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Provider: Norfolk and Suffolk NHS Foundation Trust Requires improvement

Read our previous reports on Norfolk and Suffolk NHS Foundation Trust, published on 3 and 6 February 2015.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 January 2020

  • We rated well-led, responsive, effective and safe as requires improvement and caring as good. In rating the trust, we took into account the previous ratings of the three core services not inspected this time. We rated the trust overall for well-led as requires improvement. This was an improvement from the last inspection. Four of the trust’s 11 core services are now rated as good and five as requires improvement, one service was outstanding and one inadequate.
  • The trust board and senior leadership team were newly formed. At our inspection in 2018 we had significant concerns about the safety, culture and leadership of the trust. Since then, there had been a change in leadership. At this inspection, we found that, although some of the concerns had not fully been addressed, there had been a shift in approach and foundations had been laid to improve the direction of travel. We saw early improvements in almost all areas, but there had not been enough time to judge if these changes would be sustained. For instance, recent changes to the leadership structure had not yet embedded throughout the whole organisation and there were still a few key posts to be filled. We saw early improvement with the trust moving in the right direction, however, there was still much work to be done.
  • Our findings from key questions demonstrated that whilst governance processes had improved, they had not yet fully ensured that performance and risk were managed well. For instance, waiting lists remained high in the specialist children and young people community mental health teams. Staffing was also a concern within this core service. We saw risk assessments were not always updated within this core service.
  • The environment in the learning disability inpatient service was not safe or fit for purpose. The trust had made little attempt to remove or reduce the number of ligature points or improve lines of sight, nor was it a recovery focussed environment, as it did not encourage independence due to the number of risks within the environment. We had identified in the last inspection that not all wards were safe and fit for purpose.
  • Managers did not have effective oversight of medicines management nor checking of emergency equipment in six of the eight core services we inspected. Despite increased assurance work and an improved board assurance framework, medicines management issues we found had not been identified as a concern by the trust.
  • The trust missed opportunities to prevent or minimise harm. For instance, we found that the management of patients on enhanced observations was not always robust within the inpatient wards with gaps being found in some documents. This posed a direct risk to patient safety. Staff did not ensure patient records in all section 136 suites were completed or added to the system in a timely manner. This posed a risk to patient safety as if the patient accessed another service within the trust there would be no information or previous plan for staff to access and use when making clinical decisions. Staff did not consistently implement the smoke free policy. This led to patient frustration and increased the risk of fire setting.
  • We continued to see similar themes and recommendations (such as poor documentation in clinical records) from serious incident reviews which demonstrated learning was not always effective in improving practice. The trust recognised this and were proactively exploring ways to ensure learning took place across teams.
  • Some services had not yet embraced the cultural changes leaders were trying to develop. In one location in Suffolk, across four core services, we were concerned that some staff continued to report a lack of engagement with managers and pockets of low morale. We also saw evidence of bullying in one team in Norwich. The trust had sight of these issues and had acted, however action taken had not yet been sufficiently embedded to create wholesale change.
  • Some stakeholders did not feel that changes had truly positively impacted all patients, with feedback advising that some still did not feel listened to, with poor communication being a key feature of feedback from patients or their families. Equally, a lack of access to attention deficit hyperactivity disorder (ADHD) services and specialist children and adolescent community services (CAMH) was raised as a concern by stakeholders. We found that this aligned with our findings at this inspection.
  • The new governance and management structure were not yet fully implemented and embedded within the new care groups.  For example, the role of the people participation lead was new and not yet fully developed. Not all staff fully understood the roles and responsibilities of the leads. Leaders had not yet successfully provided all teams across the organisation with an understanding of how the new care groups worked. Some staff expressed concern that the organisational changes were too fast and lacked consultation.
  • Not all teams provided a range of treatment and care for patients based on national guidance and best practice. For instance, some community services had significant waiting times for psychological therapies. Teams lacked enough psychology staff to provide the range of care recommended by the National institute for Health and Care Excellence guidelines.

However:

  • Since the last inspection the trust had implemented a new quality strategy to include quality improvement (QI) as a core component within their strategic direction. The trust quality improvement plan (QIP) had been revised and was aligned to the new strategy. One hundred and eighty-seven staff had completed the three-day improvement leaders programme and were developing initiatives within local teams designed to improve care. Some of these initiatives had been identified as important by the local service users reflecting leaders increased focus on service user participation and co-production. We saw some of these initiatives within the local teams and noted increased efforts made to engage and listen to the service users voice. Staff across services told us that they were involved in the planning and delivery of their own service. This initiative was in the very early stages of implementation and had, therefore, not yet brought about the improvements that were envisaged.
  • The trust had a ‘putting people first’ strategy aimed at improving service user participation and to facilitate cultural change and de-centralise decisions. Concerns had been raised about organisational culture in the last four inspection reports, and the 2018 inspection report identified concerns that there was widespread low morale with staff feeling ‘done to’.  Following the 2018 inspection, the trust leadership team undertook (and continued to undertake) a range of engagement visits to services ensuring they were accessible to staff, although some staff reported that were unaware of visits to their services. At this inspection, more staff reported a sense of optimism and hope that real change was happening. More staff felt listened to, felt they could influence change, felt supported and had good working relationships with their managers.

