home. The trust was working with other providers and the local clinical commissioning group on devising an end of life strategy for Somerset. This was to make sure patients across Somerset had joined up delivery and continuity of service from all providers involved in their care. Individual teams of staff demonstrated a commitment to deliver good end of life care and to develop end of life provision. The staff we spoke with told us they had a high level of respect for their line managers at local levels and felt able to discuss issues or problems with them.

7,8,9,10,11 Sept 2015

During an inspection of Community health services for adults

Overall rating for this core service requires improvement

We rated the safety of community health services for adults as 'inadequate'. Investigation of incidents was thorough but shared learning was not reliable. Staff shortages were evident and lack of a staffing tool resulted in ineffective oversight of safe staffing levels. The duplication of record keeping in paper and electronic format led to omissions of important information essential for safe patient care. Clinical risk assessments relating to nutrition, pressure care and falls were not consistently completed or reviewed. Wound assessments were not sufficiently thorough. Staff knew how to raise a safeguarding concern however, the level of training for safeguarding children was below recommended guidelines. Compliance with mandatory training varied. Some nursing equipment was stored beyond its expiry date, meaning that there was no guarantee of the sterility of the items. However, there were adequate systems in place for cleaning, maintaining and disposing of equipment.

We rated the effectiveness of community health services for adults as 'requires improvement'. Staff working in patients’ homes did not always have access to the information needed to deliver effective care because they could not connect to the electronic record keeping system. Staff assessed patients’ pain but did not use a standardised tool to help them to do this. Staff screened patients for nutritional needs but this was inconsistent. Therapists used individual outcome measures to monitor patients’ progress, and some specialist teams used outcome measures and patient reported experience measures to benchmark the performance of the service. However, the district nursing and independent rehabilitation teams did not use outcome measures to benchmark their performance. There were good examples of multidisciplinary working on a case-by-case basis but current systems did not encourage formalised multidisciplinary exchange. Although staff reported good access to training, there was mixed compliance with appraisals and a lack of consistent approach to the supervision of staff. Telehealth was used effectively to enhance care and treatment. Compliance assessments for National Institute for Health and Clinical Excellence guidelines had been completed for most relevant quality standards.

We rated community health services for adults as ‘good’ for caring. Patients were given emotional support to help them cope emotionally with their condition. Referrals could be made to the ‘talking therapies’ service for emotional health checks. The ‘life after stroke’ group at Williton provided emotional support for patients following stroke. We observed nurses and therapists giving care to patients. All interactions between staff and patients were respectful, professional and kind. Staff listened to patients and took care to protect their dignity. Staff used creative techniques to educate patients and relatives and encourage their understanding. Patients told us they felt involved in their care.

We rated responsiveness of community health services for adults as ‘requires improvement’. District nursing and independent rehabilitation teams were usually available seven days a week and were able to respond to patients whose needs were urgent within 24 to 48 hours. However, patients with less urgent needs did not receive timely assessments. There were 865 patients who had waited more than six weeks for an assessment by the independent rehabilitation teams. Of these, 115 had waited more than 18 weeks. For podiatry, 88 patients had waited more than 18 weeks for an assessment. In speech and language therapy, some patients waited two weeks for staff to consider the urgency of their referral. There were good examples of learning from complaints, and projects such as the ambulatory care clinics were flexible to meet individual patient needs. However, people using services were not included in the planning and design of services in the district nursing and independent rehabilitation teams.

We rated community health services for adults as ‘requires improvement’ for its leadership. Staff were positive about the benefits of further integration but they did not know what their role would be in achieving the new vision of integrated care. Staff were not aware of their role in action plans for the key risks affecting the services. The system for ensuring the safety of staff working alone at night was not reliable. Public engagement was minimal within the larger services such as district nursing or the independent rehabilitation teams. Divisional risk registers reflected the risks evident in the teams but there was a lack of ownership of the risk associated with unreliable wireless internet connectivity, and leaders on the front line were not aware of progress with mitigation plans for key risks affecting the service. There were action plans in place to address the risk resulting from increased demand and decreased capacity in the district nursing service.

7 - 10 september 2015

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We rated Somerset Partnership NHS Foundation Trust acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

  • Vulnerable patients were not being referred for safeguarding when they needed to be.
  • Wards were not managing mixed sex accommodation adequately which meant the dignity and safety of patients was not always protected. Nurses’ offices were not ideally positioned to enable nurses to quickly attend to an incident.
  • Medical equipment was not being checked and maintained and some medicines were not stored appropriately.
  • Patients were not always involved sufficiently in the planning of their care and consent to treatment had not always been asked to consent to their treatment.
  • Although there were opportunities for patients to feedback about the service, not all of the wards displayed information about how to complain. When patients did complain there was no clear process for staff to receive feedback and learn from the complaints.


  • Wards were clean and were equipped with patient call systems, staff personal protection devices and CCTV was installed in some areas.
  • Staff were supervised and appraised and who worked well together in teams. Morale amongst the staff was good.
  • Due to the principle of least restrictive practice, patients were given freedom and were only observed closely, restrained or secluded when this was necessary for their welfare and/or the welfare of others.
  • Physical health care was monitored while people were in hospital and the medicines they were prescribed were given in line with national guidance.
  • Patients were assessed quickly when they were admitted and their risks were carefully considered and planned for. There had not been any recent serious incidents and all patients were being risk assessed effectively.
  • There were a range of different activities for patients to get involved in, as well as quiet places and gardens for them to use.

8-11 September 2015

During an inspection of Community health services for children, young people and families

Overall rating for this core serviceGood l

Overall community health services for children and young people were found to be good.

Somerset Partnership NHS Foundation Trust provided community services for children, young people and families in Somerset. As part of this inspection we talked to professionals delivering these services. We also met and spoke with children, young people and their parents. We visited services across the county and also spent time on home and school visits with health visitors, school nurses and therapy staff.

Overall we judged the safety of community health services for children and young people as good. Risk was managed and incidents were reported and acted upon with feedback and learning provided to most staff. However, the area for improvement concerned the high vacancy rate in health visiting which presented a risk to capacity and continuity of care.Care was effective. Care was evidence based and followed recognised guidance. There was excellent multidisciplinary team working within the service and with other agencies.

Care and treatment of children and support for their families was delivered in a compassionate, responsive and caring manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their families.

Staff understood the individual needs of children, young people and their families and designed and delivered services to meet them.

