Somerset NHS Foundation Trust

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.

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.

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.

However:

• 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.

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.

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.            

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.

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.

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.

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

However:

• 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

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.

However;

• 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.

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.

However,

• 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.

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.

However:

• 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.

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.

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.

However:

• 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.

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.

However:

• 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.

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.

However:

• 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.

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.

However:

• 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.

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.

However:

• 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.