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Provider: Southern Health NHS Foundation Trust Requires improvement

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 21 May 2018 to 05 July 2018

During a routine inspection

  • We rated three of the key questions, ‘are services safe, effective and well-led’ as requires improvement. We rated two of the key questions, 'are service caring and responsive' as good.

  • We issued a warning notice due to immediate concerns about the safety of young people on the child and adolescent mental health wards. There were not always sufficient levels of staff on the Bluebird House to ensure young people were protected from avoidable harm and not all shifts were covered and fell below the safer staffing level. This had resulted in observations, including physical observation not being carried out as needed and section 17 leave being cancelled. Ligature reduction work in Leigh House did not go far enough to ensure that young people were protected from the risk of unavoidable harm. We undertook an unannounced, focussed inspection on 18 July 2018 and found the trust had addressed all of the actions required, as such we lifted the warning notice.

  • The trust faced significant financial challenges. The cost improvement programme was off track with the trust still having to find a £2 million saving. At the time of the inspection the trust had been concentrating on engaging staff, changing the culture and improving the quality of care. The trust were taking steps to reduce the financial risk posed by the slippage of the cost improvement programme.

  • Staffing levels on the acute wards for working age and psychiatric intensive care units, and wards for people with mental health problems were not always being met.

  • Care plans in the community based mental health services for adults of working age and the mental health crisis services and health based places of safety were not always person centred, holistic, recovery orientated and up to date. Care plans were not always stored correctly in either service.

  • Supervision for staff on the wards for older people with mental health problems and the mental health crisis services and health based places of safety was not always being completed frequently or consistently.
  • Medicines were not always appropriately managed in the community health services. In the inpatient services medicines were not always stored safely and in line with the manufacturers guidelines.

  • Governance systems in the mental health crisis services and health based places of safety were not collating and using information to support the services activity. There were issues with the reliability of data used to provide assurance of the safety of services in the child and adolescent mental health services.

However:

  • Within the trust, 29 core service domain ratings improved. We rated three of the core services as outstanding in the caring domain, and the remaining 12 as good.
  • We rated long stay and rehabilitation wards for adults of working age and wards for people with a learning disability or autism as outstanding overall. We rated community health services as good overall.
  • There was a positive, strong senior leadership team with the capability and integrity to continue to build on developments and improvements that had been progressively made over the last 12 to 18 months. The board was relatively new, including a new chief executive officer. There was now a wide range of experience and expertise and a clear programme of board and executive team development coupled with specific development for individuals.

  • There were examples of positive leadership throughout the organisation. Leaders identified areas of improvement and had strategies in place to action these.
  • The trust had clear vision and values. Staff are clear about the vision and signed up to it. The values are generally reflected throughout the organisation.
  • The trust had developed a new governance system to provide assurance although some refinements was still required to ensure the trust board could be assured about the quality of care across the trusts.

  • Staff felt respected, supported and valued and reported significant change in the culture and a developing sense of optimism over the previous 18 months. Frontline staff felt positive and proud of their work and said the trust was heading in the right direction.

  • The majority of wards and facilities in the services we inspected in the mental health and community services were clean and well maintained.
  • All the mental health services and community health services inspected had a range of suitably skilled healthcare professionals.
  • Staff in the mental health services and community health services were knowledgeable about the needs of patients, patient risks and completed comprehensive assessments. The majority of care plans were holistic with patients and families having been involved in decisions about the care they received.
  • Staff were respectful, compassionate and supportive towards patients. Staff demonstrated high levels of motivation towards patients and their families and carers.

  • Patients and carers gave positive feedback about the care received. The trust had significantly improved how it used patients and families the views about their experience to improve care and services.

  • There was a comprehensive serious incident reporting and investigation process in place and a culture of detailed examination and challenge over serious incidents and deaths. The appointment of a family liaison officer was a positive step in supporting family involvement in investigations.
  • The trust had embarked on a significant programme of quality improvement (QI) training for staff. There was high profile given to research and development which complimented the trusts focus of wanting to be a centre of excellence.