  • The trust had improved its approach to learning from and managing serious incidents as a result of feedback from families and staff. Trust committees and the trust board had sight of incident data. The trust took proactive steps to address themes identified and improve ways to share learning across services. A new serious incident scrutiny panel and serious incident team had been created to report findings from investigations to the board. The trust recognised there was still work to be done to embed and improve this process further.
  • The trust collected reliable data and analysed it. This was a significant improvement from the last inspection. Staff across most services could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Staff submitted data or notifications to external organisations as required. New ways of monitoring and addressing waiting lists had been implemented with evidence that many lists had reduced. This meant leaders were able to understand what was happening in their organisation and act when needed.
  • The trust had participated in some national improvement and innovation projects and undertook a wide range of quality audits and research. The trust was involved in 65 approved research projects during 2018-19 with 1800 people recruited over the year. The trust was recognised as being in the top 15 highest mental health organisations nationally for research recruitment. The trust had undertaken a quality improvement programme, steered by the Royal College of Psychiatrists, to reduce the incidents of restrictive interventions and restraints as part of a national programme. This was a significant piece of work which continued to have impact. The programme involved the patient voice who shared their experiences with staff. This success has been recognised by the Royal College of Psychiatrists who are leading the national programme.
Inspection areas

Safe

Requires improvement

Updated 15 January 2020

Our rating of safe improved. We rated it as requires improvement because:

  • Staff had not always followed best practice when storing, dispensing and recording medication in six out of the eight core services. Internal audits were not effective in identifying concerns. This was raised as a concern following the last inspection in 2018. Medication management across five of the eight services we inspected was poor, despite reported trust oversight and audit. For instance, the hospital carried out internal audits which did not identify the concerns we found on inspection relating to errors.
  • Staff did not always fully complete or update risk assessments for each patient in the community adult community service and specialist children and adolescent community services. This was raised as a concern following the last inspection in 2018.
  • The environment in the learning disability inpatient service was not safe or fit for purpose. The trust had made little attempt to remove or reduce the number of ligature points or improve lines of sight. We had identified in the last inspection that not all wards were safe and fit for purpose.
  • The trust missed opportunities to prevent or minimise harm. For instance, staff did not ensure patient records in all section 136 suites were completed or added to the patient notes system in a timely manner. This posed a risk to patient safety. Staff did not consistently implement the smoke free policy. This led to patient frustration and increased risk of fire setting. Inspectors found cigarette lighters in patient rooms on two occasions during inspection. Lighters were not permitted on the wards but systems to prevent this were not always effective. We found that the management of patients on enhanced observations was not always robust within the inpatient wards with gaps being found in some documents. This posed a direct risk to patient safety.
  • The trust did not have sufficient staff in three core services, to effectively manage caseloads. This impacted on staff ability to carry out tasks such as record keeping, one to one sessions, physical health checks, and update risk assessments. There was a lack of suitably qualified medical staff within the crisis and home treatment teams. The trust had not ensured that sufficient numbers of suitably qualified staff were available in all teams to meet the needs of people who used the service. In August 2019, there were 34 occasions, in Norfolk crisis teams, where staff had not been able to assess patients within the four-hour emergency target due to staffing levels. The trust had not ensured that sufficient numbers of suitably qualified medical staff were available to meet the needs of people who used the service.
  • Equipment was not always maintained, and staff were not always completing checks on automated external defibrillators in community teams.

However:

  • Staff had made significant improvements in reducing restrictive interventions within the acute wards for adults of working age and psychiatric intensive care units. Seclusion episodes had reduced and there was evidence of attempts by staff to use less restrictive interventions before considering the use of seclusion. Clinical documentation of seclusion episodes followed MHA code of practice guidance in most instances.
  • Staff completed risk assessments on all patients within the inpatient wards which were updated as required. We saw evidence that incidents were reviewed, and immediate learning was acted on and shared within the team.
  • Most of the premises were clean, well equipped, well-furnished and well maintained, with the notable exception of the learning disability inpatient service.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • Access to clinical information overall had improved.

Effective

Requires improvement

Updated 15 January 2020

Our rating of effective stayed the same. We rated it as requires improvement because:

  • Not all teams provided a range of treatment and care for patients based on national guidance and best practice. There were vacancies throughout teams in two core services which impacted on the ability to provide psychological therapies. Teams lacked sufficient psychology staff to provide the range of treatment recommended by the National institute for Health and Care Excellence guidelines. This was a concern raised at the last inspection.
  • Not all teams received supervision and appraisal as per the trusts’ policy. This was raised as a concern at the last inspection.

However:

  • We found an improvement in care plan completion and saw that most reflected current need, were personalised and individual to the patient.
  • Staff assessed the mental health needs of people on admission, and there were comprehensive physical health plans in most core services.
  • Staff knew and understood their role in compliance with the Mental Health Act and Mental Capacity Act. Staff routinely carried out capacity assessments where necessary and consent to treatment was recorded for patients in most services. The trust provided effective support and governance to ward staff with Mental Health Act compliance, and paperwork showed correctly completed documentation.

Caring

Good

Updated 15 January 2020

  • Staff showed caring attitudes towards their patients. We saw numerous positive interactions between staff and patients with complex needs and staff managed extremely challenging situations with knowledge and compassion. Staff demonstrated a respectful manner when working with patients, carers, within teams and showed kindness in their interactions.
  • Patients and carers gave positive feedback about the caring nature and kindness of staff and made positive comments about the therapeutic relationships they had with their loved ones. Patients had access to advocacy services.

However:

  • Stakeholder feedback told us that there were still times when patients where not spoken to with kindness and sometimes families told us there was a lack of communication.
  • Not all teams could show how they involved patients, parents, carers and nearest relatives in the design and delivery of the service.

Responsive

Requires improvement

Updated 15 January 2020

Our rating of responsive improved. We rated it as requires improvement because:

  • The design of the learning disability inpatient environment was not fit for purpose. It was not a therapeutic environment. The building was tired, poorly maintained and did not promote a welcoming or comfortable space for recovery.
  • Waiting lists within the children and adolescent community services continued to be high. Trust data at the time of inspection showed that 421 patients were waiting for assessment. Only 39% of referrals were seen within the trust target of ten working days, with 150 people waiting more than ten days. This was raised as a concern at the last inspection.
  • Some people waited over 12 months for assessment within the attention deficit hyperactivity disorder service. This team had just one nurse with a caseload of 175 patients with 120 people on the waiting list in August 2019. This had reduced to 80prior to the inspection in October 2019.
  • Two core services had significant waiting times for psychological therapies in most teams.
  • Discharge planning did not always contribute to patients staying out of hospital. There had been insufficient improvement within the acute and psychiatric intensive care service in the last 12 months. The number of readmissions had reduced on four wards but had increased on six wards.
  • Staff had not always communicated effectively when transferring patients from one ward to another. This impacted on patient experience.
  • There was not an effective system to record and review complaint outcomes and look at themes and trends. We saw plans to improve efficiency of the end to end complaint process, with plans to co-produce responses and a new electronic system had been approved, aimed at improving the recording and sharing of information in an effective and speedier manner. These initiatives were yet to be implemented. The trust also confirmed there was a backlog of complaints. Complaints were not responded to in a timely manner with just 28% of complaints being resolved within target. We saw improved involvement with patients when responding to complaints and a new process for tracking and logging complaints was in place.

