All inspections: Northamptonshire Healthcare NHS Foundation Trust

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

There was a truly holistic approach to assessing, planning and delivering care and treatment to all people who used services. We saw safe use of innovative and pioneering approaches to care delivery. New evidence-based technologies were used to support the delivery of high quality care. Staff provided a range of treatment and care for patients based on national guidance and best practice. They ensured that patients had good access to physical healthcare and supported them to live healthier lives.
The continuing development of the staff’s skills, competence and knowledge was recognised as being integral to ensuring high-quality care. Staff were proactively supported and encouraged to acquire new skills, use their transferable skills, and share best practice. Staff, teams and services were committed to working collaboratively and had found innovative and efficient ways to deliver more joined-up care to people who used services. Staff from different disciplines worked together as a team to benefit patients.
The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Leaders encouraged innovation and participation in research. Leaders had an inspiring shared purpose and strived to deliver and motivate staff to succeed. There were high levels of satisfaction across all staff.
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 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.

Since our last inspection, the trust continued to deliver high quality, safe services across the five mental health services we inspected.
There was a strong focus on patient and staff safety as a priority agenda. The trust had made improvements to how they learnt from investigations into serious incidents and engaged and supported families and relatives throughout the process.
There was a strong culture of openness, honesty and learning. There was evidence of sharing practice with others, and an ethos for embracing constant opportunity for learning and improving. The trust had formed a strong relationship with a neighbouring trust and embraced a ‘buddy’ relationship. The trust board were clear that this was not only an opportunity to support another NHS organisation, but an opportunity to improve and learn for themselves.
We heard how the trust had continued to prioritise their values in every interaction every day, and the culture of staff in the trust was one of kindness, teamwork and pride to work for the organisation. The trust had embedded the importance of training, supervision, talent management and development of staff. Staff had access to numerous opportunities to learn and develop within their roles.
All services we visited had continued to engage with carers and received positive feedback from the users of services. It was clear that co-production, involvement and engagement had continued to go from strength to strength across the trust. ‘I want great care’ continued to be integral to obtaining feedback from service users and carers.
We found staff completed thorough and detailed risk assessments, and the trust had effective processes for reviewing and updating them. We saw staff assessed and monitored physical healthcare well and teams had multi-disciplinary approaches that promoted healthy lifestyles. Staff completed person-centred, collaborative care plans which involved families and carers.
Quality improvement was embedded around the trust. The trust consistently encouraged and supported staff to innovate and develop new ideas. Staff were consulted and felt included in strategic changes and developments.
Staff felt valued by the trust, their managers and by each other. There was an emphasis on staff well-being and leaders saw this as a priority focus for those who worked at the trust. The board had invested in well-being events, changed policies, well-being conversations and promoted work-life balance as integral to ‘teamNHFT’. The culture was one of encouraging distributed and collected leadership throughout the trust. Staff felt supported to make decisions where appropriate.
Equality, diversity and inclusion had developed further since our last inspection. The trust had taken steps to promote further inclusion and collaboration of minority groups. Links with the community, the wider system and stakeholders was very strong and survey data showed an improvement in most areas of workforce equality. Directors told us that reverse mentoring had had a profound effect on their working and personal lives. The trust had robust plans for a wider roll out of this programme within the trust.
The trust had won several national and local awards throughout 2018 to 2019. The trust was shortlisted for other awards. The board made a conscious decision to celebrate such success internally, which positively impacted on morale of teams, staff and ultimately patient care.

However:

We had concerns about safe practice in isolated areas at some locations. We found an infection, prevention and control measure issue at one location, environmental concerns at both Health-based Places of Safety and high levels of restraint and seclusion in Acute Wards for adults of working age and PICU services. Across two services, we had concerns over safe management of medicines.
Two services had experienced organisational changes which had impacted on staff morale. The trust had plans in place to address this, but staff told us it had been a challenge.
Staff in Wheatfield Unit had not correctly documented Section 17 leave in 13 of 17 cases.
In community mental health services for people with a learning disability or autism, we found that both adults and children in the ADHD pathway, waited over 18 weeks for assessment or treatment.

The service provided safe care in a safe and clean environment. The wards had enough nurses and doctors to operate safely. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Managers dealt with staff sickness in line with provider policy. There was enough staff to maintain patient safety on the ward, and managers were aware of the pressures on other staff members due to gaps in some roles. We saw quality improvement plans developed to address the issues.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff provided a range of treatments suitable to the needs of the patients, which were in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward staff had access to a range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a 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.
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, and actively promoted co production whenever possible.
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 or Ministry of Justice 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:

Managers had not ensured the multidisciplinary staffing establishment met the needs of patients. This followed an increase in patient numbers and the reassignment of a key post. There was significant long-term sickness on the ward, which resulted in high usage of bank staff.
The patients self-catering kitchen was not clean, and there was no effective system for ensuring that this kitchen was cleaned after every use.
Manual handling training compliance was 63%, which fell below the trust target.

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 to meet the needs of patients. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients which were in line with national guidance and best practice. Staff engaged in clinical audits 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. Managers ensured that these staff received training, regular supervision and an annual 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.
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 managed beds well. A bed was almost always available locally to a person who needed admission. Patients were discharged promptly once their condition warranted this.
The service was well-led. Governance processes were established and ensured that ward procedures ran smoothly. Innovative ideas to reduce restrictive interventions had made a positive impact on patient care.

However:

Staff did not always follow systems and processes when safely prescribing, administering, recording and storing medicines.
Incidents of restraint and seclusion had not reduced since our last inspection.

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

The service provided safe care. The clinical environments were generally safe and clean. The teams had enough nurses and doctors. Staff assessed and managed risk well. Staff managed most medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, 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 and best practice. 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 patients. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those external to the teams and trust who had a role in providing care. Staff planned and managed transitions and discharges well and liaised well with external agencies.
Staff understood and discharged their roles and responsibilities 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 understood their roles and responsibilities under the Mental Health Act 1983, although there were no patients subject to any section of the Mental Health Act during inspection.
Staff treated patients with high levels of compassion and kindness, truly respected their privacy and dignity, and fully understood the individual needs of patients. They actively involved and collaborated with patients, families and carers in care decisions. People who used services were always fully involved in writing their care plans and action plans. Staff consistently provided care plans and treatment information in easy read and visual formats. The service routinely encouraged involvement and feedback from people who used service and their carers including recruitment of staff.
The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

Due to organisational changes, and a change in the staff group since the last inspection, some staff described ‘significant niggles’ and difficulties in the team. Organisational changes had had an impact on the morale of some staff.
Only 53% of staff had attended Mental Capacity Act training. Therefore, the trust had not met its target of 90%.
The attention deficit hyperactivity (ADHD) and Asperger’s service had not met the trust target. The waiting time for this service was 244 days (34 weeks) against a trust target of 126 days.

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

There were a number of innovative ways people could access support for crisis care across the county. The crisis cafés had become overwhelmingly popular and alongside the crisis house, had reduced the number of admissions to acute wards, and attendances at local accident and emergency departments. The treatment pathway and access to crisis services in the county was exemplary and had been recognised for national awards.
The mental health crisis service was available 24-hours a day and was easy to access, which included a dedicated crisis telephone line. The referral criteria for the mental health crisis teams did not exclude patients who would have benefitted from care. Staff assessed and treated patients thoroughly and promptly. Staff consistently followed up with patients who missed appointments.
The mental health crisis care pathways were committed to improving crisis services for the public by ensuring current and future services were informed by the feedback of service users and carers.
Staff were overwhelmingly positive and passionate about their roles and the client group they supported. Staff felt highly valued by the leaders within the service, who themselves were dynamic. Staff felt very proud about working for the trust and within their teams. Patients told us staff listened to their choices and went “the extra mile”. Patients told us heartfelt stories about the care they had received had exceeded their expectations.
Leaders within the service had an in-depth understanding of the service. They had the skills, knowledge and experience to perform their roles effectively. They explained clearly how the teams worked to provide high quality care. Leaders had an inspiring shared purpose, strived to deliver high quality and safe care, and motivated staff to succeed.
Staff thoroughly assessed and managed risks to patients and themselves. They responded promptly to any sudden deterioration in a patient’s health. When necessary, staff in the mental health crisis teams and the psychiatric liaison mental health services, worked in collaboration with patients, families and carers to develop crisis plans.
Staff assessed the mental health needs of all patients. Staff routinely worked with patients, families and carers to develop individual care plans and updated them when needed.
The crisis pathway at the trust had been awarded national recognition for the services provided and develop in collaboration with patients.

However:

The physical environment of the Health-Based Place of Safety at Northampton did not meet the requirements of the Royal College of Psychiatrists standards on the use of Section 136 of the Mental Health Act 1983. The room could not be observed externally and required staff to enter the room to observe patients effectively. At times, staff observed patients with the door ajar and some attempts by patients to abscond from the room when aggressive, led to episodes of restraint.
The Health-Based Place of Safety at St Mary’s hospital did not have an observational panel or CCTV, in line with the Mental Health Act Code of Practice. Access to the room in an emergency, could not be gained via a second door.
The Warren crisis house did not adhere fully to infection control principles. Patients’ personal bathing items were stored together in a shared bathroom. Infection Prevention and Control training was low across this core service at 70% which was below the trust target of 90%.

The summary for this service appears in the overall summary of this report.

Our rating of the trust improved. We rated it as outstanding because:

