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Provider: 2gether NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 1 June 2018

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

  • We rated effective, caring, responsive and well-led as good. We rated safe as requires improvement. Our rating for the Trust took into account the previous ratings of services not inspected this time.
  • Staff worked to ensure care plans were holistic and patient centred. In the majority of the teams we inspected, there was a good range of different mental health professionals who worked well together (and with other agencies) to ensure patients received care in line with national guidance.
  • Staff were caring and respectful towards patients. Patients and carers gave positive feedback about the care received. They said they were involved in decisions about their care and staff considered their well-being and experiences as a patient, as well as their physical health needs.
  • In the majority of the services we inspected, we found that staff were working to help patients to recover in a responsive way. This was reflected in the time it took for patients to receive an assessment and then their treatment, and in the way the inpatient staff in the majority of the wards we inspected worked to help patients to be ready for discharge.
  • The trust’s senior leadership team had the skills, knowledge, and experience necessary to successfully oversee a large organisation. We found the trust board was preparing well for the acquisition of Gloucestershire care services community trust. They had appointed a joint chair in January 2018 and were in the process of recruiting a new joint chief executive in March 2018.
  • We saw evidence of some excellent leadership at all levels across the trust with many dedicated, compassionate staff who were striving to deliver the best care for their patients.
  • 2Gether NHS trust had its own research base called the Fritchie Centre, which participated in national and local studies aimed at increasing the understanding of mental health conditions.

However:

  • We rated safe as requires improvement. We found that there were a number of issues still with the wards for people with learning disabilities. These included improvements that were needed in providing handwashing facilities for staff, storing food appropriately, and a lack of an agreed vision with the local clinical commissioning group for the service.
  • There were particular problems with the ongoing recruitment for Cantilupe ward. Also, the staff on Jenny Lind ward did not have access to regular supervision sessions and team meetings. Both of these were wards for older people with mental health problems.
Inspection areas

Safe

Requires improvement

Updated 1 June 2018

Our rating of safe stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as requires improvement because:

  • The ward for people with learning disabilities needed to improve in infection control measures. There were insufficient hand washing facilities and staff did not regularly monitor that food was being stored safely in the fridges on the ward.
  • Staff on the ward for people with learning disabilities reported a high number of incidents of the use of physical restraint to manage challenging behaviour. Staff had not devised a plan to reduce the need for physical restraints. Subsequently, the trust provided the reducing restrictive intervention strategy.
  • Staff had delayed reporting a safeguarding concern to the local authority on the ward for people with learning disabilities.
  • There had been difficulties with recruitment on one of the wards for older adults with mental health problems, and in one of the specialist community mental health teams for children and young people that had affected their ability to provide care.

However:

  • The facilities in the services we inspected were clean and well maintained.
  • Staff assessed risk and these assessments were comprehensive.
  • The majority of the services we inspected followed the trust’s safeguarding policy and raised concerns appropriately.

Effective

Good

Updated 1 June 2018

Our rating of effective stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as good because:

  • Care plans were appropriate and met patients’ needs. These followed national guidance where appropriate. For example, in community mental health teams for children and young people in Hereford, we saw that care plans were updated regularly and were jointly created with patients and carers.
  • Staff were experienced, and were supported to maintain their skills. The teams we inspected had a good range of professionals to provide patient care.
  • All staff were aware of the duties they had under the Mental Capacity Act and the Mental Health Act.
  • In the majority of the teams we inspected, staff received regular supervision in line with the trust’s guidance and targets.

However:

  • Supervision and appraisals were below the trust’s target on the ward for people with a learning disability.

Staff in the specialist community mental health teams for children and young people did not always routinely assess the patients’ physical health needs.

Caring

Good

Updated 1 June 2018

Our rating of caring stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as good because:

  • All staff were respectful and kind to patients.
  • Staff were knowledgeable about their patients and tried to meet their needs in a patient centred way.
  • Where staff were working with patients with communication needs, they had the skills and facilities to meet these needs. We saw staff using these tools to great effect on the wards for older adults with mental health problems.
  • Staff on the wards for older adults with mental health problems had taken many steps to ensure an appropriate pathway for end of life care. This had involved many changes to ensure that people in palliative care were cared for in comfort and peace.

