All inspections: Oxford Health NHS Foundation Trust

The date of assessment 20, 21, 27 and 28 November2024.

Oxford Health NHS Foundation Trust provides forensic/secure inpatient services for adults with mental health conditions. Patients are detained under the Mental Health Act 1983. The trust provides 153 inpatient beds across three sites, one in Oxford, one in Aylesbury and one in Milton Keynes. Littlemore Mental Health Centre in Oxford includes the Oxford clinic The Oxford Clinic has 3 medium secure wards for men. On the same site there are 4 other wards, a low secure ward for men, a Pre-discharge unit for men and women and Thames House which has two low secure wards for Women. Buckingham health and wellbeing campus has a male low secure unit and in Milton Keynes there are two male medium secure wards.

During this comprehensive inspection, we visited Kennet Ward, Kestral Ward, Kingfisher Ward and Evenlode ward at the Oxford clinic, Woodlands Ward at Aylesbury and Watling ward and Chaffron ward at Marlborough House in Milton Keynes.

During this comprehensive inspection we assessed all quality statements from the 5 key questions and found areas of good practice. We rated the service as good overall.

The senior staff team were felt to have strong presence on the wards. However staff told us that ward managers were not always present on the wards.

Ligature risk assessments were not easy to access by the staff and staff could not always tell us what the environmental risks were, and how they were working to mitigate these risks. This also meant that there was a risk that new agency or bank staff who were not familiar with the ward environment would not be shown how to successfully manage environmental risks.

The approach to managing blanket restrictions could be strengthened and we found it was being managed at senior management level rather than at a local level. This meant that staff on the wards were not always in charge of the decisions around blanket restrictions.

There were some environmental challenges that were evident in the Kennet and Kestral ward seclusion areas. Although the seclusion and long term segregation environments met the code of practice, the issues we found had a negative impact on the patients using these areas. Some patients had to request staff to let them in and out of their bedroom corridors and patients in seclusion could be seen from the corridor.

The environment at Woodlands House Aylesbury needed reviewing. The therapy rooms did not offer privacy and dignity to patients. There was a lack of natural light in the seclusion room and ability to observe a clock. We found garden areas across the services that we visited were very bland and were not seen as therapeutic spaces by the patients and staff. This was also noted at the two wards at Marlborough House. We raised this at our last inspection in 2019 and during this inspection we found this had not improved.

However, we saw strong multidisciplinary working. For example, the provider offered holistic therapeutic groups like the women’s group at Thames house which brought together elements of occupational therapy, nursing and psychological therapy. Patients had good access to various therapeutic interventions by specialists both in a group and one to one setting.

The provider had made positive progress with their international recruitment campaign and this had improved the consistency of staffing. Both patients and staff told us this had been beneficial in forming therapeutic relationships and improving relational security.

Improvements had been made to the cohesion of the multidisciplinary team and we saw consistency and transparency in the reporting of incidents of abuse.

We observed good management and auditing of restrictive practices across the wards. The teams on the medium secure wards worked with patients to reduce restrictive interventions and we saw that on Chaffron ward this had worked particularly well.

On Evenlode ward, staff used a tailored approach towards supporting the patient group and we observed good examples of this in practise.

The senior leadership team had good oversight of the wards and a good understanding of the challenges within the services and priorities for improvement. There was evidence of good oversight of the individual patient risks and environmental concerns.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Our rating of this service stayed the same. 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.
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. 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 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 was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

Staff had not consistently assessed and recorded capacity clearly for patients who might have impaired mental capacity.

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

Since the last inspection in 2018 the trust has continued to make improvements despite facing some challenging funding issues. An independent report on the level of funding for mental health services in Oxfordshire (commissioned by Oxfordshire CCG, NHSE/I and OHFT) determined that there was a significant funding shortfall in mental health services. A further review carried out by Oxfordshire CCG highlighted a £12m shortfall in mental health funding but also a £10m shortfall in funding for community services. The shortage of funding has required an additional level of dedication and capability from the trust leaders and all the staff to maintain the capacity and quality of the services whilst managing scarce resources.
During this inspection we inspected six core services and carried out a well led review.
In rating the trust, we have taken into account the previous ratings of the ten mental health and community health core services not inspected this time. Following this inspection 14 core services were rated as good overall, one was rated requires improvement and one was rated outstanding.
We found that the trust was led by a highly skilled and experienced senior team, including the chair and non executive directors. There was a strong patient focussed, learning culture within the trust and staff showed caring, compassionate attitudes, were passionate and proud to work for the trust and were involved in the development and improvements within the trust.
The trust had made the majority of the improvements we said that it should make following our last inspection.
Across the trust the majority of the environments were safe, clean, well equipped, well maintained and fit for purpose.
In community services waiting lists were managed well, the number of patients on the caseload was not too high to prevent staff from giving each patient the time they needed and anyone needing to be seen urgently was seen in a timely manner.
In the wards for people with a learning disability staff had received training in positive behaviour support, patients had individualised behaviour support plans and staff were supporting patients who had challenging behaviours appropriately.
Generally, staff completed comprehensive risk assessments and managed risks well. Physical and mental health needs were assessed and monitored, and care plans were holistic and recovery orientated. Staff followed good practice with respect to safeguarding.
Patient safety incidents were managed well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons with their teams and the wider organisation.
Staff provided a range of care and treatment interventions suitable for the patient groups and these were consistent with national guidance on best practice.
Staff across all the services we inspected were kind, compassionate, respectful and supportive respected the privacy and dignity of patients. Feedback from people using services and their relatives and carers was highly positive. People who used services were appropriately involved in making decisions about their care. Staff ensured that the emotional and spiritual needs of people who used services were addressed, along with their mental and physical healthcare needs.
The majority of services had access to the full range of specialists required to meet the needs of patients under their care. There was enough staff with a range of skills needed to provide high quality care. Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
Staff planned and managed discharge well. Inpatient services, including wards for people with a learning disability and forensic secure wards, liaised well with services that would provide aftercare and were assertive in managing the discharge care pathway. As a result, people who used services did not have excessive lengths of stay and discharge was rarely delayed for other than a clinical reason.
The trust had strong governance systems supported by good quality performance information. This meant that at all levels of the organisation staff and members of the board had access to useful information that enabled them to gain assurance and make improvements where needed. This enabled the trust to achieve a balance between assurance and improvement work.
The trust had positive and collaborative relationships with external partners and was actively engaged with the local health economy in shaping services to meet the needs of the local population.
The trust continued to build on their innovation as a Global Digital Exemplar, sharing learning and supporting other trusts to make improvements in technology. There was good practice and innovation around IT that was patient focussed such as access to records and ‘I want great care’ and the Blue Ice app.
The trust had a strong focus on research and had strategic research links both to the University of Oxford and Oxford Brookes University. The trust ran one of only two mental health biomedical research centres in England.

However:

The seclusion rooms at both Evenlode ward (wards for people with learning disability and autism) and Watling ward (forensic inpatients) did not always offer privacy for patients. Staff on Evenlode were not secluding patients for the shortest possible amount of time. Records showed that patients who were settled were not removed from seclusion promptly so not protecting their human rights. Documentation was not always completed at the correct time.
Patients on Evenlode did not have access to a speech and language therapist; there had been no provision for 18 months.
In forensic services the quality of physical healthcare provided to patients was inconsistent between wards and the quality of pre-prepared meals on wards at the Oxford clinic was poor.
In forensic services there was a lack of parity of access to entertainment between wards. Patients on male wards had access to satellite television and a range of activities, whereas patients on the two female wards had been made to choose between having satellite TV and some activities that incurred a cost (for example, baking).
Ligature risk assessments were carried out but not always acted upon in Marlborough House inpatient ward.
In specialist community mental health services for children and young people the increase in demand and capacity issues had created increased wait times for non-urgent referrals.
Some staff said they found it hard to access supervision.
The was a lack of robust board level oversight of the Mental Health Act.

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

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well and managed medicines safely. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour 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 patients with a learning disability (and/or autism) and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
Managers ensured that staff received training, regular 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 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.
Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed, other than for a clinical reason.
The service worked to a recognised model of mental health rehabilitation. It was well-led and the governance processes ensured that ward procedures ran smoothly.

However:

Staff did not follow good practice guidance when secluding patients. They did not complete a seclusion care plan at the correct time and seclusion records did not demonstrate that patients had been only been secluded for the shortest possible amount of time. The seclusion room did not always offer the patient privacy.
There was no speech and language therapist for the ward and staff had not been able to access one for 18 months.
The trust did not keep staff up to date with changes to the Mental Health Act and the Mental Capacity Act. Agency staff did not always follow care plans.
Patients reported that staff disturbed them at night by not closing doors quietly.

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 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 young people and in line with national guidance about best practice. Staff 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 young people 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 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. They actively involved young people and families and carers in care decisions.
Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However;

In Marlborough House the ligature risk assessment did not always include actions staff should take to ensure areas with ligature risks were safe. They were not updated to include work that had already been completed.
In Marlborough House staff members did not always ensure that any changes to young people’s care plans were updated quickly to ensure staff members work consistently with the young people.
In Marlborough House young people’s physical health assessments were kept in the clinical notes. They were not easily assessible to staff because they were not kept with the information in the young person’s care plan.

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 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 individualised, 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 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. In general, 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.
Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

The quality of physical healthcare provided to patients was inconsistent between wards. Staff teams from different wards had developed local processes which were largely dependent on nursing staff to deliver.
The location of the seclusion room on Watling ward was adjacent to the central communal area of the ward so other patients could potentially see into the room and could hear when the occupant was distressed. The CCTV screen for the Kestrel ward seclusion room was located in a high position and so was visible to other patients using the intensive care area of the ward at that time.
Patients were not happy with the Halal options on the menu of pre-prepared meals offered on some wards, such as Kennet.