However;

  • The trust was able to demonstrate how they responded to emergency and urgent referrals. Whilst we saw there remained breaches of targets, we also saw there was a reason given and a review undertaken when targets were missed. The process was an improvement from the last inspection.
  • Bed management had improved. Figures provided by the trust demonstrated that the number of patients using out of area beds had significantly reduced since April 2019 which, at that time, had high numbers of patients placed out of area. However, further work was required to embed changes and improve this further so that beds were available not just within the trust but within the town closest to the patient’s home.
  • The trust had taken positive steps to reduce all other waiting lists and this had been successful in reducing waiting times, particularly within older peoples and adult community services. The trust had implemented a weekly ‘tracker list’ meeting and system to monitor patient waiting times, and ensure clinical priority was considered. This was undertaken for all services.
  • The trust met the needs of all patients including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. 
  • We saw that people using the older people’s community service, could access the service easily. Its’ referral criteria did not exclude patients who would have benefitted from care. Staff assessed and treated patients who required urgent care promptly and patients who did not require urgent care did not wait too long to start treatment. Staff followed up patients who missed appointments. The service had significantly reduced the waiting times for patients to be assessed and commence treatment following referral since the last inspection.

Well-led

Requires improvement

Updated 15 January 2020

Our rating of well-led improved. We rated it as requires improvement because:

  • The trust board and senior leadership team were newly formed. At our inspection in 2018 we had significant concerns about the safety, culture and leadership of the trust. Since then, there had been a change in leadership. At this inspection, we found that although some of the concerns had not fully been addressed, there had been a shift in approach and foundations had been laid to improve the direction of travel. We saw early improvements in almost all areas, but there had not been enough time to judge if these changes would be sustained. For instance, recent changes to the leadership structure had not yet embedded throughout the whole organisation and there was still a small amount of key posts to be filled. We saw early improvement with the trust moving in the right direction, however, there was still work to be done.
  • Some stakeholders did not yet feel that changes had truly benefited all patients, with feedback advising that some still did not feel listened to, with poor communication being a key feature of feedback from patients or their families. Equally, a lack of access to attention deficit hyperactivity disorder (ADHD) services and specialist children and adolescent community services (CAMH) was raised as a concern by stakeholders. We found that this aligned with our findings at this inspection.
  • Despite improved recruitment outcomes, we remained concerned about staffing, specifically within the CAMH community service and Adult ADHD team. Also, some Norfolk crisis teams were not meeting the target to see people within four hours with staffing being cited as the reason in 34 of the 46 breaches. Managers did not have effective oversight of medicines management and checking of emergency equipment across in six of the eight core services we inspected. This had not been identified as a concern by the trust.
  • Managers did not have effective oversight of medicines management or checking of emergency equipment in six of the eight core services we inspected. Despite increased assurance work and an improved board assurance framework, medicines management issues we found had not been identified as a concern by the trust.
  • Our findings from the other key questions demonstrated that while governance processes had improved, they had not yet fully ensured that performance and risk were managed well. Not all of the previous areas of concern had been addressed. Staffing levels were not sufficient in all areas. Some Norfolk crisis teams were not meeting the target to see people within four hours. Medication management required further work. The trust risk registers did not reflect all the concerns that we found regarding staffing levels, missed targets, record keeping and medication management.
  • We raised concern about the effectiveness of systems to ensure learning took place across core services as appropriate. The quality assurance committee and trust board had sight of serious incident data. We saw similar themes and recommendations identified from serious incident reports such as poor documentation in clinical records. At the time of inspection there were 161 serious incidents open to the team. There were 80 serious incident actions outstanding, meaning that the recommendations and actions had not been signed off as completed within the services they related to.  
  • Morale remained low in some services such as inpatient wards and some community services at Bury St Edmunds, learning disability inpatient services and some children and young people services in Suffolk. In these services staff did not always feel listened to and expressed concern that care was not improving at a pace they would like. This was supported by core service findings in these areas.  
  • The trust had not yet addressed all the concerns raised in previous inspections.

However:

