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Provider: 2gether NHS Foundation Trust Good

Reports


Inspection carried out on 22 March 2018

During a routine inspection

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.


CQC inspections of services

Service reports published 1 June 2018
Inspection carried out on 22 March 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 384.47 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
Inspection carried out on 22 March 2018 During an inspection of Wards for people with a learning disability or autism Download report PDF | 384.47 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
Inspection carried out on 22 March 2018 During an inspection of Specialist community mental health services for children and young people Download report PDF | 384.47 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
Inspection carried out on 22 March 2018 During an inspection of Community-based mental health services for older people Download report PDF | 384.47 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
See more service reports published 1 June 2018
Service reports published 27 January 2016
Inspection carried out on 27–30 October 2015 During an inspection of Community-based mental health services for older people Download report PDF | 379.7 KB (opens in a new tab)
Inspection carried out on 26 – 30 October 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF | 303.25 KB (opens in a new tab)
Inspection carried out on 20 - 22/10/ 2014 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 315.46 KB (opens in a new tab)
Inspection carried out on 19 October 2015 During an inspection of Forensic inpatient or secure wards Download report PDF | 270.6 KB (opens in a new tab)
Inspection carried out on 26-30 Oct 2015 During an inspection of Wards for people with a learning disability or autism Download report PDF | 312.46 KB (opens in a new tab)
Inspection carried out on 26 to 29 October 2015 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 309.78 KB (opens in a new tab)
Inspection carried out on 26-30 October 2014 During an inspection of Community-based mental health services for adults of working age Download report PDF | 383.54 KB (opens in a new tab)
Inspection carried out on 26-30 October 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 370.1 KB (opens in a new tab)
Inspection carried out on October 19-23 2015 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 309.21 KB (opens in a new tab)
Inspection carried out on 26 - 30 October 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 464.73 KB (opens in a new tab)
See more service reports published 27 January 2016
Inspection carried out on 26 – 30 October 2015

During a routine inspection

We found that 2gether NHS Foundation Trust was performing at a level which led to a judgement of good because:

We rated two of the 10 core services that we inspected as ‘outstanding’ overall and seven ‘good’ overall.

  • 2gether NHS trust has much to be proud of. The majority of patients and carers were positive about their experiences of receiving care and treatment. Staff were caring, enthusiastic and committed to delivering high quality care and treating patients and carers with dignity and respect. Across the majority of services patients had good access to emotional support and clear evidence that staff considered patient’s diverse and cultural needs.

  • The trust was well-led with an experienced, skilled and committed board, including an inspirational, astute and dedicated executive leadership team, insightful and supportive non executives and a dedicated board of governors who provided a robust level of challenge. There were many skilled and enthusiastic leaders and staff throughout the organisation who were working hard to manage the day to day delivery of care, whilst striving to improve the quality of services and provide evidence based and innovative approaches to care and treatment to ensure services would be sustainable and fit for the future. Staff morale was very good across the trust and staff spoke highly of the leadership of the organisation.

  • Two of the trust services received an overall rating of ‘outstanding. The crisis and health based place of safety service and acute inpatient services for adult of working age. Both of these services were able to demonstrate excellent practice and innovation which went above the standards expected.

  • The crisis and health based place of safety services received a rating of ‘outstanding’ for the key questions, ‘are services caring’ and ‘are services responsive’ and a rating of ‘good’ for all other key questions; giving an overall ‘outstanding’ rating. There was a strong person centred culture within the teams where staff supported patients with wider needs including physical health, emotional wellbeing and social needs. The heath-based place of safety was well managed and was purpose built to provide a safe and effective service. The crisis teams saw patients quickly and patients had thorough, up-to-date risk assessments and care plans, which looked at both their physical and mental health needs.

  • The acute in patient services received an ‘outstanding’ rating for the key questions, ‘are services safe’ and ‘are services well-led’ and a rating of ‘good’ for all other key questions; giving an overall ‘outstanding’ rating. There was an underlying philosophy of providing care in partnership with patients and tailoring interventions to meet patient’s individual needs. There was excellent relational security on all wards and an open door policy which allowed patients to come and go as they wished but clear and positive management of patients who were detained under the Mental Health Act. Traditional seclusion was not used, instead staff worked with patients to effectively manage challenging behaviour and interactions were considered and supportive. The environment supported the delivery of high quality care and there was a culture of continuous improvement.

  • We found that there were some aspects of care and treatment in some services that needed improvements to be made to ensure patients were kept safe. However, the vast majority of services were delivering effective care and treatment. Staff fully supported patients with their wider needs including physical health, emotional wellbeing and social needs, treating them with kindness and respect while involving them in their care and treatment. Across all services the staff were good at recognising when patients and carers needed safeguarding and the trust encouraged staff to report incidents; incident reporting in all services was good. There was a widespread culture of learning from incidents and there was shared learning across services, through regular ‘briefing notes’ and bulletins.

