North Staffordshire Combined Healthcare NHS Trust

We rated the community based mental health services for older people as Good because:

• Staff showed good knowledge of their patients.

• Staff had a good understanding of safeguarding adults and children policies and the procedures to keep people safe from abuse.
• Patients we spoke to were very positive about the service they received.
• Patients told us they could get appointments when they needed them and doctors were accessible to both staff and patients.
• Patients told us that they could easily contact their allocated worker when they needed to speak with them.
• Individual teams within the service had well-developed systems to gather patient and carer feedback.
• The service worked well with other teams and agencies to enable patients to move between services as their needs changed.
• The service was responsive to the needs of patients, carers and care homes.
• The service worked well together in order to prevent hospital admissions and support patients to be cared for in their own homes.
• Local leaders were visible and accessible to staff and demonstrated that they led their teams well

However

• Risk assessments were not routinely completed or updated.
• Patients did not have crisis plans so plans to mitigate risks to patients in a crisis were not in place.
• The trust failed to provide evidence that patient areas were free from ligature risks or that any risks were appropriately mitigated.
• Records of patient care and treatment were not always up to date.
• Records of patient care were not always easy for staff to use because files were stored in a number of locations.
• Mental capacity assessments were not routinely undertaken.
• The trust could not tell us how many patients were on staff caseloads.

We rated the Long stay rehabilitation mental health wards as requires improvement because:

• There were ligature risks in a garden which are difficult for staff to monitor.
• There were recording errors on four consent to treatment certificates.
• Mental capacity assessments lacked detail to support judgements and were not always completed prior to treatment being started.
• Risk management plans lacked detail and were not always updated to reflect significant risk incidents or changes in the level of risk.
• Care plans lacked detail and it was not always clear that patients’ views had been sought. Patients were not always offered a copy of their care plan.
• There was little evidence of meaningful physical health monitoring and little evidence of care plans to address specific physical health issues such as weight gain.
• There was poor recording of metabolic monitoring for patients prescribed clozapine medicine.
• Staff gender and skill mix was not always appropriate. There was one recorded and reported incident of staffing level and gender ratio not being sufficient to manage risk on the ward in a respectful and dignified manner.
• Risk incidents documented in patients’ care records were not always reported and recorded as per the trust incident reporting procedure.
• One of the wards had no staff with specific training in working with people with autistic spectrum disorders (ASD), personality disorders (PD) or substance misuse issues.

However:

• Staff in the service were noted to be kind, caring and compassionate in their interactions with patients.
• Physical restraint is rarely used. All staff describe the use of de-escalation and distraction as the preferred response to any incidents of disturbed behaviour.

We rated the acute wards for adults of working age as requires improvement because:

• There was no seclusion room compliant with the Mental Health Act (MHA) 1983 Code of Practice (2015);
• There were blind spots on all wards, which meant staff could not always ensure patients’ safety;
• There were a number of ligature risks throughout the wards, including pierced grills beneath the windows of Ward 1 that were not effectively managed;
• There was no clear evidence of review of risk assessments after incidents;
• We observed blood spillage not dealt with in the appropriate manner in line with legislation and guidance;
• We found an informal patient on Ward 3 who was prevented from leaving the ward without apparent legal authority;
• Recovery focus was limited and inconsistent in care plans. There was poor evidence of patient involvement;
• Non clinical moves occurred between wards;
• Not all staff had a good understanding of the Mental Capacity Act (MCA) 2005;
• The failure to record fully the administration or omission of medication was evident on all three wards.

However:

• Staff demonstrated kindness and compassion in their interactions with patients.

• Patients appeared to be involved in their care; they spoke positively about staff and said they were respectful, kind and caring.
• Relatives spoke positively about the care patients were receiving. They felt they were involved in the patients’ care.

• Systems were in place to learn from incidents.
• Staff knew how to support patients to make a complaint and they received feedback on the outcome of complaints on their respective wards.