There were clear lines of local management in place and structures for managing governance and measuring quality. However, some staff felt isolated from the main trust and highlighted a lack of engagement and visibility from senior managers.

8 - 11 September 2015

During an inspection of Community health inpatient services

During our inspection a team of inspectors, specialist advisors, and an expert by experience visited all of the community hospitals. Eleven were visited during the announced inspection (8th to 11th of September 2015); two were visited during the unannounced element of the inspection on 24 September 2015. Our Pharmacist looked at medicines management in six community hospitals. We spoke with 94 staff (including managers, nurses, health care assistants and therapists) and 40 patients, relatives and carers. We also spoke with five volunteers and reviewed 29 medical records and seven care records.

We rated safety in the community inpatients as requires improvement. We found that where serious incidents were reported they were investigated thoroughly using a robust investigation methodology. However, we found the threshold of what was reported as an incident was high, particularly where there were medication errors, which meant that opportunities for learning were limited. Since the inspection an action plan had been introduced. We looked at 27 prescription and administration records across six community hospital inpatient wards. We saw 22 gaps in the administration records. Staff had not recorded they had given the medicine and had not recorded the reason if it had been omitted. We found there was a sharp contrast in the environments which people were cared for. In the community hospitals that were new or newly refurbished we found light bright environments with consideration for dementia awareness in their design. However, we found that hospitals such as Chard Community Hospital had safety concerns around access to fire escapes training of emergency equipment in the event of a fire. We also found that at Dene Barton Community Hospital the day room was small and cramped and did not allow easy access by patients. Staffing was recognised as a significant risk for the community hospitals, with 40% registered general nurse vacancy rates. Although many shifts were being filled by bank and agency staff there were a high number of shifts which did not meet safer staffing guidelines. As a result of this the trust agreed with the clinical commissioning group to reduce the number of beds provided by the trust. At the time of our inspection 61 beds were closed with an additional 20 beds in use by a local acute NHS trust.

We judged the effectiveness to be good. We saw good examples of where evidence base and audit results were having a positive effect on care and treatment and found that best practice guidance was being followed. However, where there was good practice, this was not effectively shared and used throughout all of the hospitals. Patient outcomes collected were limited to length of stay and audit results which reduced the understanding of how effective the treatments they were giving were. Staff we spoke with all had appraisals and competency training and were being given opportunities to develop further in their careers. Staff were recognising when a patient required pain relief and patients’ nutrition and hydration needs were met. Consent processes were followed appropriately and staff had a good understanding of the mental capacity act. Flow through the hospital was being affected by delays with social services which were outside of the control of the trust. This resulted in regular and extended delays in discharge. However, where there were extended delays the divisional managers worked with the community hospital staff, the trust board, the local clinical commissioning group and social services to resolve the problems.

We judged care provided by staff to be good. We observed compassionate care from all of the staff at the community hospitals and patients were complimentary about the care being given. Patient led assessments of care rated the hospitals to be better than the national average. When talking to patients and staff we were given multiple positive examples of how staff were working with compassion, were involving the patient’s relatives and carers and were providing emotional support. The therapies teams (occupational therapists and physiotherapists) were highly regarded by the patients and we observed good care when watching interactions with patients. We spoke with volunteers who work at the community hospitals. Their interactions with patients were having a positive effect on patients wellbeing. If patients didn’t have visitors volunteers would go and sit with them and have conversation or do puzzles or play games with them.

We rated the responsiveness of the service as requires improvement. We found that where there were active and affluent league of friends there was a vast array of activities available to patients for stimulation (for example at Williton Community Hospital and South Petherton Community Hospital). However, we found that in other community hospitals there were none for example Chard Community Hospital and Dene Barton Community Hospital. We also found that personalised care was only applied to those who most needed it and not everyone. We found that services were planned and delivered to meet people’s needs with access to in reach services. There was flexibility in how patients were managed and the Primary Link Service always tried their best to place patients at their preferred choice of location. We found that if a complaint was received through patient advice and liaison service thorough investigations were done with learning shared between community hospitals. However, if a complaint or concern was raised in a community hospital every effort was taken to resolve the issue locally. This restricted the level of learning taken from the incident and didn’t allow staff to pick up on, monitor, or introduce mitigating actions from these incidents.

We judged the inpatients service as requires improvement in its leadership. We found that the governance systems and practices were not providing effective governance, risk management and quality measurement and did not allow effective communication between different community hospitals or to different levels in the organisation. Risk management was reactive when an incident occurred rather than proactive in mitigating potential risk. Understanding of governance varied between the community hospital matrons. One matron discussed having items on the risk register to keep external contractors available to quickly fix infrastructural issues and another said that risks were managed locally without recording them. The leadership and culture of the service varied greatly between the community hospitals. Innovation wasn’t shared effectively and there was little understanding from the divisional leads of issues, risks and concerns in the community hospitals. Matrons felt well supported with any issues that arose by senior staff and staff in the community hospitals felt well supported by their matrons and ward sisters.            

07-11 September 2015

During an inspection of Community dental services

Overall rating for this core service Requires Improvement

Although we rated the service outstanding for providing caring services and good for providing effective services, overall, we rated the services as requiring improvement.

Somerset Partnership NHS Foundation Trust has 17 dental clinics across Somerset, Dorset and the Isle of Wight area. There are 13 clinic locations, excluding the locations where general anaesthetic services are provided. There are 10 clinics in Somerset, plus 2 Hospital locations. There are 3 clinics in Dorset, and one location for paediatric general anaesthetic services, as well as a Community Hospital location for adult general anaesthetic services.

During our inspection we visited seven locations which provided a special care dental service:

Bridgwater Dental Access Centre – special care dental treatment for all age groups.

Glastonbury Dental Access Centre - special care dental treatment for all age groups.

Taunton Dental Access Centre – special care dental treatment for all age groups.

Yeovil Dental Access Centre – special care dental treatment for all age groups.

The Browning Centre – dental treatment for adults with an impairment, disability or complex medical condition.

Canford Heath Dental Clinic – dental treatment children who are unable to tolerate treatment in the general dental practice setting.

The Dorset County Hospital - oral health care and dental treatment for adults with an impairment, disability and/or complex medical condition.

Overall we found dental services provided effective and caring treatment. We observed and heard practitioners were providing and excellent service in all locations with exceptionally caring compassionate and respectful staff.