The trust responded in a very positive way to the improvements we asked them to make following our inspection in January 2017. At this inspection, we saw significant improvements in the core services we inspected and ongoing improvement and sustainability of good quality care across the trust as a whole. The senior leadership team had been instrumental in delivering quality improvement and there was a true sense of involvement from staff, patients and carers towards driving service improvement across all areas.
We were particularly impressed by the strength and depth of leadership at the trust. The trust board and senior leadership team displayed integrity on an ongoing basis. The trust’s non-executive members of the board challenged appropriately and held the executive team to account to improve the performance of the trust. The trust leadership team had a comprehensive knowledge of current priorities and challenges and took action to address them. The board were seen as supportive to the wider health and social care system, with both the chief executive and finance director taking up key roles in the local system including through the Health and Care Partnership Board (also known as the STP). Reports from external sources, including NHS improvement and commissioners were consistently favourable. The trust had a clear vision and set of values with quality and sustainability as the top priorities. The trust benchmarked their ‘business as usual’ against the vision and values and kept the message at the heart of all aspects of the running of the organisation. Local leadership across the trust was strong, visible and effective. Staff were particularly praising of the chief executive and the chair of the trust.
We were also impressed by the trust attitude towards innovation and service improvements. The delivery of innovative and evidence based high quality care was central to all aspects of the running of the service. There was a true sense of desire to drive service improvement for the benefit of patients, carers, and the wider system, evident throughout the inspection. Staff included patients in service improvement and used their feedback to change practice. The trust actively sought to participate in national improvement and innovation projects and encouraged all staff to take ownership, put forward ideas and remain involved throughout the process. We saw many examples of innovation and projects that had been trialled and then implemented in the trust. One such example was the development of a gum shield, made by the trust’s community dental department, for use by patients undergoing electroconvulsive therapy. The intended benefits of the gum shield included reducing post-ECT headache. The trust was in the process of evaluating this outcome. The trust was also in the process of producing a research paper for this innovation to encourage other providers to consider this option. We were shown many research projects and research publications, underpinning current practices within the trust, including transcranial magnetic stimulation in clinical practice and the feasibility of using body worn cameras in an inpatient mental health setting. The trust had been asked to participate in the first clinical evaluation of magnetic seizure therapy worldwide and was in the process of obtaining ethical approval and advice from the Royal College of Psychiatrists’ ECT and related treatments committee for the evaluation.
The trust included a module for innovation and research within their ‘leadership matters’ programme. The trust had set aside funds so that staff could undertake small projects under the QI banner. The trust was focused on improving pathways and is continuous in its encouragement of innovations to do so, which are then subsequently reviewed and challenged by the board. The trust had been recognised for its innovation in a number of areas, for example, the breathing space service in Northamptonshire won the Pathway Innovation of the Year Award at the National Primary Care Awards; FAB awards 2017,
Staff, patients and carers were actively involved in a number of different ways and the trust prioritised engagement at every level and through all services. The trust’s mission statement "making a difference for you, with you" was co-produced with staff, patients and stakeholders. Patients, families and carers were encouraged to provide feedback on the care they had received by a number of routes, for example via the ‘I want great care’ initiative. This service allowed patients and carers to comment on the care they have received via the internet. The trust had a ‘I want great care’ lead, who reported to the medical director. The lead oversaw the system and either responded directly or forwarded to the relevant team for action. The trust reported 90,939 pieces of feedback since the initiative started. The initiative was embedded into governance, quality and strategy processes.
Staff across all services spoke highly of the executive team, without exception. We observed that the vision and values of the organisation were truly embedded throughout the trust and reflected in all aspects of care delivery; including service design. The trust was regarded by Northamptonshire Carers and the Carer’s Strategic Partnership as a carer friendly organisation and one that was committed to championing the important role that carers play in an effective care relationship. The Chief Executive had signed up to the principles of the County Carer Strategy. The trust were key participants in this development with a view to ensuring that the strategy covered carers of all ages, including young and working carers. The WRES action plan was co-produced with BME staff and as a result of this plan, the reverse mentoring initiative and staff led focus groups were implemented. The executive all participated in a reverse mentoring programme. They spoke emotively and powerfully about this and it informed their planning and practice. The National Director for WRES had recently visited the trust and praised the culture and approach.
Staff showed caring, compassionate attitudes, were proud to work for the trust, and were dedicated to their roles. We were impressed by the way all staff in the trust embraced and modelled the values. The values were embedded in the services we visited and staff showed the values in their day-to-day work. Throughout the trust, in both mental health and community health services, staff treated patients with kindness, dignity and respect. Consistently, staff attitudes were helpful, understanding and staff used kind and supportive language that patients would understand. The style and nature of communication was kind, respectful and compassionate. Staff showed strong therapeutic relationships with their patients and clearly understood their needs. Staff offered guidance and caring reassurance in situations where patients felt unwell or distressed, confused or agitated. Overall, positive feedback was received from those patients, families and carers spoken with about the care and treatment received from staff. Patients told us that they felt safe across the trust. The trust promoted a person-centred culture and staff involved patients and those close to them as partners in their care and treatment. Staff provided positive emotional support to patients.
The trust had robust systems and process for managing patient safety. Staff recognised when incidents occurred and reported them appropriately. The board had oversight of incidents, and themes and trends were identified and acted upon. Managers investigated incidents appropriately and shared lessons learned with staff in a number of ways. When things went wrong, staff apologised and gave patients honest information and suitable support. The trust applied the duty of candour appropriately. We reviewed serious incident reports and found investigations were thorough and included participation from family and carers; where appropriate. Outcomes from investigations had influenced changes within services for the protection of patients. Staff had training on how to recognise and report abuse and applied it. The trust had effective systems for identifying risks and planning to eliminate or reduce them. We were particularly impressed with the trust focus on reducing risks of falls across a number of services. The trust was committed to improving services by learning from when things go well and when they went wrong. Staff training and service development was prioritised.
Staff kept clear records of patients’ care and treatment. Patient confidentiality was maintained. Care and treatment records were clear, up-to-date and available to all staff providing care. The trust provided care and treatment based on national guidance. Patients had access to psychological support and occupational therapy. The physical healthcare needs of inpatients with mental health needs were met. Patients in community health services benefitted from the support provided by staff.
Staff were compliant with mandatory training across all services and staff had opportunities for further training to support care and treatment for patients. Managers ensured staff received supervision and yearly appraisals. The trust had introduced a new electronic staff record system which had provided greater oversight to staff compliance with mandatory training and supervision. All staff and managers had access to the system.
The trust ensured safe staffing levels were maintained. Staffing levels and skill mix across all core services was planned and reviewed so that people who used services received safe care and treatment. Managers ensured services across the trust increased staffing based on clinical need or made arrangements to cover leave, sickness and absence.
Trust premises across all mental health and community services were clean and well maintained. Across most services staff had completed environmental risk assessments. Where issues had been identified, staff mitigated these risks by carrying out additional checks or had taken other actions to resolve the issues. The trust had robust estate management processes and ongoing plans for improvements.
Trust staff worked well with each other and external organisations to provide care and treatment to patients based on national guidance. We were particularly impressed by the work undertaken by the young persons’ dementia team who had multiple links to outside agencies and assisted patients, families and carers to access these services.
Staff completed Mental Health Act paperwork correctly. There was administrative support to ensure these records were up to date and regular audits took place.
Systems for the safe management and administration of medicine were in place. Incidents and errors within the pharmacies were reported and investigated and outcomes and learning shared with staff. The pharmacy team reviewed serious incident reports when medicines were involved.
Bed management processes were effective and included daily bed management meetings. Whilst staff could not guarantee that patients had access to a bed on the same ward upon return from leave, as the acute wards regularly admitted new patients into leave beds, to resolve this staff completed risks assessments for all patients on leave; should they return unexpectedly. On occasions staff had made other areas of the ward into temporary bedrooms for these patients for short periods. On return patients were asked if they would prefer to be placed out of area, or when appropriate provided alternative care, for example additional support from the home treatment team. We noted the trust were lower bed weighted per population (14 beds per 100,000 against an average of 18 beds per 100,000). We considered the trust was managing these patients in a safe manner and the privacy and dignity of patients had not been compromised.

However:

During this inspection we identified some issues the provider needed to review within the acute wards for adults of working age. The trust secured beds out of area when local beds were not available and the numbers of patients affected had increased since the last inspection.
We had some concerns about the trust's approach to the use of restrictive practices. The trust reported high numbers of prone (face down) restraint across the acute wards (56% of all recorded restraints between December 2017 and January 2018, reducing to 38% between February and June 2018). While data showed an average of 96% of prone restraints related to administration of rapid tranquilisation or safe seclusion exits; we considered the trust needed to review its practice in accordance with the Mental Health Act and Code of Practice. Staff had not fully completed seclusion paperwork. There were some gaps in seclusion documentation and seclusion care plans. Staff did not fully record how to meet patients’ needs while in seclusion, or what bedding and clothing was to be provided.
Staff on some adult acute wards administered prescribed medications up to three and a half hours after the prescribed time, and had not reflected this in documentation. There was a risk that insufficient time between doses of medication might occur.
We found that some environmental and equipment problems had not been completely resolved. Improvements to the interview rooms for the psychiatric liaison team in both Kettering and Northampton general hospitals had not been completed satisfactorily. These rooms did not meet the Psychiatric Liaison Accreditation Network standards. However, the trust provided information to show that an action plan had been in place since our last inspection, and the trust was expecting its PLAN peer review assessment in early July 2018. The health based place of safety in Kettering did not comply with the Royal College of Psychiatists’ standards as there were ligature points. Within the community health services for adults, not all small, electronic equipment had been serviced when required. There was not a robust governance process to ensure equipment was always maintained within clinics managed by an external organisation.

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

The ward environments were clean and tidy, which patients confirmed was always the case.
Patients confirmed that staff were available to them on the wards. Leave or activities were not cancelled due to staffing shortages.
Patients said that they felt safe.
Staff completed detailed risk assessments for patients on admission and reviewed them regularly.
Staff monitored patients’ physical health regularly from the point of admission.
Staff were warm in their interactions, quick to respond in a kind and caring manner.
Patients and carers were encouraged to be involved in their care and they knew how to complain if needed.
There was a range of treatments and activity delivered by skilled and experienced staff.
Staff reported good morale, felt they were supported by managers and were happy in their roles.
We reviewed 39 prescription charts and saw generally good management of medication on Brookview, Spinney and Orchard wards. Medication was prescribed within recommended guidance and most documentation was present and in date.

However:

On Riverside ward we found a number of missed medication doses and staff did not always report using the incident reporting system.
Not all care plans were recovery focused or personalised and some paperwork had gaps.
Mental capacity assessments were not documented in detail and lacked evidence of family or Independent Mental Capacity Act Advocate involvement.
Some patients reported that they would like a television in their bedrooms.

Overall rating for this core service

We rated the community dental services at this trust as outstanding.

We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed their dedication in what they did.
The community dental service was well led. We saw a service that had strong and effective clinical leadership at its heart and there were effective governance and risk management structures in place. We found a local operational management team that was effective and visible and the working culture appeared open and transparent.
We saw that the way staff delivered care and organised the running of the service embodied the organisation’s overall vision of how care should be delivered. Staff told us they were well supported by the management team and that they could raise any concerns at any time and reported that their concerns were always dealt with in a timely manner.
Staff protected patients from abuse and avoidable harm. We saw that there were effective systems in place for identifying, investigating and learning from patient safety incidents. Effective infection control procedures were in place and followed published guidance in relation to primary care dental services. We observed an environment and equipment that was clean and well maintained and medicines and emergency equipment were available at each site we inspected to deal with medical emergencies.
The dental services were effective and focused on patients’ and their oral health care. The care provided followed current professional guidance in relation to special care dentistry, best practice prevention, general anaesthesia and conscious sedation.
To help address the needs of more vulnerable members of the community in Northamptonshire we saw an effective and outward facing oral health promotion unit led by an enthusiastic and committed clinical lead. For example, this service reached out to vulnerable groups in care homes, adults with a learning difficulty, homeless, those with drug and alcohol dependence, those living with dementia and chronic obstructive pulmonary disease support groups. We saw a comprehensive package of training that had been developed by the clinical lead to assist care home workers in maintaining good oral health to the residents in the care home.
Staff responded to patients’ needs at each clinic we inspected. The service kept treatment delays for routine dental treatment within reasonable limits through effective resource management. Effective multidisciplinary team working ensured the service provided patients with care that met their needs, at the right time and in the right place.
Patients, relatives and carers reported that they had positive experiences of care within the service. We saw good examples of staff providing compassionate and effective care. We also saw effective interactions taking place between individual staff members which resulted in a happy yet calm working environment.

We rated end of life care services at this trust as good overall because:

Patients were protected from avoidable harm. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Arrangements to minimise risks to patients were in place.
Patients were protected from abuse; staff had an understanding of how to protect patients from abuse and could describe what safeguarding was and the process to refer concerns.
Patients received effective care and treatment that reflected current evidence-based guidance, standards and best practice.
Patients had comprehensive assessments of their needs, which included nutrition and hydration and physical and emotional aspects of their care.
Care from a range of different staff groups was coordinated effectively; there was effective multidisciplinary working, with staff, teams and services at this trust working in partnership to deliver effective care and treatment.
Staff understood the consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005; this was reflected in the Do Not Attempt Cardio-Pulmonary Resuscitation orders reviewed during our inspection.
The care provided to patients in the end of life care service was good. Patients were truly respected and valued as individuals and were empowered partners in their care.
Feedback from patients, relatives and carers was consistently positive and there were many examples of staff being caring, compassionate and providing dignity in a respectful manner.
Patients’ needs were mostly met through the way end of life care was organised and delivered.
The service was evolving, with a developing strategy. There were robust mechanisms in place to share learning across end of life services.

However,

The trust did not collect data to establish how rapidly patients were discharged from inpatient services and how often delayed discharges occurred.