CQC inspections of services

Service reports published 3 October 2018
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Wards for people with a learning disability or autism Download report PDF | 929.28 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Community urgent care services Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Community end of life care Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Forensic inpatient or secure wards Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Community health services for adults Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Community health services for children, young people and families Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Community-based mental health services for older people Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Community health inpatient services Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
Inspection carried out on 21 May 2018 to 05 July 2018 During an inspection of Child and adolescent mental health wards Download report PDF | 929.16 KB (opens in a new tab)Download report PDF | 5.12 MB (opens in a new tab)
See more service reports published 3 October 2018
Service reports published 1 November 2017
Inspection carried out on Elmleigh: 25 and 27 April 2017; Antelope House: 5 and 6 June 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 260.23 KB (opens in a new tab)
Service reports published 28 July 2017
Inspection carried out on 27 March to 31 March 2017 During an inspection of End of life care Download report PDF | 363.94 KB (opens in a new tab)
Inspection carried out on 27-30 March 2017 During an inspection of Community health inpatient services Download report PDF | 198.95 KB (opens in a new tab)
Inspection carried out on 27 – 30 March 2017 During an inspection of Wards for older people with mental health problems Download report PDF | 246.96 KB (opens in a new tab)
Inspection carried out on 27 – 30 March 2017 During an inspection of Community-based mental health services for older people Download report PDF | 237.62 KB (opens in a new tab)
Inspection carried out on 27 to 29 March 2017 During an inspection of Community urgent care services Download report PDF | 299.49 KB (opens in a new tab)
Inspection carried out on 27-30 March 2017 During an inspection of Community health services for adults Download report PDF | 386.37 KB (opens in a new tab)
See more service reports published 28 July 2017
Service reports published 10 July 2017
Inspection carried out on 28th March – 30th March 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF | 253.13 KB (opens in a new tab)
Service reports published 29 April 2016
Inspection carried out on 18-21 January 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 387.18 KB (opens in a new tab)
Inspection carried out on 19 - 21January 2016 During an inspection of Child and adolescent mental health wards Download report PDF | 363.95 KB (opens in a new tab)
Inspection carried out on 19 and 20 January 2016 During an inspection of Wards for people with a learning disability or autism Download report PDF | 387.22 KB (opens in a new tab)
See more service reports published 29 April 2016
Service reports published 2 October 2015
Inspection carried out on 5th August 2015 During an inspection of Wards for people with a learning disability or autism Download report PDF | 252.68 KB (opens in a new tab)
Inspection carried out on 5th and 6th August 2015 During an inspection of Forensic inpatient or secure wards Download report PDF | 281.09 KB (opens in a new tab)
Service reports published 25 February 2015
Inspection carried out on 7 -10 October 2014 During an inspection of Community-based mental health services for adults of working age Download report PDF | 292.34 KB (opens in a new tab)
Inspection carried out on 27 – 30 March 2017

During an inspection to make sure that the improvements required had been made

We did not re rate the core services inspected or the overall provider following this inspection.

At the time of our inspection, the trust was going through a significant period of change. The recently appointed interim chair and interim chief executive were implementing a considerable change programme. This included a change in leadership at board level and at service level (particularly in mental health) and changes that were intended to bring about improvements across all services. The trust recognised that there was still much work to do and that whilst we found it had made some significant improvements across the trust we found concerns in a number of areas.

During the comprehensive inspection of the trust in 2014 we told the trust it must make improvements in a number of areas but during this inspection we found that some of the required improvements had not been made. For example, at the previous inspection we found there had been delays in provision of special mattresses and beds for patients approaching the end of their life in both the community hospitals and at home. On this inspection we found that there were still delays in this provision although the trust was continuing to work with commissioners to try and address the issues.

Within the community health service for adults, there were still significant delays in the provision and repair of wheelchairs. This affected the safety and well-being of a large number of patients.

The requirement to review and amend the management of FP10 prescriptions had not been met. On the trust intranet, there was guidance on how to order and store FP10 prescriptions but there was no guidance on how staff should record receipt of, issue and undertake checks of FP10s. Hence, there was variability across the trust on how staff managed FP10s. In addition, we found that medicines management and reconciliation in the community hospitals was not robust or managed in line with best practice guidelines and therefore compromised patients’ safety.

There was still inconsistent and varied practice in both community health services and older people’s mental health services in the completion of do not attempt cardiopulmonary resuscitation records and sharing of information.

During our previous inspections in the mental health and learning disabilities services, we had identified inconsistencies in the completion and updating of risk assessments. During this inspection, we found this continued to be an issue, particularly in the community adult mental health teams. The trust had introduced a number of measures to continue to address this, such as training, changes to the electronic record templates and supervision tools.

At this inspection we had concerns about some aspects of care at Gosport War Memorial hospital. In some areas, there was insufficient staff to meet the assessed needs of patients. Staff did not always store or administer medicines in line with manufacturer’s guidelines, staff did not consistently adhere to the trust’s infection control policy and not all staff had a good understanding of mental capacity assessments.

Patients, families, partner agencies and CQC had previously expressed significant concerns about the trust`s complaints processes, quality of responses and learning from complaints. The trust had implemented several changes to address this. Overall, the complaints governance systems in the trust had improved over the past 12 months but further improvements were still required. However, some members of staff, patients and families told us that they believed that the trust needed to do more and that they would like to see swifter action and much more effective communication related to complaints and investigations into incidents when things had gone wrong.

