• Organisation
  • SERVICE PROVIDER

Southern Health NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

All Inspections

18, 20 and 25 October 2022

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

We rated the acute wards for adults of working age and Psychiatric Intensive Care Units core service as requires improvement because:

  • Some areas that required improvement at the last inspection in October 2021 still needed to be improved. The trust therefore needed to consider the effectiveness of its internal governance arrangements so that potential issues could be identified and addressed promptly in future.
  • Patients at Antelope House did not always have their physical health monitored as frequently as it should have been. We reported this to senior leaders who took immediate action to ensure staff understood their responsibilities in relation to monitoring the physical health of patients.
  • The process for safely managing controlled drugs was not always followed by staff on Cherry and Juniper wards at Parklands Hospital.
  • Staff did not always complete the necessary enhanced patient observations at Elmleigh.
  • Patients at Elmleigh were not always promptly reviewed by a doctor on admission to the service and did not therefore have timely access to their required medicines. This posed a risk of missed doses.
  • Improvements were needed to ensure staff had received the necessary mandatory training to safely fulfil their roles. At Elmleigh, most staff had not recently completed training in prevention and management of incidents of violence and aggression, during which they learn how to use safe restraint techniques.
  • Some blanket restrictions were in place that unnecessarily restricted the comfort, privacy and dignity of patients. These included patients not being able to lock their bedroom doors, not having access to their own private lockable space, not being able to control the viewing panels in their bedroom doors and sometimes relying on staff to locate cups for them to access drinking water.
  • Staff did not always receive regular supervision. Supervision compliance was particularly low at Elmleigh, Antelope House and on Juniper ward at Parklands Hospital. This posed a risk that staff would not receive the support they needed to fulfil their roles safely and confidently. However, a new project group had been set up to improve supervision compliance and review the style of staff supervision.
  • Staff sickness rates at Elmleigh were increasing. Staff turnover rates varied across the core service according to hospital location. Turnover was highest at Antelope House. These factors meant that patients were less likely to receive continuity of care from staff who knew them and understood their needs and preferences.
  • Although there had been progress made in relation to staff recruitment since the last inspection, there was still a significant number of vacant posts that needed to be recruited to.
  • There was significant demand for beds. Abbey ward, a 10-bed female Psychiatric Intensive Care Unit (PICU), was closed at the time of the inspection. However, the trust had commissioned additional PICU beds in the independent sector to help manage this demand.

However;

  • Staff now clearly recorded when clinical equipment was last cleaned at Elmleigh and Antelope House.
  • The process for monitoring the physical health of patients receiving high doses of antipsychotic medicines had been strengthened.
  • Patients now had their own copies of care plans and had been involved in developing their own care plans and risk assessments.
  • Staff felt more able to speak up about their concerns without fear of retribution. They also knew how to escalate concerns using the trust’s freedom to speak up guardian.
  • Staff now managed patient safety incidents well and staff received appropriate support if they were involved in an incident.

5 Oct to 3 Nov 2021

During a routine inspection

We carried out an unannounced comprehensive inspection of six of the mental health services provided by Southern Health NHS Foundation Trust as part of our continual checks on the safety and quality of healthcare services.

Following this inspection, we rated the trust ‘requires improvement’ overall. In addition, we rated each of the key questions – safe and effective as requires improvement and caring, responsive and well led as good overall. The rating of safe had reduced from good to requires improvement.

During this inspection we inspected six of the Trust’s core services and rated two as good (wards for people with a learning disability or autism, child and adolescent mental health wards) and four as requires improvement (forensic inpatient/secure wards, wards for older people with mental health problems, crisis services and health based places of safety and acute wards for working age adults and psychiatric intensive care units).

The rating for acute wards for working age adults and psychiatric intensive care units and forensic inpatient/secure wards had reduced from good to requires improvement. The rating for mental health crisis services and health-based places of safety and wards for older people with mental health problems remained requires improvement. Additionally, wards for people with a learning disability and autism had reduced to good from outstanding.

We also undertook an inspection of how ‘well-led’ the trust was, and we rated this good. Southern Health NHS Foundation Trust is one of the largest providers of mental health, specialist mental health, learning disabilities and community health services in the UK with an annual income of approximately £316 million. The trust provides these services across Hampshire. It employs 5,927 staff who work from over 200 sites, including community hospitals, health centres and inpatient units as well as delivering care in the community. The trust has 634 inpatient beds. The trust received foundation status in April 2009 under the name Hampshire Partnership NHS Foundation Trust. Southern Health NHS Foundation Trust was formed on 1 April 2011 following the merger of Hampshire Partnership NHS Foundation Trust and Hampshire Community Healthcare NHS Trust. The trust has a well-publicised history of challenges and regulatory action, culminating in successful prosecutions by CQC and the Health and Safety Executive. The trust has taken action to address the issues that resulted in the prosecutions and have used these to learn and improve the services.

Southern Health NHS Foundation Trust provides community health, mental health and specialist mental health and learning disability services for people across the south of England. Covering Hampshire, the trust is one of the largest providers of these types of services in the UK.

Our last comprehensive inspection of the core services was in October 2019 when we inspected four mental health core services.

At our last inspection we rated the trust as good overall.

The core services inspected on this occasion were chosen due to intelligence that we held, with a decision to inspect made on the balance of risk to service users. This included consideration of the previous inspection and ratings.

The trust provides ten mental health core services

  • Acute wards for adults of working age and psychiatric intensive care units (PICU's)
  • Long stay/rehabilitation mental health wards for working age adults
  • Forensic inpatient / secure wards
  • Child and adolescent mental health wards
  • Wards for older people with mental health problems
  • Wards for people with a learning disability or autism
  • Community-based mental health services for adults of working age
  • Mental health crisis services and health-based places of safety
  • Community-based mental health services for older people
  • Community mental health services for people with a learning disability or autism

The trust also provides two specialist mental health services

  • Perinatal service
  • Eating disorder service

The trust provides five community health core services:

  • Community health services for adults
  • Community health services for children, young people and families
  • Community health inpatient services
  • End of life care
  • Urgent care

On this inspection we inspected six mental health core services:

  • Acute wards for adults of working age and psychiatric intensive care units (PICU's)
  • Child and adolescent mental health wards
  • Forensic secure wards
  • Wards for older people with mental health problems
  • Wards for people with a learning disability or autism
  • Mental health crisis services and health-based places of safety

Experts by experience (people who have experience of using services or caring for those who use services) and specialist advisors (senior practitioners with specialist knowledge and experience of working in the core services areas) were part of the inspection teams for each core service inspection and so helped us collect high quality evidence and make robust judgements.

We also looked at how well-led the trust was. In order to ensure we have appropriate expertise to make a robust judgement about how well-led the trust is, our inspection team comprised an executive reviewer (a board level leader from another organisation rated good or outstanding), a specialist advisor with expertise in governance and a senior leader from NHSI/E with financial expertise as well as CQC inspection team members.

Our rating of services went down. We rated them as requires improvement because:

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

We rated two of the trust’s mental health services as good and four as requires improvement. In rating the trust, we considered the current ratings of the nine services we did not inspect this time which have retained the previous ratings.

We had serious concerns about the safety on one of the wards for older people with mental health problems. As a result of the significant concerns identified, we wrote to the trust to seek immediate assurances about the safety of the service. We advised them that if there was not significant improvement in the safety of care on the ward, we would take enforcement action to address the issues. The trust responded by reducing the bed numbers, improving the staffing ratio, reviewing risks and practices around safeguarding and falls. The trust submitted an action plan to CQC to demonstrate how the changes were to be implemented and embedded going forward. Following two further visits to the ward, the inspection team were satisfied that immediate risks to patient safety had been addressed to prevent immediate and significant enforcement action being taken. Leaders at all levels were not cited on and did not recognise the seriousness of the issues on Beaulieu Ward and the significant safeguarding concerns found in incidents were not picked up and acted upon.

