Humber Teaching NHS Foundation Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This key question has been rated good. We looked for evidence that the service met people’s needs. The service was tailored to meet the needs of individuals and delivered to ensure flexibility, choice and continuity of care. Discharge planning commenced upon admission and there was a multidisciplinary approach to planning transitions between services. Care was person centred, and staff listened to young people and carers to form collaborative care and treatment plans. Young people and carers were given information to help them make informed decisions.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Young people were able to personalise both communal areas and their individual space. They had decorated the lounge and communal areas with posters and artwork. Bedrooms had photographs of family and friends and people had brought in personal possessions from home. All bedrooms had en-suite bathrooms with a toilet and shower. Young people could manually adjust the lighting in their bedrooms. The ward environment offered lower stimulus areas, lounges that could be single sex and space for activities. The ward offered 3 quiet lounges that could be used for young people to engage with staff or relax. Young people completed artwork which they displayed on the walls around the service. Young people’s preferences were documented in care records and known by staff. Staff had one-to-one engagement with young people in line with the supported engagement policy. One-to-one time gave people the opportunity to discuss how they were feeling or to engage in activities with staff. Care records showed that one to one engagement was taking place. The supportive engagement policy reflected this, along with documentation within care records and handover notes.

Staff encouraged young people to be involved in the development of their care and treatment plans. Both young people and relatives told us they had access to the care plans and completed these with staff. Young people had regular meetings with staff and the wider team to develop their care plans, which were reviewed weekly during multidisciplinary team meetings. We attended a multidisciplinary team meeting where a person’s discharge was discussed with both internal and external professionals to ensure a successful transition to another service. During the meeting staff reviewed all aspects of the young person’s care including recent incidents. Data was analysed to look at

reduction of any incidents and inform ongoing care. This data could also identify that the young person might have escalating risks around time of discharge and subsequent support arranged from this. Interviews with staff and a review of care records showed that there were strong links between the unit and social care services to enable continuity of care upon discharge.

Upon arrival at the ward, CQC posters and ratings were in place and visible to those entering the building. We observed information posters relating to hospital admission in the visiting areas for relatives and those visiting young people. This included information about the service, how to raise complaints, how to give feedback and support groups for relatives. Managers checked care records and completed audits to ensure staff shared appropriate information with young people and carers. This included checking that staff gave information on Mental Health Act section rights, advocacy and how to raise complaints. Young people told us staff provided them with information about treatments and therapies and offered copies of their care plans. Young people had easy access to the advocacy service who visited weekly and had been given information on their rights and medication. Relatives were happy with the level of information provided and the level of involvement in the young person’s care. Staff and young people worked together to create monthly newsletters to highlight what had been happening in the service and to celebrate young people’s achievements.

Staff told us if a young person wanted to raise a request, they could do so during daily or weekly multidisciplinary team meetings. Staff supported young people to make complaints and ensured all complaints were logged and recorded. Where young people chose not to attend multidisciplinary team meetings, staff sought their feedback and shared this during the meeting. Staff used multidisciplinary team meetings to obtain carer feedback and there were allotted times within the meetings for them to share their views. Managers provided responses to issues raised in a timely manner. Staff invited family and carers to give feedback through a friends and family survey. There were leaflets on display letting them know how to do so. Data from the most recent survey showed a response rate of 75% (8 responses) which were positive regarding the care young people received. There were clear processes in place for managing complaints. Staff understood the policy on complaints and knew how to handle and escalate these. Young people said they felt safe to raise concerns or complaints with the team and that staff tried to resolve them as quickly as possible. Managers kept a log of feedback and complaints which they reviewed regularly to identify themes. We reviewed data relating to complaints and did not identify any occurring themes. To provide assurance that management is complying with the Trust’s own Complaints and Feedback Policy an internal complaints audit was carried out in 2024 where significant assurance was found. All actions were completed. The Complaints and Feedback policy is currently going through its regular review and once this latest version is approved, this will replace the current version of the policy. We spoke with the lead occupational therapist who told us she met with young people weekly prior to completing timetables of activities so that the ward environment catered to their needs. There was also an established ‘out and about’ group and young people had input into this.

Young people had access to a range of professionals including a dietician, psychologist, social worker, occupational therapist, educators. Referrals are made for young people to engage with speech and language therapy on admission if required. Staff supported young people with specific religious and cultural needs and there was an multi-faith room on site. Bedrooms were placed on separate corridors for males and females. Documentation is provided in an easy read format, and interpreters are available if required. The trust used an accessibility tool which could translate written text to different languages. Staff spoke positively about this and said it enabled better communication for young people who had language barriers. Staff shared newsletters with young people and family and gave them information about family days. Newsletters contained action managers had taken following feedback. Families attended quarterly open days where they provided feedback to make positive changes to service provision.

We did not identify any barriers to care, support and treatment. They had regard to the needs of people with different protected characteristics and made reasonable adjustments to support equity in experience and outcomes. Young people we spoke with felt they were treated fairly and equally. There were policies in place to protect both young people and staff from abuse. Staff completed mandatory equality and diversity training and at the time of our inspection, training compliance was 100%. Staff also completed training on learning disabilities and autism with training compliance at 100%. The staff we spoke with had a good understanding of the Equality Act and gave examples of how they would support someone who identified as LGBT+ , this refers to lesbian, gay, bisexual and transgender people and includes all minority sexual orientations and gender identities, unless otherwise specifically stated. Staff used people’s preferred pronouns.

We found that young people and their relatives attended and contributed to decisions around future care provision and discharge plans. In Summer 2024, a quality improvement initiative was undertaken by the ward to improve the standard of written communication in discharge letters and was noted this was of variable standard. This was independently identified by the team and actions were taken to address concerns. There was noted improvement from September 2024 from audits completed by the service managers and clinical lead. We reviewed all 18 discharge summaries competed in the last 12 months and found that these were not standardised, with staff completing these in different formats. Whilst some summaries were detailed and fully completed, others had sections left blank without a clear rationale. Some summaries were repetitive and contained the same information multiple times. We also found that one summary referred to the young person with two different names. Relatives were informed and involved in the options for discharge and said they felt listened to if they were apprehensive about discharge. Relatives felt staff were compassionate and worked in collaboration to achieve safe and effective discharges. Staff told us processes were in place to ensure all relevant individuals were involved in planning and preparing for discharges. This included social care, community teams, future placements, and family members if the young person consented to this. Young people were involved in discharge planning to ensure their choices and preferences were considered. Care plans referred to discharge planning and multi-disciplinary meetings discussed and documented actions for discharge. They referred to therapeutic practice, goal setting and focused on independence and positive behaviour support. Care plans also showed specialist involvement where necessary.