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

The service provided safe care. Clinical premises where young people were seen were safe and clean. The provider made improvement following the requirement from the last inspection in 2015 to address the number of young people on the caseload of the teams, and of individual members of staff. At this inspection, staff said their caseload was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that young people who required urgent care were seen promptly. Staff 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 that were informed by best-practice guidance and suitable to the needs of the young people. 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 young people. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. They actively involved young people and families and carers in care decisions.
The service was easy to access. Staff assessed and treated young people 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 children and young people who would have benefitted from care.
The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

Although the service made significant improvements following our last inspection in 2015 to address the variable quality of risk assessments. In the care records we reviewed we found there were still a small number of risk assessment that had not been regularly reviewed and staff were not always using any rating scale to ascertain the severity of these risk to young people.

The increase in referrals and capacity issues had created increased wait times for non-urgent referrals. The trust had a single point of access in Oxfordshire and Buckinghamshire which screened and triaged all referrals so that each could be passed to the most appropriate service or team to provide care and treatment. All children and young people referred to be seen urgently were seen within one week. All others received care and treatment within the national target of 18 weeks. However, commissioners of the service had set a target of seeing 75% of referrals within 12 weeks, some teams, for example, South East Oxfordshire and North Oxfordshire and Melksham were not meeting this target. The trust was well aware of the issues, had contracted with a private provider to outsource the assessment of children and young people deemed to be at lower risk and had a waiting time mitigation plan in place and was actively managing the waiting list.

Documentation of children and young people`s views in care plans were variable across the hubs and appeared dependent on the practitioner who wrote the care plan.

Supervision were not always recorded in line with the trust`s policy.

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

Staff treated patients with compassion, kindness and respect. They understood patients’ specific needs and helped them make decisions about their care and treatment.
Services were delivered to meet the needs of local people, and staff worked well with others in the wider health and care system to plan patients’ individual care.
There was effective leadership and senior managers developed the service vision and strategy, with engagement with partners in health and social care. The governance arrangements supported improvements in service quality. Leaders and staff understood the key risks and risks were managed and escalated appropriately.
The services were delivered based on national guidance and evidence-based practice. Staff carried out audits to ensure they followed best practice.
Staff reported and learnt from incidents.
Services were delivered in accessible premises and planned to provide convenient care, close to people’s homes. Equipment was safety checked and was in good condition. Medicines were well-organised, stored safely and at the right temperature, and staff protected people from infections by keeping the environment and equipment clean.

Staff completed and updated risk assessments for each patient and kept clear records.

The services sought patient feedback and had systems to manage and respond to complaints.
Safeguarding training targets had been met. All staff had received an appraisal within the last year. The majority of staff had completed mandatory training required by the trust although a small number of staff had not completed training in key clinical skills.
There was a positive and caring working culture. Staff respected the patients, their colleagues and managers. They responded kindly if patients were afraid or distressed. Staff understood the need for some patients to have privacy or a quiet space.
Clinical leaders were respected by staff. They were knowledgeable about quality issues and priorities, understood what the challenges were and took action to address them.

However

The service had a number of permanent staff vacancies. Leaders had identified this as a key risk and were continuing to recruit additional staff and offered in-house training to attract new staff from a range of clinical backgrounds.
At Henley and Witney staff had difficulty observing patients due to the layout of the waiting areas. There was a risk that staff might not observe patients who deteriorated and needed prioritised care.

Staff told us they found it difficult to access supervision.

We rated the service as requires improvement overall because:

We looked at the risk assessments for five patients, the risk assessments were fully completed to a good standard for one out of five patients, the remaining four were identified as present but not completed to a good standard.
Staff we spoke with were not aware of the trust having any initiatives to reduce restrictive practices. The ward had a number of blanket restrictions in place that were not being constantly reviewed.
The wards used a combination of paper-based records and electronic records.
This was a high reliance on agency staff supporting the ward and there were no long-term contracted agency staff allocated to the ward so staff consistency could not always be maintained.
Staff were not receiving regular clinical supervision and the trust did not record centrally the ward’s compliance with their policy of supervision being completed every 6-8 weeks.
The service had developed its own person centred approach to ward care planning that did not specifically follow the Positive Behavioural Support (PBS) Approach guidance by the Department of Health. Care plans were not recovery oriented and there were not clear goals set to support patients through their care and treatment pathway.
Information was displayed on communal noticeboards on the ward however it was not always presented in an accessible and easy–to-read format.

However:

Patients were not on any high-dose antipsychotic medication or multiple medications for psychosis. The clinical team tried to reduce the use of medications alongside other interventions. This meant that patients were not being overmedicated.
We found evidence of inter-agency working taking place, with care-coordinators and representatives from NHS England attending ward meetings as part of patients’ admission and discharge planning.
When we discussed care plans with the patients, we found they were all aware and had been involved in the development of their care plans along with their primary nurse. There was evidence in the care plans that patients’ personal choices had been taken into consideration.
Leave arrangements were carefully and comprehensively arranged between the clinical team and the patient and recorded accurately on the patients’ section 17 leave forms.

There was occupational therapist input to the ward and daily schedules of activities for patients including art, cookery, music, gym sessions, games, mindfulness and a regular yoga session which patients felt was extremely valuable.

Staff morale was high despite concerns with high use of agency staff. The core staff team had worked on the wards for many years and were happy with the current management structure and the development of the ward.

The service was in transition from Southern Health into the forensic directorate of Oxford Health NHS Foundation Trust. Oxford Health NHS Foundation Trust has made improvements since taking on the service and we recognise the ward was an improving service at the time of our inspection.

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

The service did not always follow relevant national guidelines around storing medicines.

While there was a system in place to assess and monitor patient risk there were instances where assessments and related care plans were not reviewed in a timely way.

The sharing of information between staff and others was uncoordinated meaning people did not always have access to the information they required.
People were at risk of not receiving effective care or treatment due to lack of pain assessment and personalised care planning.
Staff understanding of their roles and responsibilities under the Mental Capacity Act 2005 was variable. Staff did not always effectively support patients who lacked the capacity to make decisions about their care.
The governance and culture did not always support the delivery of high-quality person-centred care. There was not a clear defined strategy for the service.

However:

Staff were supported in their development.
Staffing levels were generally at safe levels.
Incidents were well managed including investigations and the sharing of learning.
Information about people’s care and treatment was collected and used to improve the service.
People were supported, treated with dignity and respect and involved in their care.
People’s needs were met through the way the service was organised and delivered.
The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

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

Governance processes were not systematic and we found repeated areas of non –compliance which were highlighted in our 2015 report. Key areas of risk were not always identified and managed appropriately and the service did not have a vision or strategy to develop the service.
Staff did not always understand or comply with essential policies and processes such as safeguarding referrals, medicines storage and staffing escalation. The environment in some areas did not meet the needs of patients and presented an infection control risk.
Although staff respected their line managers, they did not always know senior management. Staff did not always receive appraisals and supervision and there was no evidence of succession planning for the service. Senior staff did not have assurance that all staff had completed the appropriate competency assessment. There was no competency assessment in place for adult trained staff who were caring for children.

However:

Staff provided kind and compassionate care to patients and placed patients and their families at the centre of their work.
Processes for incident reporting, recognising the deteriorating patient and record keeping were embedded into practice.
The service provided care and treatment planned around the needs of patients and ensured they could easily access the most appropriate service.

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

The places of safety were well maintained, discreet, quiet and secure.
The trust provided a safe and patient-focused place for assessment, by ensuring appropriate facilities, such as safe furniture that should not cause injury, courtesy packs for patients and televisions and game consoles.
Patients were able to keep their mobile phones and electronic devices after an individual risk assessment was completed by staff.
The monthly problems in practice meetings were well attended by the police and the trust. These meetings ensured there was an appropriate setting to discuss problems and to improve and maintain their relationship.
The trust had a clear and comprehensive standard operational procedure, which had been reviewed in December 2017, and a new form in order to extend the period of detention in the place of safety following the change in the law.

However:

There were concerns that the ambulance services were not more engaged in the problems in practice meetings. In recent months the attendance at meetings had improved.
The Interagency Joint Working Protocol for the Management of Mental Health in the Thames Valley Area had not been updated with the recent change of the law.

We rated the service as good overall because:

The service maintained safe staffing levels across all the teams we inspected and both staff turnover and sickness were low.
Caseloads were manageable and both patients and carers commented positively on the availability of staff when they needed them.
Incidents were well reported and monitored and routinely discussed in multidisciplinary team meetings, with learning shared with the rest of the team.
The trust embraced the Transforming Care 2015 agenda.
Staff were highly skilled, qualified and experienced.
Care plans were well recorded and were available in accessible formats for people with different communication needs.
Patients and carers were actively involved in the care provided and praised the staff for their understanding and supportive approach.
Staff worked hard to ensure that patients gained access to the right care at the right time, through effective management of external waiting lists and tracking cases through the service.
Staff ensured accessibility for the service by travelling to patients’ homes and day services for appointments.
Feedback from patients and carers had informed significant service developments.
All staff and patients we spoke with described a positive experience of the transition of the service from the previous provider. Carers described the process as seamless and staff universally said they felt welcomed and supported and optimistic about the future of the service.
The service promoted a culture in which people with a learning disability were respected and valued as individuals and in which learning disability was not treated as an illness. A clear vision for the future of the service was understood by staff and had been shared with patients and carers.

However:

Whilst staff had a very good working knowledge of the Mental Capacity Act, teams were not recording capacity assessments consistently.
Some patients experienced a lengthy wait for nursing assessments and speech and language therapy assessments despite caseloads being low.
Outcome measures were not used to track patients’ progress.
Whilst referrals and discharges from the main teams were well managed, pathways between professionals were not always clear and could involve long wait times.
Governance systems to manage pathways and care coordination responsibilities were not always clear and in some cases resulted in duplication of work between the intensive support and community teams.