The trust recognised that there remained significant concerns and still much work to do in the way it communicated with, and involved, patients and families. It had formed a family engagement action task and finish group and recently established a ‘families first’ group. Members of the families first group were very positive that the trust had a commitment to driving this work forward and engaging more effectively with the patients, families and members of the public. A family liaison officer had been appointed and the interim chief executive was meeting regularly with a number of families to address their concerns.

However, we concluded that the trust had turned a corner. The interim chair and chief executive had a clear vision and understanding of what was required to bring about improvements and were committed to ensuring that improvement was made in a timely manner.

In October 2016, the trust initiated a review of how it provided services. This resulted in the development of a clinical services strategy. This had three key components: i. the development of a clinical strategy for mental health and learning disabilities services; ii. a review of the trust’s multi-speciality community provider work to make sure it was aligned with the mental health and learning disabilities strategy and iii. a review of how the organisation would be best structured to deliver the mental health and learning disabilities services for the new models of care. The majority of the trust governors told us that there had been a very open and inclusive approach to the development of the strategy.

Members of the council of governors and the majority of staff that we spoke with told us that they believed that the interim chair and interim chief executive were making a positive difference in changing the culture. They reported that there was now a clearer focus on quality, and that the trust leaders were improving governance processes and supporting improvements in service delivery. They also told us that trust leaders were more open and approachable than they had previously experienced.

Since our last inspection (September 2016) the senior leaders of the trust were a more visible to the frontline staff. This had been achieved through the implementation of an executive ‘back to the floor’ programme and listening events.

Overall, staff morale was good in the mental health teams we visited, although was more varied in the adults of working age community mental health teams. Staff morale in community health services on the whole had improved.

Staff in all areas of the trust responded to patients in a kind, caring and compassionate manner and treated them with dignity and respect.

There was a greater focus on ensuring that the trust implemented the actions in the improvement action plans arising from previous CQC inspections and from the review of serious incidents and mortality undertaken by Mazars. Managers monitored progress weekly and reported progress to the trust board.

There had been a notable improvement in the timeliness and quality of investigation reports following serious incidents, including deaths. In January 2017, the trust had completed 97% of the required mortality reviews within 48 hours of the death occurring (the figure was 78% in June 2016). Work had progressed to improve learning from these incidents but there was still work do to ensure learning from incidents that did not meet the serious incident threshold. In addition, we found that there was variable reporting and learning from incidents within the community health services that we inspected.

We will continue to monitor the trust closely and will undertake focussed inspections as needed. At some point in the future (in line with our methodology) we will undertake an inspection that will result in a review of the ratings across the trust.

Inspection carried out on 13 - 15 September 2016

During an inspection to make sure that the improvements required had been made

During this inspection (September 2016), we found that there had been a number of significant improvements made to the governance arrangements in order to identify and prioritise risks arising from the physical environment more effectively. The risks identified included those posed by ligature anchor points, falls from heights and from patients absconding. We saw clearer processes in place to ensure that the trust assessed the risks, tracked actions taken and that there were escalation processes in place where actions had not been undertaken or there were delays. Everyone we spoke with confirmed that there were much more effective relationships between the estates and clinical teams. We found that a range of anti-ligature work had been completed across the trust and that there was a much better appreciation of the need to drive forward and complete this work. Many of the staff and senior managers we met told us that it had become clear over the past six months that the trust were now more focused on patient safety and they were hopeful that mental health and learning disabilities services were now a higher priority.

Overall, staff morale was good. Staff felt positive about the changes taking place and the improvements to environments. However, there had been some significant changes at board and executive level and at the time of inspection, there was continued uncertainty and changes within the trust. There were a number of external reviews taking place, generating recommendations focussed on various aspects of the governance systems, including the board assurance framework, which the trust was in the process of putting in place. Whilst we recognised that the newly restructured leadership team had only recently come into post, it was our view that they demonstrated clearer recognition of the need to drive through and complete the work to assess, manage and prioritise a range of patient safety issues. There was clear evidence that action was being taken in a more timely and proactive manner.

The trust recognised that there was still significant work to do and that the new systems needed to embed. There needed to be clear assurance processes in place to ensure that effective actions had been completed. In addition, we had some areas of concern about specific sites – particularly Elmleigh. We identified on-going environmental issues at Elmleigh. In addition to the known ligature risks, during this inspection, we highlighted the layout of the wards meant that it was not easy for staff to observe patients in all areas – including those who might be at risk of acting aggressively, harming themselves or of absconding. The problem was compounded by four factors. Firstly, some of the ward fixtures and fittings could be used as ligature anchor points. Secondly, staff did not always manage the segregation of men and women well. Thirdly, there were not always a sufficient number of staff for staff to observe all areas of the ward. Fourthly, the local management team had not consistently reviewed and learned from incidents well. We raised these concerns at the time of inspection.