Overall rating for this core service Requires Improvement

We rated community health inpatient services as requires improvement because:

Vacancies existed throughout the service and bank and agency staff were required to fill gaps in service provision. Active recruitment was ongoing but staff shortages remained on the service risk register. From November 2015 to December 2016, staff reported 23 incidents, which related to staff shortages, with one categorised as moderate harm and six low harms.The moderate harm incident was not attributable to the trust.
The environment and room layout on some wards meant not all patients were easily observed. Some wards had significant health and safety hazards including leaking roofs, heating failures and trip hazards. There was insufficient storage space to store equipment safely.
Prescribed medicine was not always signed for and staff were unsure if patients had received medicine as prescribed.
Staff did not report all medicine related incidents in line with trust policy. There was no agreed training and assessment protocol for staff to undergo when they had made drug errors. Individual wards made their own decisions regarding staff competence following a drug error.
Staff did not always review patients’ prescribed medicine at the correct time.
Medicine was not always stored in line with best practice guidance or trust policy.
The service did not partake in national audits and so there was no benchmarking against other similar services and improvements could not be measured and compared.
There was a high number of delayed discharges. At the time of our inspection, 46% of all patients were medically fit to go home but were waiting for assessments by the NHS or waiting for care packages. On average, 30% of all discharges over the year were delayed.
Stroke patients were treated on different wards despite an action plan from August 2016 to accommodate all stroke services on one site. Following our inspection, the trust provided evidence that it is was working with commissioners to move stroke services to one site only.

However:

The service had a good safety record. There had been no reported serious incidents or never events from September 2015 to September 2016.
The service met its target for mandatory staff training and staff appraisals.
Additional training was available for therapy staff and healthcare assistants. These provided opportunities for staff to develop their role and take on more responsibility. This improved the staff skill mix on each shift.
Quality of care was assessed and monitored through a quality dashboard. This involved several local audits and action plans. Audit results were discussed at governance meetings and action plans were in place to address issues identified.
Multi-disciplinary working across the service was good. Therapy assistants worked seven days a week.
Patients and their families were involved in planning care and setting rehabilitation goals and they told us that they were very happy with the care they received.
Patients received a mental capacity assessment on admission. Patients living with dementia or other cognitive impairment were easily identifiable to staff. Some wards had adapted their environment to cater for patients with living dementia.
A core group of doctors and GPs provided care during normal working hours. The doctors were visible and accessible to patients, relatives and staff.
The service responded positively to our February 2015 inspection. Staff told us about the improvements made, and how they had addressed some of the issues we identified. Notice boards in public areas displayed the changes that had been made and highlighted work still in progress.
There was visible leadership in each area. Staff we spoke with told us they knew who their service leaders were and that they were accessible to them. Staff said they felt supported in their roles.

Overall rating for this core service Good

Overall, we rated the children, young people and family service as good. We found that:

Despite staffing pressures due to vacancies, staffing levels generally met patients’ needs at the time of the inspection.
Staff understood their responsibilities to raise concerns and record and report safety incidents, concerns and near misses and adhered to safeguarding policies and procedures.
For staff training, the overall compliance rate was 88% and this was comparable to the trust target of 90%.
Individual care records were written in a way that kept patients safe from avoidable harm. For example, records were maintained on the trust’s electronic record system and staff were able to access the system and update records.
Generally, arrangements for the handling of medicines kept people safe from avoidable harm. The servicing arrangements for equipment were generally effective.
There were reliable systems in place to prevent and protect patients from healthcare associated infection.
Care and treatment were planned and delivered in line with current evidence based guidelines, standards, best practice, and legislation.
Clinical audits were undertaken and outcomes used to drive improvements in the service.
The service delivered all aspects of NHS England’s Healthy Child Programme and had Baby Friendly Initiative breastfeeding stage 2 accreditation.
Staff had the skills, knowledge, and experience to deliver effective care and treatment.
There were suitable arrangements in place to enable staff to receive professional development, supervision and appraisal. Multiagency working across teams was positive and effective.
Staff worked together to assess and plan ongoing care and treatment in a timely way when patients moved between teams or services, including referral, discharge and transition.
Consent was obtained in line with legislation.
Staff involved children, young people and those close to them in all aspects of their care and treatment.
Staff were committed to empowering young people and provided them with appropriate information and support to enable them to make decisions around the care they received.
The service reflected the needs of the local population and provided flexibility, choice and continuity of care to meet needs of the local community.
Generally, patients had timely access to initial assessment, diagnosis or urgent treatment.
There were positive adjustments in place when monitoring and responding to patients with a learning disability.
Complaints’ processes were effective.
Front line staff described their senior managers as being supportive, visible and approachable and provided an open door policy.
Staff were aware of the vision and strategy for children and young people’s services and supported the changes to provide a more child centred service.

However, we also found that:

Arrangements for storing some medicines, such as vaccines storage in cool boxes, did not always keep people safe. Staff took immediate action to address this concern.
The service undertook child protection medical assessments but had no standard operating procedure for these assessments.

There were 233 children waiting on the attention deficit hyperactivity disorder waiting list and 127 patients on the autism spectrum disorder waiting list. However, the number of children on the waiting list had reduced and there was an action plan in place to monitor the waiting list.

Overall, we rated this service as good because:

There were processes in place to measure safety performance. The majority of patients that used community health services for adults received harm free care.
There was a good reporting culture across most services. Staff were encouraged to report incidents and always received feedback from incidents they had reported.
Medicines were stored securely and there were robust arrangements to manage medicines across services.
Care was provided in accordance with evidence based guidance, standards, best practice and legislation.
We observed effective multidisciplinary working to provide co-ordinated patients care.
The service reported good performance in a number of national audits such as podiatric surgery.
Services were planned and delivered to meet the needs of patients and those of the local health economy.

Staff morale was good. Senior nurses were visible to staff and staff said they felt respected and supported by their managers and colleagues.

The service scored highly in the trusts “I want great care” questionnaires with 94% of patients saying they would recommend the service to their family and friends.
Staff competencies were based on best practice guidance.
Most staff had received an appraisal.
The intermediate care team facilitated early discharge from hospital where a health monitoring or rehabilitation need had been identified.
Patients were treated with respect and kindness, and their privacy and dignity was protected. Patients understood their care and were involved in making decisions about their care.
Patients were seen for an initial assessment in a timely manner once they had been referred.

However:

Not all risks to patients and staff had been identified, assessed, monitored and mitigated. We found out of date equipment and medical consumables in storage cupboards and treatment rooms within the phlebotomy service.
Infection prevention and control processes were not always being followed. We found a visibly dirty treatment room within the phlebotomy service and dedicated hand-washing basins contained personal items.
Community nursing teams did not routinely monitor patients for signs of deterioration.
Not all staff had the appropriate level of safeguarding training. Some staff were treating children within the physiotherapy and tuberculosis services without the level of safeguarding training required.
Not all staff had received mandatory training. Mandatory training compliance did not meet the trust target of 90%.

Not all staff had received Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training.
The podiatric surgery service did not audit the five steps to safer surgery World Health Organisation checklist.

The phlebotomy service was not assessed or monitored. There was a lack of oversight of the service and it had not been delivered in line with the service level agreement with commissioners.
There was no overarching strategy for planned and unplanned care. Staff had not been involved in the development of the trust strategy and not all staff were aware of the trusts visions and values.
Some services had a high number of patients that did not attend their appointment without informing the service prior to their appointment time.
Complaints were not always responded to within a timely manner.

We rated community-based services for people with learning disability and autism as good because:

The trust employed sufficient numbers and disciplines of staff including psychiatrists, nurses, psychologists, occupational therapists, physiotherapists and speech and language therapists to meet the needs of people who used services.
The trust had policies in place to assess and manage risk to staff, a risk register was in place and clinical and safety audits were completed monthly.
Teams were able to offer a wide range of therapies across a number of disciplines.
Teams worked closely together and with other departments and external agencies.
People who used services and carers were consistently positive about staff and the support they had received from the service.
Staff were highly motivated and regularly went the extra mile to support people who used services.
People who used services were fully involved in writing their care plans and action plans. Staff provided care plans and treatment information in easy read and visual formats.
People referred to the service were assessed within the timeframe set by the trust and the intensive support team were able to respond quickly to urgent referrals.
The trust encouraged involvement and feedback from people who used service and their carers including recruitment of staff.

However:

Staff reported 46 people were waiting for access to psychological therapies, some of whom had been waiting for over 40 weeks.

We rated Community-based mental health services for older people as requires improvement because:

There was no system in place to ensure that patients received the required annual health checks, including blood tests. Staff did not know whether this was the responsibility of the service or of the GP.
Staff were not supervised and appraised in line with trust policy. When we visited the service the compliance rate for supervision was 43%. The compliance rate for appraisals was 75%. However, the trust submitted data following the inspection and these figures had improved.
Compliance with mandatory training for the service was 78%, which fell below the trust target of 90%.
Sixty-seven per cent of staff were trained in the Mental Capacity Act. This fell below the trust’s target of 90%. Staff did not consistently document mental capacity assessments and best interest decisions in care records when they were required.
Managers did not have assurance systems in place to monitor and audit the quality and performance of the service.
The consultant post at Corby and Kettering had been vacant for over two years. Locums covered this post but changed every few weeks. This meant that appointments were not always available when needed.
The service did not have information leaflets readily available in other languages. Staff told us they had to request these from the trust communications team.

However:

Ninety per cent of staff were trained in safeguarding and knew how to respond to any safeguarding concerns.
Staff responded promptly to deterioration in patients’ health. Staff worked flexibly to respond to changes in patients’ needs.
The service mostly followed National Institute for Health and Care Excellence (NICE) guidelines for the treatment of Alzheimer’s and dementia. The service offered psychological therapies recommended by NICE.
Patients told use that staff treated them with respect and were kind and caring. Patients felt that staff listened to them and were helpful.
The service was meeting their referral to assessment targets. Staff discussed new referrals in the weekly multi-disciplinary meetings and prioritised patients who needed seeing urgently.
Managers ensured staff reported all incidents, safeguarding, and complaints.
Managers and staff had the ability to submit items to the risk register.

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

All patients using the service had a comprehensive risk assessment and care plan, which was regularly reviewed and updated.
The service protected children and young people from abuse through clear safeguarding policies and procedures.
The service complied with local safeguarding children board procedures and appropriate national guidance.
Staff, including temporary staff, had undergone a Disclosure and Barring Service check (or local equivalent) and were checked against the Protection of Children Act register before appointment.
Staff used nationally recognised assessment tools.For example, the child and young people self-harm pathway, and completed integrated assessments with acute hospital staff.
Staff provided a range of therapeutic interventions in line with National Institute for Health and Care Excellence (NICE). For example cognitive behaviour therapy provided by Improved Access to Psychological Therapies training practitioners.
Regular team meetings took place, and staff told us they felt supported by colleagues.
Young people and their carers reported they were treated with dignity and respect and gave positive feedback about staff.

However:

Interview rooms were not fitted with alarms at any of the locations we visited. Staff mitigated this by always telling colleagues where they were and who they were with. Managers had not completed ligature audits in any of the locations we visited.
Two of the first aid boxes we inspected at Isebrook Hospital and Sudborough House had out of date materials in them, such as bandages.
One patient we spoke with told us they were kept waiting for an hour for an appointment
Interview rooms appeared to have adequate sound proofing for normal rate and volume speech, but if voices were raised this could be heard outside of the interview room, meaning that in those cases confidentiality may not be maintained.