The trust had difficulty attracting substantive staff. Staffing levels were not always being met. We identified concerns relating to staffing levels in four of the six services we inspected. Staff told us there were not always enough staff to effectively manage higher acuity patients at Ravenswood House Medium Secure Unit, leaving them and patients unsupported. The crisis service at Parklands reported a high vacancy rate and had an over reliance on the use of agency staff and staff on the older persons and acute and PICU wards did not always have enough staff to keep patients safe. Staff on the acute and PICU wards told us that this meant they were not always able to provide the level of care to patients that the patient should expect. This included less leave and less time in therapy focused work.

Some staff in mental health services felt unsafe due to an increase in the acuity of illness of the people they were caring for and incidents of violence against staff. Staff told us that the number of injuries to staff and patients during incidents of aggression on the acute and PICU wards were increasing and they did not always respond to changes in risk. Staff felt pressured to admit patients onto wards when it was unsafe.

There were pockets of low morale across the trust, this was impacted by staffing pressures.

In three of the services inspected, we found gaps in the recording of National Early Warning Score 2 (NEWS2) records we reviewed. This included missed entries, missed signatures and totals not completed. In the absence of these records where a patient’s deteriorating health should have been escalated in line with national guidance, this could have been missed and not escalated.

Several strategies had been put on hold during the COVID-19 pandemic and there was work to do to bring the clinical strategy and the wider trust strategy together into a comprehensive document that set out the direction clearly. There was a clear vision that was understood and articulated by a number of the senior leadership team around working in partnership and collaboration to deliver good quality services to meet the health needs of the local population – although there was a need to ensure this and what it meant is communicated effectively to a wider audience.

However:

One of the biggest risks in the organisation was staffing in the mental health inpatient wards, the trust had plans in place regarding recruitment and the board recognised this was an area which needed to be achieved at pace.

Staff were proud to work for the trust. There was a strong sense of staff at all levels putting patients at the heart of everything they do. All staff were respectful, compassionate and kind towards patients. Staff were also friendly, approachable and supportive. We saw positive interactions between staff and patients. Staff were highly motivated and provided care in a way that promoted patient’s dignity.

The trust leadership was now stable and capable. Since the last inspection the board had appointed a new chief executive and a new medical director. Two new non-executive directors (NEDs) also joined the trust during the pandemic.

The trust had a Board Assurance Framework and a risk register which were regularly reviewed. The performance team delivered good quality reports for each division to have an overview of risk within the divisions.

We found that the trust now had a highly skilled, strong, stable and experienced senior team, including the chair and non-executive directors. Leaders had the skills, knowledge, integrity and experience to perform their roles and had a good understanding of the services they were responsible for delivering. They were visible in the service and approachable to patients and staff.

There was a strong estate’s, workforce, digital and safeguarding team, medical and financial leadership. Nursing and AHP leadership were strong and the team communicated well and knew the issues they faced and were clear about how they would address them. There was strong leadership of the Council of Governors with a clear view on working in partnership whilst challenging the board to ensure safe and effective service delivery on behalf of the public.

We met individuals and teams who were very proud of working at the trust; with lots of hope for the future. The trust was building on the past and getting to grips with the job of taking the organisation forward. The trust was coming through legacy issues and learning from these, building. Everyone we met spoke positively.

People accessing the learning disability ward were receiving safe and effective care. They were treated with dignity; risks were assessed, and the environment was safe. They received kind and compassionate care.

The trust engaged well with patients, staff, equality groups, the public and local organisations. Trade union representatives were very positive about how the trust leaders worked with them in an open and transparent way and had supported staff throughout the pandemic.

The trust had reviewed their disciplinary policy and made changes based on a Compassionate and Just Culture model.

There was good practice and innovation around IT and the digital focus. Digital development and information governance systems were strong with consistent clinical and service line engagement.

Learning from serious incidents had been strengthened and the trust had been rewarded accreditation through the Royal College of Psychiatrists’ Serious Incident Review Accreditation Network (SIRAN). The trust used ‘favourable event reporting’ where they learned from things that had gone well in the same way they learned from things that had not gone so well. The aim was to replicate good practice and disseminate this across the trust. The trust had responded to serious incidents and investigated them. Following the inspection, a serious incident occurred at Parkland’s hospital that resulted in the death of a patient. The trust had commissioned an independent investigation into this and worked closely with the police.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic including on site and remote interviews by phone or online.

For the child and adolescent mental health wards inspection, the inspection team:

  • visited all three sites, looked at the quality of all the ward environments and observed how staff were caring for patients,
  • spoke with 14 young people who used the service and six family members,
  • looked at 21 electronic and paper copies of care and treatment records,
  • observed an assessment and admission meeting, a shift handover meeting, a daily team meeting and two ward round meetings,
  • spoke with 35 staff including a head of nursing, a head of operations, three modern matrons and three ward managers. We also spoke to members of the multidisciplinary team, social workers and a pharmacy technician,
  • reviewed a range of documents relating to the running of the service,
  • looked at medicine’s management, including medicine charts.

For the adults of working age and psychiatric intensive care unit’s inspection, the inspection team:

  • visited eight wards at the three sites and looked at the quality of the ward environment and observed how staff were caring for patients
  • spoke with 22 patients who were using the service both in person and via telephone calls.
  • spoke with five carers
  • spoke with the ward managers or interim managers for each ward
  • spoke with 37 other staff members; including doctors, nurses, occupational therapist, occupational therapy assistants, healthcare assistants, social workers, pharmacy technicians and a psychologist
  • attended and observed multi-disciplinary meetings and safety huddles
  • looked at 21 care and treatment records of patients
  • carried out a specific check of the medicine management on all wards; and
  • looked at a range of policies, procedures and other documents relating to the running of the service

For the wards for people with a learning disability or autism inspection, the inspection team:

  • visited Ashford and looked at the quality of the environment and observed how staff were caring for people
  • spoke with head of operation and modern matron
  • interviewed the ward manager
  • checked the clinic room
  • spoke with eight patients
  • spoke with five staff including nursing staff, support workers and positive care and safety coordinator
  • spoke with the forensic psychologist, occupational therapist, social worker
  • reviewed five care records and 10 treatment records
  • reviewed several meetings minutes and looked at a range of policies and procedures related to the running of the service

For the wards for older people with mental health problems inspection, the inspection team:

  • visited four wards
  • interviewed the four ward managers
  • checked the clinic rooms and reviewed the medicine charts
  • spoke with 17 patients
  • spoke with five carers or relatives of patients
  • spoke with 26 staff including doctors, nurses, occupational therapist, occupational therapy assistants, healthcare assistants, social workers
  • reviewed 33 care and treatment records of patients
  • reviewed several policies, meetings minutes, personnel records and supervision records
  • observed staff meetings on the wards, including multidisciplinary team meetings, ward rounds, staff handover meetings, patient safety at a glance (PSAG) meetings

For the forensic inpatient/secure services inspection, the inspection team:

  • visited six wards at the two sites and looked at the quality of the ward environment and observed how staff were caring for patients
  • spoke with 16 patients who were using the service both in person and via telephone calls.
  • spoke with 3 carers
  • spoke with five ward managers
  • spoke to the modern matrons of the two sites
  • spoke to 3 consultant psychiatrists and 5 junior doctors
  • spoke with 28 other staff members; including a psychologist, an occupational therapist, a pharmacy lead, two pharmacist technicians, a social worker, nurses, health care assistants, a ward administrator and student nurse.
  • attended and observed one handover meeting, a morning planning meeting, a Situation Report (sitrep) meeting and multidisciplinary care review meetings for three patients
  • looked at 32 treatment records of patients
  • reviewed 34 medicine prescription charts
  • reviewed eight staff records
  • looked at a range of policies, procedures and other documents relating to the running of the service.