We found the service was not providing safe care as identified risks were not always acted upon in a timely manner and equipment was not always serviced or appropriately managed for the safety of patients. The services were not responsive to the needs of patients referred to them in a number of areas, there were large numbers of patients waiting to be assessed and waiting lists were long.

The service was not well led as leadership, management and governance of the organisation did not assure the delivery of care in a supported learning and open environment across the service provision. There was limited devolved leadership to location managers and lead clinicians to empower them to make the necessary local judgements and actions for the safety and well-being of patients.

The two Dorset locations were well led locally. The issue was with the central leadership. Although this was beginning to be addressed by Clinical Support Managers who came across from the Somerset locations. Staff did report that although in its infancy it was a good innovation.

The Somerset locations were well led locally but were not always empowered to ensure all required actions for the efficient and effective running of the location. For example they told us they had reported issues relating to premises risks and maintenance and had been unable to obtain a response and action from the trust.

Dental services were effective and focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practices and sufficient staff available to meet the needs of the patients who visited the clinics for care and treatment.

All the patients we spoke with, their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion; and effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

At each of the locations we visited staff responded to patients needs. We found the organisation actively sought the views of patients, their families and carers. People from all communities, who fit the criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs, at the right time and without delay.

The service required improvement to the leadership. Organisational, governance and risk management structures were not in place to enable and empower staff in the locations to ensure safe and responsive care. The senior management team were not always visible across the area of whole area of service delivery. Staff described a culture that encouraged openness locally however some locations visited told us they could not express this a Trust level and be heard. Staff in these locations reported low morale because they did not feel supported by senior managers.

Staff were not always aware of the vision and way forward for the organisation and some said they did not feel supported or able to raise concerns.

8-11 September 2015

During an inspection of esb.services_rated.community health (sexual health services)

Overall rating for this core service Requires Improvement O

  • Somerset Partnership NHS Foundation Trust was registered to provide sexual health services under the following regulated activities: Treatment of disease, disorder or injury, diagnostic and screening and family planning. The registered location was at 7 The Crescent, Taunton where clinics were provided each day, Monday through to Saturday. We will refer to this clinic as The Crescent throughout the report. Other clinics were provided throughout the county which enabled people to access services in their local areas.
  • During the inspection we spoke with 17 patients who were attending clinics to seek their views of the care and treatment provided to them. We also received 58 comment cards which had been completed by patients prior to our visits. Comments made were positive about the staff and the treatment patients had received at the visit and for some patients who referred to previous visits. We spoke with 14 members of staff including managers, doctors, nursing, reception and administrative staff. We also spent time reviewing records and associated documentation.
  • There were procedures in place which staff followed to safeguard children, young people and vulnerable adults. The trust encouraged staff to report incidents. Staff we spoke with were confident in this system and said they received feedback following reported incidents of the action taken and lessons learnt were shared amongst the staff team.
  • There was evidence which showed the staffing skill mix and staffing levels impacted upon the service delivered to the patients. The service was involved in submitting a tender to provide an integrated sexual health service and there had been no staff recruitment since April 2015. This had resulted in some clinics being cancelled and not all services being available at all clinics.
  • The risks associated with emergency situations were not fully assessed and managed.
  • The care and treatment provided to patients was planned and delivered in line with current evidence based guidance, standards, best practice and legislation. Staff liaised with other professionals, both within the organisation and with professionals outside of the organisation to provide a service to patients.
  • We observed, and patients confirmed, that the service provided within the clinics was respectful and patient’s dignity and confidentiality was promoted. Patients were supported by staff to understand and make choices about their care and treatment options.
  • Patients were encouraged to be involved in the development of the service. Young people were consulted on the literature provided to help them understand treatment options.
  • Services were not accessible to all patients. For example, some clinics could not provide a full range of care and treatment due to the skill mix of available staff. The registered location had limited access for patients with mobility needs.
  • Patients could not always receive services in a timely manner that was in line with national guidance.
  • Patients were provided with information in the clinics on how to raise concerns and complaints. The service had received no formal complaints. Action was taken when a patient raised a concern and resulted in improvements to the service
  • Risks identified within the service, for example as identified in the fire risk assessment, were not dealt with appropriately or in a timely way. The risks identified at a service level did not correspond with those at a trust level.
  • The approach to service delivery was focussed on short term goals whilst waiting for the outcome of the tender application to provide an integrated service.
  • Not all staff had the opportunity to meet and liaise with their colleagues or managers due to the disparate nature of the service.

8 - 10 September 2015

During an inspection of esb.services_rated.urgent care services

Overall rating for this core service Requires improvement l

Overall the minor injury unit services require improvement.

The service did not manage risk effectively. Staff did not properly identify, record or take action to reduce risks. Staff recorded some risks in local registers but did not always record them promptly or clearly. Some significant risks relating to the minor injury units were not recorded. These significant risks included engagement with system wide major incident or accident scenarios, staff stress levels caused by feeling that they could take breaks only by keeping patients waiting, staff working alone without carrying personal alarms in line with trust policy and not providing management and clinical supervision in line with trust policy.

Quality and performance were measured and understood by service and trust leaders through audits, commissioning for quality and innovation targets and performance figures. A broad selection of local audits was completed in relation to minor injury units, although the analysis and conclusions drawn were minimal in the records audit where the quality of patient records was mixed. Risks to patients’ health were managed through an emergency nurse prescriber’s assessment on arrival. However, not all patients  received an assessment or triage within 15 minutes of arrival.

Many patients left the minor injury units having been assessed and treated without the need for referral elsewhere. The trust consistently discharged, admitted or transferred over 99 percent of patients within four hours of their arrival at a minor injury unit, exceeding the 95% national standard.

There were enough staff to provide a safe service for patients, although patient numbers and the increasing level of illness for some patients had been noted which had resulted in an impact on staff break times, finishing times and increasing numbers of patients seen by individual staff.

Staff understood their responsibility to raise concerns. However, the lessons learned from incidents were not clear. Medicines were kept safely although drugs used in resuscitation were not all kept in tamper evident containers.

The environment was clean and tidy and minor injury units scored highly in a recent infection control audit. However, we were not assured that the maintenance of the equipment used was up to date.