We rated mental health crisis services and health-based places of safety as good because:

Records showed that staff had completed a risk assessment during initial assessment and risk assessments were updated regularly, following an incident or prior to transfer to another team. Risk levels for patients accessing the CRHTT were discussed at daily handover meetings in order to detect any increase in risk.
CRHTT staff completed crisis plans for all patients after each contact and discussed individual patients crisis plans at team meetings.
Learning was fed back to staff during team meetings. Staff received feedback from incidents both internal and external to their core service. We saw evidence of change having been made within teams as a result of feedback from incidents.
Care plans for patients using the CRHTT were person centred, holistic and reviewed weekly during team meetings. Staff ensured that all patients who were assessed by the AMHLS were given a leaflet with an individualised crisis plan and details of who to contact in a crisis.
All mental health crisis and health-based place of safety teams reported good working relationships, both within the trust and with external organisations.
Patients were routinely transferred to the HBPoS by ambulance.
Staff were observed to be caring, warm, empathic and respectful towards patients. We observed a home assessment where we saw a good relationship between staff and the patient, including joint working and collaborative discussions.
Patients fed back positively about the care they received from staff. Patients told us that staff were willing to help and treated them with consideration and dignity.
Staff could request literature in different languages if there was a need. Staff had access to translation services and interpreters and were able to access hearing loops and sign language interpreters if required.
All patients we spoke with were aware how to make a complaint if they were not satisfied with the care they received.
Staff had regular contact with their immediate managers. All staff we spoke with reported that their managers supported them to carry out their roles and they felt able to raise concerns with their manager.
Overall, the average compliance rate for mandatory training across mental health crisis services and health-based places of safety was 93%, the average supervision rate was 99% and the average appraisal rate was 93%.
Staff said they felt supported to take part in further training, were given the opportunity to give feedback on services and input into service development and had opportunities for career progression.
The trust led on the crisis care concordat and close partnership working across commissioning and partner provider agencies. The trust reported it resulted in a range of service improvements and ensured strong leadership, working for the benefit of service users and carers using the pathways. Much of this work was co-produced with service user sand carers.
The trust led on the crisis care concordat and close partnership working across commissioning and partner provider agencies. The trust reported it resulted in a range of service improvements and ensured strong leadership, working for the benefit of service users and carers using the pathways. Much of this work was co-produced with service user sand carers.

However:

The HBPoS suite at St Mary’s Hospital and The HBPoS suite at Berrywood Hospital did not comply with Royal College of Psychiatrists’ guidance. Furniture was not sufficiently weighted and ligature risks were present.
AMHLS had two interview rooms at Northampton General Hospital, one of these rooms did not comply with PLAN accreditation standards. The AMHLS Team at Kettering General Hospital had a designated room in the accident and emergency department. The trust had identified the room did not meet PLAN accreditation standards.The trust had an action plan in place for rooms which did not meet PLAN standards.
The HBPoS at St Mary’s Hospital was not visibly clean and did not have access to a dedicated clinic room.
There was no record available of blank prescriptions held in the CRHTT south team. Staff did not carry out any audits with regard to unopened boxes held in the storage area, meaning that they would not know if any prescriptions went missing.
The HBPoS at St Mary’s Hospital did offer patients access to fresh air within a safe setting, however this was on another ward and could only be used when patients from that ward were not using it.

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

Patient records contained comprehensive assessment and person centred care plans. There was evidence of patient involvement in planning treatment and care, and patients confirmed this during interviews.
Staff adhered to the National Institute for Health and Care Excellence guidelines relating to medication management, physical health checks, perinatal services and treatment of patients with personality disorders.
Staff supported patients, and gave choice and control in relation to medication options.
The trust nurtured and encouraged service improvement and innovative practice. Teams provided groups and treatment programmes to aid patient recovery. These included patient led groups.
Staff demonstrated knowledge and understanding of safeguarding processes, and were able to recognise types of abuse.
Staff demonstrated a good understanding of the trust lone working policy to maintain personal safety while working in the community.
Care and treatment environments were clean including clinic rooms and patient waiting areas.
Patients consistently reported that their allocated workers were responsive to their needs in times of crisis, and that they could contact the team or out of hours services when needed for support.
Staff were aware of the trust’s speak up guardian, and knew how to raise concerns without fear of reprisals. Staff consistently reported that team morale was good and that they enjoyed their roles.

However:

At Campbell House the first floor waiting area did not have reception staff and patients did not sign in at the ground floor reception. There was the possibility for patients to be unaccounted for between entering the building and accessing the first floor waiting areas.
Community teams did not complete environmental ligature risk audits for rooms and waiting areas accessed by patients.
Emergency medication such as adrenaline was not stored in clinic rooms for use on site or when administering medication in the community.
From the 37 patient records reviewed for PCRT South teams, some did not contain information as to the patients MHA status. This could affect entitlement to assistance with support with care and housing services
Some patients told us they had not received a copy of their care plans. The electronic recording system did not indicate when this information had been offered to patients.
Patient records contained variable levels of recording for crisis plans with these plans incorporated into their care programme approach (CPA) reviews, with apparent confusion between CPA reviews and care plans. Care plans in some records were not individualised document.
PCRT South, Daventry and South Northamptonshire had closed access to the psychology waiting list for new referrals for those patients who required long term intervention. The psychologists were available for assessment and advice, short-term work, urgent referrals and joint casework. No indication of timescales was given for when the team would be able to accept new referrals for long term pieces of work.

We rated forensic inpatient/secure wards as good because :

Patients had a positive experience of care and told us they felt safe on the unit. Patients attended community meetings daily, raised issues, and gave feedback to staff both at the meeting and through ‘I want great care’. The service ensured patients and their carers knew how to make a complaint and patients had access to advocacy services.
Staff described the electronic system to report incidents, how learning was shared and knew their role in the reporting process.
Staff undertook comprehensive assessments and reflected patients’ needs and goals. They completed individualised risk assessments at or before admission and updated them regularly according to need.
All staff were trained in and had a good understanding of the MHA and MCA.
Staff told us they felt supported to carry out their role and had regular appraisals. Some staff had undertaken specialist training relevant to the patients’ needs.
The trust had built a new seclusion room away from the main patient area. This helped to promote patient dignity. Ligature risk assessments helped staff to manage risk along with the use of anti-ligature fittings.
Staff treated patients and their families with care, compassion and respect. The multi-disciplinary team worked well together and focused on patient recovery.
Patients gave feedback through “I want great care.” Patients scored on a variety of headings by using a computer tablet, which generated an overall score out of five. This was done every three months and at the time of inspection, the score was 4.6 out of 5. This process also enabled patients to raise individual issues.

However:

Data provided by the trust indicated that prior to the inspection there had been four vacancies for qualified nurses and five vacancies for healthcare assistants, and the manager told us the service found it difficult to recruit male nurses.
Staff were not able to see all areas of the ward and outside area as there were blind spots and CCTV cameras were not switched on, although staff mitigated this risk by zonal observations.
It was not clear that supervision meant dedicated individual time for staff to reflect and learn.
Medical staff felt that the trust had made decisions without adequate consultation, particularly over the changes to bed numbers on Wheatfield and Meadowbank. Medical staff felt that medical management was under-resourced, with the associate medical director and clinical director very thinly stretched.

We rated child and adolescent inpatient wards as outstanding because:

Patients’ care, treatment and support achieved good outcomes, promoted a good quality of life and was based on best practice. Staff actively monitored and reviewed consent practices to ensure that patients were involved in making decisions about their care and treatment.
Staff identified ligature points on an environmental audit and took actions to reduce the risk to patients. These included enhanced observation levels. Wards complied with the Department of Health’s guidance of eliminating mixed sex accommodation, which meant that the privacy and dignity of patients was upheld.
Staffing levels were appropriate to meet the needs of patients. Staff said leave and activities were very rarely cancelled or rearranged because of staff shortages.
Staff completed comprehensive assessments for patients, which they completed in a timely manner in collaboration with the patient and their families where appropriate. We looked at 12 care plans, the patient, reviewed and signed them, they were up to date, personalised, holistic, recovery orientated and included physical health checks. Specialist training was available to staff and supported by the trust, this included two members of staff undertaking a master’s degree in working with patients with eating disorders and two support workers who were advanced apprentices. Staff said they felt supported to maintain their continuing professional development.
The service held a yearly “rivers of experience” event. Patients and parents who had used the service over the preceding 12 months were invited to attend a meeting whereby they were encouraged to share their experience, contribute to developing the service and to look at where things could have been done differently.
Patients told us that they had good relationships with staff and they were very helpful, understood their problems and were always available. They said they felt safe and staff took the time to listen to them when they had a problem.
The service held a yearly “rivers of experience” event. Patients and parents who had used the service over the preceding 12 months were invited to attend a meeting whereby they were encouraged to share their experience, contribute to developing the service and to look at where things could have been done differently.
Staff gave patients information on how to make a complaint. We saw information around the units about how to make a complaint. Patients said they felt they could make a complaint if they wanted.
Staff reported extremely positive morale and job satisfaction. They reported good relationships with managers and felt empowered in their roles.
The trust was supporting the service, in collaboration with Northampton University with a poster presentation at a conference in Geneva in 2017.

However:

Staff had secluded a patient for a prolonged period of time. The patients’ notes showed that staff had reviewed the episode of seclusion as per the trust policy. However, we could not establish what the outcome of the review was or why the decision was made to continue the seclusion.
Patients did not have a lockable cupboard in their room.

We rated Long stay/r ehabilitation on mental health wards for working age adults as good because:

Patients had a positive experience of care and told us they felt safe on the unit. Patients attended community meetings daily, raised issues, and gave feedback to staff both at the meeting and through the trusts’ own feedback system called ‘I want great care’. Staff ensured that patients and their carers knew how to make a complaint and patients had access to advocacy services.
Staff treated patients and their families with care, compassion and respect.
The multi-disciplinary team worked well together and focused on patient recovery. Most staff described the electronic system to report incidents, how learning was shared and knew their role in the reporting process.
Staff undertook comprehensive assessments and reflected patients’ needs and goals. They completed individualised risk assessments at or before admission and updated them regularly according to need.
All staff were trained in and had a good understanding of the MHA and MCA.
Staff told us they felt supported to carry out their role and had regular appraisals. Some staff had undertaken specialist training relevant to the patients’ needs.

However:

Medical staff told us that the trust had made decisions without adequate consultation, particularly over the changes to bed numbers on Meadowbank. Medical staff told us that medical staffing was under-resourced.
Staff were unclear about whether a patient for whom a DoLS application had been made should be considered as detained or as informal.
One patient told us that one member of staff was unhelpful, negative and did not engage in meaningful conversation with them.

We rated acute wards for adults of working age and psychiatric intensive care units as good because:

The trust had completed ligature risk assessments across all wards, detailing where risks were located and how these should be managed. Staff maintained a presence in clinical areas to observe and support patients.
There were sufficient staffing levels on all wards. On all wards there were skilled staff to deliver care. Staff were experienced and qualified. Ward matrons made effective and immediate arrangements to cover vacant posts. Ward matrons provided appraisals, personal development planning training, supervisions and support to all staff.
Harbour ward did not fully comply with the Department of Health guidance on eliminating mixed sex accommodation. However, there was mitigation with additional staffing provided in key areas.
Wards had protocols on searching, code of conduct for ward behaviour and police liaison.
Patients had good access to psychology, dietician, physiotherapy, and occupational therapist on wards and effective pharmacy input on Avocet and Sandpiper wards. The trust employed a registered nurse to assist with assessment and management of physical healthcare needs for patients on Marina ward. The nurse worked across the acute wards also. Patient’s admissions included effective physical health checks, and monitoring of physical health care.
Staff completed comprehensive care plans. Patients on all wards were involved in care planning. We saw occupational therapist plans for individual patients.
We observed effective handovers on all wards.
Health care support workers received appropriate induction using the care certificate standards. Staff were trained in safeguarding and know how to make a safeguarding alert and to do this when appropriate.
On all wards, staff enabled patients to give feedback on the service they received and reviewed and acted on this information. Patients knew how to complain and receive feedback.
Staff were caring, compassionate and kind towards patients. We saw staff engage with patients in a kind and respectful manner on all of the wards. However on Kingfisher ward one staff member showed a disrespectful attitude towards a patient. This was addressed with the staff member on the day of inspection.
On Sandpiper ward, we observed that a patient and their family and carers were involved in care decisions in a multidisciplinary meeting. On Kingfisher, we observed three patients preparing a hot meal with the occupational therapist as part of a therapeutic programme. On Sandpiper, activities and therapy programmes were available seven days a week.
Staff responded to the needs of people from different ethnic groups and to those for whom English is not the first language.
On all wards there was effective leadership. Staff reported being well led and supported.