For the mental health crisis and health-based place of safety inspection, the inspection team:

  • Visited the crisis teams, also known the home treatment teams within Parklands and Antelope House. These teams are recognised within the Trust as Crisis Resolution and Home Treatment teams (CRHT).
  • Visited the crisis team at Elmleigh, who acknowledge and process referrals, provide face to face assessments of patients before the case is handed over to the home treatment teams located in other areas of the region.
  • Visited the Parklands health-based place of safety (HBPoS), the HBPoS at Antelope House and Elmleigh were being used during the time of our visits.
  • Reviewed 11 care and treatment records of patients using the HBPoS.
  • Reviewed nine care and treatment records of patients across the crisis and home treatment teams.
  • Attended two multi-disciplinary team meetings.
  • Spoke to 22 staff members; including clinical team leaders for the home treatment team and health-based place of safety, qualified nurses, service managers, healthcare assistants, consultant psychiatrists, operational director, patient flow manager.
  • Looked at a range of policies, procedures and other documents relating to the running of the service.
  • Spoke with one patient who had used the health-based place of safety, and five patients who had been supported by the home treatment team.
  • Spoke with one family member of a patient.

What people who use the service say

On the older persons ward except for one patient, all patients who were able to talk to us said they were happy with their care and positive about their experience. Patients were able to say the activities were good and there was a good choice of food. Patients said that staff took time to listen to them and staff are very caring. Patients said they knew who their named nurse was, and they could speak to them if they had a problem.

Within the crisis service patients told us staff were respectful and kind. Patients and their carers told us that staff were caring and supportive.

Within CAMHS, young people were largely positive about their experiences at the service. The young people we spoke with reported feeling safe and felt that the staff were kind and respectful and took a genuine interest in their care and wellbeing. Young people told us that they had the opportunity to maintain contact with their families, were involved in care and discharge planning and had copies of their care plans. Young people said that food was generally good, and they particularly enjoyed some BBQs during the pandemic. They also told us that they had access to doctors when needed.

We received mixed information from young people regarding activities. Whilst some young people in Austen House told us that activities were not cancelled and they had two activity coordinators, young people at Bluebird House told us that they were bored during weekends and there was not enough staff. Young people at Leigh House told us that there were issues with staff shortages and as a result walks were cancelled.

Some young people and relatives at Leigh House told us that they were unhappy that sometimes male staff were carrying out observations of young females. Some young people at Austen House raised some issues with us which we followed with staff and received explanations.

We also received positive feedback from the families we spoke with about the quality of care young people received from staff. Most of the relatives we spoke with felt that young people were safe and that visiting arrangements were good. Some relatives told us that that they participated in ward round meetings, kept informed and received ward round notes. However, some relatives were concerned about staff shortages and the arrangements for contact with families as sometimes they received too many calls in one day.

At Ashford people told us the staff were very kind, supportive and helped them to understand information. They praised the staff and said they were helpful and understood their needs. Although people said the ward was short staff at times, they gained attention from staff when they needed to discuss their needs and how they were going to be supported.

On the Acute and PICU wards most of the feedback we received from patients and carers was positive. Patients told us that staff were polite and respectful and that they felt safe on the wards. Patients also told us that there were enough activities and regular leave. However, they also told us that the wards were often short staffed and that leave, and activities were sometimes cancelled because of this. Patients also said that that if there were incidents on the ward they did not feel as safe. Patients told us this was because the staff had to manage the incident.

The carers we spoke to told us that staff cared for their family member or friend and treated them well. Staff involved carers in the patients care. However, they also told us it was difficult to contact the ward at times and the quality of the information you received depended on who answered the phone.

Within the forensic ward’s patients said staff treated them well and behaved kindly. Fourteen of the patients we spoke with told us staff were approachable and very supportive. However, they also commented that the quality for the food could be improved.

18 August 2021

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

We carried out this unannounced, focused inspection at Elmleigh Hospital in Havant to see if the hospital had made the required improvements identified at a previous inspection in April 2021. We visited both wards: red and blue bays. Red bay is a 17 bedded ward for female and blue bay a 17 bedded ward for males.

Following that inspection, we sent the trust a letter of intent under section 31 of the Health and Social Care Act 2008 identifying our serious concerns about the safety of patients at Elmleigh. Section 31 of the Health and Social Care Act 2008 Act is an urgent procedure whereby CQC can vary any condition on a provider's registration in response to serious concerns. However, a letter of intent asks the provider to set out, in an action plan, how it will address those serious concerns. If the action plan provides us with assurance that the provider will act in a timely manner and if we are assured, we then don’t take any further action.

In the report we also identified some additional improvements that the trust needed to make to ensure it met legal requirements. We told the trust it must ensure that patients’ physical health care needs were met, that mental health assessments were undertaken prior to section 17 leave, that all patients had access to meaningful activities and psychological interventions, that all incidents must be reported, that staff received an induction and regular supervision, that medicines were managed safely and that there were robust governance arrangements in place to identify risks so that improvements could be made as needed.

In May 2021 the trust sent us an action plan detailing how it would meet the above legal requirements, which detailed what had been done immediately following our inspection to make improvements and what it would do to ensure further improvements were made in a timely manner. This provided us with the assurance we required so we did not take any further action.

At the latest inspection we did not rate this service because we did not look at all the key questions or all the key aspects of the key questions. The previous rating of good remains. It should be noted that this rating related to all of the acute mental health services at Southern Health and not just Elmleigh.

We found that the trust had met the majority of the required improvements but that there were still some further improvements to be made.

At Elmleigh we found:

  • Staff provided a range of care and treatment interventions suitable for the patients that were in line with national guidance on best practice. Patients had access to meaningful activities and psychological and therapeutic interventions.
  • New staff received a comprehensive and tailored induction to the wards and received regular supervision, including reflective practice sessions and group sessions.
  • Staff felt supported and were more confident about raising concerns.
  • The governance arrangements had improved, and ward managers had implemented additional checks and audits to identify where improvements were still needed and action could be taken promptly.
  • Staff ensured that patients’ physical health needs were identified and assessed. Patients had appropriate physical health care plans in place which were reviewed regularly.
  • Improvements had been made with regards to patients’ mental state being assessed prior to taking leave from hospital. However, some patients told us that sometimes their mental state wasn’t assessed prior to leave.

However:

  • Staff were not increasing physical health observations in line with National Early Warning Score (NEWS2) protocol when patients’ health deteriorated. For example, if a score increased from two to three, patients were not having their observation checks increased from every 12 hours to every six hours. Patients’ baseline scores were missing and there was no rationale recorded for why these increased observations did not take place.
  • Staff were still not always reporting all incidents. For example, if an incident was a regular occurrence or was low risk of harm.
  • Although improvements had been made to medicines management, there were still gaps in recording on medications charts.

