Tavistock and Portman NHS Foundation Trust

We have given an overall rating to Tavistock and Portman NHS Foundation Trust of good.

We have rated the three services that we inspected as good.

The trust has much to be proud of and also some areas that need to improve. The trust was well-led by the senior leadership team and board. There were many committed and enthusiastic senior staff throughout the organisation working hard to improve the delivery of psychological therapies, provide innovative services and national specialist services to children, young people and adults in out-patient and community settings.

The main areas which were positive were as follows:

• We spoke with very caring staff in all of the services and teams we visited. They were clearly sighted on and understood the needs of patients they worked with. We received a lot of very positive feedback from patients and parents about staff.
• There were several excellent examples of staff working in partnership with other organisations such as local schools, GPs and health visitors.
• Staff were receiving very regular supervision, which they felt was of high quality. Staff were up to date with mandatory training and described significant opportunities for further professional development. All staff received an annual performance appraisal.
• The staff provided patients with good quality psychological therapies. The psychological therapies provided were evidence-based. Some teams were undertaking innovative projects to enhance patient care and treatment or were involved in research.
• Most staff had a good understanding of safeguarding policies and procedures in respect of both children and vulnerable adults.
• The trust had recognised particular areas of local need and developed services to help meet those needs. For example, the excellent work with refugee communities.
• Staff and managers had worked to address equality and diversity issues in the trust work force as well as improve access to psychological therapies for under-represented groups.
• The trust had developed a number of creative and innovative initiatives aimed at involving patients in services and service development.
• There were very high levels of job satisfaction amongst staff in all teams we visited and in the trust as a whole.

There were some areas which needed improvement. The main areas for improvement were as follows:

• The documentation in relation to the risk assessment and risk management of patients was sometimes poor, particularly in the Portman clinic. Assessments did not always reflect actual risks. The local network involved in managing risks affecting patients was not always identified. Patients did not always have clear crisis plans in place that staff could find quickly in an emergency. Risk registers did not extend to team level which meant there was a risk that not all risks were being captured and reported at board level. In the Portman clinic adults and children and young people shared a waiting room. Despite mitigating action taken by the trust, this was not appropriate and potentially unsafe, especially given the risk histories and previous experiences of patients attending the clinic.
• Services were struggling to implement the new electronic patient records system. Some services were keeping both paper and electronic records for the same patient, some paper records were poorly scanned making them difficult to read, and one service had not yet implemented the electronic patient record system. There were risks to patient care from running paper and electronic records systems side by side. The quality of data extracted from the system was unreliable.
• The physical health needs of patients were not made a high priority. We noted the trust had recruited a physical health nurse one day a week, and was recruiting another, to improve the support offered to patients around smoking and alcohol use in particular. However, it was not clear that staff always considered the wider physical health needs of patients.
• The trust had not carried out infection prevention and control risk assessments in all premises where patients were seen. This meant the trust could not be confident that all infection risks were being managed appropriately.
• The trust had recently contracted a new independent advocacy provider. However, staff and patients were generally unaware of the service and we saw no advertising of the service in the areas we visited.
• There was much creative and innovative work taking place in the trust. However, there was a lack of agreed strategy or frameworks in place to support continuous improvement and ensure sustainability.

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

We rated Tavistock and Portman NHS Foundation Trust specialist community child and adolescent mental health services as good because:

• Compliance with mandatory training, supervision and appraisals was high and levels of staff turnover and sickness were low. There were excellent opportunities for training and development. All staff were trained in safeguarding children level three and had a clear understanding of safeguarding procedures. Staff had a good understanding of NICE guidance and each team had a NICE champion who kept them up to date with the latest guidance. Most staff understood how to report incidents. The number of serious incidents was very low.

• Services were meeting the target time of 11 weeks from referral to assessment and were usually completing assessments in less than eight weeks. Service managers ensured urgent referrals were seen quickly. Staff described effective communication and referrals between services, such as local schools, GPs and health visitors.

• The refugee service had a diverse staff group with a rich breadth of experience and cultural competence within the team. The service had done a lot of work to engage with hard-to-reach communities and families. The trust was involved in a project to provide services to young people aged between 16 and 24 who may have difficulty with transferring to adult services.

• Staff had good understanding of issues of consent and Gillick competence in their work with young people.

• All parents and young people said staff listened to them, were caring, open, positive and respectful. They found the service very helpful and described many positive changes that treatment had brought about. Parents could easily contact staff and Staff used a range of outcome measures with young people and parents.

• The trust website provided clear information about each service and contacts for self-referral. Waiting rooms for young people and adolescent across all sites were bright, colourful and spacious.

• Staff felt that colleagues valued each other and trainees told us that the wider team were aware of their role and that colleagues were supportive of them. Staff said they enjoyed and felt proud to work for the organisation and felt the trust had a strong identity.