We rated child and adolescent mental health wards as requires improvement because:

• Risk assessment and management plans were of poor quality and inconsistent, particularly for physical health.
• There was evidence relating to two patients of some physical health checks not being completed i.e. monthly height check in eating disorder patient and recommended ECG after weight loss on leave.
• On inspection, we found staff had not identified an error in clinical measurements for a patient with Anorexia Nervosa for nine weeks. There was no evidence in the notes of an apology or what actions had been taken on discovering this discrepancy. The error had not been documented on the safeguard incident reporting system.
• We found filing errors in two care notes which could lead to inaccurate information been used or vital information not available to guide care.
• Darwin centre had admitted challenging patients knowing that they would encounter significant difficulties due to the environmental limitation and inability to increase staffing levels at short notice.
• The female only bathroom and toilet area were accessed via the mixed gender games room. This meant that males would be unable to access the games area when females needed access to female only bathroom facilities. Staff mitigated this by allocation of en suites bedrooms and by closing the room at times during the day. A protocol to manage mixed genders was being used by staff.

However

• Darwin centre followed the childrens British national formulary guidelines by recording both oral and intra-muscular as rapid tranquilisation.
• Following each admission for a short break at Dragon square, a body map was completed and kept on care notes as part of their safeguarding practice for each young person.
• Clinic rooms at both units had emergency equipment in place and were clean and tidy.
• Both Darwin centre and Dragon square had been rated with 5 stars for food hygiene by the food standards agency in 201

We rated North Staffordshire Combined Healthcare NHS Trust as inadequate because :

• Staffing levels in most services were not safe. There were not enough consultant psychiatrists, nurses, psychologists, therapists or administrators. Young people waited too long to receive non-urgent assessments, diagnostic assessments or treatment. The Royal College of Psychiatrist have published a college report entitled 'Building and sustaining CAMHS to improve outcomes for children and young ' CR182 (November 2013). This report provides an update of guidance on workforce, capacity and functions of specialist child and adolescent mental health services (CAMHS) in the UK. It aims to give a ‘rule of thumb’ tool that can be applied to any region in any jurisdiction of the UK. 
• There was not an effective system in place to assess the risks to young people whilst they were waiting for assessment or treatment.
• The number of fixed-term additional staff was insufficient. They had minimal, if any, impact on some waiting times.
• Risk assessments for young people were not always completed. When risks were assessed young people did not always have a risk management or safety plan.
• In CONNECT and First Steps services, on some days, there was no allocated duty worker. Services could not ensure that urgent matters were dealt with in a timely manner.
• Safeguarding children training was not undertaken by all staff. Not all clinical staff were required to undertake level three safeguarding training.
• In almost all services, staff morale was low.

• Not all young people had a care plan. Where young people did have a care plan, the majority were not specific, detailed or personalised. Some care plans did not address young peoples’ identified needs. Young people and carers’ views were not recorded. A clinical audit of care plans had not led to improvements.
• There was no shared care protocol regarding the physical health of young people with eating disorders. This was not in accordance with NICE guidance. Weighing scales in services were not calibrated regularly.
• In CONNECT CAMHS and First Steps services, there was no regular communication with general practitioners.
• There was no psychiatrist in, or attached to, CAMHS ASD service. This was not in accordance with NICE guidelines. There was a lack of psychiatric input into CONNECT and First Steps services.
• The clinical records of some young people were transferred between services, sometimes regularly. There was a high risk that some young peoples’ clinical records would not be complete, or always be available for staff that needed them.
• Outcome measures, to assess services effectiveness, were not used consistently in all services
• The buildings in which services were based were not suitable but there was a programme of improvement to improve services
• There was no effective system for monitoring feedback, or concerns, of young people or carers. Possible themes or trends were not always identified.
• There was a lack of robust governance systems in CAMHS community services to underpin safe and high quality care. Key performance indicators were limited in CAMHS community services.
• The plan to reduce the waiting lists was not comprehensive. It only addressed some of the difficulties, and was time limited. The plan did not have the level of impact required.
• The service managers, and their deputies, managed all of the CAMHS community services. They had limited capacity to drive quality improvement and service development.
• Plastic toys in waiting areas and interview rooms were not disinfected regularly. This was an infection control risk.

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

• The medical cover within the teams was good. There was always access to a psychiatrist.

• There was good safeguarding children and vulnerable adults processes in place. All staff had received training and they spoke with confidence about making appropriate referrals.

• All the treatment records viewed during the inspection contained comprehensive initial assessments.