How we carried out the inspection

During the inspection visit, the inspection team:

  • interviewed the ward managers and spoke to the head of operations
  • spoke with nine members of staff, including four nurses, one health care assistant, one assistant psychologist, one clinical psychologist, one activity co-ordinator and one HR advisor
  • spoke with the user involvement manager for mental health, learning disabilities and specialities services for the trust
  • spoke with five patients across both wards
  • reviewed a sample of patient care and treatment records
  • reviewed all patient medication charts, controlled drug book and physical health observation records across both wards
  • reviewed a sample of section 17 leave documentation (permission for a patient to leave the hospital)
  • reviewed a sample of incident reports and
  • looked at policies, procedures and other documents relating to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke to two patients on blue bay and three patients on red bay. All patients we spoke to said that there were lots of activities to do now but that staff sometimes did not encourage them to take part. Patients told us that they had their mental state assessed prior to leave but sometimes this did not happen. Patients also said that their leave could be cut short due to staff shortages and it was difficult to access leave for regular cigarette breaks.

21 and 26 April 2021

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

We carried out this unannounced, focused inspection because we received information about the safety and quality of the service. The concerns were specifically about Elmleigh, which is one of the acute mental health hospitals in the trust. The concerns were about a lack of therapeutic intervention from staff and activities for patients, incidents not always being reported, observations of patients not being therapeutic or engaging, patients being unable to take regular leave from hospital due to staffing levels, issues with medication administration and a poor culture amongst the staff team at all levels.

We inspected both wards at Elmleigh, in Havant. Red bay and Blue bay are acute wards for adults of working age. Red bay is a female-only 17-bedded ward and Blue bay is a male-only 17-bedded ward.

We inspected the service on 21 April 2021 due to the concerns raised above. However, during the inspection we had significant concerns about the lack of robust the monitoring of patient’s physical health care. We therefore returned on 26 April 2021 to look more closely at this specific issue.

On 29 April 2021, following this inspection, we sent the trust a letter of intent under section 31 of the Health and Social Care Act 2008 identifying our serious concerns about the safety of patients on Blue and Red bay wards and requested the trust submit information to explain how they would make immediate improvement. Section 31 of the Health and Social Care Act 2008 Act is an urgent procedure whereby CQC can vary any condition on a provider's registration in response to serious concerns. A letter of intent sets out our intention to take urgent action if the provider does not assure us that it will make the required improvements urgently.

On 4 May 2021 the trust sent us a detailed action plan which provided assurance on what had been done immediately to improve care and treatment on the ward. We therefore did not take any further enforcement action but will continue to monitor the action plan closely to ensure the trust makes the improvements within the timeframe it has set out.

Following the inspection, the trust also voluntarily capped admissions by reducing the bed numbers on each ward by three.

We did not rate this service at this inspection because we did not look at all of the key questions or all of the key aspects of the key questions. The previous rating of good remains. It should be noted that this rating related to all of the acute mental health services at Southern Health and not just Elmleigh.

At Elmleigh we found:

  • There was not enough staff with the right skills and knowledge to ensure that patients had high quality care and treatment. The ward did not have a full multi-disciplinary team and were missing input from key disciplines such as clinical psychology and occupational therapy. There was only one locum consultant psychiatrist covering both wards. There was a high number of agency staff deployed who did not always know the patients’ needs and risks. Nursing and healthcare staff were stretched, busy and did not have the time to regularly complete incident forms, therapeutically engage with patients or arrange activities. Staffing was not increased when the acuity on the ward increased, for example when additional patients required extra observations to monitor their risk.
  • Staff did not always assess or monitor all risks to patients, including mental health and physical health. We found that the physical health needs of eight patients with known conditions and risks had not been adequately assessed or monitored. Staff did not always assess risk prior to patients taking approved leave from hospital as they did not complete a mental state assessment. When completing observations of patients, staff were not considering a patient’s risk or therapeutically engaging with patients. Staff recorded basic details such as ‘appears asleep’, ‘in bed space’ or ‘in ward area’.
  • Patients did not always receive a range of care and treatment interventions suitable for an acute mental health ward for adults of working age that was consistent with national guidance on best practice. Meaningful activities on both wards were lacking. The wards had been without therapy and activity staff for some time and nursing and healthcare assistant staff were not proactive in providing activities on the ward.
  • The ward team did not include and did not have access to the full range of specialists required to meet the needs of patients on the wards. The trust had not ensured that all staff had access to training to enable them to have a range of skills needed to provide high quality care. Staff did not receive regular formal clinical or management supervision. Agency staff and new starters did not always receive a full induction to the ward.
  • Staff at all levels did not feel supported by the trust. Staff did not feel listened to and felt their concerns were not taken seriously. Staff told us they were stretched, stressed, burnt-out and that they were too busy and constantly “fire-fighting”. Morale across both wards was low.
  • The trust did not have robust governance arrangements in place to ensure managers had adequate oversight of areas of risk and improvement such as meaningful activities and psychological interventions, physical health monitoring and reporting of incidents.

However:

  • Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
  • The trust had recently recruited to the occupational therapy, psychology and activity co-ordinator vacancies.

How we carried out the inspection

During the inspection visit, the inspection team:

  • interviewed the deputy director of nursing for mental health
  • interviewed two ward managers
  • spoke with 13 members of staff, including four nurses, five health care assistants, one occupational therapy technician, one consultant psychiatrist, one ward clerk, and one human resources assistant.
  • spoke with seven patients
  • reviewed all 34 patient care and treatment records
  • reviewed all 34 patient prescription charts and physical health monitoring forms
  • reviewed a sample of observation records
  • reviewed a sample of incident reports
  • attended a multi-disciplinary team meeting and
  • completed an observation of the communal areas of both wards.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Patients told us that staff were nice, caring, treated them with dignity and respect but were always busy. Leave was often cancelled, or time was reduced due to staff shortages. Patients said they would like to do activities but there currently weren’t any. Patients said although there are always staff around, they are not always able to interact with them and they spend most of the day in their bedrooms.

Wednesday 5th August 22020

During an inspection of Child and adolescent mental health wards

We carried out a focused inspection of Austen House, a child and adolescent mental health unit at Southern Health NHS Foundation Trust.

The trust provides child and adolescent mental health wards in three locations: Bluebird house, Leigh house and Austen house. Austen house is a standalone unit with one ward set within its own grounds, close to the Tatchbury Mount site.

The wards are registered to provide the following regulated activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983.
  • Treatment of disease, disorder or injury.
  • Diagnostic and screening procedures.

We visited Austen house following concerns raised from a Mental Health Act remote review of the ward. Young people had told the reviewer that there was not enough staff and this was impacted on their access to education, therapy, activities and that they had to wait a long time before being able to access the garden and mobile phones to call relatives. There were also concerns that due to the high number of incidents and young people on high level of observations that there were not enough staff to ensure young people received adequate support in a timely manner. At the time of the inspection two young people required nasogastric feeding. This is a method of feeding via a tube from your nose to your stomach. There were concerns that not all staff had been trained to complete this procedure.

As we visited only one ward in this focused inspection, the rating from the previous inspection still applies and this inspection will not include a rating.

We conducted an unannounced focused inspection looking at specific areas of the following key question:

  • Is it safe?

During this inspection, the inspection team:

  • Visited Austen house, looked at the environment and observed care
  • spoke with the ward manager
  • spoke with five staff including three nurses, one student nurse and two healthcare assistants remotely
  • spoke with six young people over the phone as part of the Mental Health Act remote review
  • spoke with six carers over the phone as part of the Mental Health Act remote review
  • looked at five care and treatment records of young people
  • reviewed incident reports
  • looked at the previous three months of staff rotas, staff induction files and training matrix and other documents relating to the running of the wards.