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

Staff effectively managed risks for patients of acute mental health wards and the psychiatric intensive care unit. We observed shift handover sessions and multidisciplinary patient review meetings where staff discussed risk levels in light of recent events. Staff had worked to improve the clarity of the care pathway for patients diagnosed with emotionally unstable personality disorder, following two serious incidents in 2017.

Staff actively sought to use verbal de-escalation techniques to resolve, and where possible pre-empt, situations where patients were becoming agitated or aggressive. Staff only used physical restraint as a last resort, when verbal de-escalation was unsuccessful. Every ward had a member of staff nominated to lead on work to reduce the use of restrictive interventions.

Staff completed comprehensive mental and physical health assessments of each patient at the point of admission. Each ward had good access to physical healthcare. The trust operated a smoke-free environment and staff supported patients with smoking cessation groups and nicotine replacement therapy.

Vaughan Thomas ward was participating in a three-year research project to study the benefits of a specially designed unit to monitor (installed at the junction between wall and ceiling) patient movement and bodily processes whilst in their bedroom. The aim was to develop a system that allowed staff to remotely monitor patient night-time safety without having to disturb the patient whilst asleep.

All wards in this core service had gained national accreditation for demonstrating that they met a certain standard of best practice in their area. The six acute wards had gained accreditation for inpatient mental health services – working age units (AIMS – WA). Ashurst ward had gained accreditation for inpatient mental health services – psychiatric intensive care units (AIMS – PICU).

Vaughan Thomas ward had been shortlisted for a national award in the Student Nursing Times Awards for 2018. The ward was one of several nominated for student placement of the year, and was the only mental health ward on the shortlist. The winner was due to be revealed at an upcoming awards ceremony.

Staff were passionate about their work and motivated to deliver high quality care to patients. Staff told us they felt supported by their ward manager, modern (ward) matron and senior matron and able to raise concerns. We received a great deal of feedback from staff who told us that team morale had significantly improved in the last 12-18 months.

Patients had access to local advocacy services who visited each ward on a weekly basis and multifaith spiritual support was available to patients who desired it. The provider’s patient advice and liaison service (PALS) held a drop-in surgery on wards ward every week. Staff could access interpreters as needed and could provide information leaflets in over 60 languages, to cater for the needs of all patients and carers.

Staff treated patients in a caring, respectful and responsive manner. Staff displayed a high level of understanding of the individual needs and abilities of patients. Patients and carers we spoke with told us they were happy with the care provided by staff.

Staff actively involved patients and carers in aspects of care delivery. Staff sought the input of patients and carers when carrying out risk assessments and formulating care plans. Patients and carers were able to provide feedback on the service during regular meetings.

However:

Staff vacancy levels within this core service were high. The number of qualified nursing vacancies amounted to 49% of the establishment total as of 30 November 2017. During the 12-month period November 2016 to October 2017, 19% of total hours were filled by bank staff and 25% were filled by agency staff. Staff we spoke with were concerned about the impact of high levels of staff vacancies on the team and the running of the service. They spoke of the extra stress placed on substantive staff when the ward was operating with a high proportion of agency workers.

Compliance levels for some mandatory training courses were below 75% at the time of our inspection.

There were several issues with seclusion rooms. The seclusion room on Ashurst ward was quite dirty, with visible blood stains on one of the walls. The intercom unit outside the seclusion rooms on Ruby and Sapphire wards were located too far from the door, which meant that patients inside the seclusion room would be unable to see the member of staff they were talking with. There was no clock visible from the seclusion room on Ruby ward. The patient control of the vision panel in the seclusion room door on Ruby ward was broken so that a secluded patient would be unable to see outside the room.

Staff were potentially exposed to elevated risk when working on the health-based place of safety attached to some of the wards. During the course of our inspection, an incident occurred in which staff did not have a full, accurate, easily-accessible risk profile for the patient in the health based place of safety.

At the time of our inspection visit, the overall appraisal rate for non-medical staff within this core service was 58%. The trust’s target rate for appraisal compliance was 90%. The wards with the lowest appraisal rates were Ashurst with 29% and Phoenix with 31%.

Oxford Health NHS Foundation Trust provides community based mental health services for adults of working age who require a service, but do not need to be admitted to hospital for treatment. Some adults may be subject to conditions under the Mental Health Act 1983.

We inspect and regulate healthcare service providers in England.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs and well led?

Where we have a legal duty to do so, we rate the quality of services against each key question as outstanding, good, requires improvement or inadequate.

Where necessary, we take action against registered service providers and registered managers who fail to comply with legal requirements, and help them to improve their services.

We plan our inspections based on everything we know about services, including whether they appear to be getting better or worse.

At the last comprehensive inspection of this core service in June 2016 we rated the community based mental health services for adults of working age as good for the safe, effective, caring, responsive and well-led key questions which resulted in an overall rating of good. We re-inspected all five domains as part of this inspection.

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

The provider had determined safe staffing levels and the number, profession and grades of staff in post matched the overarching staffing plan. Across all teams well trained and supported agency staff were used to cover any staff vacancies.
Team managers had regular caseload supervision with practitioners to ensure that caseloads were manageable and shared equally between the team. Part time staff and social workers with responsibility for safeguarding had reduced caseloads to enable them to manage their time effectively.
We reviewed 22 care records of patients across the three teams. Staff had completed a risk assessment for each at the point of initial assessment. Staff updated risk assessments regularly and after any reported incidents. Staff shared risk appropriately with colleagues and discussed high or particular risks with senior team members in supervision, reflective practice sessions and in multidisciplinary clinical meetings. This ensured risk was clearly communicated between all staff. Crisis management plans were in place and groups were available in the day hospitals which looked specifically at planning to manage safely in a crisis.
Care plans clearly reflected the individual persons’ needs that staff had identified during the initial assessment. Care plans were personalised, holistic and recovery focused. Staff used a nationally recognised good practice care planning tool called the, ‘recovery star’ to ensure the full involvement of patients. Patients told us they had received a copy of their care plan and had participated in their risk assessment.
All teams had embedded posts, employed by a community mental health organisation, which specialised in housing and employment. These staff had strong links with local colleges, housing organisations, local employers and enabled patients to acquire living skills to support patients find employment, vocational placements or work based training. These staff could also support patients with their benefits claims to ensure they were claiming appropriate benefits.

All teams visited had a physical health clinic to ensure those using services had access to physical health screening and regular health checks. Teams were actively promoting healthy lifestyles and provided information on smoking cessation and healthy living. We saw that patients were referred and supported to attend their GP surgery.

Staff provided a range of care and treatment interventions including psychological therapy, medication and social support. Interventions such as family intervention therapy for those with psychosis were in line with National Institute for Health and Care Excellence guidelines. Treatment offered at the day hospitals included groups on mindfulness, health and wellbeing, anxiety management, mood management and wellness recovery action planning.
Whilst on inspection we saw that staff participated in wide range of clinical audits to monitor the effectiveness of the services provided. Areas covered included, ensuring good physical healthcare, ensuring adherence to the care programme approach, monitoring the quality of care plans, implementing the ‘true colours’ mood monitoring tool and developing educational, mental health information booklets. Action plans were developed to address any areas identified for improvement. Each team had a dedicated research assistant post.

Each team had a duty system to respond to any sudden deterioration in the mental health of a person using the service. Staff would be on the daily rota and would know in advance if they had any assessments to complete on that day. The team leaders and duty worker would have a daily morning meeting to discuss any planned assessments or contacts needed that day.
All three teams were working to a flexible assertive community team model which meant that patients needing increased support and contact would be identified by staff and receive more frequent and intensive contact from the team. When patients needed this enhanced support, they would be placed in the ‘step up’ category, which meant that they received additional sessions with staff and could utilise the on-site day hospital services. Each team maintained a ‘step up’ board which listed patients in this category, so all staff knew who was receiving this additional support.
Skilled staff were available to assess patients in a timely manner. Each day both the assessment and treatment teams looked at all new referrals. Urgent referrals would be prioritised and processed by the teams, if required on a twice daily basis across all community teams. No team had a waiting list for either assessment or allocation to a treatment team. Each team had daily zoning meetings at which staff reviewed the risk of patients using the service to ensure they were receiving the appropriate amount of contact from the team.
The community teams were well-led and had clinical lead managers in position. The managers were visible within the service during the day-to-day provision of care and treatment, they were accessible to staff and they were proactive in providing support and leadership. All staff we spoke with, without exception commented positively on this. The leaders of these teams had the skills, knowledge and experience to perform their role to a high standard. They had a very detailed and comprehensive understanding of the services they managed.
Team leaders had access to their teams’ performance dash boards so could monitor their team’s key performance indicators and key risk issues. Team leaders used the boards daily in handover and clinical meetings.

However:

There was some confusion with one staff member at both the Elms Centre and the Valley Centre about what emergency equipment was stored on site.

Two staff at both the Elm centre and the Valley Centre said they were not consistently ringing in at the end of each working day as per the trust lone working policy.

In four cases, across all teams, the physical health section of the electronic care records system did not always make reference to why a physical health assessment was not carried out.

The capacity section of the electronic care records did not have entries in 10 out of 22 cases to confirm that capacity was considered. However, this form had been recently introduced and capacity assessments had been recorded in a different section of the care records.