  • We saw early improvements in almost all areas, (such as the points below) but there had not been enough time to judge if these changes would be sustained. For instance, recent changes to the leadership structure had not yet embedded throughout the whole organisation and there were still a few key posts to be filled. We saw early improvement with the trust moving in the right direction, however, there was still much work to be done.
  • The trust quality improvement plan (QIP) had been revised and aligned to the new strategy. Further development work was ongoing supported by NHS Improvement/England to develop the reporting and monitoring aspects of the plan. 
  • Since the last inspection the trust had implemented a new quality strategy to include quality improvement (QI) as a core component within their strategic direction. One hundred and eighty-seven staff had completed the three-day improvement leaders programme and were developing initiatives within local teams designed to improve care. Some of these initiatives had been identified as important by the local service users in line with leaders increased focussed on service user participation and co-production. We saw some of these initiatives within the local teams and noted increased efforts made to engage and listen to the service users voice. Staff across services told us that they were involved in the planning and delivery of their own service.
  • The trust had undertaken a quality improvement programme, steered by the Royal College of Psychiatrists, to reduce the incidents of restrictive interventions and restraints. This was a significant piece of work which continues to have impact. The programme involved the patient voice who shared their experiences with staff. This success has been recognised by the Royal College of Psychiatrists who are leading the national programme.
  • The trust had a ‘putting people first’ strategy aimed at improving service user participation with a key aim to facilitate cultural change and de-centralise decisions. Concerns had been raised about organisational culture in the last four inspection reports, and the 2018 inspection report identified concerns that there was widespread low morale with staff feeling ‘done to’.  Following the 2018 inspection, the trust leadership team undertook (and continued to undertake) a range of engagement visits to services ensuring they were accessible to staff, although some staff reported that were unaware of visits to their services. At this inspection, more staff reported a sense of optimism and hope that real change was happening. More staff felt listened to, felt they could influence change, felt supported and had good working relationships with their managers.
  • The trust had worked hard to ensure that the service user voice was integral to care delivery. The new people participation lead was one aspect, however there were numerous initiatives underway to increase the service user voice in all areas of the organisation. This was beginning to develop and grow.
  • The trust had improved how they collected and used information and data to consider its performance. New ways of monitoring and addressing waiting lists had been implemented with evidence that many lists were reducing. The trust data was more reliable than we found in the 2018 inspection. This meant leaders were able to understand what was happening in their organisation and act when needed.
  • We saw improvement of learning from lessons within local teams immediately following an incident. We saw the use of reflection, safety huddles, debrief and early learning took place with action taken to improve practice.
  • The trust had participated in some national improvement and innovation projects and undertook a wide range of quality audits and research. The trust was involved in 65 approved research projects during 2018-19 with 1800 people recruited over the year. The trust was recognised as being in the top 15 highest mental health organisations nationally for research recruitment. 

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

  • Our rating of this service improved. We rated it as requires improvement because: 
  • Staff did not always complete hourly observations in line with Trust policy. We found missing signatures on observation sheets and gaps in observations on four out of five wards that we checked. We could not be assured that observations were being completed correctly which could have an impact on patient safety. 
  • Staff did not always follow systems and processes when safely prescribing, administering, recording and storing medicines or completing daily and weekly checks of emergency equipment. Patients could be at risk of harm if medications are not safely prescribed. 
  • There were vacancies for psychology staff in Suffolk. Patients in Suffolk were not able to access adequate psychological therapies in accordance with National Institute for Clinical Excellence guidelines. 
  • The planning of patient’s discharge did not always contribute to people staying out of hospital.  The total number of readmissions within 28 days had not changed significantly since the last inspection from 253 to 245 readmissions. The number of readmissions to any ward had decreased on four wards but had increased on six wards. The trust told us that the readmission rates were slightly better than the national average.
  • Managers did not provide consistent support to staff to implement the trust smoke free policy 

However: 

  • Ward staff participated in the provider’s promoting positive practice strategy and there had been a reduction in the number of episodes of restrictive practice, including restraint, across all wards. 
  • Staff had made improvements to care planning since the last inspection. We reviewed 78 care records and found that staff developed individual, holistic care plans through co-production with patients and their carers.  
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.  
  • The trust had developed a system-wide action plan and opened a new ward to address the high number of out of area placements which was a concern at the last inspection 
  • The trust had introduced a quality improvement leadership programme for staff at all levels and, as of September 2019, had trained 200 staff.  
  • Most of the staff we spoke with felt that the culture of the trust was improving.  Staff felt more listened to, more positive about working for the trust and that senior managers were more visible. 

Community mental health service for adults of working age

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

  • Staff did not always update risk assessments routinely or after incidents at all teams; we found this in 20 out of 57 records reviewed. We found out of date risk assessments at North Norfolk CMHT and Bury South IDT by up to four years. We found one patient who had been referred to Norwich City CMHT in January 2019 did not have a risk assessment or care plan present. Not all care plans were reviewed regularly and not all were up to date. We reviewed 57 care and treatment records. We found two patients at Norwich City CMHT and one patient at North Norfolk CMHT did not have a care plan present. 
  • We found that the recording of physical health was poor across most adult community teams. We reviewed 49 care records in this area, 30 of these records did not have physical health assessments recorded and 25 had no evidence of ongoing physical health monitoring. At Waveney CMHT we saw evidence of recording physical health checks on paper, but this was not transferred to their electronic system. 
  • There were waiting lists across all community sites for psychological therapies. Waiting lists for psychological therapies ranged from six and half weeks to one year. Staff told us they did not feel there was enough psychology staff which impacted on rising caseloads. 
  • We found staff at North Norfolk CMHT had not ensured medical equipment had been regularly checked or cleaned. Medicines management systems did not always adhere to trust guidance and policy. We found issues with stock management, poor oversight of clinic rooms and access to keys for medicine cabinets. 
  • The ligature risk assessment at Bury South IDT did not capture all risks in each room.
  • Managers at Norwich City CMHT had little oversight of caseload allocation of incoming referrals. The referral process did not ensure equity of caseloads for staff. To ensure there was no waiting list for allocation, all new referrals were allocated immediately resulting in high caseloads ranging from 11 to 70 with an average of 47 per care co-ordinator. Staff told us they were unaware of trust plans to review the process, however the trust shared information on how they were acting to address caseload concerns. This demonstrated there was a need to ensure there was improved communication between managers and the staff teams. 
  • Suffolk staff reported a disconnect between them and higher senior management. Some community service staff within Suffolk teams said that they felt communication and visibility of higher senior management was poor.  
  • There was inconsistency with what was placed on the risk register. For instance, demand and capacity had been highlighted on the risk register in Norfolk community services, however, Suffolk services experienced the same issue and it had not added to their risk register.  
  • Managers had not reviewed capacity versus demand for services in the adult community mental health services, consequently the staffing establishment was based on a significantly lower number of open referrals to their services than the number of open referrals they had.  

However: 

  • The number of patients on the waiting list had reduced and there was an improved system for monitoring patient waits. We saw systems in place to ensure those patients waiting were reviewed and emerging risks were identified earlier than before. 
  • Most clinical premises where patients received care were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding. This was an improvement since our last inspection.  
  • Staff provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided. 
  • We saw effective multi-disciplinary working to benefit patients. The teams had effective working relationships with relevant services outside the organisation. 
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. 
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. 
  • The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude patients who would have benefitted from care. 