08 – 10 October 2019

During an inspection of Child and adolescent mental health wards

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

  • The service provided safe care. The ward environments were generally safe. The wards had enough nurses and doctors to keep young people safe and meet their needs. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding. Staff assessed and managed young peoples’ risks and followed best practice in anticipating, de-escalating and managing challenging behaviour. There had been a reduction in the use of restraint since our previous inspection.
  • The design, layout, and furnishings of the wards supported young peoples’ treatment, privacy and dignity. Staff and young people had a range of rooms and equipment to support treatment and care including clinic rooms, sensory rooms, games rooms, gyms, multifaith rooms, activity and lounge areas. The wards all had gardens that young people could access.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the young people and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of young people on the wards. Managers ensured that these staff received training and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. Young people could feedback and were involved in decisions about the service, including the development of the new unit.
  • Young people were encouraged and supported to attend the onsite schools and study for qualifications. Staff actively involved young people and families and carers in care decisions. Staff supported young people in their recovery by involving them in care planning, enabling then to make advanced directives and providing them with information and carefully considered discharge plans. Staff looked after young peoples’ physical health with observations and health eating cooking classes.
  • Young peoples’ families and carers were appropriately involved in their care and could visit, attend ward rounds and receive updates from the ward.
  • Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • Staff felt respected, supported and valued and they were committed and felt positive and proud of their work. Staff are involved in the development of the service. They had access to support for their own physical and emotional health needs. Staff met each other regularly to discuss their work and learn from the performance of the service.
  • Leaders understood the issues, priorities and challenges the service faced and managed them. They were visible in the service and supported staff to develop their skills and take on more senior roles. Managers monitored risks through appropriate systems such as meetings to discuss their risk register. Leaders had closed one of the wards due to staffing shortages and were working hard to recruit and retain staff. There were systems and processes in place to ensure service developed in response to learning from complaints and untoward incidents. Staff were debriefed and received support after serious incidents.

However:

  • Young people and staff told us young people did not have enough to do when they were not at school. Some young people told us they did not like the food at Bluebird house; staff were trying to address this.
  • Staff morale was varied at Bluebird house and some staff said they were stressed about forthcoming moves.

08 – 10 October 2019

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

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

  • At this inspection we found that all of the improvements we told the trust to make had been made.
  • The trust had responded to staffing problems by reduced bed and increasing staffing levels on wards. It had also increased the senior presence and oversight on each ward, ensuring that there was always senior, experienced nursing staff available on each site every ward. Numbers to ensure safety while stabilising the staffing teams and recruiting more staff. Managers told us that there continued to be challenges with staffing but that the service had been successful in recruiting several newly registered nurses, support workers and block booked agency to ensure the consistency of agency staff. Ward teams were now more stable and staff felt able to deliver safe care and meet patients’ needs.
  • Staff now received regular supervision and regular team meetings were held on all wards to provide staff the forum for raising concerns and sharing learning. Staff told us that they felt supported by their peers, teams and their managers. Regular away days had been introduced. Staff told us that they felt well supported by their peers and by their managers.
  • The trust had acted to mitigate ligature risk on the wards. There was a programme of ligature reduction and we found further modifications to fittings such as curtains and doors had been made since the last inspection. Staff managed ligature risks well. All sites visited were clean and well maintained, staff demonstrated knowledge and good practice around infection control. Clinical rooms on all wards were fully equipped with accessible resuscitation equipment and emergency medications which staff checked regularly.
  • Patients told us that there were staff available in the ward areas and that there were enough around to ensure that they had regular one to one time. Staff knew what incidents to report and how to report them, we saw evidence of raised concerns and reported incidents and near misses in line with trust policy. Managers debriefed and supported staff after any serious incident.

  • Staff completed risk assessments for each patient on admission using a recognised tool and reviewed this regularly, including after any incident. Staff used observations of patients and the ward environment to assess and monitor risks. Staff knew about risks for each patient and acted to prevent or reduce risks. Staff applied restrictions on patient’s freedom only when justified.
  • Staff spoke to patients about their preferred physical interventions if it became a restraint situation. Staff used restraint as a last resort. There was a culture of using the least restrictive interventions on wards and staff made every effort not to use restraint.
  • Staff carried out comprehensive assessments with all patients following their admission. The duty doctor completed physical health assessments for all patients on admission. Staff monitored ongoing physical health conditions requiring care, such as diabetes or epilepsy, by completing national early warning score (NEWS 2) forms.

  • Staff developed a comprehensive care plan for each patient that met their mental and physical health needs. Staff involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. They ensured that patients had easy access to independent advocates.

  • Patients had access to a range of therapies recommended by National Institute of Health and Care Excellence. Staff used the Health of the Nation Outcome Scale to rate the progress and outcomes of patients. The service had a full range of specialists to meet the needs of the patients on the ward.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • Ward managers told us that wherever possible they ensured beds were available for patients living in the catchment area and made every effort to prevent out of area placements. They worked with bed management co-ordinators to review if other patients were ready for move on or discharge to make beds available. Beds were always available when patients returned from leave. Staff carefully planned patients’ discharge and worked with care managers and coordinators to make sure this went well. Discharge was planned for in advance where possible. Each patient had their own ensuite bedroom, which they could personalise.
  • Staff made sure patients had access to opportunities outside of the service through activity and signposting to job or volunteer opportunities. Information on patients’ rights, local services and how to complain where displayed in each ward and were noted patient welcome packs. 
  • Patients had access to appropriate spiritual support while on the wards. Each ward had visiting chaplains and a multi-faith space for patients to use. Staff understood the policy on complaints and knew how to handle them.
  • Leaders within the teams had the skills and abilities to run their wards. They demonstrated passion for patient care and showed they had the knowledge to help run the service. The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Staff felt respected, supported and valued.
  • Leaders managed performance using systems to identify, understand, monitor, and reduce or eliminate risks. Staff had access to information and technology to support them in their work. 
  • All staff were committed to continually improving services and had a good understanding of quality improvement methods.

However:

  • Staff on Hawthorn 1 and 2 told us that the furniture was not fit for purpose as it was an infection control risk. Although a capital bid had been put to the board to replace it this had been unsuccessful as the trust had other immediate priorities that it needed to fund. Staff said it was difficult to get maintenance work done in a timely manner. For example, the washing machine on Saxon ward had been broken for some time and despite reporting this it had not been fixed.

  • It was difficult for staff to observe or communicate with a patient in the seclusion room at Hawthorns 2 when they were using the toilet facilities. Staff had raised this as a potential risk issue, but this had not been addressed by the trust. Staff made every effort to manage patients safely and there had not been any incidents.

  • There were no female PICU beds within the trust, so staff needed to refer out of area if a bed was needed. There had been a small number of occasions when patients admitted to Elmleigh ward had needed to be secluded in the health based place of safety suite while they waited for a PICU bed.

08 – 10 October 2019

During an inspection of Mental health crisis services and health-based places of safety

  • Due to recent changes in the way crisis services and health-based places of safety suites were managed both managers and staff of the services unclear who the senior manager was who held responsibility for the service. 
  • Staff working for the crisis teams still did not consistently develop and record holistic, recovery-oriented care and crisis plans informed by a comprehensive assessment and in collaboration with families and carers.
  • Leaders did not have assurance that the trust was meeting its legal obligation to ensure people did not stay in the health-based places of safety for longer than 24 hours or have an extension granted by an approved person because staff were not consistently completing the required hourly checks. There were no systems in place to ensure staff entered correct entry times, completed the hourly checks or to ensure staff would escalate appropriately so action could be taken if people had been in the health-based places of safety nearing the 24 hour time period.
  • The physical environment of the health-based places of safety did not fully meet the requirements of the Mental Health Act Code of Practice. For example, two of the three suites did not have a clock (this is important so that people brought into the suites know how long they have been there). There was no toilet door at the Antelope House suite and in the Elmleigh suite the toilet had no walls or door for privacy.
  • Staff in the crisis teams did not always record that they had considered a patients capacity to consent to treatment or did not record whether patients had capacity in the patient electronic records. It was therefore not clear to all looking at the records whether a patient had capacity or not to make a particular decision or when best interest decisions had been made.