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

The wards, including the clinic rooms, were clean, had good furnishings and were well maintained. Staff ensured that equipment, including emergency equipment, was also well maintained, checked annually and was clearly monitored. Ward doctors prescribed medicine in a streamlined way and in line with the National Institute for Health and Care Excellence (NICE) guidance. The recording and maintaining of good medicines management was in place across all wards and there was good input from pharmacy colleagues.
The management of risk both within the environment and to patients was well managed. Staff had completed a risk assessment for each patient at the point of initial assessment and managed patients’ physical and mental health risks in line with trust policy and NICE guidance. Staff were aware of risks, documented and communicated this well. Staff followed good policies and procedures for the use of observation and adjusted observation levels according to individual patient need.
Care planning was inclusive and included input from a range of disciplines as well as the patient and their carers. Patient welcome packs included a ‘Knowing Me’ questionnaire that asked patients and carers questions around personal likes, dislikes and preferences.
There was a good skill mix of staff on the ward and mental health nurses had access to a physical health course. All staff received level one dementia training and level two dementia training was being piloted. Ward based psychologists offered therapy in line with NICE guidance that included weekly cognitive stimulation groups, cognitive behavioural therapy and provided formulation training for staff. There was a good range of occupational therapy and access to a full range of rooms and outdoor space.
There was a good multi-disciplinary approach to care treatment and discharge. There were regular ward rounds on each of the wards that included a wide range of disciplines and had discharge planning as a key focus. The wards contributed to daily inter-county bed management teleconferences with community mental health teams. There was a trust social care lead in place who assisted with planning and discharge.
Staff demonstrated good awareness of safeguarding issues, how to report an incident and learning from these was shared. However, safeguarding incidents and referrals were not collated on the wards for the purpose of data collection or review.
Training compliance with the Mental Capacity Act 2005 was at 100% and above the trust target. Staff demonstrated a good understanding of the Act, in particular the five statutory principles, Deprivation of Liberty Safeguards (DoLS) and trust policy around best interest meetings.
Staff demonstrated respect, patience and compassion for patients and were very aware of any changes to a patient’s presentation. There was a clear emphasis on promoting patient choice and independence and staff sought patient and carer views to inform the care plans. Patients felt safe and well cared for on the wards. There was access to a lesbian, gay, bisexual, and transgender lead for the wards and patients received support to access tools that translated key care information into their first language.
The wards varied in how dementia friendly they were. Sandford and Cherwell wards were decorated to assist patients with dementia, with the use of colour zoning and good signage that included pictures accompanied by large words. All wards had plans in place, at various stages, to create a sensory garden. Amber ward had minimal signage and colour zoning that would have assisted patients with dementia.
Ward managers had access to a development programme designed to link leaders, improve communication skills and help them understand trust priorities. Organisational changes were communicated effectively and staff felt supported by their line managers and described feeling valued. They felt positive and proud about working for the provider and their team.
To address the high number of staff vacancies, senior staff worked with local universities to engage with nursing students at an early stage. We saw examples of other staff, such as housekeepers, that had been encouraged to undertake training as healthcare assistants.
At the time of our inspection, all three wards had received Accreditation for Inpatient Mental Health Services (AIMS) – OP (Wards for older people). The Royal College of Psychiatrists ‘Essential Standards’ were assessed across the wards and in February 2018 the results were found to be ‘good’ overall.

However:

Staff vacancies were high overall. Shifts were usually covered by bank or agency staff who knew the wards. The ward managers could adjust staffing levels daily to respond to the wards’ changing needs.
There were no nurse call buttons in the patient bedrooms on Amber ward except for the assisted bathrooms and two assisted bedrooms. The ward mitigated the risk and the trust planned to install an alarm system for patients on Amber ward in July 2018.
Trust audits showed a high variance of compliance across the wards for timely assessments of malnutrition and incontinence and the inclusion of incontinence in care plans.
Not all medicine charts contained patient photographs when the patient had consented. The lack of photographs on medicine charts was contrary to trust policy.
Mandatory training for staff in this core service fell just below the trust’s target of 90% and this included staff training compliance in the Mental Health Act (1983). However, staff had a good understanding of the Mental Health Act (1983), the Code of Practice (2015) and the guiding principles.
Compliance with appraisals was below the trust’s target rate of 90%. Staff told us they had had an annual appraisal.
Despite patients presenting with this diagnosis, there was no specialist training in emotionally unstable personality disorder.
Staff on Amber ward told us that morale was sometimes low and they attributed this to the ward staffing issues, particularly when they were required to work with agency staff that did not know the patients. Some staff on this ward also reported feeling isolated from the rest of the trust at times. However, the trust had appointed a modern matron to work across both Oxford and Buckinghamshire to ensure consistency and equity.

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

Of the eight core community health and mental health services that we inspected on this occasion, we rated five as good and three as requires improvement. When we include the previous ratings of mental health and community health core services at the trust that we did not inspect on this occasion, one is rated as outstanding, 12 are rated as good and three are rated as requires improvement. In rating the trust, we have taken into account the previous ratings of the eight mental health and community health core services not inspected this time.
Incident reporting and investigation systems were robust in the trust.
The Chief Executive actively promoted research in the trust to improve the care and treatment of patients. The trust ran one of only two mental health biomedical research centres in England.
The trust had planned well the transfer of the learning disability services into the trust. The learning disability services were brought into the trust with care, compassion and respect for the patients, carers and staff involved.
Leadership at directorate level was very strong. The directorates had clear plans and strategies to improve patient care and treatment. Trust governance systems supported and encouraged the development of strong, local leadership teams.
The trust supported and encouraged wards and services to take part in external accreditation schemes.

However:

Following this inspection, we have rated one key question – safe – as requires improvement. In rating the trust, we have taken into account the previous ratings of the eight mental health and community health core services not inspected this time.
The trust continued to have significant issues with recruitment and retention of staff particularly qualified nurses but we were assured that the trust was undertaking key work to find new and innovative ways of attracting staff to work at the trust.
The community health services operated by the trust were generally rated lower than the mental health services. Staff in the community health services did not feel as embedded in the trust structure or as well supported by the trust senior teams. This issue had been identified by the trust and the directorate re-organisation due to be completed by June 2018 planned to strengthen the management and support for community health services by establishing a community health directorate.

We inspected the safe, effective and well led key questions and found the following areas of good practice:

The ward environment was in very good condition and kept clean.

There was good medicine management in place with strong oversight by the pharmacy team. Emergency medicine and equipment was checked and in date.
The ward had well-formulated and patient-centred care and treatment plans. Risk assessments and risk summaries were thorough and were updated regularly in response to incidents and changes.
Ward rounds were inclusive, comprehensive and patient-centred. There was a focus on discharge planning from the start of admission and reviews included discussions with patients regarding their responsibility for their safety on discharge.

Staff told us that despite the staffing challenges, they felt part of a very strong, supportive team. Patients and staff had positive comments about other staff members including senior managers.
Patients and their carers had access to a range of information and support to encourage them to participate in their care.

However, we also found areas that the service provider could improve:

Recruitment challenges and staff sickness meant that there was a high use of agency nurses on the ward. This meant that care was not always delivered to the highest standard. Staff members and patients told us they sometimes felt unsafe when there were mainly staff on duty who were unfamiliar with the ward and the patients.
There has been a lack of consistency in the senior leadership of the ward over the previous 18-24 months due to locum posts and turnover of senior team members. However, the trust was taking action to improve recruitment and retention of staff.

We rated community-based mental health services for adults of working age as good because:

There were well equipped clinic rooms at each team base with a range of well-maintained equipment to carry out physical health assessments and treatments. The teams had interview rooms that were fitted with alarm systems. Staff had access to a personal alarm and this helped ensure the safety of staff and patients.

The clinical records of patients were well organised and reflected care of a good quality. Risk assessments were comprehensive and contained contingency and crisis plans to assist patients during a deterioration of health. Care plans contained a broad range of goals relating to the assessed needs of patients. Staff used planning tools, such as the recovery star, to support assessments. Staff monitored and recorded the physical health needs of people using the service, including the health checks necessary for monitoring the effects of prescribed medicines.

The teams were safely staffed with a range of qualified professionals who had completed mandatory training, were receiving regular supervision and an annual appraisal.

We observed good interactions between staff and patients using the service which gave space for people to ask questions and discuss options about their care and treatment.

Patients and carers were positive about the attitude of staff and the service they were receiving. They reported that staff including psychiatrists were helpful and reassuring and treated them with respect.

All the teams had effective multi-disciplinary clinical and business meetings and a daily handover between day and evening staff. The meetings were attended by doctors, nurses, social workers, occupational therapists, and support workers.

All the teams had effective processes to receive and triage referrals. Patients using the services were given options about their appointment times and the venue to suit their circumstances.

The service could respond flexibly to peoples’ changing needs by offering more intensive support. This was available between 7am to 9pm seven days a week. Team doctors maintained a daily emergency appointment slot so that patients could be seen quickly without a scheduled appointment.

Patients were aware of how to make a complaint. Team managers kept a log of local complaints and could review the information for themes and trends.

The staff at the City and North East team told us that morale in the team had improved. Senior managers had agreed to increase the team’s staffing by four care coordinators.

There was a detailed plan being followed to integrate psychological therapy staff in to the AMHTs. Staff at the teams were involved in developing the plan and in the short term additional psychology staff were being recruited in to each team. The waiting list for psychological therapies was overseen by a senior clinician who reviewed the waiting list every week.

Learning from incidents was shared with the team by email and discussed at the team meeting.

However:

The City and North East and Aylesbury staff were not following procedure to record fridge temperatures in the clinic room. Therefore it was not possible to state that medicines were safely stored.

We rated this core service as good because:

The service had worked hard to ensure that care plans were now holistic and recovery orientated and that patients were involved in their care as much as possible. Risk assessments were thorough and updated regularly.

Staff had identified ligature risks and managed and mitigated them well across the service. The service had undertaken maintenance work to remove as many ligature risks as possible, including in the gardens.