The trust had introduced a standardised safety and risk management plan to incorporate an individual’s risks in relation to the specific ward environment. We were told that every patient now had this in place, but found that there was no safety and risk management plan relating to the environment in a quarter of the 143 records we reviewed. We also raised concerns about risk assessment processes at Ravenswood House medium secure unit.

Overall, we concluded that the trust had taken sufficient action to meet the requirements set out in the warning notice. The trust remains in breach of a number of regulations of the Health and Social Care Act 2008 (regulated activities 2014) from the previous October 2014 and January 2016 inspections; as a result of this inspection the two additional regulation breaches are listed at the end of this report.

Inspection carried out on 18 - 21 January 2016

During an inspection to make sure that the improvements required had been made

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

Our remit in this inspection was to:

  • review the trust’s governance arrangements and approach to identifying, reporting, monitoring, investigating and learning from incidents with a particular focus on deaths, and review how the trust was implementing the action plan required by Monitor in light of Mazars review;
  • review how the trust was implementing the Duty of Candour;
  • review the trust’s approach to managing complaints;

follow up on the improvements required from previous CQC inspections.

Summary of what we found and the action we took as a result

  • We found that the trust had not put in place robust governance arrangements to investigate incidents. As a result, the trust had missed opportunities to learn from these incidents and to take action to reduce the likelihood of similar events happening in the future.

  • The trust had not put in place effective arrangements to identify, record or respond to concerns about patient safety raised by patients, their carers, staff or by the CQC. We found examples of this in a number of the trust’s mental health and learning disability services. Where the trust and others, including CQC had identified risks to the delivery of safe care arising from the physical environment, the trust had not ensured that these risks were mitigated in a timely and effective way. The trust had also failed to identify, record or respond effectively to staff who expressed concerns about their competence to carry out their roles.

  • These key risks, and actions to mitigate them, were not driving the senior management or board agenda.

  • We asked the trust to take immediate action to ensure the safety of patients at Evenlode and Kingsley ward at Melbury Lodge. We served a warning notice that informed the trust that:
  • it must make significant improvements to protect patients from risks posed by some of the mental health and learning disabilities ward environments

  • It must put in place effective governance arrangements to ensure robust investigation and learning from incidents, including deaths, to reduce future risks to patients

  • We required the trust to provide CQC with a report by 13 April 2016 setting out the actions it will take to become compliant with Regulation 17 (2) (a) (b). Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 imposes a legal duty on the trust to ensure good governance.

The trust’s response

  • The trust did not challenge the warning notice. It identified a number of actions that it had taken because of issues raised by CQC during, immediately following the inspection and in response to the warning notice. For example, it wrote to us describing the improvements it at made at Kingsley ward at Melbury Lodge, including increasing staffing levels and security and reviewing environmental risk assessment. It also described improvements it has made to its governance arrangements for reporting, investigating and learning from incidents and deaths; for example, ensuring the initial management assessment completed following an incident contains all relevant information from the patients care records, ensuring the investigation process has clinical and senior oversight and implementing a variety of methods to share learning with staff across the trust.

Review of incidents, including deaths

  • Following the publication of the Mazars report, the trust accepted that the quality of its processes for reporting and investigating the deaths of patients needed to be better. In response to the recommendations of the report, the trust developed a mortality and serious incident action plan. Monitor (now NHS Improvement), clinical commissioning groups and NHS England were overseeing this.

  • On 1 December 2015, the trust introduced a new, trust-wide system for reporting and investigating deaths. Its purpose was to improve the quality of reports and investigations, increase monitoring and scrutiny and ensure that the trust shared learning with all staff. From 1 December 2015 to the date of our inspection, the trust identified that it had reported and investigated 74 deaths through its new system.

  • We reviewed a random sample of 58 investigations into deaths and four investigations of other serious incidents. These were drawn from a range of services, not just mental health and learning disabilities and had occurred between April 2015 and February 2016. We found that the quality and detail of the incident reports (reports on the electronic incident reporting system) and initial management assessments (IMAs) varied considerably. Some of the reports we reviewed were the result of a comprehensive investigation and adequately reflected the information available in the care records. However, in a quarter of initial management assessment reports that we reviewed, we found deficiencies relating to one or all of the following:

  • the accuracy and/or detail of the content of the IMA did not adequately reflect all the relevant details relating to the death/incident in the care plans;
  • the review had not been undertaken within the required timescale;
  • appropriate actions had not been taken;
  • learning points had not been well identified and/or there had been missed opportunities to identify learning.