However:

  • The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed team caseloads well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff provided a range of treatments that were informed by best practice guidance and suitable to the needs of the patients.
  • The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The crisis services and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the crisis teams well. The services did not exclude patients who would have benefitted from care.

08 – 10 October 2019

During an inspection of Wards for older people with mental health problems

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

  • Female patients did not always have a female-only designated area as the female-only lounges were accessed by male patients. The female only lounges were often used for other activities and meetings. We saw male patients wander into female lounges. One was a frequent user of the female lounge because he wanted to use exercise equipment in the room.
  • Staff did not protect patients from infection control issues when disposing of clinical waste. Staff did not work in line with the trust policy on handling and disposal of healthcare waste. There was a carpet on Beechwood ward that posed an infection control risk . Staff had escalated this but this had not been addressed. Patients on five of the seven wards had limited access to a clinical psychologist and psychological therapies. Two wards had recruited a psychologist for two days per week, but others had no provision and nursing staff told us that they didn’t have the skills to deliver any psychological therapies.
  • Staff across the services had limited understanding about the use of Mental Capacity Act. The service did not have a procedure for monitoring the use of the Mental Capacity Act and recording of mental capacity assessments was minimal and variable within the patient records.
  • Patients on Beaulieu ward were unable to access a nurse call alarm from their bedroom areas so could not call for help from their bedrooms in an emergency. Staff told us these had been removed during refurbishment.
  • Some patients had to sleep in dormitories. While the trust had plans to eradicate dormitories in the future staff had little knowledge of what the plans were and when this might happen.

However:

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

  • Patients were monitored closely by staff to make sure they were not at risk. Risk assessments for falls, skin problems, pressure ulcers and bone density, as well as those related to their mental health issues were robust and detailed.

  • Staff used nationally recognised tools to assess patients and environments were generally dementia friendly

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

08 – 10 October 2019

During a routine inspection

Our rating of the trust improved. We rated it as good overall because:

  • We found that the trust had a highly skilled, strong, stable and experienced senior team, including the chair and non-executive directors. Leaders had the skills, knowledge, integrity and experience to perform their roles and had a good understanding of the services they were responsible for delivering. They were visible in the service and approachable to patients and staff.

  • There was a clear vision, underpinned by a set of values that were well understood by staff across the trust. We noted some really clear thoughts and developments around aligning with partners across the health and care economy to further develop services that put patients at the centre of care. The trust was taking a leading role in a number of the system wide developments and the chief executive was leading on progressing mental health services.

  • The leadership team had taken significant steps to improve the culture across the trust and this was paying dividends. Staff across the trust felt valued but there was a real focus on doing what was best for people, both staff, patients and carers and a real commitment to the delivery of good quality patient care at every level. Staff at all levels of the trust were proud to work there and morale amongst staff was good. Both the Council of Governors and the trade union representatives were very positive about how the trust leaders worked with them in an open and transparent way.

  • Leaders ensured there were structures and robust systems of accountability for the performance of services. There was a clear focus on delivering high quality care whilst maintaining clear oversight of finances. Some positive work had been done with commissioners to identify the underfunding in mental health services and the trust was working with commissioners to address this in order to ensure the sustainability of services in the future.

  • There were some positive developments around succession planning at senior level and thinking to the future in developing the ‘rising stars’; including some really good work around equality and diversity to ensure the senior leaders of the future were representative of the population the trust served and the staff group.

  • The leadership team had engaged proactively with a number of families who had previously not received the appropriate level of care, consideration and investigation into their loved one’s deaths or poor experience of care (under a previous leadership regime). Each family worked with a senior member of the trust's leadership team of their choosing in a partnership arrangement. The trust partners included a member of the executive team and a deputy director of nursing as well as both medical and clinical directors. In late 2018, the trust sought the assistance of NHS Improvement to help address the outstanding concerns of five families which then commissioned an independent review undertaken by an experienced barrister. This report is due to be published in January 2020.                   

  • All in the trust had worked hard to address most of the concerns we raised in the last inspection. Two out of the four services we inspected (acute wards for adults of working age and tier 4 child and adolescent mental health services (inpatients), which were previously rated as requires improvement, have been rated as good following this inspection. Two services (wards for older people with mental health problems and crisis and health based place of safety) remain requires improvement but several improvements have been made.

  • Staff put patients at the centre of everything they did. Staff treated all patients with compassion, respect and kindness. The privacy and dignity of patients was maintained. Patients were supported by staff to understand and manage their care and treatment. Staff actively involved families and carers of patients in their care appropriately. For example, families were heavily involved in the development of Austen House, the new child and adolescent low secure inpatient unit.
  • Services had enough medical and nursing staff to keep patients safe and meet their needs. Most teams in the organisation had access to a full range of specialists required to meet the needs of patients in their care. Care was planned and provided in a way that met the needs of local people and the communities the trust served. Staff met the needs of patients with a protected characteristic. Staff supported patients with communication, advocacy and cultural and spiritual support.
  • The trust had made some really positive steps in implementing quality improvement work across the organisation. The pace of progression had been considerable even though it was still early days but staff at all levels were enthusiastic although there was still much to do to ensure quality improvement work was embedded in all areas. The trust had employed an expert by experience specifically to engage in engage in quality improvement projects. Their role was to ensure co-production at all levels. All the improvement initiatives involved patients and/or carers; there were 250 patient/carers involved in initiatives across the trust.
  • The trust managed incidents well and investigated them thoroughly. Staff understood how to report them appropriately. Lessons were learned from incidents and shared with staff across the trust. The trust was also progressing some positive work around learning from deaths.
  • The trust treated concerns and complaints seriously. The organisation investigated concerns and complaints and shared lessons learned with staff. Patients were included in the investigation of their complaint.

However:

  • The trust had not yet made all of the improvement that we identified needed to be made at the last inspection in older people and crisis services.

On wards for older people with mental health problems:

  • Female patients did not always have a female-only designated area to use as the female-only lounges were accessed by male patients.
  • Staff across the services had limited understanding about the use of Mental Capacity Act.
  • Patients on five of the seven wards had limited access to a clinical psychologist and psychological therapies.

On crisis and health based place of safety suites:

  • Due to recent changes in the way crisis services and health-based places of safety suites were managed both managers and staff of the services were unclear who the senior manager was who held responsibility for the service. 
  • Staff in the crisis teams did not consistently develop and record holistic, recovery-oriented care and crisis plans informed by a comprehensive assessment and in collaboration with families and carers.
  • Senior leaders did not have assurance that the trust was meeting its legal obligation to ensure people did not stay in the health based places of safety longer than 24 hours or had an extension granted by an approved person because staff were not consistently completing the required hourly checks or recording information accurately.

In addition, we found:

  • That the board, particularly the non-executive directors were not representative of the community Southern Health served or the staff group. This was known and high on the trust’s agenda.
  • In older people’s services staff did not work in line with the trust policy on handling and disposal of healthcare waste.
  • Patients on Beaulieu ward (older people’s services) were unable to call for a nurse in the event of an emergency from their bedroom areas. Staff told us that call bells had been removed during refurbishment and had not been replaced by any other means for patients to call for help.

20 February 2019

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

Prior to the inspection, in response to concerns raised by patients, staff and the local leadership team regarding the safety and quality of care at Antelope House the trust had made a number of key changes to the staffing structure including new leadership and additional checks on safety and support for staff. The trust introduced these key changes on 11 February 2019 so had only been in place nine days prior to our inspection.