The service had reduced restrictive practices that were identified on the previous inspection. Patients had access to the garden at all times and were allowed electronic devices on the wards once risk assessed.

Staff assessed patients’ physical health needs and managed these well.

Ward teams consisted of appropriately trained and qualified members of staff. These staff worked together as efficient multi-disciplinary teams.

Staff ensured that Mental Health Act documentation was in good order. Staff were complying with the code of practice and had good knowledge of it.

Morale was high across the service and all staff worked hard to ensure that patient needs came first. Patients commented on how staff had a caring attitude towards them.

Staff had put in place a very good programme of activities for the patients. There were good facilities to enable these throughout the service.

However:

The service recently purchased new wardrobes for every bedroom that posed a ligature risk to all patients. The trust was working to resolve this quickly with the manufacturer and risk management for the interim was appropriate.

There was a high reliance on bank and agency staff across the service.

Mental Capacity Act and Deprivation of Liberty Safeguards knowledge varied greatly from ward to ward.

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

Staff were well qualified and experienced. Mandatory training rates were high, appraisals were at 100% and staff supervision happened regularly.
Safeguarding procedures and policies were thorough and all staff knew how and what to report.
Mental capacity was discussed as appropriate and Mental Capacity Act processes were followed. Staff gave examples of when the Mental Capacity Act may be used.
Team meetings happened regularly and had a variety of formats including business meetings, health and wellbeing meetings and reflective practice. Staff were well supported.
The full range of mental health disciplines provided input into the ward. Multi disciplinary working was robust.
There was a comprehensive and well structured activity programme suitable for a rehabilitation ward. The ward had a full range of activity rooms and accessible outside space available for use.
Patients were treated with respect. Staff were interested and engaged with patients. There was a happy atmosphere on the ward.
Patients were encouraged to participate in the running of the ward. Community and planning meetings happened daily and patients were involved in the development of the new activity programme.
All blanket restrictions noted at the last inspection had been lifted. Any restrictions still in place were for health and safety reasons.
The policy of using short term leave beds for inpatients from other wards had ceased. This was a trust directive.
The ward offered an inreach service to patients on the waiting list to help them prepare for admission. An outreach service was also offered to those patients on long term leave and ready for discharge to ensure continuity of care.
Staff morale was high. Staff reported good working relationships with each other and good management at ward level.

However:

Staffing levels continued to be a challenge and all staff reported staff shortages. This had improved over recent months and procedures were in place to ensure safe staffing and improve recruitment and retention.
There was no money management policy on the ward. This could patients at risk of money mismanagement and staff at risk of allegations.
Care plans did not include the entirety of the work being done with patients. This work was happening but was not reflected in the care plans.
Some gaps were noted in checking of emergency drugs, the cleaning rota and the safety testing sticker for electrical equipment. This was brought to the attention of management during the inspection who agreed to resolve this.

Following this re-inspection, we have reconsidered the overall rating for the trust and have now rated it good because:

When we undertook our comprehensive inspection in September/October 2015, we rated nine of the 14 core services provided by the trust as good and one (community health services for children, young people and families) as outstanding.This re-inspection assessed three of the core services that we had rated as requires improvement. We have now revised the ratings of these three core servces to good.
Following our previous inspection, the trust managers developed an action plan and worked with stakeholders to address the areas that required improvement. A group chaired by the deputy director of nursing monitored progress.This work had resulted in significant improvements in the care and treatment of patients and in the care environments.
The trust had developed a new estates dashboard. Any issues identified from daily environmental checks were passed to the facilities and estates management via the intranet system or telephone. The introduction of the estates dashboard had resulted in real improvements in the speed and efficiency of response.
When we inspected the rehabilitation ward for working age adults in September/October 2015, we rated it as requires improvement for safe, effective, responsive and well-led.Following our re-inspection, we have rated this core service as good for all key questions other than safe.The improvements that staff had made include: changes to the ward to bring it in line with the guidance on the provision of same-sex accommodation; the introduction of more personalised and holistic care plans; the removal of unnecessary blanket restrictions and improvements in ward governance.
In September/October 2015, we rated acute wards for adults of working age and psychiatric intensive care units as requires improvement for safe, effective, caring and well-led.Following our re-inspection, we have rated this core service as good for all key questions.The improvements include: better management of risks to patients from potential ligature anchor points; improved assessment and management of the physical health of patients and the introduction of a fuller schedule of ward activities.
After our inspection in September/October 2015, we rated community-based mental health services for working age adults as requires improvement for effective and well-led.We have now rated this core service as good for all five key questions.Since the previous inspection staff had improved the quality of clinical assessments and care plans.
Staff in all clinical areas that we visited during our recent re-inspection had high morale.
CQC inspectors from the Primary Medical Services directorate undertook a follow up inspection of Luther Street medical practice in April 2016. Luther Street provides primary health care services for homeless people over the age of 16 and people vulnerably housed in Oxford. Overall the practice is now rated as outstanding. It was outstanding for provision of caring and responsive services. Good for safe, effective and well led services.

However:

Following our comprehensive inspection in September/October 2016, we rated seven of the 14 core services as requires improvement for safe.We have not re-inspected four of these core services and have again rated the rehabilitation ward for working age adults as requires improvement for safe.

Overall we rated this core service as ‘requires improvement’ because:

Whilst staff were working hard to identify and manage individual risks, some ward environments had a high number of ligature risks. There is a programme of works to remove identified ligature risks but further work is needed to improve lines of sight ensuring the safety and dignity of patients.

Restrictive practices were evident during our inspection. These included access to the gardens, patients not enabled to lock their bedrooms and secure their personal property.
Care plans were not personalised and recovery focussed did not include patient’s strengths and goals and did not include their views.

Systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients who may be at risk were not effective. This meant that assessing, monitoring services to ensure quality was impaired. However:

We found positive multidisciplinary work and observed staff were supporting patients.

We gave an overall rating for forensic inpatients/ secure wards of good because:

All patients told us that they felt safe. The two mixed gender wards complied with guidance on same sex accommodation. Wards across all sites were clean, had good furnishings and were well maintained. There were enough suitably qualified and trained staff to provide care to a good standard. Staff proactively attempted to reduce restrictive practices such as seclusion and restraint. Patients’ risk assessments and plans were robust and we found the service had strong mechanisms in place to report incidents and learn from when things go wrong for example taking time to think through incidents together to establish a root cause.

The assessment of patients’ needs and the planning of their care was thorough, individualised and had a strong focus on recovery. All wards had access to a good range of psychological therapy on an individual and group basis. Staff had a good understanding of the Mental Health Act 1983 (MHA), the Mental Capacity Act and Deprivation of Liberty Safeguards and the associated Codes of Practice. Multidisciplinary teams were consistently and pro-actively involved in patient care, support and treatment.

We consistently saw respectful, responsive and kind interactions between staff and patients. The majority of patients and relatives we spoke with commented on how caring and compassionate the staff were towards them. We found strong and innovative practices were used across the services to engage and involve patients in their care and treatment. For example, all wards held at least twice weekly morning meetings where patients were invited to feedback on any concerns they may have or suggestions for improving the service. We found a confident and thorough understanding of relational security with all of the staff we interviewed. Relational security is the method staff use to keep wards calm and safe through the knowledge and understanding they have about their patients.

Bed management processes were effective. There was a clear care pathway for patients to move through secure services, into less restrictive environments within the hospitals and on into the community. The forensic community teams functioned well and supported patients on discharge from the wards. The service model supported patients’ recovery, comfort and dignity. There was a varied, strong and recovery orientated programme of therapeutic activities available over seven days, every week. Work opportunities were available for patients both within the hospitals and in the local community. There were good facilities available at all three sites. The service was responsive to listening to concerns or ideas made by patients and their relatives to improve services. When staff where able to, these ideas were taken on board and implemented to improve service delivery.

Staff had high morale and they felt well supported and engaged with a highly visible and strong leadership team, which included both clinicians and managers. Staff were motivated to work in secure services and described the ‘can do’ attitude which they were so proud of. Senior managers had controls in place to be confident that the service was provided to a good standard. Governance structures were clear, there were the right meetings in place, good policies and procedures, good documentation and this was consistent across the wards. Staff were familiar with local risk registers and were confident in raising any concerns to their managers for inclusion on the registers. Teams across all three sites had a clear understanding of their duty of candour and were encouraged by their managers to be open and honest with patients.

However:

At Marlborough House seven out of eight patients, receiving high dosages of antipsychotic medication, had not received a three monthly physical health monitoring check as per the trust’s policy.

Since January 2015, there were 10 occasions when women from Kestrel ward have had to use the seclusion room on the male low secure ward, Wenric. This involved being taken, on foot, in a restraint hold to another building. This meant risks were introduced in safely moving the women across two car park areas from one building to another. This also compromised the privacy and dignity of the women.

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

Two rooms were not fit to be occupied by the patients staying in them and we found lack of maintenance was an issue.
Handover of important information between staff was poor and could have placed patients and staff at risk.
The hospital had a policy in place of moving patients back and forth between the acute wards and Opal ward in order to create bed vacancies on the acute wards. This was disruptive to the patients.
The hospital did not take into account the impact on patients when planning their policy.

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

Patients had a multidisciplinary assessment completed on admission and care plans were developed from this. All patients had a risk assessment. Staff were trained to deal with challenging behaviour and could access extra support when necessary. Patients had their physical healthcare needs responded to. Outcome measures were used to measure patients’ progress. Medication was handled and administered correctly.

Patients received care from a range of staff that included doctors, nurses, occupational therapists and physiotherapists. There was limited psychology input. Staffing levels were satisfactory and managers actively managed their recruitment and use of bank and agency staff. Staff received supervision and appraisal. Staff were positive about the teams they worked in.