Wards for older people with mental health problems

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

  • The service provided safe care. The ward environments were safe and generally clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding. 
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff had engaged in clinical audit to evaluate the quality of care they provided. 
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare. 
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983. 
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. 

However;  

  • The environment on Laurel ward, Abbeygate did not meet dementia friendly environment guidance. 
  • Managers did not have oversight of contract cleaning schedules on Maple ward, Abbeygate to ensure appropriate levels of cleanliness and infection control. 
  • Managers did not ensure that staff recorded capacity and best interest decisions on the correct document named in the trust policy. 
  • There were gaps in medicines administration records and clinic room checks on Abbeygate ward which meant that medicines related policies were not being followed. 

Mental health crisis services and health-based places of safety.

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

  • The trust had not ensured that sufficient numbers of suitably qualified staff were available in all teams to meet the needs of people who used the service. In August 2019, there were 34 occasions in Norfolk where staff had not been able to assess patients within the four-hour emergency target due to staffing levels. The trust had not ensured that sufficient numbers of suitably qualified medical staff were available to meet the needs of people who used the service. 
  • We reviewed 18 care records of patients using health-based places of safety. For ten patients who had used the section 136 suites at West Suffolk Hospital and Northgate Hospital there was a lack of contemporaneous records on the electronic recording system.  
  • The service had systems in place to safely prescribe, administer, record and store medicines but they did not always reflect local practice and staff did not always follow them. Each area conducted audits of prescription charts, but the audit process was inconsistent between teams and the good practice seen in some areas was not shared.  The number of errors we found in some teams showed that the audit process was not effective in identifying and addressing gaps in recording.  
  • The crisis teams in Norfolk had not always met the target for seeing patients within four hours of receiving an emergency referral. Throughout 2019, the trust had not met its own target of 95%. The health-based places of safety were not always available when needed in West Suffolk.  
  • Our findings from the other key questions demonstrated that while governance processes had improved they had not yet fully ensured that performance and risk were managed well. Not all the previous areas of concern had been addressed. The corporate risk register did not reflect the concerns that we found regarding staffing levels, missed targets, record keeping and medication management. 
  • Managers in Norwich told us that while staff morale had improved it was not yet good, and that a positive culture was not fully embedded across the service. The trust needed to continue to develop communication across all staff groups.  
  • Some stakeholders had identified negative feedback from some patients regarding responsiveness and attitude of some staff. Whilst it was evident that work had been undertaken to address the culture of the organisation, this was evidence that more work was required.  

However: 

  • Overall management of referrals and waiting times had improved. For example, managers had developed an electronic dashboard which showed them when patients had accessed the service, when referral to treatment targets had not been met the and the reasons for this. This allowed managers to support their teams to mitigate the risks to patients. Incidents were reported, investigated and learned from. 
  • Clinical premises where patients were seen were safe and clean and the physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice.  
  • The number of patients on the caseload of the mental health crisis teams, and of individual members of staff had reduced since our last inspection and was not too high to prevent staff from giving each patient the time they needed. Staff ensured that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding. 
  • Staff working for the mental health crisis teams developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided. 
  • The mental health crisis teams included or had access to the full range of specialist staff required to meet patient’s needs in line with the current standard operating procedure for the crisis pathway. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.  
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. 
  • Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff. Staff knew and understood the provider’s vision and values and felt respected, supported and valued.  
  • Staff collected analysed data about outcomes and performance and engaged actively in local and national quality improvement activities. 

Community based mental health services for older people

Our rating of this service improved. We rated it as good because: 

  • The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding. The trust now had environmental risk assessments, including ligature risks, in place across the service where patients were seen on trust premises. 
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided. 
  • The teams included or had access to the full range of specialists required to meet the needs of the patients. The trust had actively recruited psychologists and occupational therapists into teams. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation. 
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. 
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. 
  • The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude people who would have benefitted from care. The service had significantly reduced the waiting times for patients to be assessed and commence treatment following referral since the last inspection. 
  • The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly. 

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

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

  • Staff assessed and managed risks to patients and themselves. They responded promptly to sudden deterioration in a patient’s health. When necessary, staff worked with patients and their families and carers to develop crisis plans. Staff monitored patients on waiting lists to detect and respond to increases in level of risk. Staff followed good personal safety protocols. 
  • Staff took a function-based approach to assessing the needs of all patients. They worked with patients, families and carers to develop individual care plans and updated them as needed. Care plans reflected the assessed needs, were personalised, holistic, function-based and recovery-oriented. 
  • Staff provided a range of treatment and care interventions that were informed by best-practice guidance and suitable for the patient group. They ensured that patients had good access to physical healthcare and supported patients to live healthier lives. 
  • Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. 
  • Staff had the skills, or access to people with the skills, to communicate in the way that suited the patient. 
  • Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, were visible in the service and were approachable for patients and staff. 

However: 

  • The service did not meet the trust’s target time of 12 weeks from referral to assessment. Patients were waiting for up to eight months for an assessment by the autism child and adolescent mental health team and up to nine months for an assessment by the autism adult team. Patients were waiting for over 12 months for an assessment by the attention deficit hyperactivity disorder adult team who had just one qualified nurse managing a caseload of up to 175 patients and a waiting list of 120 patients for over a year. The Waveney adult team and the Ipswich adult learning disability teams did not achieve supervision rates above 75 percent for their staff between July 2019 and September 2019. 
  • The Waveney adult team and the Ipswich adult learning disability teams did not achieve supervision rates above 75 percent for their staff between July 2019 and September 2019. 
  • The décor at the Waveney adult and child and adolescent service was tired, had peeling paint on its walls and required updating. 