However:

  • Some confidential information was displayed in public areas in the ward for people with learning disabilities.
  • Some patients reported that they had not been given a copy of their care plan by the community mental health teams for older adults,
  • Advocacy services were not available for children and young people

Responsive

Good

Updated 1 June 2018

Our rating of responsive stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as good because:

  • The wards we inspected had a range of facilities for patients. For example, the ward for people with learning disabilities had good access to outdoor space that could be personalised by patients. The wards for older adults with mental health problems were also equipped with a range of facilities for therapeutic activities and had a range of sensory equipment for the patients with dementia.
  • The community teams we inspected were able to respond quickly to new referrals and had clear criteria for the patients that would be seen by the service.
  • A social worker had been hired at Charlton Lane hospital to help reduce the delays in discharging patients from wards for older adults with mental health problems.
  • Information was available for patients on how to complain, and staff could demonstrate learning from complaints. Some patients told us they were not sure of how to complain.

However:

  • The length of stay on the ward for people with learning disabilities was high (on average nine years) and while five out of six of the patients there were ready for discharge, there were no current discharge plans in place. This was due to challenges in finding appropriate placements to meet the needs of the client group.
  • Some of the facilities used by the community mental health teams did not support patients privacy and dignity.

Well-led

Good

Updated 1 June 2018

Our rating of well-led stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as good because:

  • The board and senior leadership team had a clear set of values that were at the heart of all the work within the organisation. They worked hard to ensure staff understood them in relation to their daily roles.
  • The trust strategy was directly linked to the vision and values of the trust, local sustainability and transformation plans and the joint work with Gloucestershire care services community trust.
  • The trust was committed to improving services by learning from when things go well and when they went wrong, promoting training, research and innovation and it enabled localities to share learning across the trust.
  • The trust included and communicated effectively with patients, staff, the public, and local organisations. It supported localities to develop their own engagement strategies and encouraged staff to get involved with projects affecting the future of the trust.
  • Trust leaders frequently visited front-line teams, which helped to make the senior team visible to staff across services. Many of the staff we spoke with told us they felt the senior team were open and approachable.
  • Senior leaders understood the challenges to quality and sustainability the Trust faced, with workforce, consistency of service delivery, and access to services identified as key challenges. They were able to explain clearly the actions they had taken and the plans they had in place to further address those challenges.
  • The Trust operated a targeted programme of internal audits to monitor quality of services, clinical standards, and operational and financial performance. We did not look in detail at the Trust’s financial management in this inspection. The Trust was operating with a financial surplus and had been for the majority of the last five years. We did not identify any instances where financial pressures had compromised the standard of care. Quality impact assessments were always carried out to ensure quality was never compromised by any cost improvement programmes.
  • We found that the trust had developed a detailed governance system to support it to achieve its vision. The process for monitoring risks was strong and the board were sighted on both the corporate and operational risks facing the organisation. These were presented in board meetings via a comprehensive risk register, which was clear and concise.
  • The trust held a serious incident panel every fortnight which was attended by the director of nursing and medical director.
  • The board actively engaged with service users and we saw evidence how each board meeting started with a patient experience presentation, undertaken by someone who has first-hand experiences of using the trusts services.
  • There was a programme of Experts by Experience who were involved in a wide variety of trust activity including recruitment of trust staff, research, and committee activity.
  • We saw clear evidence of how appropriate action was taken by senior leaders to address staff behaviour and performance that was inconsistent with the Trust’s vision and values.
  • Many of the staff we spoke with expressed pride in working for the Trust. They told us they were valued and able to raise concerns freely and without fear of retribution in what they felt was an atmosphere of openness.
  • The Trust had effective systems in place to ensure that services discharged their specific powers and duties according to the provisions of the Mental Health Act, 1983 and Mental Capacity Act, 2005.