Patients and carers were positive about the staff on the wards and the care they received. The interactions and care we observed was friendly and respectful and demonstrated that staff understood patients’ individual needs and concerns. Staff prompted patients to eat and drink, and tried to engage with patients even when they were confused. Patients and carers could access the complaints process, and had access to an advocacy service. There was limited evidence of patients being involved in the development of their care plans.

There was pressure on beds, but staff responded to this through daily meetings to determine who needed to be cared for on the ward and who could be supported in the community. Some patients were moved at short notice, which could be disruptive.

There were groups and activities seven days a week, and facilities on the wards such as a gym, garden, quiet room, OT kitchen, and general occupational therapy and craft room.

There were environmental risks including ligatures but there were plans to remove these where possible, or manage them safely. The wards were clean and there were infection control policies implemented. The bedrooms on Amber ward were single with ensuite bathrooms. Most of the rooms were single on Cherwell and Sandford, with shared bathrooms, but there was a programme of refurbishment underway.

There were systems for monitoring and taking action in response to incidents and gaps in the service. This included information collected by ward managers and submitted to the board centrally.

However, Amber ward was not compliant with gender separation guidelines. There were separate corridors for male and female bedrooms, but women were placed in bedrooms on the men’s corridor.

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

The wards were safe and clean.
Staffing levels were appropriate to the needs of the patients and additional staff could be used when necessary.
Staff received mandatory and specialist training.
There were low levels of serious incidents.
Patients’ needs were assessed on admission and care was planned against the assessments. Care plans were generally well documented.
Individual and group therapies were provided.
Patients were treated with respect and dignity by staff.
Patients were involved in their care, understood why they were in hospital and the treatment they were receiving.
Familes and carers were actively encouraged to be involved in their child’s care.
The services are commissioned by NHS England to provide beds for children across England. Beds were usually available for children and young people when they needed them from the local areas in which this trust provides services.
Patients were able to attend regular education.
Age-appropriate activities were available on the wards.
The wards had strong multidisciplinary leadership teams.
Systems were in place to ensure staff received mandatory training, appraisal and supervision.
The trust used electronic performance dashboards.
The wards were members of the quality network for inpatient child and adolescent mental health services.

However:

Some of the clinic equipment had not been checked regularly or did not have up to date portable appliance testing.
There were blanket restrictions in place at Marlborough House.
The Highfield Unit had high levels of restraint and seclusion. Patients had been admitted to the Highfield Unit whose needs and risks proved difficult to manage in a general child and adolescent mental health service ward.
The Mental Capacity Act applies to people from the age of 16 years but we found that knowledge of the use of the Act was poor.
The use of seclusion and long-term segregation at the Highfield Unit was not in accordance with the Mental Health Act Code of Practice definitions.
The patients at Marlborough House did not have the same level of proactive support and assistance from the advocacy service that was provided to patients at the Highfield Unit.
Some patients told us there was a lack of activities at weekends.

We rated specialist community mental health services for children and young people as good because:

Young people and their families and carers who used the service were effusive in their praise for the staff. The outstanding caring by staff for young people and their families and carers was observed by our inspection team and commented on by other agencies who worked with the services.
The overall positive culture we observed was all the more remarkable given the size of the child and adolescent mental health services that the trust provides.
The services were responsive, designing and delivering interventions appropriate to young people’s needs.
The trust was creative in the way it developed services in response to young people’s needs, typified by the creation of apprenticeships for young people who have used the service which aim to help them engage with the job market.
The trust had comprehensive crisis support for young people with a very positive assertive outreach service.
Services were well led with dynamic leadership at a local and senior level.
There was very good learning from incidents.
We saw evidence of excellent multiagency working.

However:

There had been such a focus on addressing waiting lists that caseloads had become very high in some areas putting the quality of care and patient safety potentially at risk.
The quality of risk assessments was variable across the services. In particular we were concerned about the risk assessments in Melksham, Swindon and Oxford central. However we did see staff considering risk with young people and their families/carers at all times.
Mandatory training rates were low. We were particularly concerned about Mental Capacity Act training and staff knowledge surrounding this.

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

The City and North East assessment function team had assessments and care plans which were in date, however some of the plans were not detailed enough and none were adequately person centred with clear goals. This applied to patients that the assessment function team had been working with for over their targeted time of four weeks.
Aylesbury team had care plans that were not detailed enough. They did not address all the needs identified in the assessment stage. The care plans were not person-centred and did not have clear goals.
The teams had a long waiting list for patients to receive psychological therapies recommended by National Institute for Health and Care Excellence as part of their treatment. There was a waiting list of over a year to receive specialised psychological therapies; some patients received psychological therapy interventions delivered by AMHT staff whilst waiting for more specialist support.

The City and North East team told us that morale was low in the team due to staffing levels, workload and high staff turnover. Staff told us that they worked over their agreed hours weekly in order to cope with the workload.

The management did not continuously review and adapt to respond to the changing needs of staffing levels.

Records showed that the average rate for completed staff mandatory training for City and North East team was 68% for treatment function staff.

The percentage of non-medical staff that received an appraisal in the last 12 months was 50% for City and North East team.

However:

The units had clinic rooms equipped with all required emergency equipment such as automated external defibrillators and oxygen. Staff checked equipment regularly to ensure it was in good working order, so that it could be effectively used in an emergency.

All teams carried out risk assessments on every patient at the initial assessment. This took account of previous medical history, risk, social and health factors. Staff regularly reviewed them.

The teams had arrangements in place to respond to any sudden deterioration in a patient’s mental state. The teams would provide an emergency assessment by two professionals from the assessment function team within four hours.

The teams had an effective way of recording incidents, near misses and never events. They knew how to recognise and report incidents through the reporting system. Staff were open and transparent and demonstrated that the outcomes of incidents were explained to patients and their families.

Records showed that the teams assessed and supported patients with their physical health care needs. They carried out health checks and monitored prescribed antipsychotic medication for any undesirable outcomes.

Staff carried out a range of regular clinical audits such as care records, care programme approach and medicines to monitor the effectiveness of the service provided. The results were used to identify and address changes needed to improve outcomes for patients.

Staff told us they had undertaken training relevant to their role. Staff had received training in areas such as autism awareness, psychosocial interventions, and clinical risk assessment.

All teams had regular and effective multi-disciplinary team meetings that discussed patients’ needs in detail to ensure that patients got the treatment they needed. These meetings involved doctors, nurses, social workers, occupational therapists, support workers and housing officers.

We observed good interactions between staff and patients. Staff were polite, kind, respectful and compassionate.

Patients and their families were highly positive about the attitudes of staff and the support that they received. Staff showed that they understood the individual needs of patients and could describe how they supported patients with complex needs.

Staff involved patients in their clinical reviews and care planning and encouraged them to involve relatives and friends if they wished.

The teams could respond on time and effectively when patients required crisis and routine care. All teams could see patients on emergency referrals within four hours at any time of the day.

Staff provided patients with accessible information on treatments, local services, patients’ rights, advocacy services, carer support, how the services were run and how to complain.

Patients knew how to raise concerns and make a complaint. Patients told us they felt they would be able to raise concerns should they have one and were confident that staff would listen to them

Staff knew and agreed with the trust’s values. Staff knew who the most senior managers in the trust were. These managers had visited the teams.

Staff told us that they knew how to use the whistle blowing process and felt free to raise any concerns.

The trust used key performance indicators and other measures to gauge the performance of the team. Where performance did not meet the expected standard action plans were put in place.

Staff told us the board kept them informed about developments through emails and intranet.

We rated community-based mental health services for older people as good because:

Documentation on patients care records was of a consistently good standard. Risk assessments were well recorded in all three teams and care plans were up-to-date, holistic, recovery-orientated and person-centered. We saw examples of thorough analysis of risk including crisis and contingency plans.

All older adults’ community mental health teams operated an extended-hours duty system. This acted as a single point of access and crisis team and could respond promptly to sudden deterioration in people’s health. Patients referred in a crisis were seen within four hours. The duty team used a step-up and step-down model. Step-up services were aimed at preventing the need for hospital admission and step-down services facilitated discharge from hospital.

Physical healthcare needs were routinely considered.

All the teams were meeting their targets for referral to assessment times and memory clinics were meeting their targets for referral to diagnosis.

Each team had a safeguarding lead and staff had good awareness of safeguarding procedures.

Cognitive stimulation therapy, which is an evidence-based treatment for dementia that is recommended by NICE, was available in north Buckinghamshire and Oxford central.

Staff had regular supervision that was of good quality.

Staff in all the teams spoke and behaved in a way that was respectful, kind and considerate. Staff were knowledgeable and helpful.

Patients told us that they felt able to make choices about their treatment.

Managers demonstrated strong leadership. Staff felt supported by team managers and morale was good.

However:

There were no fixed or portable alarms at Oxford central (Manzil resource centre) or south Buckinghamshire (Shrublands). Although there had not been any incidents as a result of the lack of alarms, staff may have been unable to summon help if required in an emergency.

Current medication and prescription details were difficult to find on electronic care notes in all the cases that we looked at. We could not attribute any incidents to this, but it had the potential to result in medication errors and cause delays.

Medication was kept in a room in the Whiteleaf centre that was too hot. Temperatures of fridges that were used to store medication in south Buckinghamshire had not been recorded for nearly 3 weeks.

Access to the Manzil centre and Shrublands was difficult for people with poor mobility. Parking was very limited and cars blocked a disabled parking space outside the Oxford central team’s building when we visited. The Shrublands building had a slope to the front door from the road, there were no handrails outside and the ground was uneven around a manhole cover beside the front door.

Managers had difficulty getting quality reports for key performance indicators since the transfer from the RIO electronic patient record system to carenotes.