Wards for people with a learning disability or autism

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

  • The trust had made little attempt to remove or reduce the number of ligature points in the bungalows, though this issue had not been raised in the previous inspection report. Bedrooms had several ligature points and no clear lines of observation from the corridor.  
  • The fence around the garden area created a potential safety risk. Patients could climb over the fence and abscond or attempt to climb the fence and injure themselves. There had not been any reported serious incidents relating to this risk.
  • The design and safety of the bungalows did not support patient’s treatment. It did not enable patients to develop their optimum level of independence or effective independent living skills. The environment was not homely, and décor was tired and dated. 
  • The design of the buildings used for learning disability inpatient services, meant one patient was cared for on an alternative ward, which was not a ward that was designed to meet their individual needs.  
  • Staff had not picked up a medicine error as part of their medicines check and audit. The administration of PRN medication was an issue reported on at a previous inspection, the trusts action plan for this was that the clinical team lead would ensure that PRN medication was being given appropriately, monitored and recorded.  
  • Staff found it difficult to locate care plans and risk assessments on the electronic system. There were numerous different care plans in different places on the electronic system. To overcome this staff kept summarised paper copies as well. This meant that staff could miss key information. Staff may not always have all the information they needed to implement or update care plans. 
  • There were no nurse call bells in any patient areas, patients could not summon help in an emergency. 

However: 

  • This core service overall rating of requires improvement remained the same as the last inspection. Effective, caring and well led had improved from requires improvement to good, while safe went down from requires improvement to inadequate and responsive went down from good to requires improvement.  
  • Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviours that staff found challenging. Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability and or autism. Treatments were in line with national guidance about best practice.  
  • The care team included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with those people in other services who would have a role in providing aftercare. 
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. 

Specialist mental health services for children and young people

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

  • The trust had not fully addressed all issues reported at previous inspections. We rated responsive and well-led as inadequate. We rated safe and effective as requires improvement and caring as good. 
  • The trust had not addressed all actions identified at the inspection in 2018.These related to ensuring adequate staff available to reduce the patient waiting lists for triage, assessment and treatment, staff, for engagement of staff in development of the service in Suffolk, regular line management, clinical supervision and appraisal, risk assessments and infection control.  
  • The trust had not ensured adequate staffing to meet the needs of the service. This meant staff had extra pressure on them to deliver a better service without much additional resources. 
  • We continued to find examples of backlogs where patients waited a long time before receiving triage, assessment and treatment.  
  • The multi-agency ‘emotional well-being hub’ team triaged referrals for young people needing health or social care across Suffolk. They had reduced the number of patients awaiting triage from our 2018 inspection from 394 to 389. We found examples where staff took more than the trust target time of 28 days to contact patients and then direct them to the right service. Children and family and youth teams gave examples where assessments were not adequate which meant more work was required to effectively screen referrals. 
  • Staff had not fully completed or updated 28 patients (39%) comprehensive risk assessments. Staff did not always complete a comprehensive mental health assessment of each patient who were receiving treatment as 15 care plans (21%) across teams needed improvements. Staff in Norfolk and Suffolk still had different systems for assessing and monitoring risks for patients awaiting assessment.  
  • We found risks to patients’ safety as staff did not always identify and report safeguarding concerns. Haverhill, Sudbury satellite clinics and North Bury did not have separate children waiting areas.  
  • Thirteen of 19 patients (68%) and 21 of 45 (47%) carers gave negative feedback about the support provided. Feedback themes included a lack of support when they contacted teams for help during a crisis and a lack of information or communication.
  • Trust systems for engaging patients, carers, staff and stakeholders in the development of the children and young person service were not fully effective as we received concerning feedback about the accessibility and communication of the service. Staff at Ipswich youth did not record informal complaints and there was no evidence of how these were resolved. Responses were not always timely. 
  • The trust had not supported new managers (particularly in Suffolk) to help them access key performance indicator data, which posed a risk they would not have clear information to be able to check how their team was performing. We found pockets of low staff morale, for example, in Ipswich, South Bury and Central Norfolk teams. 
  • Improvements were still needed to ensure a safe and clean environment. Staff were not completing checks of automated external defibrillators at South Bury IDT and Ickworth Lodge locations. We found examples where teams were not routinely monitoring cleaning of rooms and equipment. The trust had not completed accurate ligature assessments at South Bury, Great Yarmouth, Waveney and West Norfolk teams, which captured all potential risks. This meant staff would not be aware of all areas which needed more supervision.  

However: 

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. 
  • The trust had made extensive changes to the leadership and were changing their systems for monitoring, assessing and mitigating the risks to patients. The trust now had two care groups for children families and young people services across the trust to give clearer accountability and oversight of this core service. The trust had improved the quality of their risk registers with more identification of the service risks. The backlog of patients waiting for treatment had reduced. The culture of children and young people’s services had changed since our 2018 inspection. Staff told us their morale was improving and they were more hopeful that trust changes would make the service better. 
  • Staff provided a range of treatment and care for patients based on national guidance and best practice. We found examples of staff using the ‘THRIVE’ integrated, person-centred and needs-led approach. Staff used recognised rating scales to assess and record severity and outcomes such as Routine Outcome Measures (ROMS). They supported patients to live healthier lives. 
  • The trust had involved patients and staff in the development of Kingfisher ward their mother and baby unit. 
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice. 

Checks on specific services

Community-based mental health services for adults of working age

Requires improvement

Updated 15 January 2020

The summary for this service appears in the Overall Summary of this report.

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

Requires improvement

Updated 22 October 2021

We carried out this unannounced, focused inspection of Southgate Ward because we received information giving us concerns about the safety and quality of the services.

Norfolk and Suffolk NHS Foundation Trust provides services for adults and children with mental health needs across Norfolk and Suffolk. Services to people with a learning disability are provided in Suffolk. Southgate Ward is a mixed sex acute admissions ward, with 16 beds, for acutely unwell adult patients. This ward is based at Wedgwood House in Bury St Edmunds, Suffolk. The ward is included in the Trust’s portfolio of acute wards for adults of working age and psychiatric intensive care units.

We did not inspect the other acute wards within the trust because we were responding to concerns raised specifically about Southgate ward. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

We did not rate this service at this inspection. The previous rating of requires improvement remains.