We saw staff gaining consent to care and treatment, although evidence to show that patients’ needs were assessed and care and treatment were delivered in line with legislation, standards and evidence-based guidance was sometimes incomplete in patients’ records. A recent audit identified that patients received timely pain relief although not all patients had the relevant information recorded about pain assessment.

Staff had and continued to develop the skills, knowledge and experience necessary to deliver effective care and treatment for minor injuries. However, assessment and treatment of minor illnesses was an area in which some staff felt they needed more training because of the number of patients who were presenting with a greater acuity. The trust had training programmes in place to support this.

The service worked with other providers to support patients’ minor injuries and illnesses. Pathways to more urgent and emergency care were also followed. Staff, teams and services worked together to deliver care and treatment and staff had the information needed to deliver effective care and treatment to patients who use services from their electronic records system.

Staff treated patients and other people with kindness, dignity, respect and compassion while they waited for and received care and treatment. Patients were given appropriate and timely support to cope emotionally with their care, treatment and conditions, and such support was offered equally across all patient age ranges. Staff showed an encouraging, sensitive and supportive attitude to patients who used services and those close to them.

Governance responsibilities for the minor injury units were through board representation via the chief operating officer. The service was then managed by a divisional lead who worked with the service manager and, the nurse consultant. The emergency nurse practitioner leads supported teams of emergency nurse practitioners and other members of the team. Emergency nurse practitioners did not receive scheduled one to one supervision. There were other methods of support available. The overall culture of the minor injury unit service was one of openness and transparency. This culture promoted good quality care and in general patients were satisfied people with the service provided. Members of the public were engaged through the friends and family test and while there were some complaints the feedback was over whelmingly positive.

8 - 11 September 2015

During an inspection of Forensic inpatient or secure wards

We rated forensic inpatient\secure wards as good because:

  • the ward was clean and in a good state of repair
  • there were enough staff to meet agreed safe staffing levels
  • staff demonstrated a good understanding of the local safeguarding process
  • there were detailed risk assessment and management plans
  • a physical health drop-in session, run by a GP, took place weekly
  • there was good access to advocacy
  • there were activities on the ward
  • staff felt confident about raising concerns
  • there was commitment to quality and innovation


  • there were no accessible toilet facilities for patients in seclusion
  • care records did not show that patients were being given their Section 132 rights
  • care records did not show that the responsible clinician had assessed patients’ capacity to consent to their medication
  • patients’ opinions about their care was not recorded in their care plans
  • patients, we spoke to, said they did not like the staff uniform
  • we did not see any quality improvement targets displayed on the ward

8 – 11 September 2015

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated long stay/rehabilitation mental health wards for working age adults as good because:

  • The ward was clean, bright and airy and staff adhered to the infection control principles.
  • Staffing levels had been assessed and the ward was working to agreed safe staff levels.
  • Patients had good access to the independent mental health advocacy services and an independent mental health advocate visited the ward at least once a week. There was clear ward information about patients’ rights and advocacy. There was access to specialist treatments, such as a cognitive behaviour therapy and therapy specifically for dual diagnosis patients.
  • The ward was part of the trust wide triangle of care initiative that included supporting and involving carers and family members and all the patients we spoke to felt involved in their individual care. We saw that staff treated patients with dignity and were observed to be kind and respectful.
  • Discharges were planned and happened at an appropriate time of day and beds were available when patients returned from leave.
  • Patients were aware of how to complain and regularly attended facilitated ‘have your say’ meetings.
  • There was good staff participation in clinical audit programmes, such as care plan audits and suicide prevention. Incidents were discussed and the ‘see something say something ‘initiative was embedded in the culture of the ward.
  • Staff had completed annual appraisals and attended weekly reflective practice meetings, although they had not received recent and regular one to one management supervision.


  • Medical equipment and portable electrical equipment were not regularly checked in accordance with trust policy and guidelines and as a result some medical equipment was out of date
  • Detained patients’ capacity to consent to treatment was not always recorded and leave authorisation forms for detained patients did not always record conditions of leave and include specific leave risk assessments.
  • One patient told us that they had the opportunity to record their views each week but overall we found that patients’ views were not always clearly recorded in care plans.
  • Although staff told us that they felt supported within the ward team, staff did not feel supported by the executive team overall. Morale on the ward had been adversely affected by the trust wide phased integration work, including the ward being considered for closure.

8 – 11 September 2015

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We found that the provider was performing at a level which led to a judgement of requires improvement because:

Information specific to the community services for adults with learning disabilities

  • The community teams for adults with learning disabilities did not provide care and treatment in a way that would prevent avoidable harm or the risk of harm. The community teams for adults with learning disabilities did not always respond appropriately to patients’ individual needs so as to ensure patient welfare and safety. Due to this we took enforcement action by serving a warning notice.

  • We found a a lack of robust assessment of individual patient risks and of person-centred care planning. There was also limited evidence of behavioural support plans being in place where needed. Documentation was often not completed appropriately and there was limited evidence that reviews of the risks and outcomes of care and treatment had been carried out. There was limited evidence that patients had been involved in developing their care planning and care plans were not always formatted in a way that patients could understand easily. In addition, there was ineffective working practice with other services/organisations where responsibility for care was shared or transferred. There was a lack of appropriate reporting of incident through the datix system (electronic incident reporting system); incidents and safeguarding concerns were not always logged on datix, and consequently there was a failure to identify and mitigate risks and learn from incidents that had occurred. The trust did not operate a waiting list for the community learning disabilities services or the rapid intervention team; as a consequence there was no understanding of the number of patients requiring the service or their needs or risks. Additionally, the trust failed to assess the needs of people with a learning disability who required a service but who did not meet the eligibility criteria for community learning disability services. This meant that people were not directed to appropriate services and put people at significant risk of not receiving the care and treatment that they needed. Prior to the CQC inspection the trust had failed to recognise the scale of the issues identified.

  • We asked the trust to take immediate action to address concerns. The warning notice required the trust to undertake an immediate review of service caseloads, which it must have completed by early November 2015. The warning notice also required the trust to commence a comprehensive review of assessment and care planning which it must have completed by the end of March 2016.

Information about the trust as a whole

  • We found significant variation in the quality of care delivered by teams and across the trust.

  • We had serious concerns about community health services for adults due to significant staff shortages that placed excessive strain on the district nursing workforce. Nurses did not consistently complete baseline observations and clinical risk assessments relating to nutrition, pressure care and falls. There were two record-keeping systems in operation. However, neither system could be relied on as a complete patient record presenting a potential risk of omissions of important information essential for safe patient care.