• Staff had a good knowledge of the Mental Capacity Act. There was evidence in treatment records of patients capacity to consent being assessed and recorded. Where patients were found not to have capacity a multi-disciplinary approach was taken to best interests decisions.

• There was a project underway led by the hearing loss specialist nurse within the community team to change the working practices around patients experiencing hearing loss. The project would introduce the use of ipads and digital apps to provide instant access to signers when a patient with hearing loss was accessing services.
• The intensive support team had developed an electronic clinical pathway system. This contained electronic copies of all the documents which may be needed and provided a chronological pathway for staff to follow to ensure patients received a holistic and patient focused package of care.

• Staff felt supported by their immediate managers, morale was good and the team were supportive of each other.

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

• The wards were clean, spacious, and safe. They were secure, whilst being patient and age friendly, with pleasant outdoor areas and a variety of rooms and activities. They were grouped together on the same site, so that they could benefit from each other’s support and facilities, as well as support and facilities from the rest of the hospital.

• Risks to patients were individually assessed, monitored and managed effectively.

• Patients’ physical health, as well as their mental health, was monitored and treated effectively with a clear focus on recovery and discharge in a timely manner. Joint working between the mental health & acute trusts on ward 4 was working particularly well in speeding and enhancing patients’ recovery.

• There was a good mix of well-trained, motivated, professional and caring staff to help patients. Staff were enthusiastic, positive and had a good understanding of the needs of all patients and how to meet them.

• Wards worked well with other agencies and kept carers and patients informed about and involved in individual needs and progress. They were able to treat and discharge patients within reasonable time limits.

• Patients and relatives were overwhelmingly positive about the staff, the food, the service and the care and treatment offered.

• There was a good range of activities available to aid patients’ well-being and recovery.

However,

• There was no evidence of any psychology input that might benefit particular patients.

• Not all staff working with dementia patients had received in depth dementia training.

• Although they felt well supported and supervised, staff did not have regular recorded supervision.

• Not all medication given was properly recorded.

We rated wards for patients with learning disabilities or autism as good because:

• Both wards were clean and tidy with a cleaning rota that ensured the ward was cleaned systematically.
• All patients had a physical examination on admission. Ongoing physical health care needs were assessed with all patients and was seen in the care plans for 9 of the 10 patients. For all the records we checked, we found evidence of physical healthcare checks having been undertaken within the last year.
• In the care plan of a patient that had the most incidents of restraints recorded, the positive behaviour plan had been used with good effect in managing the challenging behaviour to reduce the amount of restraint used by using alternative de-escalation techniques.
• The ward used the health of the nation outcome scales for learning disabilities (HONOS-LD). This was an 18 scale risk assessment too and is completed on admission of a patient and regularly reviewed throughout their ward stay. It is also completed at the point of discharge of the patient.
• We observed staff treating patients with kindness, dignity and respect. The patients said they felt they were well treated even when they were unwell.
• Staff showed a good understanding of patients’ needs.
• Patients were admitted to the assessment and treatment ward by the intensive support team who would assess their needs and if the admission was appropriate. The intensive support team would also help facilitate discharge.

However:

• There was a lack of easy read signage on both wards. On arriving at both wards, there were populated notice boards but both were situated in a small cramped area that was between two locked doors. The locked doors had to be operated by staff. This did not allow visitors time to read any notices that were displayed. There was a lack of easy read notices and not all necessary information was there.
• There were many ligature points on both wards. These had all been identified by a trust risk assessment. The risk assessment highlighted what action needed to be taken with each ligature risk.

• Both patients and staff reported that there were not always enough staff on duty. This had it greatest impact on leave from the unit and organised activities away from the ward.

• The assessment and treatment ward had mixed sex patients. The layout of the ward does not allow one female to use the bathroom and toilet facilities without crossing over a communal area.

• On both wards 10 sets of treatment records were examined. The care plans were well written and covered different aspects of care - showing individualised care planning. All of the care plans were not written in the first person and nor did they all show evidence (in the form of comments or signatures, or documented refusal to sign) of patient involvement. In these cases it was difficult to find further evidence of patient involvement.

• A care plan relating to one patient subject to a deprivation of liberty safeguarding still made reference to being an informal patient.