We found:

  • Staffing was challenging for this service. On the day of the inspection, we were shown rotas that indicated there were a number of occasions where the staffing levels on the ward fell below the safer staffing levels set by the Trust. Following the inspection, the Trust told us that, on these occasions, managers moved staff from other wards or deployed the unit duty senior nurse onto the ward. All the staff we spoke with told us it was a challenge to provide quality care, spend one to one time with patients and keep patient care plans updated.
  • The service did not always have enough staff on each shift to carry out any physical interventions safely. Staff had not completed and were not up to date with mandatory ‘Prevention and Management of Aggression (PMA) – Physical Intervention training’. At the time of the inspection, the ward manager provided evidence that only 11% of staff were up to date with physical intervention training and 63% of staff were up to date with personal safety training. Following the inspection, the Trust told us that due to an error in their recording system, the actual compliance rate for PMA training was 34%
  • Managers did not always support staff through regular, constructive clinical supervision of their work. At the time of the inspection, the supervision compliance figure for Southgate was 47%. At this time there was increased acuity on the wards and staff would have particularly needed support to prevent burnout and a culture where poor practice could develop. The Trust told us they provided others systems of support for staff such as multi-disciplinary team discussions, reflective practice sessions and awaydays.
  • Staff did not always follow trust policies and procedures when they needed to search patients, or their bedrooms, to keep them safe from harm.

However:

  • Managers deployed staff to ensure that general and enhanced observations were prioritised to keep patients safe. Managers checked that staff were carrying out observations as per the therapeutic observation policy and patient care plans.
  • Patients we spoke with told us that, despite being very busy, staff were polite, kind and caring.
  • The local leaders we spoke with demonstrated the Trusts’ core values.

How we carried out the inspection

During the inspection we:

  • Spoke with the ward manager for Southgate Ward and the modern matron.
  • spoke with five staff
  • spoke with three patients
  • looked at six care and treatment records
  • reviewed staffing rotas
  • reviewed observation records
  • and reviewed a range of policies and procedures, data and documentation relating to the running of the service.

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

What people who use the service say

We spoke with three patients. Patients we spoke with told us that staff were polite and kind and caring, but they were often very busy. All the patients we spoke with told us that there was a lack of activities to do on the ward.

One patient told us that they always felt safe on the ward. One patient told us that sometimes they felt unsafe when other patients were exhibiting distressed behaviours.

One patient we spoke with told us that they were given extra support to enable them to attend a medical examination

Mental health crisis services and health-based places of safety

Requires improvement

Updated 22 January 2021

Specialist community mental health services for children and young people

Inadequate

Updated 1 May 2020

This was a focused inspection looking at specific areas of concern. The inspection was of the CAMHS youth service located at St Stephens Road, Norwich. The ratings shown in the report are from the previous inspection of specialist community mental health services for children and young people across the trust which took place in October 2019.

At this inspection we found the following areas where the trust needed to improve:

  • We were not assured that patients who were on waiting lists for assessment or treatment were being adequately managed by the teams responsible for their care. Patients on those waiting lists were not always being adequately monitored or supported. Where a change in the patients’ individual risk was identified, their risk assessments were not always being updated. We also found some appointments and therapy groups being cancelled as there were not enough staff available. This meant that there was a risk that patients whose needs changed might not be identified or receive support in a timely manner.

  • Whilst the trust was working to rationalise the waiting lists in place and establish a principal list for each team, at the time of the inspection staff were still referring to numerous waiting lists. This was confusing, ineffective and did not ensure there was appropriate oversight for the teams.

  • The building at 80 St Stephens Road was not well maintained and the décor was shabby. Internet access at the time of the inspection was not reliable which meant that patient records were not always accessible.

  • Whilst the trust was refining its governance arrangements they were not yet working effectively for this service. The data on waiting lists needed improvement to ensure staff in the teams had the information they needed to meet the needs of the patients. The trust also needed to be assured that patients were being assessed and treated in a timely and safe manner. In addition, the meetings taking place in the service had been revised and needed to be embedded so they were working well. Staff particularly in the North team needed the support and guidance from leaders to use the new systems and processes.

However:

  • In response to the concerns raised within this report, the trust leadership team provided assurance of action which had begun just prior to the inspection. For instance, on 13 February 2020, an executive-led rapid improvement board had been established. This aimed to accelerate improvements and had increased senior leadership oversight. The care group leadership team were spending four to five days per week at St Stephens Road. We were told of plans in place to undertake a large scale clinical review of the waiting list in early March 2020. A review of the duty system and supervision processes were also planned. New terms of reference for leadership meetings had been agreed including a specific section on learning from incidents, complaints and inquests. A programme of site meetings was planned along with maintenance walkarounds. This had already seen the implementation of hygiene audits and projects identified to improve the environment at 80 St Stephens Road.
  • Recruitment into posts had begun and we saw key roles had been appointed to with plans in place for further recruitment. The trust had also increased senior management oversight to the service. This was an improvement on staffing which was of particular concern in the North team in December 2019.
  • Work had begun just prior to this inspection to pull all the waiting lists together and provide a clear view and understanding of action required. This was being developed as one service user tracker list (SUTL) to monitor all patients. This system had been successfully implemented in other teams at the trust. It involved a weekly meeting to discuss actions required for patients on the list.

Community-based mental health services for older people

Good

Updated 15 January 2020

Our rating of this service improved. We rated it as good because:

The summary for this service appears in the Overall Summary of this report.

Wards for older people with mental health problems

Good

Updated 15 January 2020

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

The summary for this service appears in the Overall Summary of this report. 

Community mental health services with learning disabilities or autism

Good

Updated 15 January 2020

The summary for this service appears in the Overall Summary of this report.

Wards for people with a learning disability or autism

Requires improvement

Updated 15 January 2020

The summary for this service appears in the Overall Summary of this report.