  • We asked the trust to look again at three specific investigations. This was because we found that the investigation by the trust had not considered key facts. These related to one unexpected death of a patient on an older persons’ mental health ward, one unexpected death of a patient on a learning disability ward and one expected death of a patient on a community health ward. The trust had undertaken two of these investigations before it had introduced its new process. The trust agreed to re-open the investigations of these deaths and contacted all the families involved to explain what had happened and what action it was going to take going forward.We also asked NHS England to undertake an independent review of one of the investigations due to the nature of the patient’s death and inaccuracy/lack of details of the information contained in the IMA.

  • In addition, we reviewed 38 incident reports from across the core services we inspected. An incident report is a form completed in order to record details of an unusual event that occurs at the trust, such as an injury to a patient. We found that there was a lack of consistency and that the level of detail contained in the reports varied considerably. The trust had failed to take appropriate action and ensure lessons had been learnt in a number of the incidents reviewed. For example, nine reports of incidents involving assaults on staff had not been completed accurately and subsequently had not been followed up appropriately. This was despite the fact that the incident report had been subject to the trust’s own quality assurance process through which the incident reports were sent to 10 different people, including senior managers. None of the people reviewing the incident reports had questioned any of the errors or omissions.

  • From information supplied by the trust, we concluded that the trust did not have effective systems in place to meet statutory reporting requirements of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) consistently or to analyse data to understand organisational risks and take proactive action to protect patients or staff.

  • Commissioners and the trust reported that the trust had made some improvements in the reporting of serious incident requiring investigation (SIRI) over the 12 months prior to our inspection. All organisations providing NHS funded care are required to report SIRIs to the Strategic Executive Information Systems (STEIS) within 48 hours and completed investigations within 60 days. Despite these improvements, at the time of this inspection, the trust accepted that it still failed to achieve these targets and that the quality and the closure of incidents remained unacceptable.

  • Whilst it was too early to gauge the impact of the new process introduced by the trust on 1 December 2015, we concluded that it had the potential to monitor serious incidents and deaths more robustly and to identify when further investigation was required. We recognised that the process was at an early stage of implementation and was not fully embedded. To ensure that it is effective, the trust would need to ensure it encouraged an open and transparent culture of reporting. This would require training and support for staff and senior and robust oversight to ensure that incidents are investigation properly.

Review of the implementation of the Duty of Candour regulation

  • The Duty of Candour regulation requires healthcare providers to be open with patients and to apologise when things go wrong. When staff reported incidents on the trust’s electronic incident reporting system, the system required staff to confirm that they had considered or acted in accordance with the Duty of Candour. However, this identification consisted of ticking a box named ‘Duty of Candour applied’. There was no requirement for staff to provide any further information. There was therefore no record of whether discussions had taken place with families. The trust could not supply information about what actions had been taken in any of the incidents were staff had ticked ‘Duty of Candour applied’. It informed the CQC that said this would mean manually searching each care record to identify action taken.

  • We reviewed data supplied by the trust for 15 SIRIs in the Southampton community teams and for 182 deaths (across five divisions) from 1st April 2015 to 11th January 2016. We cross-checked these with the data that the trust provided for all incidents where the trust had identified that the Duty of Candour had applied. Only four of the incidents reported as SIRIs and nine of the deaths were included in the list of incidents that had been identified by the trust as having the Duty of Candour applied.

  • We reviewed the sample of 58 investigations into deaths and the four serious incidents to see how the trust had applied the Duty of Candour. The reports and records did not describe clearly how decisions were made about when the Duty of Candour should be applied or whether patients and families had been involved. We found that entries in patient records varied considerably from brief notes to comprehensive letters. In one of the deaths that we asked the trust to investigate further, the trust had identified that the Duty of Candour was not applicable. The poor quality of several IMA reports meant that the trust might have missed several opportunities to involve patients and families.

  • We wrote to 75 patients and carers who the trust had identified that it had informed about or involved in an investigation in relation to the Duty of Candour regulation to ask about their experiences. Two were returned as ‘not known at this address’. We only received one response. One person told us that they were unhappy with the discharge process and felt that this had contributed to the incident; they confirmed that the trust had involved them in the investigation.

Review of the management of complaints

  • We reviewed a sample of ten complaints received from patients and carers between April 2015 and April 2016. The trust had improved the way it managed and responded to complaints since our last inspection. Overall, the tone of responses to complaints had improved over that period. However, some letters did not answer all of the concerns that had been raised by the complainant. Some reports into the investigation of complaints were superficial and appeared rushed and not challenging. Most of the action plans were poor, incomplete and did not identify actions, learning or change of practice. There was some evidence of learning from complaints in some clinical teams but this was not widespread across the teams inspected.

Review of patient safety risks

  • We had serious concerns about the safety of patients with mental health problems and learning disabilities in some of the locations inspected. Although staff were working hard to provide good quality care, governance arrangements were ineffective in identifying and prioritising risks arising from the physical environment. These included risks posed by ligature anchor points, falls from heights and from patients absconding.