  • Bed management practices were good and we saw effective systems in place for access and discharge across all adult inpatient areas. The trust had only recorded five delayed discharges in the last six months and these were reasons outside of its control. We heard of plans which commissioners had in relation to the new provision of children’s inpatient beds (known as tier 4), as there are non-available within the trusts catchment area.

  • The trust had a programme to reduce the use of restrictive interventions on wards which was in the early stages of development. The aim was to work towards eliminating the use of these approaches as reflected in the “positive & safe” national programme. The trust had adopted two nationally recognised models of behavioural management; positive behaviour management (PBM; for learning disability & older adult services in Gloucester) and preventing and managing violence and aggression (PMVA; for working aged adult and older people’s services in Herefordshire). Both these models advocated the least restrictive intervention being used.

  • Staff across the trust had good access to mandatory training, there was good induction programmes for all staff, as well as opportunities for continuous professional development. In the majority of services 80% (or above – up to 100% in some services) of staff had completed mandatory training. The trust declared that 48% of staff had received training about the Mental Health Act (MHA). The trust provided MHA training but this was not mandatory. However, it was incorporated into the matrix of ‘professionally required’ training and recommended for clinical staff working at bands five and above. All new health care assistants participated in training for the Care Certificate, a national induction standard for healthcare assistants. The trust planned to ensure that all HCA had access to this training.

  • Staffing levels were generally good across all inpatient and community teams. Where bank and agency staff was used, the wards and community teams tried to use the same staff for continuity of care and often trust staff would work bank shifts. The highest proportion of staff vacancies was across the inpatient learning disability services. The trust was managing these vacancies within a plan agreed with commissioners in order to minimise the potential impact on staff redundancies from the ongoing reconfiguration of the service. We observed excellent multidisciplinary working across the trust.

  • The trust had its own occupational health service called “working well” and was led by a consultant occupational health physician. The service aimed to improve the health and wellbeing of staff, both within the trust and for external public and private sector organisations.

  • The trust had a clear vision; to “make life better” for the patients in its care and the carers who supported them. It had established this through a consultation process and aimed to achieve this through delivering high-quality care which would have been suitable for “their own family members”. Staff we met across all services and at all levels showed a high awareness of the trust’s vision, priorities and commitments.

  • We found that the trust had developed a detailed governance system to support it to achieve its vision. The process for monitoring risk was robust 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. Local services also maintained local, operational risk registers which fed into the strategic risk register.

  • The structure of committees and meetings, which provided the board with assurance, were well established and effective. Most had non-executive director oversight. This ensured an objectivity and appropriate challenge. The trust achieved ‘ward to board’ assurance through a number of mechanisms. The trust governance committee oversaw all aspects of quality (patient safety; outcomes and experience) for the organisation. This included; safeguarding; infection control; patient safety and serious incidents; safer staffing levels for inpatient units; complaints and user experience; locality risk register monitoring and triangulation of information. This committee gave assurance to the board and provided notification on exceptions/ areas of concern. The trust had the right policies in place to support staff in their work.

  • The board actively engaged with service users. We observed that board meetings started with a patient experience presentation, undertaken by someone who had first-hand experiences of using the trusts services. Each quarter the board received a service experience report which identified the experience of patients and carers, provided examples of the learning that has been achieved, emergent themes from clinical services, complaints, concerns, comments and compliments and survey information.

  • The trust had a strong track record of working in partnership with the independent sector using an integrated model to provide services in Gloucestershire. However, with the recent decision by Herefordshire council to remove social workers from the trust we had concerns about how well the system would operate in the future. We received many positive comments about the trust from clinical commissioning groups, local authorities and health watch groups. They told us the trust was proactive in its local relationships and provided an open and transparent dialogue. However, some third party organisations, representing specific patient groups, were less complimentary about the trust performance and how it engaged with them.

  • We found the trust had effective systems in place for financial reporting. These along with key performance indicators for all teams ensured the trust management team were aware of the organisation’s performance throughout the year. The trust planned to report deficit of £0.5m for 2015/16. It intended to return to breakeven in 2016/17, but this statement was based upon the full delivery of next year’s cost improvement plan. This would be the first time the trust had forecast a deficit in 31 consecutive quarters of reporting a financial surplus.

  • The friends and family test showed that an average of 75% of staff said they would be likely or extremely likely to recommend the trust as a place to receive care or treatment; 60% of staff said they would be likely or extremely likely to recommend the trust as a place to work and 85% of patient respondents were likely or extremely likely to recommend the trust services.