However:

  • Clinical supervision information could not be provided by the trust as part of the provider information return.
  • We heard of concerns that there may be gaps in safeguarding support and a lack of Safeguarding practice for adults, due to a lack of dedicated resource in the staff team, if the non-recurrent support agreed with the staff team was not maintained within the staff team on an ongoing basis
Checks on specific services

Wards for older people with mental health problems

Good

Updated 1 June 2018

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

  • Staff had resolved the breach of the guidance on eliminating mixed-sex accommodation that we identified at the last inspection in January 2016 on Jenny Lind ward. The ward was now compliant with national guidelines.
  • The wards were recovery-oriented and provided a suitable environment for the patient group. There were images, posters and paintings with a reminiscence focus. The wards at Charlton Lane, in particular, had utilised colours and images to mark patients’ bedrooms to make them more dementia friendly and had a range of sensory equipment along the corridors for stimulation.
  • All the wards were clean, odour-free and well-maintained with suitable furnishings and fittings. The communal areas were bright and airy, and the wards had a range of facilities for therapy intervention.
  • Charlton Lane wards had developed a ‘Lofthouse suite’ - a room with padded walls and soft furniture which staff could use as a calm and safe space for patients at higher risks of falls.
  • All staff members, including bank and agency, were provided with a good induction so that they were familiarised with the ward environment and the service provided.

However:

  • At the previous inspection in January 2016, staff did not monitor the overall temperature in the clinic room at Cantilupe Ward. At this inspection, this was still the case and there was no thermometer in place. This was confirmed by the staff on the ward.
  • The trust struggled to recruit a sufficient number of qualified nurses for night shifts on Cantilupe, and at the time of the inspection there were six vacancies for qualified nurses. Due to vacancies, the service could not guarantee that staffing levels matched their minimum staffing complement during the night shifts.
  • There were no supervision arrangements in place on Jenny Lind ward. In the 12 months leading up to the inspection, staff had not had access to regular supervision sessions, and team meetings. According to the trust policy, substantive staff were meant to have eight supervision sessions in twelve months, along with yearly appraisals and on Jenny Lind this process had not been followed.

Wards for people with a learning disability or autism

Requires improvement

Updated 1 June 2018

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

  • Staff were not following trust policies such as recording meal and fridge temperatures in the unit’s kitchens (the unit had a main kitchen, and separate, smaller kitchens in each flat). There were no hand cleaning facilities at the entrance to clinical areas and staff did not carry hand gels.
  • There was no overall ward strategy to reduce restrictive practices such as physical interventions.
  • Staff had not reported a safeguarding incident as soon as possible.
  • The average length of stay at this service was nine years and all patients had been there more than a year. These high lengths of stay in hospital are not consistent with the expectation of the Transforming Care Programme that hospital should not be a home for people with learning disabilities. However, we were persuaded that the trust had taken every reasonable step to try to facilitate discharge and that the reasons it had not succeeded were not within the trust’s control. The trust was working with its commissioners to meet the expectations of the Transforming Care Programme.
  • Staff did not manage patient records appropriately. Patient timetables did not show what therapeutic input they were having. Staff had displayed confidential care information about patients in areas used by more than one patient.
  • Staff used items banned for patients in front of them. For example, using ceramic cups, when patients were not allowed to use them.
  • Governance systems did not always allow learning and changes to take place. The service could not show how it learned from complaints or incidents at the ward or from elsewhere in the trust. Audits did not result in changes to improve the service.
  • Staff had different views on the purpose of the service. There was no plan to in place to show how the service shared the trust visions and values.
  • Staff reported low morale and were mixed on whether they could safely raise concern with the management team. Staff were not aware of how they sent information to the trust’s governance systems. The manager did escalate information to the central risk register despite reporting concerns to the inspection team and did not keep a local risk register.

However:

  • Staff managed medication appropriately. Staff followed the trust guidance on emergency medical equipment and completed the six-monthly emergency test.
  • The ward recruitment policy rewarded staff with the experience and skills needed to work with patients with a learning disability.
  • Staff treated patients with care, respect and communicated in a way they could understand. Patients could give feedback about the service and families reported being involved in care and welcome on the unit.
  • The ward offered ample personal space for patients and staff supported them to visit the local community.