Ward matron was the point of contact for all ward operational matters. This person had the authority and administrative support to lead the ward team.

However:

There were environmental issues identified. These included heating problems on Harbour, poor drainage in shower floor. On Bay ward one patient was involved in an incident of self-harm in the garden where there were poor lines of sight. Some measures were put in place to mitigate the blind spots. On Bay ward some staff told us there was no de- brief for staff after local incidents to consider whether improvements could be made to ward safety. On Cove ward some aspects of the ward environment were in disrepair and not addressed. The garden was dirty and strewn with litter. The adapted bathroom was used as a storage room. On Kingfisher, Avocet, Cove and Bay some parts of the wards and garden areas were over looked by nearby houses. There were no screens or frosted glass provided.
We saw on Avocet ward large numbers of staples used on patient noticeboards. The staples were a risk to patient safety. Staff told us all the noticeboards were due to be covered with laminate, and the staples would no longer be used. However, the ward matron did not feel the risk required immediate action.
Senior managers failed to consistently assess all health and safety risks to the premises, which impacted on the safety and wellbeing of patients.
On Kingfisher ward one patient out of six care records examined did not demonstrate alternatives to restraint and efforts to de-escalate.
Patients on Cove and Harbour wards did not have input from psychology services.
Marina and Kingfisher seclusion rooms were compliant with the Mental Health Act Code of Practice. However, in the Kingfisher ward staff area outside the seclusion room, staff could not easily view a part of the seclusion room as a desk blocked the view.
There were three out of area placements on Marina ward. Bay ward had 17 beds, however three patients were on leave and they had been filled with three other patients. This meant that the ward had 20 patients allocated to the 17 bedded ward. If a patient needed to return early to the ward, there may not be a bed available. Seven patients on Avocet ward were ready for discharge, but placements were not available.
On Bay ward two T2’s were inaccurate and on Marina ward one T2’s was missing one medicine. The ward matron took immediate action with the consultant. There were some medication errors on Harbour and Cove ward with gaps in signatures. Harbour, Bay and cove clinical room temperatures were tested each day but, not recorded.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We rated the trust overall as good because:

The trust responded in a very positive way to the improvements we asked them to make following our inspection in February 2015. At this inspection, we have seen improvements in most core services across the trust.The senior leadership team have been instrumental in delivering quality improvement within the trust.
Throughout the trust, in both mental health and community health services, staff treated patients with kindness, dignity and respect.Consistently, staff attitudes were helpful, understanding and staff used kind and supportive language that patients would understand. The style and nature of communication was kind, respectful and compassionate.Staff showed strong therapeutic relationships with their patients and clearly understood their needs. Staff offered guidance and caring reassurance in situations where patients felt unwell or distressed, confused or agitated.
Staff encouraged patients to give feedback about their care.Staff offered patients the chance to give feedback in a variety of ways. A feedback system had been introduced across the trust called I Want Great Care. This received feedback from carers, patients and staff about the care of patients and other issues. The trust received 61,000 reviews since the system began.
Patients were involved in projects across the organisation and we saw evidence of this in the core services.This included reviewing documents, delivering training, and recruiting and interviewing staff.The trust had a patient involvement group that was well attended by patients from the mental health pathway.
Information leaflets were available in easy read formats and we saw evidence of information available to patients on how to access interpreters should they need one.
The trust had a robust governance structure in place to manage, review and give feedback from complaints. Staff consistently knew how to handle complaints, and managers investigated complaints promptly and gave feedback to patients, carers and staff about outcomes of complaints.
The trust had a clear vision and set of values.The vision and values had been widely communicated across the trust through posters, presentations, and the intranet page called the staff room, screen savers and board members visits to wards. Staff in mental health services and community health services were, for the majority, aware of the trust’s vision and values.
The trust had safeguarding policies and robust safeguarding reporting systems in place and described how they worked with partner agencies to protect vulnerable adults and children.
An operational management tool was in place which recorded data for 40 areas of patient safety and areas of compliance for the trust.The trust board had oversight of this.
The trust had developed and invested in an extensive range of well-being schemes for the staff.They told us about physical fitness classes, recruitment and retention rewards, counselling, and support groups available.
The trust ensured staffing levels and skill mix across 15 core services was planned and reviewed so that people who used services received safe care and treatment. The majority of services across the trust increased staffing based on clinical need or made arrangements to cover leave, sickness and absence. Managers had authority to make these decisions.
Physical environments across most services in mental health and community services were clean and well maintained. Across most services staff had completed environmental risk assessments. Where issues had been identified, staff mitigated these risks by carrying out additional checks or had taken other actions to resolve the issues.
Emergency medicines and equipment were available in all of the inpatient clinical areas that we visited. All emergency equipment was in date and staff checked them daily. Antipsychotic medication was prescribed within the British National Formulary (BNF) limits and monitoring was in place.
The trust was meeting Department of Health guidance for eliminating mixed sex accommodation.
Staff completed detailed and clear risk assessments at seven of the 10 mental health core services and at all community health services.Staff involved patients in their care plans and risk assessments and where possible, staff gave copies to patients.Staff across mental health services completed comprehensive assessments and person centred care plans in a timely manner, and in collaboration with the patients.
The trust used an electronic system for reporting incidents. At all services staff knew what incidents needed to be reported and how to report them. Managers monitored the reporting and recording of incidents.The trust had robust systems for sharing lessons learned from incidents.
The majority of mental health services and used best practice to influence treatment and care offered to patients. Staff used a wide range of outcome measures within their practice, across most mental health services. The trust monitored and audited outcomes using rating scales, best practice and a range of audit.
All mental health services had access to psychological therapies. All teams within mental health services and described effective and collaborative team working and had effective working relationships external agencies.Core services reported effective handovers between teams.
Physical healthcare needs had been addressed at inpatient mental health settings. Information needed to deliver care was stored securely on an electronic record system which the GP also had access to, this improved continuity of care.The trust was nominated for a health service award following their work to introduce this system.
The trust made available and supported specialist training and induction. Staff felt this training helped them in delivering services to patients.Both registered and non-registered staff had access to further training.
The trust average compliance for supervision was 93% but this varied across services.
The trust provided information that overall MHA training compliance was 92%.Most services showed compliance in adhering to the MHA and MCA. In all services we visited, staff told us about how patients could access independent mental health advocacy services
The BME group had reconvened and had made progress in highlighting their goals for the year ahead.The trust supported the agenda and provided opportunity for meetings, projects and feedback and had a Workforce Race Equality Standard (WRES) action plan in place.
The trust board encouraged candour, openness and honesty from staff. Staff knew how to whistle-blow and the majority of staff felt able to raise concerns without fear of victimisation.
Senior managers told us frequently that there had been much organisational change and transformation of care within the trust. Staff told us they accepted change but they positively embraced the opportunity it provided. They felt supported by the board to work with change and felt able to provide feedback about their experiences.

However:

Some environments were not clean and well maintained and furniture was not sufficiently weighted. On acute wards and in some CHS hospitals, there were environmental issues identified.These included heating problems, drainage issues, and observation blind spots, areas of disrepair and privacy issues.
There were no ligature audit assessments in place for any of the locations inspected within community-based mental health services for adults. Managers on community-based mental health services for children and young people had not completed ligature audits for the sites we visited.
Weston Favell Health Centre (CHS Adults) had out of date equipment in a treatment room used by phlebotomists. In CHS Adults at Weston Favell and CHS for Inpatients, infection prevention and control processes were not always being followed.
Medication was not being managed safely at Danetre Hospital and Corby Community Hospital.
The trust did not meet compliance target for non-medical staff supervision in all core services.Systems used to record supervision were inconsistent across the trust.Some services used 1:1 supervision, group supervision or team meetings as a way of carrying out this task.Clinical and managerial supervision data was not collected separately.The trust wide average appraisal compliance rate was 65% at September 2016. During the inspection data showed there had been an increase in average compliance from 65% to 90%.The difference in this data suggested that data collection required a review by the trust.
Staff compliance with MCA and MHA training was 67% for community-based mental health services for older people, below the trust compliance target of 90%. Staff did not consistently document mental capacity assessments and best interest decisions in care records where they were required. Some staff were not able to tell us how they would put the Mental Capacity Act into practice in their work.
There was a high number of delayed discharges from CHS Inpatient hospitals. Data showed 46% of all patients across the service were medically fit to be discharged home but remained in hospital because there were no care packages available or the patients were waiting to be assessed.
The trust did not meet its target for mandatory training compliance of 90%.At the time of inspection, mandatory training compliance was 89% with the lowest compliance for a core service at 62%.
CHS for Adults had waiting lists and no way to monitor deteriorating patients.Some acute mental health services used beds for new admissions that were already allocated to patients on leave.Discharges from forensic inpatient services were affected by a reduced number of beds on the rehabilitation ward.
CHS for Inpatients had high vacancy and sickness rates which put additional pressure on substantive staff. The strategy to move all stroke patients to one hospital site was delayed. Plans started in August 2016had not been completed. However, the trust provided evidence that they are now working on this strategy. Not all risks had been identified on the risk register and some risks had not been recognised or responded to.
The trust did not assess or monitor the phlebotomy service in CHS for Adults. There was a lack of oversight of the service and it had not been delivered in line with the service level agreement with commissioners.

We gave an overall rating for community services for people with learning disabilities as good because:

There were robust risk assessments and plans in place to keep patients and staff safe.
Staffing levels were appropriate to meet assessed patient need. Vacancies were being covered by bank staff and the trust was actively recruiting for new staff.
There was good multi-disciplinary working within the teams and between other services.
Staff showed a good understanding of the Mental Health Act and Mental Capacity Act.
There were effective methods for obtaining feedback from service users and carers and feedback was acted upon.
Staff were caring and committed to providing high quality care and showed a person-centred approach.
Staff received regular supervision and all had received an appraisal in the last 12 months.
The local managers monitored the environment for staff, carried out local audits and checked performance of staff on a regular basis.

However:

There was a vacancy rate of 34% across these services.

We have rated substance misuse services as Outstanding because:

The service was safe. It had an appropriate number of rooms for patients to be seen in. The locations were clean and had resuscitation equipment, which was checked regularly. Staff had been appropriately trained to carry out their roles.
The service was effective. They made appropriate assessments and were responsive to changing patient needs. NICE guidelines were used to ensure best practice and multi-agency teams worked well together.
The service was exceptionally caring. Staff viewed patients in a positive way and were person centred in their approach. The service was recovery focused and had developed pathways with other agencies to build on recovery capital for patients who used the service. All the patients spoken to felt they had benefited from the service and told us how caring staff were.
The service was responsive. There were no waiting lists for treatment, all patients were seen within two weeks of referral and many the same day. The service had meaningful service user involvement and held weekly service user forums as well as a peer mentoring scheme.
The service was well led. There was a clear vision for the service which staff understood. Staff told us they felt senior management were visible and they felt listened to and valued. There was evidence of regular supervision, appraisal and performance management. Morale amongst the staff team was good.