Prior to the new staffing arrangements being implemented the senior management team spent time talking with staff, visiting the wards to ensure they understood the issues facing staff and consider what changes needed to be made to make improvements to the quality and safety of patient care.

Changes had been made to managerial and nursing roles and additional medical support was put in place to support staff. Daily safety huddles were also set up to discuss risks and concerns within Antelope House. Changes were communicated to staff in writing and in person. However, these were new and not fully embedded.

During the inspection, we found:

  • Staff had not ensured that risks concerning a patient’s physical health had been fully addressed.
  • Staffing levels were not always sufficient and fell below the trust ‘safer staffing levels’ on both wards approximately once per week. There were a number of vacant posts on both wards and a high level of staff sickness. The wards were heavily reliant on bank and agency staff and some shifts were left short by one or two staff members once or twice per week.
  • Staff morale on Hamtun ward was low, three staff were off sick and the remaining staff team were feeling under pressure. Staff said that prior to the changes they had felt undermined by senior management regarding admissions to the wards and felt that communication had been poor.

However:

  • The trust had recognised that staff morale was low on Hamtun ward and had put in place arrangements to bring about improvements. During the inspection staff told us told us that they felt there had been more support from senior management recently.
  • The trust had implemented daily safety huddles to discuss any concerns on the wards and provide additional support to staff and monitor patient safety.
  • Staff on Saxon ward felt that morale was good.

21 May 2018 to 05 July 2018

During an inspection of Community health services for adults

  • Sufficient numbers of suitably trained staff were deployed to meet patients’ needs. Further training opportunities were provided by the trust to allow staff to expand their skills and professional knowledge.

  • Staff followed professional guidance and applied this in their treatment to provide safe and effective care to patients.

  • Patients received outstanding care delivered by staff who took exceptional care to ensure their emotional and wellbeing needs were met.

  • Staff recognised and acknowledged patients who had additional support needs associated with their illness or long-term health condition. Patients were supported by staff who understood how to meet these additional needs.

  • The trust was led by a strong executive team who demonstrated a visible presence to staff. Staff spoke positively of the service leadership saying they promoted a patient centred culture which was focused on improving the lives of the patients they supported.

However:

  • One team did not have access to the trust’s ‘Store and Forward’ record keeping system on their laptops. This meant not all patients had up to date information available in their homes for other health and social care professionals to follow.

  • The investigation of complaints did not take place in a timely way leading to delays in responding to the complainant. The service did not complete investigation of, respond to, and close complaints within agreed timescales.

21 May 2018 to 05 July 2018

During an inspection of Child and adolescent mental health wards

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

  • The Care Quality Commission issued a warning notice due immediate concerns of the safety of young people using the service. We required the trust to make significant improvements to the quality of care delivered in the service by 16 July 2018.
  • At Bluebird House there were insufficient levels of staff on the wards to ensure that young people were protected from avoidable harm. There had been an increase in the number of prone restraints, there was a high number of incidents and observations and physical health monitoring, including physical health monitoring following rapid tranquilisation were not always being conducted as needed. Bluebird House was dealing with some extremely challenging situations at the time of the inspection which CQC escalated to NHS England as the commissioners of the service. NHS England recognised that it needed to support the service to help resolve and/or deal with the challenges (which are still ongoing) and made further funding available to increase staffing levels to help the service to deal with the challenges.
  • We found a significant number of ligature risks at Leigh House that were not being managed appropriately.
  • The risk register was not being used effectively to escalate the seriousness of the staffing problems to the executive team and trust board. The data about the use of restraint and seclusion was unreliable so could not provide robust information about restraint and seclusion practice and prevalence.
  • Staff and young people felt that there were often too few activities being offered and young people said there was often little to occupy them.
  • At Bluebird House staff told us that there were times when they felt unsupported and experienced significant stress.
  • Individual supervision was not in line with the expected completion rate set by the trust.
  • Staff, across the two sites, had varying knowledge of the Mental Capacity Act (MCA) and Gillick competency.

However:

  • The trust responded immediately to the concerns we raised and voluntarily agreed to suspend admissions until it had addressed the safety issues. The trust provided an action plan that set out how it would make the improvements required by the warning notice. We undertook an unannounced, focussed inspection on 18 July 2018 to check that the trust had taken the actions identified in its action plan. We found the trust had reconfigured the wards at Bluebird House and had increased staffing levels on each shift; no shifts were left uncovered and as such there were always sufficient, suitably qualified and competent staff on duty at all times. Observations were being conducted appropriately although some further work was needed to ensure these were always recorded. Environmental work to address the ligature risks at Leigh House were nearing completion and staff had detailed knowledge of the management of the risks. Staff and young people told us that they now felt safe. As such we lifted the warning notice.
  • Young people had their mental health needs assessed prior to admission. Admissions to the wards were discussed and screened to review risks. Staff completed comprehensive risk assessments and recorded these in the patient care record.
  • Care plans across both sites consistently demonstrated a holistic approach to care.
  • There were consistently good outcomes for young people. Staff planned care in conjunction with young people focussing on recovery from their mental health problems.
  • The service provided a number of psychological therapies recommended by the National Institute for Health and Care Excellence (NICE).
  • Discharge was planned in advance.
  • Young people said that the staff were caring and treated them with dignity and respect. Both sites had service user forums and young people were involved in decisions about the service. Families and carers received regular updates from the wards when appropriate.
  • Staff were aware of how to recognise and report incidents. Managers refused admission if the wards were unsettled.
  • Young people admitted to the wards had their own bedrooms. There was a range of facilities at both sites and there were disabled adaptations. The school at Leigh House supported young people to gain outstanding academic results.. Young people knew how to complain and staff responded well to concerns and complaints.
  • The buildings were in good order, clean throughout and well maintained. Clinic rooms were well equipped, including with resuscitation and emergency drugs.
  • Young people on the eating disorder programme had their meal plans monitored to ensure treatment was effective.
  • The teams appropriately inducted new staff into the service. Staff received specialist training to work within the service. Multi-disciplinary teams met weekly with young people to review progress and treatment
  • Staff were trained in the Mental Health Act and they conducted seclusion reviews in line with guidance.

21 May 2018 to 05 July 2018

During an inspection of Community mental health services with learning disabilities or autism

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

  • Staff were caring, respectful and compassionate. Patients and carers gave consistently positive feedback about staff. Staff understood patients’ needs and preferences and found creative ways to communicate with patients and involve them in their care.
  • Carers felt supported by the staff teams and felt staff helped them solve problems and were available for additional support. An intensive support team created tailored care programmes for carers and ensured they could implement the plans.
  • There were active service user groups in each locality. Staff offered patients training and coaching to enable them to be on interview panels, chair meetings and review documents relating to the service.
  • Staff were motivated to provide high quality care. Access to the service was efficient and waiting lists were short. Staff supported patients to access physical health care from other services and developed documents with patients to help them express their physical and mental health needs. They supported patients during transitions between placements.
  • Teams were well led. There were enough staff with the appropriate skills to deliver a safe and effective service. Staff told us managers were available and approachable. Managers praised staff for doing a good job. Managers monitored staff performance. They ensured staff were well trained, appraised and supervised. They enabled staff to develop their skills and pursue special interests. Morale was good.
  • There was an open culture and a willingness to learn. Staff developed the service in response to learning from complaints and incidents. Staff welcomed feedback from patients and carers. There was a good structure of meetings for staff to discuss the safety and quality of the service. There were processes for escalating and monitoring service risks and staff were involved in the process.