• For patients who might have impaired capacity, capacity to consent is assessed on admission through the multi-disciplinary team. In the care plans reviewed all records had a capacity assessment present but these were not always detailed or specific.

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

• Staff were able to show how they provided care and treatment to both patients and carers in line with the National Institute for Health and Clinical Excellence (NICE) guidelines. However, the records  read did not identify the involvement of patients in partnership with their health and social care professionals. For example; out of 27 records within the access team we found that 18 did not identify the patient’s relative or carer’s involvement in the care planning/management plan process. We found no evidence of a review of patient’s care/management plans within 18 of the records read.
• Of the care records reviewed, 29% had no risk assessment evident.A further 46% had some evidence of risk assessment having taken place but there were errors present with inconsistent data regarding suicide risk of one patient. Historical risks had been identified in some risk assessments but lacked detail of antecedents, static or dynamic risks and crisis plan.
• We found inconsistencies in the care planning and risk assessment documents. Some risks identified in the trusts 3 point risk assessment tool which was to be updated on a six month basis were not transferred to a more comprehensive modular risk assessment tool.
• Of the care plans we reviewed, 44% in had no evidence of being recovery oriented. Patients strengths and goals were not identified.
• Of the care records we reviewed, 58% had no evidence of informed consent.

• Staff told us that the integration of the trusts community rehabilitation and Assertive Outreach function had taken place in June as part of the trusts cost improvement programme.  However, they felt there was a lack of a management of change programme to accompany this.
• Staff told us that they felt unable to always deliver quality care due to increased pressure of workloads in the community teams.
• Annual personal development review (PDR) compliance within the ICMHT's was below the trust standard of 95% and had an average score of 70%. The trust reported that having confirmed the results with the team managers, more PDR's had taken place, but had not been recorded appropriately.
• Most community staff confirmed their caseloads were manageable. Staff said they could effectively monitor the people on their cases and there were both daily and weekly team meetings to review these. However the city ICMHT staff reported having higher caseloads. Within the city ICMHT the average caseload sizes were 37 at the Sutherland centre and 35 at the Greenfields centre. Staff within the city ICMHT's told us that they felt unable to always deliver quality of care due to increased pressure of workloads in the community teams. The trust currently have no policy for the effective and safe management of caseloads.
• The highest combined caseload of a non medic member of staff was at Greenfields ICMHT which was 76. This was a combination of people on the care programme approach (CPA) and standard care.  Staff reported having placed their team on the trust risk register due to high clinician case loads and low staffing levels.
• Staff in the city ICMHT's reported that there had been increased pressures due to vacant posts and increased caseloads. Staff within the services told us there had been further workload pressures due to staff being absent due to long term illness.
• Carers and services users told us that there can be lengthy waits for appointments with community teams.
• Staff told us that combined paper and electronic notes meant that duty staff working weekends at the Greenfields site were not able to view progress notes of patients not under the care of that team as they were at a separate location. This meant that all information was not in an accessible form or readily available.
• No evidence of adherence to NICE Guidance regarding offering discharged service users the opportunities to pursue advocacy or moratorial services.
• Standard operating procedures within the Access team stated that should people need to wait before an assessment this is for no longer than 20 minutes after the agreed appointment time. The manager we spoke with said the team did not monitor or measure the outcome of whether they were meeting this.
• The teams we inspected had a lone working policy but not all staff were aware of how to use this correctly.  Two staff were unaware of the trust wide safety word for alerting others should there be an issue whilst on community visits.  One staff member described the teams approach to the lone working policy as "ad hoc and loose".
• Two staff we spoke to told us that they were aware of the requirement to check the patients electronic notes on the Corporate Health Information Programme (CHIP's) prior to home visits to be aware of changes to risk, but this did not always happen.
• Two of the three clinic rooms we visited within the ICMHT's had temperatures of 25 degrees centigrade during our inspection.
• Managers were not able to use the trust based governance tool to provide an overview of their team compliance with statutory and mandatory training on a regular basis. Managers were provided with a weekly spread sheet from the trust data management system but this included the training details of all staff including those in unrelated clinical teams.
• Staff were not up to date with statutory and mandatory training with an average of 93% compliance in training across the three integrated community mental health teams and the recovery and resettlement team. The trust standard for staff to be fully compliant is 95%
• The paper records seen across the services showed that consent to care and treatment and information sharing was inconsistently recorded.