Overall summary

We rated community services for people with mental health problems overall as good because:

Staff were committed and effective in treating older people with mental health problems.
Each service inspected had a high proportion of staff that were experienced, skilled and long-serving within the service.
The service had a good safety record and good safety protocols in place.
People were seen and assessments took place in a timely manner.
Information was stored securely and was accessible when needed.
Different parts of the service worked well together sharing information and skills for the benefit of people using the service.
Staff responded promptly to urgent requests for help.
People using the service were positive about the support, kindness, effectiveness and responsiveness of staff.

Staff were well trained and generally felt well supported.

However:

The older people’s community mental health team at Stuart Road did not have a record of medicines received and medicines taken out. This meant it could not account for the proper use of medicines it was responsible for. Managers confirmed that this concern would be addressed promptly.
Some concerns were expressed by staff at the high levels of caseloads.
A shortage of psychologists at Rushden meant that psychological therapies were not always available.
Staff at Stuart Road felt that a lack of management support had a negative impact on their effectiveness. This showed in the high stress levels there amongst staff.

We gave an overall rating for wards for people with learning disabilities as good because:

There were robust risk assessments and plans in place to keep patients safe.
Staffing levels were appropriate to need.
There was good multi-disciplinary working within the teams and between other services.
Staff showed a good understanding of the Mental Health Act and Mental Capacity Act.
There were effective methods for obtaining feedback from service users and carers and feedback was acted upon.
Staff were caring and committed to providing high quality care and showed a person-centred approach.
Staff received regular supervision and all had received an appraisal in the last 12 months.
The local managers monitored the environment, carried out local audits and checked the performance of staff on a regular basis.

However: -

One of the four wards visited, the learning disability assessment and treatment unit, was not fit for purpose. It was recognised there was a plan to move to an alternative site in July 2015.The trust recognised the importance of ensuring that safety was maintained at this location. This included taking measures to ensure the physical safety of patients and staff, providing sufficient training for all staff, including bank or agency staff, and ensuring on-going leadership support to the recently appointed manager.
There was sometimes a delay when the personal alarm system was activated.
The same medicine cards were used for each stay at the short breaks wards. This resulted in gaps in the signature section which could cause confusion.

We gave an overall rating for community services for adults of working age of good because:

Risk management was good across the teams and the service had found ways to keep people in treatment who were difficult to engage with.

Staff showed an awareness of the Mental Capacity Act and deprivation of liberty safeguards.

Paperwork relating to community treatment orders was generally in order across the team.

Good team working was taking place.

Staff were compassionate and had a caring approach to people who used the services.

Risk management was good across the teams and they had found ways to attempt to keep people in treatment who were difficult to engage with.

The waiting list for treatment was being managed proactively with staff allocated to ensure people were signposted to the most relevant service in a timely manner.

Documentation of incidents and the investigation of serious untoward incidents showed the trust had learnt from these and changes had been made as a result.

However:

There were gaps in the records of drug storage refrigerators at Isebrook hospital and there was no provision for consistently monitoring the temperature on days when the clinic was closed or over the weekend as per trust policy.

The two ECG machines at the Northampton CMHT location were not maintained in working order. One was not working and the other was reported as unreliable. These were managed by an external contractor but had been out of action “for some time”. The blood pressure machine and scales had not been calibrated at the Isebrook location and there was no thermometer for use in the physical health clinic.

There was no trust wide system in place for capturing, analysing and demonstrating learning from concerns raised or complaints made at a local level.

The different crisis teams had a clear vision in using the least restrictive option to care for people in crisis. This vision related to the trusts overall vision and values. There were staffing levels that enabled referral targets to be met and caseloads to be managed. Staff undertook risk assessments and related them to care plans. The wellness recovery action plan (WRAP) tools were used to assist patients & staff plan & monitor recovery. Patients had choices and the teams took into account individual needs, making efforts to link patients to support net works, employment , education and social networks. Carers were involved in patients care and were able to have carers assessments. Staff followed the lone working policy and carried out assessments of people not know to hospital services in GP clinics and outpatient hubs to manage risk.

The number of incidents, serious untoward incidents and safeguarding's were low. Staff had been trained in reporting incidents and making safeguarding referrals and this was done appropriately. Lessons learnt were shared in team and business meetings.

There was a good induction programme that staff had completed. Staff appraisals were up to date. Management supervision was carried out regularly by staff. Mandatory training was up to date and monitored in performance reports.Staff told us they had good job satisfaction and would recommend the trust as a good place to work.

There was inter agency working taking place. There were individual information sharing agreements in place between the trust and agencies such as local councils, police, and Northamptonshire carers. There was a multi-agency partnership agreement in place for the Health Based Place of Safety (HBPoS). Regular meetings took place to look at the performance data for the HBPoS.

There were few audits carried out by crisis teams

There were gaps in the medicine management policy which did not support primary dispensing. We found that teams were able to dispense medications from their stock cupboard which should not happen, as nurses should only be able to secondary dispense medications.
There were no crisis plans. Staff told us that a “future safety plan” had just been introduced. Records reviewed did not have any completed ones.
There was a lack of psychologist input in to crisis teams to provide therapies for patients.
There was a local crisis concordat plan in place. However crisis teams were not familiar with it, nor had they seen the CQC crisis thematic data for their area.

We gave an overall rating for long stay/forensic/secure services of requires improvement because:

Clinical audits were not carried out regularly to monitor the effectiveness of the service.

Staff had not received training in MHA.

Staff had not received training in the use of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff did not demonstrate a good understanding of MCA and DoLS. Managers and staff were not aware of any checks taking place to monitor the use of the MCA.

Patients on olanzapine depot were not monitored for post injection set of symptoms to ensure they did not experience undesirable results. Staff did not know about the necessary standard of monitoring patients soon after administering olanzapine depot injection and the units did not have a protocol in place.

There was inconsistent practice on Historical Clinical Risk Management (HCR-20) which is needed for forensic patients.

The location of the seclusion room was in the main patient area in the corridor leading to the entrance door. This did not protect patients’ privacy and dignity and between secluded and non-secluded patients.

In Wheatfield a patient telephone was situated in the dining room area and there was no privacy. We saw patients talking on that phone whilst other patients were sitting around.

We found that patient’s individual needs were not met. No adjustments had been made to meet patient’s individual needs.

We identified that the team’s and the organisation’s values were not embedded in practice. Particularly in Wheatfield, the practice did not completely reflect a person centred approach and positive risk taking.

The trust had governance processes in place to manage quality and safety. However, we identified areas needed improvements in clinical audits, MHA and MCA training and MCA procedures.

The medical team felt they were not listened to and were side-lined. The consultants had a lot of work load. The forensic services were isolated and disconnected to the rest of the trust. Staff felt pressured to work extra shifts to cover staff shortages and there was unfairness on accepting flexible working hours to staff.

The units were not participating in a national quality improvement programme such as AIMS.

There were effective procedural security measures and robust operational policies and procedures that were followed by staff to ensure safety of patients. Patients were able to access medical input day and night. Patients’ needs were appropriately assessed and clearly identified their needs and these were regularly reviewed. There was an effective way of recording incidents and learning from incidents.

There was good collaborative working within the multi-disciplinary teams and had a number of different professionals internally and externally who attended review meetings.

Staff were polite, friendly and willing to help and treated patients with respect and dignity. Patients were involved in their care planning and reviews and were free to air their views and where appropriate, their families were involved.

We rated the child and adolescent mental health wards overall as ‘good’ because:

Each patient had an individualised risk assessment. These had been reviewed by the multi-disciplinary team.
Staff received training in how to safeguard patients from harm and showed us that they knew how to do this effectively in practice.
Staff had received training on the use of restraint and seclusion records were well maintained.
We saw that the trust had systems to report incidents, manage emergency situations and investigate any serious untoward incidents.
Assessments and care planning were completed to meet patient’s needs with systems for ensuring these were updated as these changed.
Treatment and care best practice was supported through the use of nationally recognised assessment tools and a range of therapeutic interventions in line with the National Institute for Health and Care Excellence (NICE) guidelines.
Staff reported effective team working and joint working across units and other services.
Most patients reported they were treated with dignity and respect and gave positive feedback about staff.
Both units had an education department which had been rated as “outstanding” by OFSTED.
Staff could access specialist support and services if patients required specific help.
Units had ‘you said we did’ boards which showed how they were responding to issues raised by patients.
Staff knew who the most senior managers in the trust were.
Managers had access to governance systems that enabled them to monitor the quality of care provided.

However:

We found areas across both units where patient safety may be at risk. For example, staff had not identified some ligature risks and some were not being managed effectively.
The Burrows had a seclusion room which was partially non compliant with the Mental Health Act 1983 Code of Practice (2015).
At the Burrows, we found issues regarding food safety which could pose a risk to patients.
Both units had staff vacancies and staff and patients said this impacted on the service delivery.
Trust procedures for recording mental capacity and consent to treatment assessments of patients were not robust.
Records did not always detail when detained and informal patients had been informed of their legal rights.
Records seen did not always capture the involvement of patients in the treatment they received.
Minutes of patient engagement groups (PEG) did not always detail actions taken to issues raised.
Staff told us that patients sometimes had to be placed in other hospitals a long way from their home area which made it difficult for family and staff to keep contact.
Ward managers did not have access to any complaints’ themes and analysis and it was unclear how staff were learning from these to plan and develop services.
Managers had access to trust data such as incident reporting to gauge the performance of the unit. However managers’ access to this information differed across units and it was not evident how they were using this to improve the overall quality of the service.

We rated Northamptonshire Healthcare NHS Foundation Trust Older People Mental Health Inpatient Services as Outstanding because:

Patients told us they felt safe and there were good care plans and risk assessments in place.

Different professions worked effectively together to assess the needs of patients.

There was an active training plan in place for staff to enable them to keep up to date with their clinical skills and to develop these further.

There were close links with an independent advocacy service that supported patients with making decisions.

There was an active occupational therapy and physiotherapy team on site in both locations and they developed individual plans and therapeutic activities with patients.

Patients and their carers told us that staff treated them with kindness, dignity and respect.

Patients were involved in the running of their wards and felt listened to when they had ideas and suggestions.

There was an active chaplaincy service on both sites which supported patients with their spiritual needs and helped them to engage with faith groups in the community if they wanted to.

Staff showed a clear understanding of the Mental Health Act and the mental capacity act including deprivation of liberty safeguards.

Staff told us they felt valued and supported by the trust and felt confident they could report their concerns and believed these would be acted upon.

There were robust systems in place to allow managers to monitor the quality of the service they provided and to respond to changing patient need.

However:

Some doctors felt undervalued by the service and did not feel nursing staff trusted them to make medical decisions.

The trust used a different computer system to the local acute trust and some medical staff told us they could not easily access test results, which caused delays in treating some patients.

Staff also told us it took four years to get new hand rails and to move essential hygiene equipment on Brookview and Riverside units.

Some outdoor garden areas are not easy for patients to use because they have uneven floors.

There were some gaps in the cleaning rota for one of the clinic rooms.

Experienced staff found it difficult to locate some important records on the computer system because information might be stored in different places by different staff.

Overall rating for this core service Requires improvement

We found that community inpatient services required improvement.

There were high levels of bed occupancy within community inpatient services. To facilitate patient flow, the service led a twice weekly telephone patient tracking meeting with colleagues from social care.