Long stay or rehabilitation mental health wards for working age adults

Requires improvement

Updated 28 November 2018

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

  • We observed a lack of learning from lessons or action taken from audit or incidents. There had been overall improvement in collating raw data, but this was not always translating into improving standards. We saw audit had been completed but conclusions and findings of the audits were not always turned into action.
  • The ward only accepted patients with low risk of self-harm or violence onto the ward. This was not the criteria reflected in the operational policy of the trust. It was not clear how the needs of the higher risk patient group were met, if rehabilitation was an identified clinical need. The policy referred to the service as an open rehabilitation environment but failed to specify the type of service as per best practice guidance. The operational policy required review.
  • We continued to see information stored in different places in the electronic care records. This meant that staff had to spend a lot of time finding the information they needed to do their jobs. We saw the trust had invested to improve capacity and efficiency and although the system froze fewer times than during previous inspections, it remained a concern.

However:

  • Staff were pro-active in discharge planning and ensured patients views were at the centre of the process. This was an improvement from previous inspections.
  • We saw that patients had access to local community services and were actively encouraged to access work and educational courses. There was also a strong occupational therapy presence to support patients with activities of daily living.

Child and adolescent mental health wards

Outstanding

Updated 28 November 2018

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

  • The Unit was exceptionally clean, bright, welcoming and well-maintained throughout. Patients were fully involved in designing and planning the further improvements which were being made to the outside area. Patients were protected by a strong comprehensive safety system: The unit had an up to date ligature risk assessment and staff mitigated risk on the unit by using relational security, positive behaviour plans and staff observation alongside convex mirrors and CCTV. The Unit had a positive, non-hierarchal culture where all staff were encouraged to express any concerns, and a focus on openness, transparency and learning when things go wrong.
  • The Unit had enough nursing staff to provide safe care. Staff found their jobs rewarding and felt valued, respected and supported by the unit manager. One staff member talked about how lucky they felt to work on the unit. Staff were encouraged to pursue personal and professional development opportunities and seek out, and implement, innovative and best practise, for instance by visiting other services and taking advantage of external training. Staff gave up their free time for the benefit of patients, for example by helping to organise a summer fayre.
  • The service provided age-appropriate structured and individualised therapeutic programmes, group activities including wellbeing and exercise, art therapies and education. Activities were offered in the evenings and at weekends. Staff prioritised daily 1-1 sessions with the patients and they had access to psychologists, occupational therapists, a social worker and a family therapist on the ward. The psychologists and family therapist worked across the ward and community to ensure continuity of care.
  • The Unit employed staff to prepare freshly cooked meals on site. Staff discussed with patients their dietary requirements and preferences, including working with them around making healthy choices. The menu was varied and interesting using fresh, locally sourced products. Baking was offered as a therapeutic activity and food tech was part of the education curriculum.
  • Care records were comprehensive, person centred, recovery focused and up to date. Care records showed that patients physical health care needs were assessed and monitored. Patients were fully involved in devising their care plans and were given an updated copy every week. Services were tailored to meet the needs of individual young people and were delivered in a way to ensure flexibility, choice and continuity of care.
  • Staff were knowledgeable about how both the Mental Health Act and Mental Capacity Act applied or not, to the young people they worked with. Staff sought appropriate consent from patients, for example Gillick competency for examinations and treatment. Staff had explained rights to patients detained under the Mental Health Act and repeated these at regular intervals. Patients had access to a social worker and advocacy and knew how to make a complaint if they needed to.
  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.
  • Feedback from patients and carers was continually positive. Both a patient and carer said that this was the best child and adolescent unit they had been to, that patients were safe and secure and staff took a collaborative approach and were genuinely caring ‘without exception’. Patients felt truly respected and valued as individuals and empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service.

Forensic inpatient or secure wards

Good

Updated 28 November 2018

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

  • Managers had completed detailed ligature audits and management plans. The trust had carried out work to reduce ligature risks on the wards.
  • Staff had completed detailed, holistic and person-centred care plans and risk assessments in patient records reviewed. Staff completed full physical health checks for patients on admission and patients had care plans to meet physical health needs.
  • Staff treated patients with kindness and respect. Patients told us that staff were very nice, helpful, open minded and friendly. We observed caring interactions between staff and patients. Staff involved patients in their care plans and risk assessments. Patients could give feedback on the service and their treatment and staff supported them to do this. Patients were involved in staff recruitment.
  • Staff supported patients to meet their goals, and made sure patients had access to opportunities for education and work. Examples included a patient completing a business degree and another working as a volunteer in a café. Patients had access to a recovery college and to light industry workshops on and off site. Staff supported patients to access activities in the community, including sailing, rambling and dog walking.
  • Managers of the service provided strong, local leadership. Managers used dashboard information to monitor and improve the performance of their teams. Team morale was positive. Managers ensured staff were supported in their roles through supervision, team meetings, reflective practice sessions and training.

However:

  • The trust had not ensured robust recording and learning from serious incidents. The trust had not shared learning from a patient death in 2014. There was a patient death in the forensic service in 2017. Both patients died after using the same style of ensuite door as a ligature anchor point. The trust were planning to pilot anti-ligature ensuite doors in new bathrooms but were not replacing existing ensuite doors. Staff had not recorded a serious incident that had occurred on Whitlingham ward in the patient’s progress notes. Details of the incident were not handed over to the next shift. Staff had not updated the patient’s risk assessment.
  • Staff did not always manage medicines and equipment safely. We found out of date medicines and medical equipment on five out of six wards. We found staff had administered as required medicines above prescription limits on two wards and had not always completed medicine administration records on one ward. Staff did not ensure that wards were fully equipped with accessible resuscitation and emergency equipment. Staff were not checking emergency bags and resuscitation equipment in line with trust policy on five out of six wards.
  • Seclusion was not always managed well. The trust had not ensured the seclusion room on Yare ward was free from hazards. Staff did not always follow the Mental Health Act code of practice for patients in seclusion and long term segregation. Reviews and observations were not carried out as required and staff had not instigated seclusion processes for a patient secluded in the courtyard.

Reference: not found

Requires improvement

Updated 18 June 2021

Inspection report