Midlands Partnership University NHS Foundation Trust

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

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients and acted on them. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• The reception area at Haywood Hospital did not allow the receptionist to clearly observe all patients in the waiting area.
• Some of the clinical notes were not detailed enough to capture all necessary information such as the red flags.
• Supervision was not recorded consistently.

• Not all staff demonstrated a good understanding of the Gillick Competency and Fraser Guidelines.

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  
• Staff developed holistic, recovery-oriented or strengths based supportive 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 ward teams included the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 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 so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.

• The service was well-led, and the governance processes ensured that ward procedures ran smoothly.

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

We rated caring as good and safe, responsive, effective and well led as requires improvement because:

• Across the core service there were inconsistencies in addressing issues from the previous inspection. There were differences in quality of practice between Shropshire and Staffordshire. We concluded that services in Staffordshire were of a good quality. Our concerns were about the services for the people of Shropshire.
• In Shropshire there were concerns in the way the trust triaged referrals within the access team. At the time of the inspection despite the service having been commissioned, the trust had allocated no staff to assess people for attention deficit hyperactivity disorder (ADHD). This meant that the waiting list for pathways was high and waits were getting longer.
• Not all risk assessments were updated regularly and care plans within Shropshire lacked detail and did not reflect the views of the children and young people or their families. Carers and young people told us they were not given copies of care plans.
• Staff considered patients’ capacity to make decisions about their care but did not consistently or effectively record these considerations in the patient’ records within Shropshire.
• Services in Shropshire made limited use of outcome measures. This reduced their ability to monitor patient progress. Not all staff were aware of or involved in clinical audits.
• Staff morale in Shropshire was generally low and staff felt isolated from the other teams in the trust.
• Local managers in Shropshire had not ensured thorough and robust oversight or audits around the quality of documentation within the clinical records.
• Staff did not complete regular environmental risk assessments. Staff were not aware of where the environmental risks were.
• Staff were not consistently checking calibration of clinical equipment and there was no system in place to monitor this.
• Although we found that staff received regular supervision, the trust did not have a consistent and effective system for collating and monitoring supervision data.

However:

• Staff regularly reviewed the effects and side effects of medications on each patient’s physical health. This was an improvement since the transfer of Shropshire services into the trust.
• Staff knew how to identify abuse and safeguard young people in line with current recognised guidance and trust policy. Staff followed safeguarding processes and ensured that they highlighted any safeguarding information on the electronic recording system.
• Young people felt that staff listened to them and provided them with appropriate emotional and practical support. Young people described the staff as caring, supportive and non-judgemental.
• Staff in the teams provided a range of treatment and care for patients based on national guidance and best practice. Staff supported young people with their physical health and encouraged them to live healthier lives.

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability (and/or autism) and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training and appraisal. The ward staff worked well together as a multi-disciplinary 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.
• 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 did not always offer staff support in their roles. Staff were not always receiving regular one to one supervision, and managers were not documenting that supervision had taken place, in line with trust policy.

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

• We rated safe, caring, responsive and well-led as good. We rated effective as requirement improvement.
• The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.

• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multi-disciplinary 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 so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.

• The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

• Managers had failed to provide support for staff through regular supervision or record sessions in line with the local policy. This left staff without the benefits regular supervision offers and no way to evidence and review development plans between annual appraisals.

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

• The service provided safe care. Clinical premises where patients were seen were safe and clean and the physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high. Staff assessed and managed risk well and followed good practice with respect to safeguarding.

• Staff working for the mental health crisis teams developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and staff engaged in clinical audit to evaluate the quality of care they provided.

• The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that staff received training, supervision and appraisal. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.

• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

• Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

• The mental health crisis service and the health-based places of safety were easy to access. Staff assessed people promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude people who would have benefitted from care.