There were processes in place for reporting and learning from incidents. However, not all risks had been identified on the risk register.

Staffing was not always sufficient. We found wards were short of nursing staff and one to one care was not consistently provided. Significant vacancy rates and high sickness levels put additional pressure on substantive staff. There was no clinical supervision provided for nurses. Despite this, staff told us they worked as a team and enjoyed their jobs.

Patient records across community inpatient services were not always completed fully; consent was not always obtained and recorded.

Staff were not aware of local contingency plans and emergency procedures. The emergency procedure was difficult to locate on the trust intranet and needed to be reviewed.

We saw patients were treated with compassion and respect. All of the patients we spoke with told us they were happy with the care provided by staff. Feedback was invited through an online survey “I want great care” and generally the service received positive comments.

We found good multidisciplinary working on wards. However, whilst there was some evidence of shared learning, the systems in place were not robust or comprehensive for effective shared learning and innovation across community inpatient services and this meant that patient experience, care and engagement varied across services.

Overall rating for this core service Requires Improvement

Overall this core service was rated as Requires Improvement. We found that community health services for children, young people and families in caring was good, but in safe, responsive, effective and well-led requires improvement.

We rated the service as required improvement overall because:

There were not always reliable systems, processes and practices in place to keep people safe and safeguarded from abuse.
Gaps were identified in the health visitor caseload, regarding the frequency of contact by health visitors for children with a child protection plan.
Staffing caseloads did not always have a consistent approach to planning and team capacity.
Staff said all professionals, including trust staff, needed a better understanding and awareness of the referrals process and the thresholds criteria being used to trigger a safeguarding response for referrals to the Multi-Agency safeguarding Hub (MASH).
There was no integrated electronic records system to share information about vulnerable children who accessed the Integrated Sexual Health Service, or identify if young people using the service had a child protection plan with other children’s teams, however the trust had a number of systems in place to mitigate this risk.
There was variation in record keeping across the service with some records not being updated regularly or containing appropriate information in accordance with trust procedures.
Not all of the centres we visited had appropriate hand washing facilities; we saw staff using hand-sanitising gel as they could not wash their hands. The trust told us that not all centres or buildings were owned by the trust, for example village halls and schools and that the use of hand- sanitising gel was an appropriate action and was in line with the trust’s infection control policy.

There was not always effective communication, appropriate information sharing and decision-making about children and young people’s care across all the services involved both internal and external to the organisation.
Multiagency working within the teams that worked within the service had a focus on meeting the child or young person’s needs. Working with social care partners was identified as being difficult, contributed to by the high number of agency social workers which impacted on continuity.
Parents we spoke with told us that they were not always able to have continuity from the same health visitor at each key contact of the Healthy Child Programme (HCP) 0 to 5 years.
Antenatal contacts were not being undertaken in all areas by health visitors which impacted on the equity of access.
There was variation in appropriate levels of supervision and appraisal of all staff.
The provider engaged with commissioners of services, local authorities, other providers, but not always with people who use services and those close to them to provide coordinated and integrated pathways of care that meet people’s needs and to provide comprehensive universal services and health and wellbeing programmes.

Parents told us there had been no consultation with parents about the rationalisation and the changing model of child health clinics. The trust told us that formal consultation was not required because there was no fundamental change to the model of child health clinics merely an enhanced offering of extending hours based on informal engagement with the families. One clinic was affected by long term sickness and appropriate action was taken to ensure contact with the parents were in place.

Most parents had to travel outside of the county for the treatment of tongue tie. There was a referral pathway for staff to refer parents directly to Milton Keynes or Bedford for treatment, although there was the facility to provide the service at Kettering Hospital.

Therapy services at one location we visited had no clear database of scheduled appointments, non-attendance could be missed.

Within school nursing staff shortages in some teams had resulted in prioritising service provision for child protection, Children in Need, immunisations and screening. One school nursing team had to decrease pupil ‘drop in’ sessions in schools.

Although some staff knew about the trust vision, staff did not consistently demonstrate knowledge of the goals and values of the service.
Systems were not in place to audit the effectiveness and quality of the referral process, caseloads, supervision and risk assessment across all teams.
Governance arrangements were not always consistent in oversight of quality and performance across all teams.
Management changes had impacted on leadership and the way staff felt connected, respected valued and safe. Not all staff felt senior managers were visible.
There was a culture of staff working long hours to cover for staff absence in most teams.

However,

There was an action plan in place to ensure that staff compliance rates for safeguarding training at Level 2 and Level 3 were at 80% by February 2015.
Electronic records completed by school nurses, had care plans with specific outcomes, referrals and evidence of multiagency working.
Systems were in place to report incidents and to share learning from incidents.
The service had, were required, appropriate systems in-place for the storage and administration of medicines.
Staffing establishments (levels and skill mix) were set and reviewed to keep people safe and meet their needs.
There was evidence of good practice seen in the Integrated Sexual Health Service (HIV, GUM and family planning); specialist school nurses had developed training packages to deliver training to school staff. There were only three key performance indicators in school health.

The Integrated Sexual Health Team had incorporated the Fraser Competency within the Child Sex Exploitation (CSE) best practice protocol.

The specialist school nursing team were responsive to the needs of children and used safe systems for training, care planning, documentation, with good multi-agency working.

A school nurse competency framework had been developed within the last year; the purpose was to help develop and support new staff in developing the service.

Parents had been extremely positive about the support they had received from the specialist infant feeding team. Funding for the team had been secured until the end of March 2015.

A range of comprehensive Standard Operating Procedures (SOP) had been developed for the health visiting service.
Parents who used the service felt supported and that their children were well-cared for by staff, which were kind and had a caring compassionate attitude.

Children and their families were treated with respect and dignity by staff which was observed during the inspection.

Parents were positive in the feedback they gave about staff.

An effective translation service was provided by the trust.

Health visitors offered home visits to parents to meet specific needs, if they could not be met during a child health clinic contact.

A new initiative that had been introduced for parents and babies was a ‘Healthy Day’ session at a children’s centre. Mothers could attend on a drop in basis without an appointment.

The ISHS was accessible and flexible.

The service had an effective system in place to seek feedback from parents and young people and that complaints were handling in accordance with trust procedures.

Staff we spoke with were supportive of one another, there was a willingness of people working together to provide a good service to children and young people.

Staff felt able to raise problems and concerns to senior managers and generally were positive about their local leadership.

We gave an overall rating for community health services for adults required improvement because:

The trust management had ensured that learning from serious incidents was shared with front-line staff. This meant that these staff members had the benefit from the results of investigations into the incidents. Staff were able to speak openly about issues and incidents, and felt this was positive for making improvements to the service. The service had taken action to reduce new pressure ulcers and slips, trips and falls. The environment was clean and staff followed the trust policy on infection control.

Treatment and care were provided in accordance with evidence-based national guidelines. There was good practice, for example, in pain management, and the monitoring of nutrition and hydration of patients in the perioperative period. Multidisciplinary working was evident. Patients told us that staff treated them in a caring way and were kept informed and involved in the treatment received. We saw patients being treated with dignity and respect.

The medical staffing was appropriate and there was good emergency cover. However, there was a shortage of nursing staff with a high number of vacancies.

Staff had access to training and had received regular supervision and annual appraisal. Staff had awareness of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS).

National waiting time targets for Referral To Treatment (RTT) for 18 weeks for those services applicable to the trust were being met. There were longer waiting times for the dietetic service. Services were being developing to improve response to increasing demand. There was a high number of delayed transfers of patients ready for discharge. This was due to delays in accessing care home or care packages. There were various inefficiencies in discharge arrangements for patients. This resulted in patients being discharged without the prior knowledge of the community teams.

There were long waiting times of up to eight months for patients referred for physiotherapy classed as non-urgent which did not meet the clinical commissioning groups’ two week to referral appointment times. Patients at the surgical podiatry service at Battle House had an average wait of between six to nine months from assessment to referral to surgery time.

There was support for people with a learning disability and reasonable adjustments were made to the service. But information leaflets and consent forms were not available in easy-to-read formats. An interpreting service was available and used. Patients reported that they were satisfied with how complaints were dealt with.

We found that community services were well-led. There was positive awareness among staff of the values and expectations for patient care across the trust. Some staff said they felt pressurised when patient referral fluctuated and some felt that they received poor support during stressful periods. The services had identified the risks and had action plans and outcomes in place to manage this risk.

Despite the work pressures, staff were compassionate, sensitive and kind to people who use the service. Service managers provided good leadership and were visible and accessible to both people who use the service and staff.

Overall rating for this core service Requires Improvement l

We found that the trust was performing at a level which led to a rating of Requires Improvement.

A training system was in place to redress issues with training following a high turnover of staff. However this had not yet been achieved.

We attended multidisciplinary team meetings and saw evidence of wide communication throughout the services we visited, however supervision, appraisals and staff support was not always effective.

Staff told us that they did not always receive effective clinical supervision so people could not be sure that the service is providing an up to date and well-led service.

A specific end of life pathway care plan had been developed to replace the “Liverpool Care Pathway” which had been withdrawn, but it was not fully embedded in practice across the service.

Staff told us the care planning tool available at the time of inspection was not specific to end of life care, and difficult to edit to reflect the specific care pathway of the patients. The service had available a “care of the dying person” template care plan on the electronic patient record system that was specific to providing palliative care. Staff were unable to tell us about plans to improve the care plan system, and were resigned to accepting the system they were given to use.

At Cransley Hospice we saw evidence of clinical audits carried out by the Matron, however in we found no evidence of clinical audits at any level at Cynthia Spencer Hospice, other than infection control audits, or medical audits with national data sets at either hospice. This meant that there was not an effective system in place to ensure that clinical practices are in line with current research.

Clinical supervision was not consistent across the service and at Cynthia Spencer Hospice due to short staffing and unavailability of sisters due to sickness and other issues staff had not received effective clinical supervision for some time.

The trust did not carry out pain audits either in the community or in the hospices but we did see effective pain relief was offered to patients during the inspection.

In the community it was not clear how nutrition and hydration of patients was monitored. Staff recorded problems with nutrition and hydration on admission to the team and care planning, but this was not always updated during visits to people in their own homes.

At Cynthia Spencer Hospice and in the palliative care teams there was no evidence of audit systems in place to monitor the effectiveness to the care provided to patients.

The trust had not taken part in the National Care of the Dying Adult (NCDA) audit for some time, but the service manager told us that there were plans to contribute to this data this year.

Cynthia Spencer Hospice had difficulties providing blood transfusions for some patients due to staff not having completed training in haemovigillance (to minimize the potential risks associated with safety and quality in blood processing and transfusion for donors, patients and staff).

Staff were engaged in their roles but they told us that they did not feel they were consulted about previous changes, or would be involved in future plans of the trust despite information newsletters, emails and meetings that were in place.

The service did not have an effective system in place to continually monitor and improve the service.

The palliative care team at Kettering General Hospital did not have a clear management structure, and this meant that staff were not supported effectively in their roles.

There was variation in levels of support for different teams due to unclear and inconsistent management and leadership across the service.

However;

We saw evidence of comprehensive maintenance records for the environment and equipment, and saw that this was implemented in the areas we visited. We saw a system in place that ensured equipment was removed prior to servicing in order to ensure equipment was safe.

All incidents, accidents, and near misses were logged onto a trust-wide computer reporting system.

Staffing levels were adequate to provide the level of care people required on the day of our visit, and call bells were answered promptly. People told us that they did not have to wait long for assistance if they pressed their call bell.

We looked at care planning documentation and saw that the needs of people were documented clearly with their plan of care to ensure that it was safe and effective for people using the service.