  • The trust was committed to developing its services and had developed a number of excellent and innovative areas of practice including:

  • The trust had established a recovery college. The college had been developed and co-delivered with service users. The recovery college provided courses and educational workshops that taught patients to become experts in their own recovery and self-care. The courses that were offered had been co-produced with patients

  • There was a programme of Experts by Experience who were involved in a wide variety of trust activity including: recruitment of trust staff; research; committee activity; development and scrutiny activity etc.

  • The Gloucestershire Young Carers organisation delivered an integrated project to support young carers of adults with mental illness

  • The trust participated in the ‘national viewpoint’ study last year. The trust had been selected as one of two sites in the UK to pilot a survey about mental health stigma with Time to Change

  • The trust participated in a number of Royal College of Psychiatrists’ quality improvement programmes or alternative accreditation schemes. Acute wards for adults of working age had an 'excellent' accreditation rating from the accreditation for inpatient mental health services programme.

  • Throughout the inspection the trust was very receptive to any comments that we made and we saw immediate action taken when we raised a concern. For example, it rectified a concern immediately about the environment at Lexham Lodge, a temporary facility used by the managing memory team in Gloucestershire whilst their facilities were being rebuilt. It made provision for patients to be seen at home if they could not attend another facility and stopped using Lexham Lodge to see patients altogether. The trust also made the decision to make Mental Health Act and Mental Capacity Act training mandatory for all clinical and appropriate other staff.

However,

  • There were some area of care and treatment that clearly needed improvement. We received a number of negative comments from patients and carers. Some patients and carers expressed some serious concerns about the care, treatment and services they had received from the trust. They made it clear that they felt the trust needed to make improvements in some areas and take more appropriate action to deal with their complaints and concerns..

  • Overall, we rated the trust as ‘requires improvement’ for the key question ‘are services safe’? We found pockets of poor practice and poor services that needed improvement in wards for older people, rehabilitation wards, wards for people with learning disabilities and community services for older people and those for adults of working age. None of these were generic in nature or widespread across the trust.

  • Whilst we welcomed the trusts approach to not using seclusion, we were concerned that staff within the learning disability wards were using a form of it but not recording it as such appropriately. The trust had been working with Gloucestershire clinical commissioning group and Gloucestershire county council to agree and develop a new model of care for patients with learning disabilities for some considerable time. Whilst there was a commitment by all to provide high quality services close to home for patients with complex needs and some redevelopment work has started at Hollybrook there had been several setbacks with the plans to develop a community supported living facility. In addition, there was no clear discharge process for patients and those with discharge plans had no timeframe for discharge.
  • On one older person’s ward (Jenny Lind); standards for privacy and dignity on mixed sex wards were not always met. There were no en-suite washing facilities or separate sleeping and washing areas for males and females but we saw plans the trust had for refurbishing the rooms to provide en-suite facilities.
  • On rehabilitation wards policies and procedures were not always followed in ensuring incidents were reported and the facilities at Oak House needed significant improvement.
  • In community services for older people staff working at the memory assessment services had caseloads of over 300 patients per full time worker, resulting in 11% of annual reviews being missed. There was a long wait of up to six months for access to psychological therapy in Herefordshire. Sickness levels were high in Herefordshire with one team at 9%; there was a lack of clinical supervision for staff and a lack of managerial supervision for staff in Gloucestershire.
  • In community services for adults of working age sound proofing in the team base for Herefordshire meant that patient confidentiality could be compromised as conversation could be clearly heard outside of rooms used to see patients and cleaning arrangements needed attention to ensure all areas were clean and suitable for patients.
  • In a number of services across the trust we had some concerns that staff did not always record all relevant information in electronic patient records (RiO). This included staff not recording risk assessments, risk alerts and medication reviews in care plans. Care plans were not always comprehensive and it was not always clear whether patients had been involved in developing their care plans. Crisis plans, outcome scales and consent to care documentation was missing from patient records some information was either not located in the correct sections or was missing altogether. Staff in community services experienced particular difficulties around the completion of records on RiO, travelling long distances to see patients, the inability to input information in ‘real time’ and having to go back to bases to input information impacted on their ability to maintain robust and contemporaneous records. However, the trust had developed a number of programmes of work to help address/improve this. The director of quality was leading work to ensure the trust met its milestones for delivering improvements.
  • 2gether NHS Foundation Trust provided caring, effective and responsive services to the people it serves. In the main services were safe although some improvements were needed in some services. It was a well-led organisation and we are confident that the trust will continue to ensure it delivers high quality, contemporary and innovative services and will ensure improvements are made in all the areas that we have identified as needing improvement. We will be working with the trust to agree and action plan to assist it in making improvements were needed.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

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


Mental Health Act Commissioner reports

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

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