• The services were well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

We rated it as good because:

• We rated safe, effective, caring, responsive and well-led as good.
• There were sufficient numbers of suitably qualified staff to provide safe treatment for patients. Staff were encouraged to compete mandatory training relevant to their roles. Mandatory training rates were good, and these were actively monitored by managers.
• There was good use of skill mix within the service including that of dental hygiene therapists and dental nurses with extended duties. There was a proactive approach towards multidisciplinary working, these included the trust’s learning disability team with whom they had a good working relationship.
• Premises were clean and hygienic and used dental instruments were decontaminated and sterilised in line with nationally recognised guidance.
• There were systems in place to protect patients from abuse or neglect. The service had a good safety record and there were systems in place to reduce the likelihood of never events occurring.
• Staff were aware of the importance of obtaining informed consent prior to treatment. They had a good awareness of their responsibilities under the Mental Capacity Act 2005 and the principals of Gillick competence.
• Patients were treated with dignity and respect. Patients told us that staff were friendly, amazing, cheerful and fantastic. Staff took time to help patients who needed extra support such as those with learning disabilities, mental health problems and patients who suffer from dental phobia.
• The service took into account patients’ needs. All clinics we visited were fully accessible for wheelchair users or those with limited mobility. Translation services were available for patients who did not have English as a first language.
• The appointment system met patients’ needs and there were arrangements for patients requiring emergency treatment both in and outside normal working hours. Waiting times for initial assessment and treatment were generally good.
• There was a clear vision and strategy for the service and there were plans in place of how to achieve these. Staff morale was generally good across the service. There were effective governance arrangements in place. Staff engaged with patients, other healthcare professionals and external stakeholders in order to continually improve the service.

However:

• We found some out of date adrenaline in the emergency drug kit at one clinic. This had not been identified or disposed of by the process in place for checking the medical emergency drugs.
• Glucagon was not stored in a temperature-controlled environment and the expiry dates had not been changed to reflect this.
• At two clinics which we visited there were no size 4 oropharyngeal airways.
• At one clinic we visited the aspirin was not of the dispersible form as described in nationally recognised guidance.
• Medical emergency equipment and medicines were not taken on domiciliary visits. This had not been formally risk assessed.
• Although the service received very few complaints they were not always dealt with in a timely manner.

We rated the service as requires improvement because:

• The service did not have enough nursing staff with the right qualifications, skills, and training, to keep people safe from avoidable harm and to provide the right care and treatment. The service did not plan for medical emergencies and not all staff understood their roles if one should happen.
• The service did not monitor the effectiveness of care and treatment and therefore could not use findings to improve them. They did not compare local results with those of other services to learn from them.
• Managers did not always ensure that staff were competent for their roles. Not all staff received an annual work performance appraisal and the service did not provide structured clinical supervision.
• The service did not meet accessible information standards. People with communication issues did not have their individual needs met at the units.
• The service did not use a systematic approach to continually improve the quality of its service and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. Complaints were not responded to in a timely way and learning was not shared with staff.
• Managers at all levels in the service did not always have the right skills and abilities to run a service providing high-quality sustainable care, and the leadership team was new. The service did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However:

• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.
• Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
• The trust provided services to ensure people living in more rural areas had a local service that they could access. The service had links with mental health services for people who needed them.

We rated the service as good because:

• We rated safe, effective, caring, responsive and well-led as good.
• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors and provided training in key skills. Staff assessed and managed risk well and used control measure to prevent the spread of infection.
• The service provided care and treatment based on national guidance and made sure staff were competent for their roles. Staff of different kinds worked together as a team to benefit patients. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment
• 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 planned and provided services in a way that met the needs of local people and people could access the service when they needed it. The service took account of patients’ individual needs and treated concerns and complaints seriously.
• Managers at all levels in the service had the right skills and abilities and promoted a positive culture. The service had a vision for what it wanted to achieve and workable plans to turn it into action. The service had effective systems for identifying risks and managed information well to support all its activities. There was a strong sense of involvement in the service and pride in the hospital from staff.