Specialist community mental health services for children and young people

Good

Updated 1 June 2018

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

  • Services were safe. There were effective policies and procedures in place to ensure the safety of children, young people, families, carers and staff. Staff had the skills, knowledge and training required to perform their role and they managed identified risks. Staffing levels were good across all teams.
  • Staff kept comprehensive and up to date care records for children and young people. Information was recorded from the point of referral and frequently updated. There was evidence of joint working between children and young people and staff.
  • The service offered a range of treatment and care options in line with national guidance. Each team base had a range of rooms and equipment to deliver care and treatment. Teams included a range of professionals such as nurses, psychologists, social workers, occupational therapists and psychiatrists.
  • Staff treated children and young people with respect, dignity and as partners in their care.
  • There were effective governance systems in place to support the delivery of good quality care.

However:

  • There were no independent advocacy services for children and young people. Staff did not always understand the importance of an independent advocate and felt that they were able to advocate for children and young people.
  • We had concerns about confidentiality in both the Linden centre and Park House as therapy rooms were not soundproofed.
  • The physical health of children and young people using the service in Gloucestershire was not always recorded.

Community-based mental health services for older people

Good

Updated 1 June 2018

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

  • Staff vacancy rates were low across the teams. Managers monitored and managed the effects of sickness absence well in most teams.
  • Caseloads were manageable within the teams. Patient records contained current, relevant and comprehensive holistic information. All patients had care plans in place.
  • Staff completed risk assessments on admission. Staff assessed the physical health health of patients regularly and took action to address any physical health problems.
  • There were three serious incidents reported in the previous 12 months. Staff used effective reporting systems and learned from incidents.
  • All the environments we visited were comfortable, clean and welcoming. Environments had disabled access and toilets. Conversations could not be heard from outside interview rooms and staff were aware of issues around privacy and dignity during confidential interviews.
  • Staff understood their responsibility around safeguarding adults and children. Staff attended mandatory training and knew how to raise a concern.
  • Clinic rooms were well equipped and maintained. Staff made sure equipment was checked regularly.
  • Staff were focussed on the health and wellbeing of patients. Staff involved carers in assessment and treatment and offered support and advice on issues and services. Patients, families and carers told us they were happy with the care received.
  • Staff received supervision and appraisals. Teams discussed clinical and managerial issues in weekly multidisciplinary meetings. Managers identified learning needs of staff and provided opportunity to develop.
  • There was evidence of strong leadership across the teams, particularly in the services our previous inspection identified as requiring improvement. Managers were visible and supportive, and motivated their teams to create a positive culture. Managers challenged underperforming members of staff.
  • Staff morale was generally good. Staff were positive about the leadership in the trust. Staff were also aware of the senior management team, and told us that senior managers were visible and accessible.

However:

  • Staff sickness levels in the Tewkesbury service had an impact on patient visits. Visits were often cancelled and staff needed to telephone instead at these times.
  • All patients had care plans in place, but they varied in quality and patients did not always have a copy of their care plan. Staff did not always document if they did offer a copy.
  • Staff highlighted the complaints procedure to patients and families. However staff did not always manage informal complaints transparently. We could not establish how teams decided if a complaint should be handled formally or informally.
  • Although all patients had robust initial risk assessments, records demonstrated they were not always updated regularly.
  • Some staff did not carry personal alarms at all times.