We saw examples of do not attempt cardio pulmonary resuscitation (DNACPR) forms that were completed in accordance with trust policy.

Staff understood the Mental Capacity Act and records showed that they had received training to ensure staff had a level of understanding about people’s rights. We saw examples of mental capacity assessments to assess people’s capacity to make decisions about their end of life care.

The culture we saw within the service was open and kind. The interactions we saw between staff, families, and people using the service were kind, professional, and not rushed.

Service user surveys were carried out and the feedback was generally very positive about the service.

People we spoke to said positive things about the service they had received and the staff working in the service.

People’s dignity and privacy was respected.

Family members and carers were kept involved and informed about the care and treatment of patients.

All of the staff we spoke with were cheerful and enthusiastic about the service they provided. Staff worked flexibly to ensure that patients received a high standard of care.

Patients told us that the staff in the hospices and in the community were kind and caring, and that they “could not fault” the service they had received.

Spiritual and emotional support was provided to meet the needs of individual patients.

We saw that changes had been made in the way the service was run in response to problems and changes in legislation that had been identified by management. This showed that the service was learning from challenges and improving the service they provided.

Waiting times for responses to calls were within the trust’s target of 24 hours, and visits or admissions were arranged within three days of referral in the main.

We spoke to a number of staff working in different areas and they told us that they received information in newsletters and meetings from the trust.

Overall rating for this core service Requires improvement

We found that overall the community dental service required improvement because:

Systems, processes and standard operating procedures were not always reliable or appropriate to keep people safe, and monitoring whether safety systems were implemented was not always given top priority.
There was inconsistent practice amongst staff in the management of day to day risks. National guidance for day to day safety checks were not always adhered to for management of digital x-rays, environmental cleaning, medicines safety, and legionella testing.
We raised urgent concerns about the unsafe storage of medicines at St Giles Street clinic, and saw where immediate corrective action was taken.

There was some participation in local and national audits, however data and performance measurement were incomplete, and participation in external audits and benchmarking was limited.
The service was not always responsive to meet the needs of the local population. The facilities at Brackley Health Centre had been closed since November 2014. Prior to that it had been running a dental clinic one day a fortnight which meant clinical capacity was limited.
We saw no evidence that people who used the service, the public, or other organisations were consulted or informed about the change in services.
There were not always arrangements in place to provide alternative cover for anticipated or unplanned absences of the dentist or for staff vacancies. In addition to a reported increase in new referrals this meant people were not always seen within the target waiting times.

However:

We saw safe practice where decontamination of dental instruments was carried out, that emergencies were planned for, and that equipment checks were in place.
There were clearly defined systems for safeguarding of children and vulnerable adults. Staff had received up to date training in all safety systems.
People’s treatment was generally planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
Staff were suitably recruited, trained, supervised and qualified to carry out their roles effectively, and felt supported in induction training of new roles and in their ongoing learning and development.
We saw where staff treated patients with kindness and respect, and where privacy and confidentiality were ensured.
Patients and those supporting them spoke positively about the way they were cared for, their treatment and the emotional support they were given.

We gave an overall rating for acute wards for adults of working age and the psychiatric intensive care unit (PICU) of requires improvement because:

There were blind spots on all wards that meant that staff could not ensure patients’ safety.
Seclusion rooms were not fully compliant with the Mental Health Act 1983 Code of Practice (2015).
There were ligature risks in the gardens on wards at St Mary’s Hospital.
Harbour and Kingfisher wards did not comply with the guidance on same sex accommodation.
Some staff had a limited awareness of safeguarding procedures.
Staff did not demonstrate a good understanding of the Mental Health Act (MHA) and Mental Capacity Act (MCA). It was not clear how patient’s capacity to consent to their treatment had been assessed.
Staff on Harbour ward had other tasks such as bed management and managing the 136 suite which meant that staffing levels did not always ensure patients safety.
Blanket restrictions of locking bedroom, lounge, kitchen and garden doors had been applied on some wards. There were also restrictions on patients having access to hot drinks on some wards.
Action had not been taken as a result of an incident that resulted in a patient’s death.
The records system was cumbersome and meant that staff could not always access all the information they needed about a patient.
Information was available in a range of formats to meet patient’s needs.
Some patients were not clear about how to make a complaint.

Staff were caring. The occupational therapy service was very good and the model used helped patients to engage and develop their skills and abilities.

We gave an overall rating for long stay/rehabilitation mental health wards for working age adult of requires improvement because:

There was no risk management or action plan in place to adequately manage the potential ligature risks identified in the communal bathroom.

The unit did not comply with the guidance on same sex accommodation. There were not enough rooms where patients could relax and or sit privately and quietly. There was one lounge shared by both females and males.

The unit had a tiny clinic room which was not fit for purpose. The unit did not have a physical examination room and resuscitation equipment. Staff did not know about the requirements of emergency equipment.

In some cases the risk assessments were not followed. There was risk identified that patients were smoking in their bedrooms. However, no plan was put in place to manage this.

Staff demonstrated an understanding of how to identify and report abuse to ensure that patients were safeguarded from harm. However, we found that some incidents were not reported as safeguarding.

Staff knew how to recognise and report incidents through the reporting system. However, we found that some of the incidents were not reported and these were confirmed by staff.

Care records were not detailed enough and did not contain all relevant information about care provided.

A patient on a high dose of clozapine for some time was not checked for the level of Clozaril in the blood to find out if they were on the right dose. Another patient who had abnormal blood test results had no further investigations to assess the reason.

Clinical audits were not carried out regularly to monitor the effectiveness of the service.

Staff told us that they had not received training on the Mental Health Act (MHA) and the Code of Practice. There was some inconsistent practice on patients’ capacity to consent to their treatment.

Staff had not received training in the use of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff did not demonstrate a good understanding of MCA and DoLS.

Our observation of practice, review of records and discussion with staff confirmed that the unit was admitting patients with more complex needs than what the staff in the rehabilitation service were used to and skilled to care for.

Patients’ privacy and dignity was not always protected.

Patients told us that they knew how to raise complaints when they wanted to but most of them felt that they were not listned to and did not feel confident to complain as staff would not act to resolve the issues.

We found that the team’s and the organisation’s values were not embedded in practice. The staff knew who their senior managers were and told us that they rarely visited the unit.

The trust had governance processes in place to manage quality and safety. However, we identified areas of improvements in safeguarding and incident reporting, clinical audits, MHA and MCA procedures.

We found that there was lack of good clinical leadership. The consultant was a locum and provided one session a week to the team. The senior management and clinical team did not share information about underlying issues on the unit that could affect care and treatment.

Morale within the staff team was very low. All staff told us they felt demoralised by changes over the past year. Staff felt there is a huge disconnect with senior management. They told us that senior management did not listen to them or get them involved or consulted in changes.

The units were not participating in a national quality improvement programme such as AIMS.

However, during our inspection the senior management immediately implemented and shared an action plan with us to resolve some of the issues. The following actions were taken, introduce additional staff, clinical reviews with all patients to start the most appropriate pathway for their presentation, review access to the ward and the practicability to create a female-only access directly on to the female corridor, review operational policy, including referral/acceptance criteria and review pathways to create the most appropriate environment for single gender and to move clinic room to a larger room on the unit.

On admission every patient had an assessment of needs that took account of previous history, risk, social and health factors. There was good collaborative working within the multi-disciplinary teams (MDT) and had a number of different professionals who attended review meetings. Staff were polite, friendly and willing to help and treated patients with respect and dignity. Staff demonstrated a good understanding of the individual needs. Patients’ individual needs such as cultural and religious needs were met. Staff were aware of the trust’s whistleblowing policy and felt free to raise concerns.

We rated the community mental health services for children and adolescents overall as ‘requires improvement’ because:

Following restructure, there were 25 staff vacancies across CAMHS teams. Staffing vacancies had affected service delivery. Therefore contingency planning for managing the transformation had been affected.

Amongst the 16 care records that we examined. We found three examples of a risk assessment not being updated after a young person’s risks had increased across north and south teams. We found two examples of safeguarding issues that were not managed effectively at the time they were reported. Managers were made aware of this and told us of the actions they would take. Five care plans in the South team which had not been updated following a change to a person’s needs. The recording of discussions and assessments with young people regarding consent to treatment varied across teams. This included the recording of prescribing “off licence” medication. Assessment and treatment records seen did not always reflect young people’s involvement.
There were delays with the referrals process. This meant that young people were not always able to access support in a timely way. Complaints had been made by people related to the length of waiting times.
The service was commissioned to provide 24 hour cover this was operated via an on call Consultant rota

A response team was developed to work intensively with young people in crisis but was not fully operational due to staffing vacancies.
There was a pathway for requesting hospital admission; the trust was not responsible for any delay as this sort of placement was commissioned by NHS England. The children would be placed out of county according to local availability and their risk profile.

In 2014/15 two young people were admitted to adult wards both were over 17 years of age at time of admission. Currently if a young person below the age of 18 is admitted on the adult ward, this is immediately placed on the risk register and NHS England is informed. There is a meeting arranged to discuss why the young person is on the adult ward and all effort is made to move them to a suitable environment.

However

There had been no serious untoward incidents within this service in the last year.
Staff could arrange interagency complex case panels where they were concerned about the risk to a young person.
Staff received training in how to safeguard young people who used the service from harm.

Staff used nationally recognised assessment tools. For example, the child and young person’s self-harm pathway completing integrated assessment tools with acute hospital staff.
Staff provided a range of therapeutic interventions in line with National Institute for Health and Care Excellence (NICE) guidance such as cognitive behavioural therapy (CBT).

Regular team meetings took place and staff told us that they felt supported by colleagues.
Young people and carers reported they were treated with dignity and respect and gave positive feedback about staff.
Brief intervention and skills-based workshop programmes were offered to provide earlier intervention and reduce the need for specialist intervention services.

The trust had set up an ADHD and ASD team to work with young people in response to a high number of referrals.

The service had undergone a transformation that included how services would be delivered to young people through an integrated service. Consultations with staff and the public had been undertaken to gain feedback. This meant people were given the opportunity to have a say in the way the services were designed.

We found that Northamptonshire Healthcare NHS Foundation Trust was performing at a level that leads to a judgement of requires improvement.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

Northamptonshire Healthcare NHS Foundation Trust provide both Community Health and Mental Health & Learning Disability services. The differences between the two is evident and showed some marked contrast. The Community Health Services were all given a rating of Requires Improvement whereas we found some Outstanding practice in the mental health provision within Older People’s Mental Health Inpatient services and in the Substance Misuse Services.

We found areas of concern; most notably within Quayside Ward, a Long Stay Mental Health Rehabilitation service at Berrywood Hospital. We found there to be several issues of practice that required improvement in relation to medicines management and pathways of care.

Recruitment and retention of staff is an area that requires development trustwide but particularly within Community services. However, we observed evidence that the Trust has taken steps to address this issue. We also found learning from incidents and complaints to be variable with a discrepancy in the quality and assimilation of an effective learning culture.

We found a great deal that the Trust can be proud of. Caring was consistently of a Good standard and we found staff to be dedicated and kind. The aforementioned Older People’s Mental Health Inpatient services at the Forest Centre are to be particularly commended due to the state of the art facilities, excellent use of therapeutic tools and the involvement of patients in their care.

We found the Trust to be well-led at board level. The Trust’s values are visible in most of the services provided and the work that the Leadership team are undertaking to instill these throughout the organisation in order to promote a caring, transparent and open culture is notable. The Executive team impressed us both individually and collectively and demonstrated cohesion and determination to improve and enhance the quality of care provided to those who use services within the Trust.

We will be working with the Trust to agree an action plan in order to improve and develop the quality of services.

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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