  • The trust’s governance systems failed to adequately identify key issues that allowed it to assess, monitor and improve the quality and safety of services provided. For example, there was variation in management of informal complaints and limited learning from complaints at a local service level; variation in medicines management and use of risk registers and limited learning from incidents generally. Understanding of governance systems and their application and importance in monitoring the quality of services was patchy across the services.

  • There was variation in the management of risks across services. Risks were not consistently identified or effectively managed to ensure recommendations were addressed promptly. Risks were not consistently shared between local teams and senior management. In several services, risks had been identified at service level that did not correspond with risks identified at trust level.

  • A number of services did not have systems to mitigate risks to people who were waiting to access care and treatment. Some services had long waiting lists. The trust did not adequately monitor patients who did not attend appointments or mitigate risks for people who required services but could not access them due to not meeting eligibility criteria.

  • In a number of services there were insufficient numbers of staff to meet patient needs. Although the trust faced a number of challenges because of the area in which it was situated it recognised it needed to be more imaginative in addressing staffing shortages. However, there was no clear workforce recruitment and retention strategy to address staffing issues. The trust informed us that it was waiting for a new director of human resources to commence in post; this person would be responsible for developing a comprehensive organisational development and workforce strategy.

  • The quality and detail of patient records varied across services and teams. Care plans were not always person-centred and lacked the detail required to demonstrate an understanding of an individual’s circumstances and needs. Capacity, consent and details about who information could be shared with were not always recorded and patients in a number of services, particularly mental health services, did not always feel involved in planning their care.

  • The trust’s vision and set of values were displayed on posters throughout the trust. However, many staff could not clearly explain these and some staff were unaware of them. Staff were able to describe principles such as working in partnership and providing quality care, but some staff felt that they had not been involved in development of the trust vision.

  • The trust had been through a period of considerable change since 2011 when it merged with Somerset Community Health, the community health service provider of NHS Somerset. The trust’s vision for the service was to provide a fully integrated service across the three counties and it had begun a process of transformation of services which it called ‘integration phase two’. The trust advised that the public and patient engagement aspect of integration phase two project was informed by the National Voices survey, the joint mental health strategy and Somerset’s community services review. However, there had been little public or patient engagement following the development of the transformation plans. Implementation was at an early stage at the time of our inspection.

  • While the majority of staff were aware that the implementation of ‘integration phase two’ was taking place and many were positive about the perceived benefits of further integration, some staff felt there had not been enough consultation and engagement. In addition, many staff we spoke with across the services felt the process of change had not been effectively managed. The majority of mental health staff felt that the emphasis of the integration was on physical health care services to the detriment of mental health services.

  • The board were aware of some of the concerns staff had about the service redesign and managerial changes. However, the trust did not have a clear plan to support staff and monitor the impact of the service re-design, location and management changes on staff health and wellbeing.

  • At the time of the inspection many of the managers of services were new in post (some only days or weeks) and had not yet had time to develop a detailed understanding of the service or chance to identify key issues of good practice or areas for improvement.


  • The trust responded positively when we raised issues about community learning disability services. It quickly provided an action plan following receipt of the warning notice and provided regular updates on action taken. In the update of 13 November 2015 the trust indicated that all actions required by early November had been completed. (see below for additional information)

  • Under the leadership of its current chief executive who was widely respected, the trust had maintained its foundation trust status since May 2008 and retained financial stability throughout. The chief executive was leaving the trust at the end of the year. At the time of the inspection his successor was in the process of being appointed.

  • The majority of the trust board and senior management team acknowledged there was a need for the culture within the organisation to change from the ‘top down’. The board was committed to ensuring that the trust changed and successfully implemented its change programme. It also recognised and was fully committed to significantly improving engagement with staff to ensure staff felt valued and fully supported.

  • Local leadership was seen to be good by staff in most of the services inspected. Staff reported good morale and felt well supported by their immediate managers for operational support and career development. We were told that generally there was a good level of openness and honesty at a local level, although staff identified a disconnect between what happened locally and the senior leadership

  • The trust had developed a new governance framework and put in place a number of committees and meeting structures to implement and oversee both the governance framework and the wider transformation of services. The trust had also developed a new dashboard to monitor performance, and the board now received regular quality reports. The executive team had commissioned audits of some of the risk and governance systems and were committed to implementing change. However, the new governance framework and dashboards were at an early stage of implementation and therefore it was too early for us to assess their impact.

  • We found many areas of good practice across the services, with a caring, enthusiastic and committed workforce that in the main treated patients with dignity and respect. Staff in all services took time to interact with patients and it was evident that good relationships were in place between patients and staff. In community dental services we found staff cared for patients in an outstanding manner, delivering care with thoughtfulness and consideration.

  • The trust had a carer’s charter; a ‘triangle of care’ steering group worked hard to ensure this charter was applicable and meaningful to carers in the trust’s community health and mental health services. The trust worked effectively in partnership with voluntary organisations to support patients and carers.

  • In July 2014, the trust executive team created ‘employee of the month’ and ‘team of the month’ staff awards. Their aim was to celebrate a team or individual that went “above and beyond their role to deliver great patient care”. Quarterly ‘voicebox’ meetings were established in January 2015 as a staff-led engagement forum for raising key areas of concern.

  • The trust had progressed a number of innovative initiatives and several services had received nominations or recognition from national organisations. The trust was committed to participation in research and development and was involved with 15 national research projects.

  • There was a range of audits conducted in the trust including national, local clinical and commissioning and quality innovation audits. The outcomes of these audits were used to influence and improve practice.

Somerset Partnership NHS Foundation Trust requires improvement. The trust recognised that it needed to change in order to deliver contemporary, high-quality services to patients. It also recognised that it needed to engage much more effectively with its staff and organisations that it works in partnership with. The board was committed to ensuring it brought about these changes and recognised that it needed to conduct its business with renewed focus and energy in order to realise its vision in a timely and collaborative manner.

We will be working with the trust to agree an action plan that assists in improving standards of care and treatment. We will also return to the trust to ensure it has taken the action necessary to fulfil the requirements of our warning notice.

Additional information about community learning disability services

  • In September 2015, we inspected the services delivered by the community teams for adults with learning disabilities as part of the comprehensive inspection. During the inspection we found that the trust was not meeting the standards expected in this service as it did not have appropriate measures in place to prevent avoidable harm, or risk of avoidable harm to patients using the service.