Acute wards for adults of working age and psychiatric intensive care units

Outstanding

Updated 27 January 2016

We rated acute wards and PICU for adults of working age as good because;

  • All wards had a wide range of activities from 9am to 9pm seven days a week. These were tailored to patients’ individual needs and encouraged engagement. We also witnessed staff interacting with patients in a motivated and enthusiastic way.
  • There was clear evidence of relational security on all wards and this was observed in the interactions between staff and patients. Staff were able to demonstrate detailed knowledge of the patient group.
  • All wards at Wotton Lawn were clean, soft furnishings and décor was in good condition and well-presented and the environment was well lit. Patients had had input into the decoration of the ward areas and patients’ art work was hung on the walls around all common areas of the wards. At Mortimer ward the best use had been made of the environment. It was clean and well-lit and blind spots and ligature risks had been identified and mitigated with control measures in the most cases.
  • There was evidence of a programme of continual improvement. ‘Safewards’ was being introduced across all wards. Staff were members of national groups linked to their areas of work. The trust had introduced a nationally recognised certificate in healthcare for all new health care assistants.

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Forensic inpatient or secure wards

Good

Updated 27 January 2016

We rated 2gether NHS Foundation Trust as good because there was evidence of good practice in all five domain areas of safe, effective, caring, responsive and well-led.

Fourteen months before our inspection there had been  a homicide on the ward; a member of staff had been murdered by a patient. We found that the staff on the ward had worked very hard to recover from this incident as a team whilst supporting patients and maintaining a safe environment. The team had supported each other well and it was evident that, whilst the emotional effects of the incident were still felt, the staff team had been able to prioritise patient care. Measures had been put in place to address safety but this had been done in a way which minimised blanket restrictions and continued to support patients towards recovery and independence.

The environment was clean and safe with good staffing levels and use of bank staff familiar with the ward. Seclusion was not used and restraint used rarely. There were very clear procedures for managing risk. Incidents were reported and staff learnt from these.

Staff carried out a thorough assessment of patients' care needs before admission and updated this regularly. It was evident that patients were involved in this process but this was not fully reflected in care plans. There was a high standard of physical healthcare monitoring. We found good multi-disciplinary working with a range of professionals available and an open culture which encouraged all members of staff to contribute.

Interactions between staff and patients were warm and respectful. Patients were positive about their treatment on the ward. Patients were involved in their care and staff supported patients to maintain contact with their families.

Admissions to and discharges from the ward were planned. Beds were never used when a patient was on leave. There was a range of rooms available on the ward included a fully equipped gym which was accessible throughout the day. There was a range of activities available on and off the ward seven days a week. Patients knew how to complain. However, no record was kept of complaints resolved at a local level.

Team morale was good. Staff felt supported by local management and by colleagues within the team. Staff had access to additional as well as mandatory training and told us that they were easily able to access informal supervision. Following the serious incident last year the team had felt supported by the local management and there was a comprehensive action plan in place.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 27 January 2016

We rated 2gether NHS Foundation Trust as good because:

  • Clinic rooms were clean and well maintained in the rehabilitation wards, medicines were mostly managed safely.

  • Care plans were of high quality, holistic and based on patient identified goals.

  • Strong multidisciplinary teams provided high quality interventions and worked effectively. Staff had access to further training to allow them to provide higher quality care to patients.

  • The vast majority of patient feedback on the care received was positive. Patients said that staff were always available and that they valued the way staff treated them.

  • We observed staff had treated patients with care and respect.It was evident that they had built solid therapeutic relationships based on kindness and respect.

  • Patients had free access to outside areas; all of the wards had a range of rooms to provide activities for patients.

  • Patients received food in line with their dietary requirements; one ward had an in-house chef which meant that patients could collectively decide what food to eat that day.

  • Patient feedback was sought in a variety of ways; staff listened to patient concerns and took action.

  • There was strong local leadership and high staff morale.

There were elements within the overall service that could be improved, such as improvement in governance systems to ensure that policies were being followed and the facilities in Oak House.

Community-based mental health services for adults of working age

Good

Updated 27 January 2016

We rated 2gether NHS Foundation Trust community mental health services for adults of working age as good because:

  • Staffing levels were safe and caseloads were manageable. There was good access to psychological therapies and to group activities. We observed very good care being delivered and patients gave very positive feedback about their treatment in the service.
  • Teams worked well together, met regularly to discuss their work and were supportive of one another. There were opportunities for leadership development and career progression. Managers at all levels were available and supportive.
  • The service were referring to National Institute for Health and Care Excellence guidelines to ensure best practice.