  • The trust had a poor understanding of the current risks in ward environments including, how to prioritise these and address them  effectively and promptly to mitigate the serious risk they posed. CQC had identified concerns relating to ligature risks in inspection reports for acute inpatient mental health and learning disabilities services in January 2014, October 2014 and August 2015. During this inspection (January 2016), we found that the trust had failed to make sufficient changes to specific environments such as Kingsley ward at Melbury Lodge and Evenlode. The trust had failed to mitigate sufficiently against the risks posed by these environments and make them safe for patients. The trust’s governance arrangements did not facilitate effective, proactive, timely management of these risks. Where substantive action was taken by the trust to mitigate risk, this was delayed and mainly done in response to concerns raised and/or repeatedly raised by the CQC.

Positive findings

  • Staff were kind, caring, and supportive and treated patients with respect and dignity. Patients reported that some staff went the ‘extra mile’.

  • The child and adolescent mental health service wards at Leigh House and Bluebird House had undertaken comprehensive risk assessments. At Leigh House, the trust had completed work to improve the safety of the environment in October 2015. For example, in the high care area bathroom, the trust had replaced the mirror with special shatterproof glass and fitted new sanitary ware with sensor taps. In Bluebird House, staff had undertaken comprehensive ligature risk assessments on all three wards. These had identified areas of concern and there was a clear plan to address or mitigate the risks.

  • The trust had made a number of improvements to the acute mental health care pathway that it hoped would reduce patients’ experience of repeated transfers between different teams and improve communication and joint working between the teams. For example, it had combined the acute mental health teams (which provided intensive support for those in a crisis) with its acute inpatient wards to form a single care pathway for patients. The trust had introduced the care navigator role at Elmleigh acute mental health unit, and the plan was to extend this to other in-patient units. This was a role developed to support safe transitions through the acute care pathway.

  • In Southampton, the trust had redesigned the community pathway as part of its improvement plan. The community teams were based across three hubs. These delivered all functions of community mental health care. Staff undertook mental health assessments and, where allocation within the team was appropriate, a range of more specialist assessments and interventions. The trust had redesigned the crisis care pathway and established a 24-hour team that was available seven days a week to support patients who were acutely unwell. The team worked with people at home or arranged admissions and discharge from hospital as needed. There was a plan to increase the psychiatric liaison service at Southampton General Hospital by March 2016. The improvement plan included a focus on improving the pathway for patients who were in hospital. The aim was to ensure that patients did not remain in hospital any longer than they needed and that local beds were available when patients needed admission. The majority of staff felt that they had been consulted and engaged with the improvement plan and thought that it would improve services.

  • The acute mental health teams performed an effective gatekeeping role to beds on the acute wards. They managed most admissions and discharges from the local inpatient units, supported by each locality acute care transfer coordinator. Beds were usually available at a local acute inpatient unit and patients rarely had to transfer out of the area to receive acute inpatient care.

  • Transition and discharge processes at Leigh House and Bluebird House had significantly improved and there was clear documented evidence of discharge planning.

  • The trust had a clear vision and a set of values developed in consultation with staff, patients and external stakeholders. It had developed some innovative approaches to services that were starting to have benefits for patients.

  • By the time of our inspection, the trust had taken some action in response to CQC’s previous inspections and the Mazars review. The trust had implemented or was starting to implement some governance structures and processes with the potential to provide it with robust oversight and assurance. For example:

    • standardised divisional governance arrangements which were beginning to be embedded, renewed processes for reporting, recording and investigating incidents and deaths and the introduction of a dedicated investigation team and a corporate panel for reviewing the investigation of serious incidents and deaths;
    • the electronic management of complaints;
    • the quality improvement programme;
    • the introduction of ‘Tableau’ (the trust's new business intelligence tool).

  • Some of these were beginning to have some positive effects and show improved outcomes as evidenced by improved key performance indicators in a number of areas. However, it was too early to be assured that the systems and processes would have the desired effect. Many staff working with these new or revised systems and processes for reporting and investigating incidents and complaints still did not fully understand them or have the capability to use them.

Inspection carried out on 7 to 10 October 2014

During a routine inspection

Southern Healthcare NHS Foundation Trust delivers a wide range of community health care, mental health, learning disability and adult social care services from many locations across a wide geographical area and whilst we found many areas of good practice and services, including some outstanding practice and services, there was a lack of consistency across the trust.

We rated community health services for children, young people and families, community mental health services for adults of working age, rehabilitation mental health services, community-based mental health services for older people and eating disorder services good across all five areas (safe, effective, caring, responsive and well-led). We rated perinatal services outstanding across all five areas. However, eating disorder services and perinatal services are not part of our core services suite so these ratings do not count towards the overall provider level rating. The rating for Urgent Care services also does not count toward the overall rating as this too is not one of the core services used in the aggregation of ratings. 