  • We found that the trust was in breach of Regulation 12 (1)(2)(a)(b)(i) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued a warning notice on 28 September 2015. We told the trust it must comply with requirement detailed as part one of the warning notice; to take an immediate review of caseloads and put in place safety plans to mitigate risk, within six weeks of serving the warning notice and comply with requirement detailed in part two of the warning notice; to undertake a comprehensive review of the assessment and care planning, within six months of CQC serving the warning notice. The trust sent us an action plan and later confirmed that it believed it was compliant with the requirements of the first part of the warning notice.

  • We carried out an unannounced, focussed inspection on 24 November 2015 to assess if the trust had addressed the concerns and to check the progress that had been made. During our inspection we spoke with three staff; two clinicians and a manager and reviewed 17 care records.

  • The trust had set up an improvement group to lead its response to our concerns. Action taken by the trust included identifying a learning disability community service in another trust with a similar population that had been rated ‘outstanding’ for caring and 'good' overall by the CQC. Staff from this trust had agreed to advise and support a review of practice and for it’s nurse consultant to work with staff from Somerset Partnership NHS Foundation Trust to help develop their practice. Staff in the service told us that they felt positive about the support and training that was now being provided. They said they could see that there was now a sense of energy in addressing the improvements the CQC inspection had identified.

  • On the day of our inspection staff within the services were receiving training that included incident reporting and safeguarding. The trust had also provided staff with training on clinical assessment and the management of risk.

  • The trust had undertaken a review of all 900 open patient cases and had identified the key risks for each patient. All 17 records that we sampled had been reviewed and the risks identified. However, despite the detailed action plan and progress made, we were concerned that in 14 of the 17 records we viewed the care plans had not been updated to reflect the risks or risk information identified during the review. The care plans in these records were of poor quality. Patients’ physical health risks had not been addressed and staff had not considered the impact of patients’ previous histories, for example, if there had been a history of aggressive, disturbed or inappropriate behaviour that could pose a risk for the patient or to others. The risks identified by the trust had focussed on the risks to patients but had not considered risks to staff or others.

  • Although some good progress had been made and the new service director had put in place several positive changes that in time would result in significant improvement in services for patients we found that the trust had not met all the requirements of the first part of the warning notice. However, at this time we will not be taking any further enforcement action but will continue to monitor the work being undertaken by the trust to comply with the warning notice.

8 – 11 September 2015

During an inspection of Wards for older people with mental health problems

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

  • We identified issues in relation to the safety of the environment at the three wards. Although some of these issues had also been identified by the trust’s staff, they had not been effectively addressed by the provider at the time of inspection.

  • Each of the wards had a range of different rooms and equipment to support treatment and care, and there was access to attractive and well maintained outdoor spaces. However, we identified a number of problems in relation to the design and layout of the wards which impacted on staff’s ability to promote recovery and maintain patient comfort, dignity and confidentiality at all times. For example, meeting rooms were inadequately sound proofed and not all bedrooms had ensuite bathrooms.

  • There were high occupancy rates at each of the three wards inspected. Although largely beyond staff’s control, this resulted in a number of issues including delays to discharge and not being able to keep beds free for people to return to following leave from the ward.

  • We identified a number of instances where the trust had failed to meet its legal obligations under the Mental Capacity Act 2005 (MCA). Staff had not identified when a patient should have had the input of an independent mental capacity advocate (IMCA) to support them through the process of a long term move. In relation to do not attempt resuscitation (DNR) forms, we were concerned that for some patients the DNR decision appeared to have been reached without discussion with the person or their relatives and that the DNR decisions were also not being regularly reviewed.


  • The 20 care records we viewed were complete, up to date, person-centred and in most cases contained evidence of people’s involvement in planning their own care.

  • We saw good evidence of changes having been made by staff and improvements to safety as a result of feedback and learning following incidents. We saw examples of good practice in relation to staff assessing and managing risk to patients. Care plans, for example, contained detailed and up to date risk assessments.

  • There were appropriate processes and procedures in place for the effective management of medicines.

  • Patients 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.

  • Morale was good among staff at a local team level. Staff told us they were unaware of any issues with bullying, that their managers and peers were supportive, and that they enjoyed their jobs. They knew how to use the trust’s safeguarding and whistle-blowing processes and felt able to raise concerns without fear of victimisation. Staff demonstrated openness and ‘duty of candour’ when communicating with relatives following incidents.

8-11 September 2015

During an inspection of Community-based mental health services for adults of working age

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

The number of service users awaiting allocation of a care co-ordinator across all specialities was 120.

The assessment teams and early intervention team reported delays in transferring patients to the recovery teams because of the pressure on that team’s caseloads. This was confirmed by the recovery team managers we spoke with, who told us these issues were to be addressed as part of the service reconfiguration.

Comprehensive assessments were completed at each referral meeting and immediately uploaded on to the electronic record. These included ascertaining a range of details such as; the patients personal circumstances, any historical mental health issues, physical health and risk factors.

We did not see effective trust-wide processes to show how learning from incidents (including serious incidents) and complaints was shared across other teams. During our inspection we reviewed the serious incident policy and the community mental health teams (CMHTs) operational policy. Both of these needed of updating in order to reflect the latest NHS England advice on serious incidents and the current situation of the CMHTs.

However, staff treated patients with kindness, dignity and respect. They provided an empathic approach and were professional in their dealings with patients and carers.

There were systems in place which ensured staff received mandatory training, appraisals and supervision. Incidents were reported appropriately and there was evidence of some local learning as a result of these, complaints and serious incidents.