However: 

• Patients told us that there was access to a psychiatrist when required.
• We saw evidence within the Moorlands ICMHT of learning from the outcomes of serious untoward incidents and the team were able to describe and demonstrate changes in practice as a result of this.
• All areas were clean and well maintained, there were well equipped clinic rooms with equipment regularly checked.

We rated mental health crisis services and health-based place of safety as inadequate because:

• The home treatment team did not complete assessments for new referrals. They did not review or update assessments that were being used by other teams when patients were referred to their service. When patients’ needs changed, the home treatment team did not update existing risk assessments which were completed by other services.
• The risk management plans across all teams were not detailed enough to identify how staff were to safely manage patients. There were no clear guidelines on how staff should respond and address the risks identified. The home treatment team did not review management plans regularly.
• All teams did not complete risk assessments for all visits to patients’ home to ensure that staff were safe.

• The home treatment team did not have appropriate arrangements for the management of medicines. There were no drug charts for medicines administered by nurses to sign that medicines had been given. Staff did not follow guidance for controlled drugs storage to ensure that controlled drugs were stored safely.
• Staff were able to show how they provided care and treatment to both patients and carers in line with the National Institute for Health and Clinical Excellence (NICE) guidelines. However, the records read did not identify the involvement of patients in partnership with their health and social care professionals. For example; out of 27 records within the access team we found that 18 did not identify the patient’s relative or carer’s involvement in the care planning/management plan process. We found no evidence of a review of patient’s care/management plans within 18 of the records read.
• Observation levels carried out by staff to manage the potential risk of ligature points of taps and a pipe in the Health Based Place of Safety (HBPoS) bathroom compromised patients’ privacy and dignity when using the facilities.
• The home treatment team did not complete admission assessments or update the assessments that had been carried out by other teams when patients were referred to their service. The team did not ensure that patients received care and treatment that was based on current assessment of their needs.

• The Access, Raid and home treatment teams did not have care plans that were personalised, holistic or recovery orientated. The home treatment team did not have up to date care plans. The teams provided care and treatment that did not reflect person-centred care that was based on individual needs and preferences.
• Records within the teams were not well organised and different team members could not access patients’ records when needed. The Access team out of hours did not have readily available access to paper based records of patients known to other teams. This could not provide staff with easy access to deliver effective patient care.
• The Access team and home treatment teams did not carry out physical health checks and there were no care plans in place for patients with physical health needs to ensure that their needs were monitored.
• Standard operating procedures within the Access team stated that should people need to wait before an assessment, this is for no longer than 20 minutes after the agreed appointment time. The manager we spoke with said the team did not monitor or measure the outcome of whether they were meeting this.
• We looked at the percentage of patients within the access team who were seen within four hours. The records showed that the Access team had achieved a target rate of 100% since November 2014 to April 2015. However, there were no records which measured the outcome of patients seen within 24 to 72 hours and 21 days.
• Staff from all teams did not carry out regular clinical audits to monitor the effectiveness of the service provided.
• Appraisal rates varied between teams. Records showed that staff from Access and home treatment team received appraisals. However, the percentage of non-medical staff that received an appraisal in the last 12 months was 44% in Raid team.
• There were no regular and effective multi-disciplinary team meetings taking place in Access, home treatment and Raid teams.

• Confidentiality was not always maintained at the Access team and Raid team.

• Patients from home treatment team did not participate in care plans and care reviews and they did not have copies of their care plans. Patients told us that they not given copies of care plans and were not aware of their written care plans.

• The teams did not carry out formal carers’ assessments.

• The Access, Raid and home treatment teams did not have a structured way of getting patients involved in decisions about their service. There were no patient forums or meetings held or involved in recruiting staff.

• Only four out of 21 records reviewed in the health based place of safety showed that patients were seen for mental health act assessment within the target time of three hours.

• The out of hours service could not facilitate admission or find a crisis bed for patients under 18 and those over 65. These cases were referred to social services emergency duty team.

• The assessment details for all teams did not address areas of disability and sexual orientation needs of individuals.

• Patients were not always provided with information about the ways that they could raise complaints and concerns regarding the service.