Some rooms at Shrublands were at the far end of a corridor and were used by the memory service and for groups. Patients who left these rooms, for example, to use the toilet facilities, had to walk past an unsecured door that opened on to a stairwell and another door that opened into a kitchen, which had a wall-mounted water heater. There was a potential risk of a patient getting hurt if they went through these doors by mistake.

We rated Oxford Health NHS Foundation Trust’s health-based places of safety as good because:

The places of safety were clean and well maintained (with the exception of Ashurst), with good sight lines. There was adequate staffing from the wards and staff followed a clear operational protocol. Staff had received training and were well supported. They carried out brief risk assessments and physical health checks and had access to emergency equipment if needed. Incidents were reported and the multi-agency problems in practice meeting reviewed them and identified lessons to be learnt.

The places of safety had a clear and comprehensive standard operational procedure which was based on the multi-agency agreement. All the places of safety accepted all ages and the only exclusion criterion was potential violence. Staff received annual training in de-escalation and the prevention and management of violence. There were good working relationships with the police and ambulance service at the senior level. However, we heard from some frontline staff that there were occasional disagreements between nursing staff and police officers about the time at which officers could leave.

Staff treated patients who were brought into the suite with kindness and respect. They were offered food and a hot or cold drink. All the units, except Ashurst, had showers and patients could be provided with toiletries. In two of the units we visited it was possible to listen to the radio or music, or to read a book or magazine.

The rate of inpatient admission after assessment in places of safety was very low. However, the numbers of people taken to police custody had dropped considerably in recent months, following the introduction of the street triage services.

Each of the places of safety was managed by the team manager of the ward to which it was attached, supported by modern matrons and senior managers. There was a commitment and clear leadership at all levels to take this challenging work forward. The trust had signed up to the multi-agency agreement with Thames Valley police and also to Oxfordshire and Buckinghamshire Crisis Care Concordats. The trust also actively participated in the problems in practice meetings. The reviews of incidents in these meetings were fed back to front-line staff. Most staff said that they felt supported by their managers.

There was some local auditing on one of the places of safety.

However,

There were some occasional episodes of the beds in the places of safety being used for other purposes, including seclusion of inpatients or emergency accommodation for someone awaiting admission.

There could be quite lengthy delays within the places of safety both before Mental Health Act assessment and after, if the person was to be admitted. The average length of time in the suite was over eight hours, but this could be considerably longer if no admission bed could be located.

Although there was a great deal of information collected for the problems in practice meetings, there was little evidence of collation of these data for further analysis.

Overall rating for this core service Outstanding O

Overall community health services for children and young people were found to be outstanding. We found that services were safe, effective, caring, responsive and well-led.

Our key findings were:

We judged the safety of community health services for children and young people as good.Staff knew how to report incidents using the on-line reporting system and were encouraged to report incidents. Most staff said they received feedback following incidents and learning was shared with them.
Staff adhered to infection prevention and control procedures and staff had completed the appropriate training. However, no infection control audits had been undertaken in the children and young people’s services. Where equipment needed servicing a plan was in place to manage this.
The majority of staff were up to date with mandatory training. However, there was a lack of safeguarding supervision recorded onto the learning and development portal by staff. The safeguarding children team record supervision and hold records of attendance locally. Staff we spoke with were knowledgeable about the trust safeguarding process. Staff highlighted the value of the trust safeguarding consultation line which provided easy access to immediate advice from a senior children safeguarding nurse.
We observed the majority of records were complete and up to date. Although some staff had difficulty accessing electronic records. However, a new electronic record system to overcome access issues was due to be implemented in October 2015.
We judged the effectiveness of the children and young people’s service as outstanding. Treatment by all staff was delivered in accordance with best practice and recognised national guidelines.
Staff were encouraged to achieve high performance in the delivery of services. This was monitored through audits and measuring outcomes for children and young people.
Staff skills and competence were assessed and staff were supported to obtain new skills and share best practice. Staff received clinical supervision and induction programmes were in place for all staff.
Children, young people and their parents understood what was happening to them and were involved in decisions about treatment and care. We observed good multi-disciplinary and multi-agency working and young people were supported when moving between services.
Staff understood consent issues such as Gillick competencies and we observed good communication between staff, young people and their parents around consent to specific procedures and sharing information.
We have judged the care given to children, young people and their families as outstanding. Parents, carers, children and young people were treated with compassion and respect.
Feedback from children, young people and parents was very positive and they were happy with the care provided by the staff. We observed numerous positive interactions between staff, children and families.
Parents were empowered to be involved in the care of their children. All parents we spoke with felt they had enough information about their child’s condition and treatment plan. They praised the kind, professional and understanding nature of staff.
We have judged the responsiveness of the children and young people’s service as good. Services were designed to meet the individual needs of children and young people and were delivered in flexible locations to suit parents and children. For example, the development of the sexual health service by school health nurses in secondary schools.
We observed staff respecting and valuing the individual rights and diversity of the children, young people and families they cared for. Specialist services were in place for looked after children. Parents told us they were aware of how to raise concerns or make a complaint.
We have judged the leadership of the children and young people’s service as good.
Good local leadership was provided throughout the various teams and staff were very positive about the support they received from their team leads and managers.
Clear management and governance structures were in place through meetings to monitor performance and service risks.
All staff were positive about working for the trust and took pride in their work.
The directorate was committed to engaging with young people to obtain feedback and encourage participation of young people in its services. A range of approaches were used to work with young people and parents/ carers and this included the ‘Article 12 group’ which had been operating for six years. It had 35 young people as members. They met regularly and had contributed to the development of the children and young person’s website.

Overall rating for this core service Good O

Overall, we rated this core service as ‘‘good’’. We found that community services for adults at Oxford Health NHS Foundation Trust were, ‘’good’’ for effective, caring, responsive and well-led services but ‘’required improvement’’ to be safe.

Oxford Health NHS Foundation Trust is the main provider of community health services for adults in Oxfordshire. Services are provided to patients in their homes and at a number of clinics held at community hospitals, health and wellbeing centres and GP surgeries. Care and treatment are provided under the regulated activates: treatment of disease disorder or injury and diagnostic and screening procedures.

Our key findings were:

There were periods of understaffing across a number of community services. This impacted on patients receiving timely access to safe care and treatment.
Pressure ulcers were the most frequently reported serious incident. Investigations into these incidents highlighted understaffing as one of the causes. A plan was in progress to reduce avoidable pressure ulcers.
Patient records did not all contain risk assessments, or these had not been reviewed in line with trust policy, to ensure clinical risks were appropriately managed.

There were systems and processes in place to keep patients safe, such as infection control, medicines management and servicing of equipment provided to patients. Learning from risks, incidents, near misses was shared with staff.

Safeguarding protocols were in place and staff were familiar with these.
Community services for adults used guidance from the National Institute for Health and Care Excellence (NICE). Services monitored and reported on patient outcomes to ensure they were providing an effective service to patients.
There was well established multidisciplinary team working across almost all the community services we visited. There was an effective system in place for referral, transfer and discharge of patients.
Staff had completed statutory and mandatory training and described good access to professional development opportunities.
Not all patients had a malnutrition risk assessment completed at their first visit, in accordance with the trust nutrition and hydration policy.
Patients received compassionate care that respected their privacy and dignity. Patients told us they felt involved in decision making about their care. We found staff were caring and understanding. Without exception, patients we spoke with praised staff for their empathy, kindness and caring approach.
Services were planned and delivered to meet the needs of the local population. Services were supportive, adapted to meet the needs of people in vulnerable circumstances and made arrangements to meet the diverse needs of local people, such as through access to translation services.
Waiting times for most outpatient services were outside the trust target of first appointment within 12 weeks of referral. Actions plans were in place to respond to these issues. Delayed transfers of care were an ongoing concern for the trust. Work was taking place with multiple providers to continue to address this.
Elements of the trust’s vision and strategic forward plan had been implemented in community services, through the implementation of integrated locality teams. Staff were adjusting to this new model of working, but could see the long-term benefits for patients.
There were effective arrangements in place, to monitor quality and safety. Staff felt supported by their immediate managers. The culture within community services was caring and supportive. However, staff felt senior management did not always listen to or respond to concerns or suggestions for improvement to services.

Overall rating for this core service Requires Improvement O

We rated Oxford Health NHS Foundation Trust as requires improvement overall for its community health inpatients services.

Improvements were required to ensure safe, effective and well-led inpatient services. We found staff were caring and compassionate and treated patients with respect and the trust provided a responsive service.

Our key findings were:

We were concerned that when patients’ appeared to have difficulties in their ability to swallow ; their drinks were routinely thickened to try to reduce the risk of choking without a clear assessment of the risk or assessment by a speech and language therapist.

Most staff were aware of safeguarding and what constituted abuse. They were able to explain the types of concerns which would result in a safeguarding alert being raised.

The process for assessing risks such as pressure ulcers, falls and malnutrition were mostly completed and care plans were developed to manage them effectively. However there was a lack of pain assessments or documentation.

All hospitals used a recognised tool to determine if patient’s health was at risk of deterioration. However, staff did not always follow the procedures such as escalating concerns.

Not all staff showed awareness of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. There were no assurances in place that the code of practice was being followed and some managers did not have a clear understanding of the process. Therefore patients were at risk of being detained unlawfully.

We found documentation consisting of paper and computer notes was not contemporaneous or stored in one place. We found variation in the completion of risk assessments and care plans.

Equipment, including emergency equipment was available. In general equipment was maintained though there were a number of pieces of equipment that required portable electrical testing.

There were a high percentage of delayed discharges and patients experienced long lengths of stay in hospital, which could have a negative impact on their welfare and wellbeing. The trust was monitoring patietnes length of stay and delays to discharges and was working with partners to address some of the issues.