However:

• Not all young people had an up to date current risk assessment present in their care records. Not all patient records contained accurate, up-to-date and complete information about the young person’s plan of care. Staff were struggling to use the new electronic patient care record system. There were inconsistencies in the recording of information, staff did not always know where to record information and it was difficult to read historical information recorded prior to the change in records system.

• Staff were not always clear how they should share crisis plans with young people and their parents. Some young people and parents were not aware who they should contact in a crisis.

• There was no formal schedule for cleaning toys to reduce the risk of spread of infection between young people who used the toys.

• Staff did not routinely assess young people’s physical health. Staff assessed smoking and alcohol intake for young people over the age of 14, although not all records contained these assessments.

• Most parents, young people and staff were not aware of the independent advocacy service. The advocacy service was not advertised in waiting rooms. Information about how to complain was not available in waiting rooms for young people. Information was not readily available in accessible formats for younger children or for young people with learning disabilities.

We gave an overall rating for specialist psychological therapy services as good because:

• The staff provided patients with good quality psychological therapies. Therapists were well qualified and experienced.Therapists undertook a comprehensive assessment of each patient at the initial assessment and corresponded regularly with referrers. The psychological therapies provided were evidence-based. The City and Hackney primary care psychotherapy consultation service (PCPCS) had won a major award in 2015 for their creative approaches to working with people with medically unexplained symtpoms. The PCPCS provided groups tailored to the needs of the local Turkish speaking population and other black and ethnic minority groups who traditionally did not use psychological therapies. Some teams were undertaking innovative projects to enhance patient care and treatment or were involved in research.

• Despite high demand, the services generally managed patient referrals well. Staff assessed most patients promptly. When this was not possible, staff reviewed patients who were waiting and offered support. Teams took action to follow up patients who did not attend appointments.

• The trust supported staff well. This was reflected in the annual staff survey which showed that the trust scored amongst the top 20% of trusts on most measures. There were few vacancies, a low staff turnover and low rates of staff sickness. Managers ensured that staff received ongoing specialist training, supervision, appraisal and professional development.

• Most patients had positive experiences of care. Staff were caring, friendly and dedicated and gave patients opportunities to engage in groups and provide regular feedback to the trust about their experience. Few patients complained about the service.

• The services had a good safety record. There had been very few incidents in the last 12 months. Staff knew how to report incidents. The trust highlighted lessons learned from incidents in the quality newsletter, at mandatory in-service training sessions and at team meetings. The care environments were safe, well maintained and visibly clean.

• Overall the teams were well-led and managers were very experienced.

However:

• Risk assessments and risk management plans were not always robust. At the Portman clinic, which cared for the most high risk patients in the trust, care records lacked vital information about the risks affecting patients and how the risks were being safely managed. This lack of information put staff and others at risk. Care records lacked important correspondence from external agencies. In some services patients did not always have individual crisis plans to mitigate risks to patients in a crisis readily available to staff

• The Portman clinic did not offer separate waiting rooms for children and adults. Due to the nature of the service and the background of the patients that attended the clinic, a shared waiting room put young adults and children at risk of harm. Despite mitigating action taken by the trust, this was not appropriate and potentially unsafe.

• The provider had not carried out infection prevention and control risk assessments in premises where patients were seen.

• Not all teams were using the new electronic patient records system. Records of children and young people using services at the Portman clinic did not demonstrate that issues of capacity or Gillick competence had been discussed or assessed.

• The Portman clinic was not accessible to people with disabilities who would benefit from group therapy. Individual therapy could be offered in another building.

We rated the gender identity development service as good because:

• Children and young people received care delivered by a skilled multi-disciplinary team who were supported to develop specialist skills and knowledge.

• Managers provided staff with frequent and effective supervision and supported the staff team through regular meetings, appraisal and reflective practice groups. The team was cohesive and proud to work for the trust.

• Most young people and family members were extremely positive about the support which they received from the service.

• The service worked to address risk and recognised safeguarding concerns where they arose.

• There was a very strong focus on research and using evidence based practice as well as extending the research base and evidence within this specialist area. Clinicians had opportunities to attend and contribute to international conferences and publish research findings. They also carry out service-specific audits with a focus on improving the outcomes for children, young people and families who used the service.

However:

• While staff understood the importance of risk assessment and management and told us they reviewed risks regularly, this was not always recorded in detail in young people’s records.

• Some parents told us that they did not receive clear information about the pathway, and care and treatment plans within the service.

• There had been some breaches of the 18 week waiting time between referral and assessment. The number of breaches had increased over the past year due to the increase in referrals.

• Some parents and carers were reluctant to make a complaint as they feared this would affect the treatment of their child. We found no evidence to suggest this was the case but staff had not been proactive in encouraging complaints or providing reassurance.