• The teams did not have robust systems and methods to effectively assess and monitor that the service is performing well around quality and safety of the service.

• However:

• Staff told us that they were trained in safeguarding and knew how to make a safeguarding alert. Staff demonstrated a good understanding of how to identify and report abuse.

• The teams had a clear structure which reviewed all reported incidents. Staff were able to explain how learning from incidents was shared.

• Staff told us they had undertaken training relevant to their role. Staff were trained in cognitive behavioural therapy, solution focussed therapy, open dialogue and clinical risk assessment.

• There was evidence of working with others including internal and external partnership working, such as in-patient services, GPs, police, Royal Stoke hospital, independent sector and local authority.

• Patients and their families were positive about the attitude of staff and the support they received. Our observations and discussions with patients confirmed that staff were friendly, polite and treated them with respect.
• The interaction between patients and staff was positive and staff responded to patients with patience, kindness and ensured that they were treated with dignity and respect.

• The percentage of patients seen for crisis assessment within four hours of referral was 95% in the last 12 months. The target was 90%.

• Appointments were rarely cancelled and where there were cancellations people were seen at the earliest possible opportunity.

• Our observations and discussion with staff confirmed that the teams were cohesive with good staff morale.

• Staff told us the board informed them about developments through emails and intranet and sought their opinion through the annual staff survey.

We rated substance misuse services as requires improvement because:

• Services were not always well staffed. For example, each service had vacancies and maternity leave and sickness that had not been covered.

• Some locations, for example the Intoxication Observation unit (IOU) at the Edward Myers Unit, presented as a safety risk to staff. There had been a recent sexual assault on a female member of staff at the Edward Myers Unit and we saw no plans to mitigate these risks.

• There were inconsistent approaches to risk formulation and management across two of the services with the exception of ORS only. This meant that risks were not always highlighted or managed appropriately and could put staff, service users, families and the public at risk.

• There was no clear commitment from leadership to standardise a consistent supervision system across all of substance misuse services.

• Despite working with a particularly vulnerable group of service users, there was no role specific training programme in place for staff. For example, although staff reported high level of novel psychoactive substance misuse (legal highs) in the demographic, there had been no specific training for staff on the effects, forms or characteristics of the new drug patterns emerging locally.

• NICE Guidance recognises high levels of blood borne viruses (BBV) among drug users and that testing and vaccinations can reduce transmission. However, there were inconsistent approaches to BBV services. For example, ORS was preparing to offer a full BBV service and the other ORL was referring to GP’s to manage.

• Naloxone is not used as standard to reduce the number of drug related deaths.

However:

• There were illustrations of outstanding practice and partnership working at One Recovery, Stafford. For example, good demonstration of joint working with health staff and ADS staff. Fully integrated clinical and medical services with recovery at the forefront. Clear and effective systems for case management, supervision and staff involvement in service delivery.

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 North Staffordshire Combined Healthcare NHS Trust was performing at a level which led to a judgement of Requires Improvement.

We found inconsistencies in the leadership at board and executive team level. The Chief Executive had been in post for 18 months; we were impressed by her leadership skills. A strategy to improve safety, quality of care and patient experience has been developed, however, this process is in it’s infancy and as such not fully embedded trust wide. Key positions in the leadership team remain interim and we were concerned by the turnover in relation to the Director of Nursing role. However, the Director of Nursing and the Director of Strategy and Development had been appointed but not yet commenced in post

Governance & data systems within the Trust were not robust and did not ensure that systems to enable the effective monitoring of safety, quality & risk are in place. However, we saw evidence that the Trust is developing systems for learning from incidents and complaints.

The provider failed to ensure that all people receiving a service were protected from potential harm due to ligature risks and poor quality of risk assessments. We have issued an Enforcement Action in relation to specialist community mental health services for children and adolescents which gives a strict timescale for them to improve.

The provider scored below the national average with regards to staff recommending the Trust as a place to work. Some of the staff that we spoke with felt disengaged from improvements that the leadership team are trying to embed. However, we saw evidence that the Trust is attempting to engage with staff and service users be developing initiatives such as ‘listening into action’ and the newly formed service user and carer council.

The Trust can be proud of the caring culture within the staff group. We saw consistent evidence of people who use Trust services being treated with dignity, kindness and respect.

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