Processes for monitoring the quality of the inpatients’ service and those to ensure risks are identified and managed were not sufficiently robust with risks not always managed effectively. There was monitoring of performance and quality using a trust wide dashboard but limited evidence of local audit of the service or patient care.

Medicines were available to patients and were managed effectively and according to medicines guidance.

Appropriate staffing levels were maintained at most hospitals and agency and bank staff covered shortages. There were adequate staff to meet the needs of patients in a safe and consistent way.

We found there was strong ethos of multi-disciplinary working. Multi- disciplinary team meetings were held on a regular basis.

Infection control procedures were followed and overall standards of cleanliness were good in the community hospitals.

Overall rating for this core service Good O

The end of life care service is delivered along with other general care services, in community hospitals and patients’ own homes.

Overall, we rated this core service as ‘‘good’’. We found community end of life care service at Oxford Health NHS Foundation Trust were, “good’’ for safe, caring, responsive and well-led services but “required improvement’’ to be effective. This was because improvements to awareness and education had not yet had an impact on patients’.

Our key findings were:

Services for end of life care were safe and there was a good culture of reporting and learning from incidents.
Staff did not have a consistent knowledge of the requirements of the duty of candour.
There were systems in place for escalating concerns about potential safeguarding concerns.
The community hospitals were clean and well maintained. Equipment was clean and fit for purpose.
The trust used a single model of syringe driver for end of life care medicines and staff had received appropriate training on the use of these. The administration of medicines by syringe driver was monitored, but the same documentation to record this was not used across the areas we visited.
Staff participation in mandatory training was below the trusts target.
The trust had recently introduced a new end of life care plan to replace the Liverpool Care Pathway, that had stopped being used in England in 2013.
There were sufficient staff to provide high quality care in community hospitals; however this was mainly due to a reduction in the numbers of available beds.
Patients at end of life had risk assessments completed where indicated.
The trust could not demonstrate that end of life care was delivered consistently against the ‘five priorities of the dying person’.
There was a combination of paper and electronic records that made getting key information difficult for staff.
Information about a patient’s preferred place of care was not always communicated. Outcome data about patient’s preferred place of care and actual place of death was not routinely collected.
Decisions about resuscitation were not always discussed with the patient or relatives. Do not attempt cardio-pulmonary resuscitation forms were not always fully or correctly completed.
We found there to be an inconsistent use of pain assessment tools with end of life care patients.
Staff demonstrated a good understanding of the Mental Capacity Act.
There was evidence of effective multidisciplinary working that put the patient at the centre of their care. This led to some good examples of joined up working that gave the patient a seamless journey.
We saw some excellent examples of staff providing care that maintained respect and dignity for the individual. There was also good care for the relatives of dying patients, and sensitivity to their needs.
Care was delivered with compassion, and staff prioritised the needs of patients at end of life.
Patients and relatives were given the emotional support they required, and felt that they were involved in the planning of their care. Staff gave patients the time they needed so their visits did not seem rushed, even when the service was under pressure.
The trust had identified that staff found it difficult to have conversations about their preferences for their care at end of life. Training to address this need had been organised.
The trust were in the process of implementing the requirements of the ‘one chance to get it right’ document for the delivery of evidence based end of life care. They were meeting with their commissioners and other partners to plan end of life care services to meet the needs of local people.
Community hospitals provided appropriate facilities for end of life care. There was provision for people with communication difficulties, this included an interpreter service.
The environments in community hospitals were designed to be suitable for patients living with dementia. Vulnerable patients were identified and effective multidisciplinary working ensured their needs were met.
Matrons who led end of life care in community services were highly accessible to community nurses, patients and GPs. They worked across boundaries to coordinate end of life care for patients.
Although the trust did not have a strategy for end of life care, strategic work was being undertaken to improve services. Leaders of end of life services were aware of areas or risk and where they needed to improve services.
We found evidence to demonstrate that end of life care was an improvement goal for the trust. There was a commitment among staff and local leaders to make end of life care better for patients.
Staff were aware that they needed further education and training particularly around advance decisions and care planning. We found that staff were engaged in making improvements to both their own knowledge and the services they provided.
The trust sought and acted on feedback received from patients and relatives.

Overall this core service was rated as good. We found the services were ‘good’ for caring, effective, responsive and well led. We rated safe as ‘requires improvement’.

Our key findings were:

Emergency resuscitation equipment was not adequately managed with potential risks to patients. The facility for children was inadequate in Witney MIU and there was not enough seating in the waiting area for patients attending this unit.
Medicines were not always managed safely to ensure emergency medicines were available and in date. The labelling of medicines for patients to take home was not in line with Medicines and Healthcare Products Regulatory Agency (MHRA) guidance.
Patients were offered medication to control their pain. Patients said they received pain control when they needed. Children’s pain was not always assessed and treated and no pain assessment tool was used.
Staff had received safeguarding vulnerable adults and children training. The majority of staff were clear about their responsibilities and were aware of the support lines available to them. There was however a lack of understanding around domestic violence and the action to take.
Staff provided care to patients based on national guidance, such as National Institute for Health and Clinical Excellence (NICE) guidelines.
Multidisciplinary teams cared for patients in a coordinated way. Staff had good access to training and opportunities to undertake additional training for their roles.
Patients presenting to MIU were assessed and in case of deteriorating conditions, appropriate action was taken. Patients were fully involved in their assessment and treatment process in order to meet their needs.
Staff provided compassionate care and ensured that patients were treated with dignity and respect. Care and treatment was planned around the individual and their needs and wishes were taken into account. . The results of the NHS Friends and Family Test (FFT) showed that a higher than average number of patients would recommend the department.
The trust has developed an innovative and successful delivery of urgent care such as the emergency multidisciplinary units (EMU) in Abingdon and Witney. There was evidence of service planning to meet local needs, including the services provided in Henley and the refurbishment of Townlands hospital.
The EMU’s were able to support local people with treatment so they were able to return home from hospital earlier, such as different infusions and administration of intravenous antibiotics.
The service met the national emergency access target for 95% of patients to be admitted, transferred or discharged from the urgent care unit within four hours.
Staff were positive about the local leadership of the service and felt supported by their immediate managers and they worked well together. Patients’ feedback was gathered and used to improve the service.
There were effective governance arrangements and staff felt supported by the local and trust’s management teams.
Lessons learnt from incidents and complaints were shared with staff.

We have rated the trust as requires improvement as in safe and effective. We have rated them as good for caring, responsive and well led.

On the whole services were safe, but the trust received a rating of requires improvement because we found pockets of poor practice. In addition, we found some environments that were outdated for the delivery of modern mental health care and this was of particular concern at the Warneford Hospital. There was poorly recorded risk planning in some areas of children’s services in mental health, unidentified ligature points in acute mental health services and a lack of basic life support training for reception and administration staff at the GP practice. These findings have resulted in requirement notices being issued.

Across all services the trust staff were good at recognising safeguarding concerns and reporting incidents. Teams learnt from incidents and complaints and shared learning across services, through regular ‘briefing notes’

Staff were compliant with mandatory training and had good induction programmes, as well as opportunities for continuous professional development.

The trust had a strong track record of working in partnership with the independent and voluntary sector using an integrated model to provide services. The trust is clearly committed to services that are multi-agency and multi-disciplinary and this was evident from the range os services on offer. We also observed board discussions about this and staff at the frontline described good multi-agency working.

We found that care plans were not always personalised and did not involve people in their care. In acute mental health inpatient wards this has contributed to a rating of requires improvement. The quality of care plans across the trust was variable and inconsistent. Staff at times were using both paper records and an electronic record system, as the trust moved to a new electronic health record system called Care Notes. This had been placed on the Trust risk register and they acknowledged that there were inherent risks in moving information from one system to another. They were partly mitigating these risks by implementing the new system in a phased way.

In most services, we found that staff were committed, dedicated and passionate about the work they did. Patients and their carers spoke positively about the care they received and felt they were treated with dignity and respect.

There was variability across the trust in their ability to respond to people in a timely way with some areas of outstanding practice and some where there were waiting lists for services. However, waiting lists appeared well managed and the trust were aware of these. They had actions in place to mitigate any risks this may present. There were a number of delayed discharges and bed occupancy levels were high. We found that some patients had been transferred between wards for non-clinical reasons in order to manage beds. The trust did have good systems in place for bed management but it was clear that this was a significant pressure point for the trust. Across most services there was good access to emotional support and the trust considered peoples diverse and individual needs.

Services were well led and staff were positive about local and central leadership. Mangers were visible and accessible and teams and services had the right meetings and handovers in place. Performance was monitored and reviewed. The process for monitoring of risk was robust and the board were clearly sighted on both the corporate and operational risks facing the organisation. These were presented in board meetings via a risk register. Local services also maintained local operational risk registers.

The structure of meetings and committees, which provide the board with assurance, were well embedded. Most had non-executive director oversight. This ensured that the trust have leaders who were well placed to provide the appropriate challenge.

The trust had the right policies in place to support staff in their work. Staff received relevant training and support.

There were some environmental concerns raised, which had not been dealt with in a timely way. For instance, the premises of the child and adolescent mental health services in south Oxford was in a poor condition. A leaky roof had caused substantial water damage which was reportedly highlighted 18 months ago. The smell of sewerage had been reported in a patient’s bedroom but this problem continued for over a year without resolution.

The trust achieved ratings of outstanding for ‘caring in ‘child and adolescent community services’ and primary medical services and outstanding for ‘responsive’ in ‘forensic inpatient services’ and in primary medical services. It received an overall rating of outstanding for children and young peoples’ services. These services were able to demonstrate excellent practice and innovation which went above the standards expected. For instance, in primary medical services the outreach offered to the homeless population was exceptional.

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

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

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

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

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