We rated the service as good because:

• The leadership team helped keep people safe from avoidable harm and provided the right care and treatment, by planning for enough nursing staff with the right qualifications, skills, training and experience.
• Staff were provided with mandatory training in key skills. Compliance was good, and education, training and development was promoted, supported and embedded.
• The team provided care and treatment based on national guidance and could evidence of its effectiveness. Managers monitored and checked practice to make sure staff followed guidance. Staff consulted and adhered to National Institute for Health and Care Excellence guidelines which meant patients received evidence-based care.
• Staff of different disciplines worked together as a team to benefit patients. GP’s, nurses and other key professionals worked together to provide good care. Joint working and collaboration with external stakeholders were embedded in the work carried out to support patients and their families.
• Staff consistently cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment.
• Staff took account of patients’ individual needs. Interpreters were available for patients who did not speak English. Patients, carers and staff could access specialist services, for example, mental health teams for support.
• People could access the service in a timely manner. Staff responded to referrals to treatment promptly and in line with good practice.
• Managers had the right skills and abilities to run a service providing sustainable care. Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The trust was committed to improving services by learning from when things went well and when they went wrong. They promoted learning and professional development.

However:

• Staff did not always use control measures to prevent the spread of infection. For example, being appropriately bare below the elbow and removing painted nails.
• Staff within a minority of teams did not always complete risk assessments for each patient. Records did not always contain complete risk information to ensure staff could access appropriate risk information at the right time.
• The quality of documented patient records was variable. They were not always clear, up-to date and available to all staff providing care.

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

• We rated safe, caring, responsive and well-led as good. We rated effective as requires improvement. Our rating for the trust took into account the previous ratings of services not inspected this time. In this case that included the historic South Staffordshire and Shropshire Healthcare NHS Foundation Trust mental health services.
• Our decisions on the overall ratings consider factors including the relative size of services and we used our professional judgement to reach a fair and balanced rating.
• We rated well-led at the trust level as good. The trust had a strong and experienced leadership team, supported by efficient reporting and governance structures. Non-executive directors and the council of governors were very active in providing independent oversight of the executive team.
• Managers had successfully managed the merger of community services into the trust in June 2018. Integration of physical health and mental health services was having a positive impact on patient care. However, some services still required support to be fully integrated into the systems and culture of the trust. This was recognised in a post-merger action plan.
• Overall, clinical services were safe and effectively safeguarded patients from harm. Risk assessments were completed and update regularly within most services visited.
• In most areas care planning was personalised and holistic reflecting input from the patient or their carers. There was effective multi-disciplinary team working across the trust both within and between individual care teams.
• Physical health care needs were effectively addressed within the core mental health services.
• Staff ensured the rights of patients detained under the Mental Health Act. The trust closely monitored its use of the act and fulfilled its obligation under the Code of Practice. There was good practice in the use of the Mental Capacity Act and staff offered support to patients to make their own decision where possible.
• Staff were caring, and we heard overwhelmingly positive feedback about their professionalism and respect for the dignity and privacy of patients.
• With few exceptions, access to services was responsive; there was effective bed management in the mental health wards and timely responses to mental health problems in the community.
• The recovery college supported patients and staff with mental health problems overcome stigma and social exclusion. Led by current and ex mental health service users the college received very positive feedback about the skills and life lessons they had learned.

However:

• Managers could not provide assurance around the safety of care in the urgent care services. We found that the urgent care services had not been effectively integrated into the otherwise robust governance systems we found within the trust. This left us with concerns about the reporting and recording of incidents within the service.
• Staff left patients potentially at risk in the urgent care services. There was no triage system to determine the priority given to patients attending the two urgent care services. The time of clinical assessment of a patient had been determined by their time of arrival rather than need. The trust did promptly address this and institute a triage system within two working days.
• Although on a recovery journey, there were still concerns about the responsiveness and capacity to meet patient’s needs within the Shropshire, Telford and Wrekin child and adolescent community mental health services.
• Managers had not supported staff through regular clinical supervision in some areas. There was no central recording of supervision to allow care group managers to monitor this.
• Staff had not dealt with complaints received by the community health services in a timely manner. Managers were making changes in the way complaints were investigated to address this.
• Some clinical areas did not have the space or facilities to ensure confidentiality, good hand hygiene and lacked capacity to meet demand for appointments.
• Staff did not always have access to accessible information for patients or communication aids to support care delivery.