However

  • There were sound proofing issues in the team base for Herefordshire which could compromise patient confidentiality. Cleaning arrangements did not ensure all areas were being cleaned sufficiently.
  • Risk assessments were missing from some patients records. Care coordinators were not completing their own mental capacity assessments and were deferring this task to social workers and doctors. This meant the person assessing the patient’s capacity was not necessarily the person making the decision on behalf of the patient. This was not in line with the procedures of the Mental Capacity Act.
  • There was no mandatory training on the Mental Health Act or Mental Capacity Act and some staff felt they needed a better understanding of these areas.
  • Some management reports were inaccurate and out of date. This made it difficult for them to ascertain compliance with key performance indicators.

Mental health crisis services and health-based places of safety

Outstanding

Updated 27 January 2016

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

  • The heath-based place of safety was well managed and was purpose built to provide a safe and effective service. Systems and procedures were in place which supported staff to keep themselves and patients safe from harm.
  • Patients were seen quickly and there were no waiting lists. Patients had thorough, up-to-date risk assessments and care plans, which looked at both their physical and mental health needs. Care plans were holistic, person-centred and recovery focused. Care plans were effective in supporting patients through their mental health crisis. Carers were identified and supported in their role.
  • Staff supported patients to take positive risks as part of their recovery. Patients could access shorter-term, psychological therapies as part of their crisis resolution and patients waited no longer than around four weeks for this. Staff referred patients to other teams for longer-term psychological interventions. Patients were supported to work toward a safe discharge from the team and were referred to other services for longer term help to manage their longer term goals and mental health.
  • Staff worked well together to provide a safe and effective crisis service to their patients. They shared important information with each other quickly and effectively. Handover and multidisciplinary meetings were well managed and were effective in managing patient risk and progress. The teams had good multidisciplinary, cross service and interagency joint working arrangements.
  • The service had developed strong links with community groups who could offer additional support to their patients. Staff worked well with the police and ambulance service to deliver an effective and responsive 136 service to patients. Where issues were identified these were proactively dealt with.
  • Staff listened to their patients. The trust had an effective and embedded system for collecting patient feedback. The service was making changes based upon feedback from patients, carers and stakeholders. Patients were extremely positive about the service they received and the staff who supported them.


Community mental health services with learning disabilities or autism

Good

Updated 27 January 2016

We rated community mental health services for people with learning disabilities and autism as good because:

  • Access to clinics and other facilities was good with ramps and disabled toilets available in clinic settings.
  • Staff were meeting the four week waiting time from referral to assessment. People who used the service were involved in care planning. Staff understood the individual needs of people who used services and knew how to support and involve them in their care. Risk assessments were routinely carried out but these were not always recorded on the electronic recording system. Care pathway planning and implementation was being developed and there was a good understanding of national and professional guidelines so staff were implementing best practice.
  • There were adequate staffing levels to meet the assessment needs of people who used services.
  • Staff were experienced and had the necessary qualifications and skills to carry out their role. There were opportunities and support to attend external courses. Informal and formal supervision was undertaken and staff felt supported operationally and clinically. There was an adequate monitoring system in place for training, supervision and appraisal in all teams.
  • Teams reported that service level leadership and management structures were good and they felt supported and listened to. Staff morale was very good and teams were enthusiastic and well-motivated. There was effective multidisciplinary and inter-agency working.
  • An incident reporting process was in place and staff were aware of how to report incidents. Systems were in place to share learning from incidents. Staff were able to identify abuse and safeguarding concerns and follow the correct procedures for their service. The patients and carers we spoke to all felt that they would be able to make a complaint if they needed to and felt that this would be listened to. A variety of easy read leaflets and documents was available to help patients who used services understand treatment options and information about the service.
  • Patients, carers and service providers spoke highly of the teams and told us that staff were inclusive, caring, responsive and they felt listened to.

However:

  • There were waiting times to access some treatments
  • Clinical audit was not embedded within the service
  • There was lack of a clear vision and strategy to continue to develop and improve the service.