We found the trust had a clear vision, had developed a clear set of goals and values that most staff knew about and understood and these were gradually being embedded throughout the trust. There was evidence of good leadership and commitment from the board, the executive team and senior managers. We heard of many new initiatives and the trust was continually looking for ways to improve. However, it was clear that time was needed to fully realise the scale and complexity of the changes and embed these across the trust.

We gave an overall rating for the provider of requires improvement because:

  • The trust was in the process of redesigning the way it delivered its services. For example, the introduction of a new divisional structure, the implementation of a recovery focussed mental health pathway for adults of working age and the introduction of integrated physical health care and older adult's mental health teams which has been recognised nationally as a model of good practice. However, these changes were at a relatively early stage of development and were not fully embedded across the trust.

  • Although the trust board had been strengthened with the appointment of new non-executive directors and a number of new executive directors and clear lines of accountability and responsibility had been established, some executive directors had only recently taken up post. The director of nursing and allied health professionals had been in post four months so was still establishing her role and raising her profile so staff and stakeholders knew of her responsibilities and plans. In addition, a number of senior managers and clinical leaders had been appointed to support implementation of the changes but many of these had only been in post a short time.

  • As result of a review of governance arrangements undertaken by Deloitte on behalf of the trust, several changes had been made to the trust governance framework to strengthen its arrangements to maintain the oversight needed. However, many of these changes were at an early stage of implementation, including the introduction of a new board assurance framework (BAF) which had only been agreed at the board meeting held in September 2014.

  • Community health care services did not always have enough staff and the gaps were not always covered. This meant that in some community teams there were missed visits to patients and long waiting times for treatment by a therapist.

  • There were delays in the supply of equipment such as hospital beds or special mattresses for home use this meant that patients could be at increased risk of pressure ulcers.

  • The number of attendances at Lymington Minor Injuries Unit (MIU) had increased over the years and due to staff vacancies there were sometimes difficulties in covering shifts with the appropriate number of staff to provide a safe service.

  • We found insufficient numbers of specialist palliative care staff meaning that patients did not always get the right level of care at the end of their life.

  • There were issues with the management of medicines at both the MIU at Lymington Hospital and Petersfield Hospital. In the theatre suite at Lymington New Forest Hospital and Sultan ward at Gosport War Memorial Hospital the Controlled Drugs cupboards did not comply with the trust’s own policies and procedures. There was insecure management of FP10 prescription pads with an incomplete audit trail of safe and appropriate use. Patient Group Directives (PDG’s) for the administration of medication in both MIU’s had been removed by the trust in September 2014, as these were past the review date. The trust had identified that most Patient Group Directives (PDG’s) were past there review date and had initiated an action plan to resolve the situation. However, when we inspected the PGDs were not available for operational use at the Petersfield MIU.

  • In community health services and some inpatient services for adults there were unsatisfactory arrangements in place for the obtaining, recording, handling, using, safe keeping, dispensing, safe administration and disposal of medicines.

  • We were concerned about the trusts ability to provide safe care to patients at Ravenswood House as the building was unfit for the purpose for which it was being used. There were plans to renovate some wards in the short term and in the longer term, the service was to be moved to a new building and plans for this were being considered at the time of the inspection. 

  • We were concerned about ligature management at Ravenswood House, Southfields and in the seclusion room at Leigh House. Although the trust had a ligature minimisation programme risk assessments had not been carried out and staff showed a lack of understanding of how ligature risks should be managed. We asked the trust to take immediate action. The trust responded positively by making some immediate changes and by providing a clear action plan of how it would manage the risks in the future. However, many of the risks to patients at Ravenswood House remain due to nature of the building.

  • In some mental health services there was inappropriate seclusion and physical intervention practices due to a lack of suitably trained staff, policies that did not provide clear direction and some staff who lacked awareness of good practices.

  • Across mental health services there was inconsistent staffing levels and skill mix; wards were not always staffed to safer staffing levels. This significantly impacted upon the care and treatment to patients being delivered at the right time and in the right way. Staff reported working longer than their contracted hours in order to deliver care to patients and said that the dependency of patients was not taken into account when deciding the numbers of staff required. The trust was actively recruiting new staff and was closely monitoring staffing levels.