7-11 September 2014

During an inspection of Mental health crisis services and health-based places of safety

We rated mental health crisis services and health-based places of safety as good because:

  • the crisis and home treatment teams assessed and managed risk to a high standard. Staff were well equipped to manage risk and skilled in identifying and mitigating risks.
  • the environments where patients were seen were clean and well presented.
  • staffing was safe throughout working hours and staff numbers and sickness were monitored closely. No agency staff were used and backfill for absences was provided through a local staff bank system.
  • the health-based places of safety were monitored well by staff. Their locations were safe with good access and exits to and from the facility. Areas were secure, well-lit and had observation windows and panic alarms fitted. There were no ligature points within the assessment suites or areas where people were detained under section 136.
  • the crisis and home treatment teams had good access to mental health disciplines needed to support people using the services. We saw there was multidisciplinary input within the teams and access to other agencies was good.
  • teams were made up of experienced and knowledgeable staff. Staff said they could access training needed to fulfil their roles and were encouraged by local management to access additional training for their development.
  • we saw excellent examples of interactions between staff and people using the service. All the staff we observed were caring, compassionate and kind, and treated the people using the crisis and home treatment teams and health-based places of safety with respect, warmth and professionalism.
  • we saw good evidence of respect for people’s privacy and dignity. There was flexibility around times and locations of visits, for example, if a person wished for a carer to be present and preferred it to be at their home, this would be arranged.
  • all the crisis and home treatment teams had local leadership in place that was described by the staff we spoke with as supportive, approachable and efficient.
  • all facilities used by people using crisis and home treatment teams were accessible by people in wheelchairs. The clinic rooms were all downstairs and there was access to disabled toilets. The health-based places of safety were both on the ground floor and with accessible toilet facilities.
  • all the crisis and home treatment teams offered extended hours including weekends. People were able to access advice and support out of hours by telephone or at either Musgrove Park or Yeovil District Hospital for assessment. The trust were planning to extend the crisis and home treatment team to a 24 hour services; at the time of our inspection there was telephone and hospital liaison support only.


  • within the health-based place of safety the wait for assessment was too long out of hours. Some people waited up to fifteen hours to be assessed. There was also a lack of clarity or understanding of procedures when a person was placed in a health-based place of safety, with regard to when doctors and Approved Mental Health Professionals for assessments should be accessed.
  • Mental Capacity Act and Mental Health Act training were not mandatory in the trust. However some of the crisis and home resolution team members had completed this online. Staff in the health-based places of safety had received training on section 135 and 136 of the Mental Health act and had requested updated training.
  • recording of mental state examination was not consistent and difficult to find in the clinical records in the Wells crisis and home treatment teams. We found some care plans were brief and did not consistently involve the person.
  • some people using the service told us they had not been involved in their care planning nor been offered a copy of their care plan.
  • there was no clock for orientation or means of distraction on the Rydon health based place of safety ward suite. On the Rowan ward health-based place of safety there was a clock however no other means of distraction or activity when waiting to be assessed.
  • formal feedback from incidents and in particular serious untoward incidents was sometimes not being received in a timely way.

8 – 11 September 2015

During an inspection of Specialist community mental health services for children and young people

We rated specialised community mental health services for children and young adults as good because:

  • Staff received mandatory training, risk assessments were being completed on first assessment and crisis plans were completed when relevant, waiting lists were monitored.

  • There was good knowledge of safeguarding procedures, lone working protocols were implemented.

  • Assessments were completed for referrals within the required six week target. Care plans were present for young people. There was a range of treatments available including therapies and medicines. Physical health assessments were completed. There was positive feedback of the weight restoration programme on the eating disorders pathway. Audits were completed against NICE guidelines. The service monitored outcomes for young people. Staff were supplied with specialist training.

  • Staff were supportive, respectful and knowledgeable about the young people under their care. Staff included external agencies, for example, schools. Parents were included in their child's care. There was participation group for young people to make changes and suggestions for the service. There was a participation information session for newly referred young people and their familes as an introduction to CAMHS.

  • The service operated a self harm rota in order for them to see young people in general hospital who had self harmed. Staff followed up young people who did not attend appointments. Two of the sites were accredited young people friendly. Staff were able to adapt to the different needs of patients through training.

  • The risk register was being used appropriately. The service monitored key performance indicators and outcomes. Morale was good and there was good local leadership.


  • There were safety concerns about the kitchen at Mendip where there were clear fire risks.There was a lack of cleaning rotas for the services toys. There was a lack of rooms available to staff at West CAMHS.

  • Risk assessments were not being updated routinely. There was vital risk information missing in the care records. Incidents were not always reported in a timely manner. There was no culture of shared learning across the service.

  • Care plans were not always holistic in nature and were not always given to the young person.
  • There was no specialist eating disorder training despite the service being provided. Appraisal rates at Mendip were only 54% complete.

  • There was very little evidence of capacity assessment or consent being sought.
  • Staff were not clear on who provided the advocacy service. Care plans were not always written from the young persons point of view.

  • There was a three to four month wait for therapy. There was little support from specialist CAMHS staff for young people in general hospital at weekends and out of hours. There were transition difficulties into the adult service. The Mendip environment was not young people friendly.

  • There was little confidence in the senior management of the trust and staff felt they were not being listened to.
  • Despite performance being monitored, effective action plans were not in place where issues had been identified.

8-10 September 2015

During an inspection of Community-based mental health services for older people

We rated older people’s community mental health services as good because:

  • Lone working procedures were robust, detailed and clearly structured.
  • Access to a psychiatrist could be on the same day if needed because they were on the same site or nearby.
  • Risk assessments were comprehensive, person centred and reviewed regularly.
  • There were infrequent incidents of harm or risk of harm and few serious incidents. Staff told us about examples of learning from incidents and we saw that these were reflected in team meeting minutes.
  • Psychologists worked in line with recommended guidance and offered the latest therapies, working across multiple services to ensure patients received the most appropriate treatment.
  • Staff showed us detailed mental capacity assessments, which demonstrated adherence to the five statutory principles of the Mental Capacity Act.
  • Staff regularly assessed standards relating to patients’ involvement in their own care using the ‘Triangle of Care’ monitoring tool.
  • Carers were closely involved in care planning and assessments. Teams employed carer assessment workers and ran practical courses for carers supporting someone with dementia. We found carers’ assessments evidenced in care plans.
  • We observed positive and kind staff interactions with patients during four home visits. Patients talked positively to us about staff and the service they received. Carers told us that they felt supported and praised the efforts of the older people community mental health teams. Staff supported patients and their carers to use the friends and family test following assessments. Staff included feedback from these sources in weekly team meetings.
  • Patients had access to local advocacy services. We saw leaflets for these services in all reception areas and staff could show us examples of when patients had used them.
  • Teams appointed a designated daily duty worker, with an additional single point of access worker, to manage large numbers of incoming referrals. Managers used support time and recovery workers to develop initial working relationships with patients who found it difficult to engage with services.
  • We saw a wide range of accessible leaflets and information packs given to patients prior to their assessments.
  • Staff responded effectively to complaints which staff followed up and actioned in team meetings. Patients and their carers told us they knew the complaints procedure and would feel comfortable complaining if they were unhappy with the care or treatment they received.
  • Staff demonstrated a resilient approach to making sure patients were not negatively affected by service issues, and they continued to provide a high quality service to patients whenever possible. Managers had submitted a risk assessment to the trust to highlight that keeping vacancies frozen and having managers doing two jobs was having a negative effect on patient care. They had also identified these issues on their local risk register.


