During a routine inspection

• 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.

During a routine inspection

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.

During a routine inspection

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.

During a routine inspection

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.