  • Patients expressed confusion and frustration about access to crisis services. Staff lacked clarity about how these services were provided and the policy was not clear. Staff told us that the acute mental health teams and hospital at home teams did not provide crisis services although this was the plan for the future and that community mental health teams (CMHTs) provided crisis services but only during office hours. Patients and carers, particularly those wishing to access services at Parklands Hospital, told us they were given a telephone number but when they called it was rarely answered. In addition, there was no crisis service for older people; the trust is not commissioned to provide these services.
  • Community mental health teams (CMHTs) often struggled to find an available bed locally for patients requiring admission to an acute mental health ward. This meant that patients were often accommodated in a hospital bed a long way from their home.
  • At both Antelope House and Elmelight Section 136 suites (health based place of safety) patients were not routinely examined by a doctor on admission to determine the presence of a mental illness. This resulted in long periods of detention for patients not suffering a mental illness. This contravenes the MHA Code of Practice. There was also long waits for assessments by an approved mental health professional meaning patients stayed in S136 suites for long periods of time.
  • The trust had reconfigured its learning disability services in Oxfordshire, closed inpatient services at Slade House and made several changes to improve services following an external review into a tragic death at Slade House. A special committee of the board was in place to oversee the turnaround of the services. However, staff, patients and carers still had concerns about on-going issues as they felt the trust had not been as open and honest as it could have been. It was clear this was impacting significantly on their welfare. The uncertainty about whether the trust would continue to deliver services in the future was affecting staff morale.
  • Information systems, particularly in community health services and mental health community services were preventing staff from delivering services as effectively as they would like; this was having an impact on care provided to service users as records were often not accessible. Staff were aware of plans to introduce new systems but were unaware of timescales for this.

However, care was delivered by kind, sensitive and caring staff that were passionate about their work and committed to delivering high quality services. Patients and their families told us that the majority of staff treated them with respect and dignity. Many of the staff we spoke with said they were proud to work for the trust, enjoyed their work, felt they had opportunities to develop professionally and felt the trust was generally moving in the right direction to bring about improvement in services. However, several commented that the pace of change was, at times, moving too quickly to embed the changes effectively.

One of the vehicles being used to achieve the trust vision and support key changes to improve services was the trusts leadership programme ‘going viral’, which was available to staff at different levels of management. A new strand of the programme was being developed for all staff. The trust had a clear commitment to investing in staff and was providing a wide range of training and learning opportunities that were appreciated by staff.

The new BAF identified a red, amber or green rating for high level, strategic risks which were mapped to the priority areas of the quality programme: quality governance structures in the divisions, reporting and organisational learning, peer reviews, estates readiness, record keeping and care planning, medicines management, workforce and patient experience. The trust had introduced an innovative information system which provided high quality performance data to allow the board to monitor its performance. This information was beginning to be used by the trust board to identify and monitor risks.

Alongside this, a number of initiatives had been introduced to support improvement, including peer review visits and local audits. These were not always identifying all poor practice so improvements were not being made in a timely manner. In addition, some issue were being identified but action was not always being taken in a timely manner or was not being taken so the opportunity to improve was being missed.

In all services we found evidence of care being delivered in accordance with evidence based guidelines and in line with recognised good practice with good examples of positive outcomes for people using services. We were impressed by the recovery college and perinatal services.

We visited all locations that cared for patients detained under the Mental Health Act and found that staff generally adhered to the requirements of the Act, including ensuring people received Section 17 leave (leave to go off the ward accompanied by staff). Some patients told us that at times they could not take Section 17 leave when they wanted due to staff not being available to support them. Seclusion and restraint practice in some areas contravened MHA Code of Practice. 

The trust had systems in place to safeguard people from abuse. Most staff we spoke with understood the importance of safeguarding vulnerable adults and children and knew how to raise an alert. It was also clear that staff were encouraged to report all types of incidents. There was evidence of learning from incidents and evidence of improvements being made as a result of reporting and sharing the outcomes of incidents. However, there were some areas were practice was inconsistent or not embedded.

The trust had a clear commitment to progressing research and had conducted 45 research studies between 2012/14 involving approximately 800 people. It had also won eight national awards for Equality and Diversity. We found a proactive approach to equality and diversity across the trust.

The trust had a range of patient groups and forums across several services which it encouraged patients to get involved in. The trust engaged with its stakeholders, including patients, people of all ages who used services and carers through 15 social media channels and had recently launched a listening App called Southern Health Listens. The trust offered a range of opportunities for patients to provide feedback about their experience of receiving care and we found that this this feedback was beginning to improve care throughout the trust.

It is our view that the provider had made significant progress in developing services and bringing about improvements and that given time, the provider would realise its vision and deliver good and outstanding services across the trust.  However, some significant work was still required to improve the quality and consistency of its services across the trust.

We found that the trust was in breach of a number of regulations. We will require the trust to meet the requirements of the regulations within a specified time period. However, we are not taking any enforcement action.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.       

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.


Organisation Review of Compliance


Reports under our old system of regulation (including those from before CQC was created)


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.