  • Staff vacancies at Stratfield Day Centre meant staff could not always deliver safe care or activities for patients and activities were reduced.
  • A number of vacancies within the other services affected staff morale because they had to take on greater responsibilities. Filling vacant posts with permanent staff had not been authorised during the integration phase two process, which had resulted in high usage of bank and agency staff and a lack of qualified nurses on shift.
  • Memory services were full and there was a lengthy filtering process for patients being referred to memory assessment services, as GPs were referring all their patients who were presenting with a suspected memory problem to the memory assessment team. Some annual reviews had been missed due to the high number of incoming referrals, meaning staff were not able to monitor these patients if they had stopped taking their medication.
  • Consultant psychiatrists allocated to older people community mental health teams were stretched across multiple primary and secondary health services and as a result, were not embedded into the older people community mental health multidisciplinary teams. Staff felt that consultants were not part of the multidisciplinary team. Consultants did join in the weekly multidisciplinary meetings but had commitments to other services too.
  • We found gaps in regular managerial supervision of staff’s work performance at services where there were management vacancies or where managers were covering more than one service. In one service, nurses could not continue prescribing because they did not get the regular clinical supervision they needed.
  • Staff at memory assessment services told us that they sometimes had to rely on carers or patients to update them when they were particularly busy, instead of care co-ordinators assessing progress through face-to-face visits.
  • Staff told us they did not feel well led due to a lack of consistent managerial presence, or because their managers had to do two different jobs and could not focus on their managerial responsibilities. Some local managers were acting up as interim divisional managers and some divisional managers were managing local teams. Staff did not feel they had been consulted on the service changes, for example, the integration process as they had not been able to take time off to attend meetings, sometimes due to teams being short staffed.
  • We heard a strong and consistent message from staff who felt their specialist mental health focus and identity would be lost, and they would not have sufficient mental health representation when they merged with district nursing and integrated care services.

7-11 September 2015

During an inspection of Community mental health services with learning disabilities or autism

We rated community mental health services for people with learning disabilities or autism as inadequate because:

  • We asked the provider to take immediate action to address concerns and also took enforcement action, serving a warning notice. The warning notice served notified the trust that CQC had judged the quality of care being provided as requiring significant improvement. The warning notice was to ensure the safety, care and welfare of patients.
  • Staff did not always assess or manage risks, which put patients at risk of harm. Staff did not always complete or review risk assessments and risk formulations. We found no consideration by staff of risk of intervention, treatment or therapy to patients documented in any of the 28 case notes reviewed. There was no evidence in the risk assessments or risk formulations to show consideration of risk to staff.
  • Staff told us that the trust did not operate a waiting list for the community learning disabilities services or the Rapid Intervention team. The service did not mitigate risks for patients waiting for assessment or treatments. The service did not put proactive control measures in place to ensure that patients who did not meet the urgent referral criteria were not at risk.
  • There was a lack of incident reporting through datix for the CTALD. We found that staff did not always log incidents and safeguarding concerns on datix. Datix is a web form used in healthcare to report risk management, incidents and adverse events that may affect patient, staff or visitor safety.  
  • Initial patient assessments and care plans completed by staff varied in detail and quality. Behavioural support plans were not in place where needed and there were generic care plans for patients.
  • Staff did not always involve patients in their care planning. Care plans were not always formatted in a way that patients would easily understand.
  • There was limited active partnership working between staff, both internally and externally, to make sure that care and treatment remained safe for patients. The CTALD were unable to access the trust mainstream community health team’s clinical notes. This meant that when a patient received care and treatment from both the CTALD and mainstream community health team, risk management data was not shared or accessible to all staff.
  • Inadequate governance processes did not ensure the service provided was monitored. The systems to identify, assess and manage risks within the CTALD did not operate effectively.


  • Patients, relatives and carers told us they found staff across the CTALD to be caring, respectful and supportive. They also felt involve in treatment and therapies. Staff we met were professional and committed to providing the best care and service they could to support people with learning disabilities.
  • The trust took part in the quality improvement programme by POMH-UK CCQI, Prescribing Observatory for Mental Health-UK College Centre for Quality Improvement, which looked at antipsychotic prescribing in people with a learning disability.
  • The trust carried out an audit to look at 'Epilepsy in Adults' which looked at care planning, access to epilepsy services and emergency plans.

8 - 11 September 2016

During an inspection of Child and adolescent mental health wards

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

  • The ward was clean, tidy had anti ligature fittings and the bedrooms were en-suite. Emergency equipment and drugs were available, stored and monitored correctly. Staff adhered to infection control principles
  • the ward was staffed consistently and levels were adjusted according to risk. Risk assessments were completed and updated regularly. There were low levels of restraint, patients physical and mental health needs were assessed. Therapies were implemented and there were outcomes recorded for patients
  • staff received mandatory training, were supervised and appraised. Audits were completed regularly
  • we heard positive comments about the care patients received from staff. Staff were professional, orientated patients to the ward, involved them in decisions and in their care planning. Families were involved in the care, carer assessments were offered. Staff sought feedback and implemented changes where possible. The ward was able to respond to changes in need
  • there was a full range of facilities available and patients had somewhere safe to store their possessions. Activities and education sessions were available. Patients were aware of how to make a complaint
  • systems were in place to monitor safety and efficacy of how the staff worked. Morale was good amongst staff and the manager was visible whilst having the autonomy to run the ward.


  • Parental consent or consent for those patients considered to be gillick competent was not recorded for any of the patients on the ward. (Gillick competence is when a patient under the legal age of consent is considered to be competent enough to consent to their own treatment rather than have their parents consent)
  • the admission assessments were incomplete. We found that the expected area of the notes that held admission information was not populated. This meant that staff were not able to easily access important information
  • we found that some section 17 leave forms did not clearly set out the conditions of leave. Old section 17 leave forms were not always scored through.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.