However:

  • Staff did not monitor if patients had been offered a copy of their care plan.
  • Staff did not always document a Mental Capacity Act assessment when they needed to, such as when making best interest decisions about patients’ treatment.
  • Some staff were stressed by frequent change and demands from the trust. Staff described having to respond to directives from senior management which they felt were sometimes risk aversive and less relevant than local issues.
  • There were information technology connectivity issues at two of the team bases that was causing stress to staff.

21 May 2018 to 05 July 2018

During an inspection of Community-based mental health services for older people

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

  • All the environments we visited were comfortable, clean and welcoming. Environments had disabled access and toilets. Conversations could not be heard from outside interview rooms and staff were aware of issues around privacy and dignity during confidential interviews. Clinic rooms were well equipped and maintained. Staff made sure equipment was checked regularly.
  • There were no waiting lists at the service due to the efficiency with which referrals were handled and caseloads were manageable within the teams. Staff completed risk assessments on admission and ensured regular monitoring of patients’ physical and mental health.
  • All patients had care plans in place which contained risks and interventions. Staff were focussed on the health and wellbeing of patients. Staff involved carers in assessment and treatment and offered support and advice on issues and services. Patients, families and carers told us they were happy with the care received.
  • Teams discussed clinical and managerial issues in weekly multidisciplinary meetings. Staff attended mandatory training and knew how to raise a concern. There were seven serious incidents reported in the previous 12 months. Reporting systems were in place and staff across the trust learned from incidents.
  • There was evidence of good leadership in all teams. Managers were visible and supportive, and motivated their teams to create a positive culture. Staff morale was generally good and vacancy rates were low across the teams. Sickness was monitored and managed well in most teams.
  • Staff were positive about the leadership in the trust. Staff were also aware of the senior management team, and told us that senior managers were visible and accessible.

However:

  • Clinic rooms did not have alarm systems fitted and staff did not carry personal alarms.
  • Although risk assessments were completed on admission, they were not always updated in the patient records. The quality of risk assessments varied across the service.
  • Staff did not always report incidents that should have been reported.
  • Some medicines that required storage below certain temperatures were not stored in a temperature controlled environment.
  • Staff did not always make a safeguarding referral when they had identified potential safeguarding concerns.
  • Patients did not always get offered their care plans and patient records did not show that staff offered care plans.
  • Some teams did not keep records of staff clinical and managerial supervision.
  • The provision of psychological therapy varied across the service, with one team having no access to psychological therapy.
  • The provision of office space in New Forest East, Parklands and Gosport was not sufficient to allow staff to complete their roles adequately.

21 May 2018 to 05 July 2018

During an inspection of Mental health crisis services and health-based places of safety

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

  • The service did not ensure that staff from the health based place of safety service collected and used information well to support all its activities. Senior trust members did not have full access to information concerning the 24 breaches where the maximum detention period in the health based place of safety had been exceeded (It is a requirement that patients, who have been not been given an extension by an approved person must not be detained more than 24 hours in the health based place of safety). Staff did not follow the trust policy of monitoring patients held in the section 136 suite hourly and the trust did not monitor this.

  • Care plans and crisis plans were not all up to date or comprehensive and so did not support the team’s delivery of safe care and treatment to patients. Staff members from the ambulance service who stayed with patients brought into the section 136 suite until the trust had completed the assessments did not have access to up to date, accurate and comprehensive information about patients in their care and treatment plans.

  • Both the crisis teams and the health based place of safety staff did not ensure crisis plans were consistently completed. The trust monitored completion monthly. Data showed that compliance was mixed across the teams. In the south team, on average 60% of patients had crisis plans. In the east, the average was between 48% and 72% compliance. However, each team had a plan in place to address this.

  • There were delays in patients being able to see a psychiatrist in the crisis teams. For some patients this mean that there were delays to them starting on the appropriate medication and others had not received a medical review when needed. Patients receiving care from the south crisis team had easy access to a psychology team who provided a wide range of psychological therapies and groups but in the north and east teams patients had to be referred to a psychologist.
  • Staff did not fully understand their roles and responsibilities under the Mental Health Act 1983 Code of Practise 2015 because patient’s ethnicity was not included in the monitoring form in line with the Code.
  • Managers of the service did not consistently monitor the number of safeguarding referrals sent to the local authority.
  • The trust did not have a process to obtain feedback from patients who had used the health based place of safety.
  • There was no toilet door in the section 136 suite at Antelope house which compromised patients’ privacy when using the facilities

However:

  • Patients were seen quickly by the crisis service. Patients could access the service when they needed it. There was an out of hours provision for patients. Patients had access to a crisis lounge in Antelope House all day and night.
  • Patients were quickly assessed by the crisis team and the staff in the health based place of safety.
  • The crisis team took a proactive approach to monitoring and re-engaging with patients who did not attend appointments
  • The trust was monitoring incidents in relation to the new ambulance provider and there was learning from each incident.
  • Staff treated patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • The managers across all teams ensured that staff had access to regular team meetings to share information and develop learning.
  • The managers promoted a positive culture that supported and valued staff.
  • Staff morale was mostly good and staff felt positive about working in their teams.

21 May 2018 to 05 July 2018

During an inspection of Wards for older people with mental health problems

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

  • Female patients did not have a female-only designated day area that was not used by male patients. Some wards had female only lounges but these were often used for de-escalation and on Elmwood ward, a male patient was present in the female lounge during the day of our inspection. Staff told us this patient spent every day in the female lounge
  • Medication across all wards was not stored at a safe temperature. The trust was aware but this had not been acted upon.
  • A patient on Beechwood ward had been detained informally without any legal safeguards. Staff believed the patient did not have capacity to consent to admission, however, they had not assessed his capacity and he was frequently trying to leave.
  • Staff on Beaulieu and Berrywood ward were not reporting safeguarding concerns in line with trust policy or legislation.
  • There was no provision for psychological therapies.
  • We had concerns of patients’ privacy and dignity. Staff told us patients did not always have access to private telephone calls. Female patients on Rose ward had to walk past communal areas to get to the washing facilities.
  • The trust did not have a good overview of some of the governance issues occurring on some of the wards. The trust did not have a procedure for monitoring the use of the Mental Capacity Act. There was no oversight of the safeguarding referral process on Beaulieu ward and Berrywood ward. The trust did not have oversight of the use of the Mental Health Act on Beechwood ward.

However:

  • Staff on all wards undertook the required mandatory training. Any new starters were quickly booked on to future training sessions.
  • Care records were mostly detailed, holistic and person centred. Records were updated as necessary and regularly reviewed.
  • Staff were routinely holding best interest meetings for patients that lacked capacity to make specific decisions. Patients’ relatives were involved where appropriate, as were Lasting Powers of Attorney for health and welfare.
  • Staff monitored patients’ physical health well. Staff used a range of tools and scales to assess and review patients’ physical well-being.
  • Patients felt respected, cared for and involved in their care and treatment. Patients were involved in their care planning process and decisions about improvements that could be made on the wards.
  • Staff planned patients’ discharges early on in their admission. Relationships with the local authority had been strengthened which contributed to a smoother discharge process for patients.
  • Staff felt supported by leadership across the wards. The executive team had become more visible at ward level and staff felt there had been improvements in culture.

21 May 2018 to 05 July 2018

During an inspection of Community-based mental health services for adults of working age

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

  • All patients had a risk management plan, and a crisis plan where appropriate. Most patients had next of kin details recorded and consent to share information details had been completed.
  • Staff responded promptly to a deterioration in a patient’s mental health. Patients were placed on ‘shared care’ when their mental health deteriorated. Patients would receive extra home visits from a care co-ordinator to provide additional support on weekdays, evenings and weekends.
  • Some teams had physical health leads responsible for ensuring patients’ physical health was monitored and their needs were met.
  • Teams learnt from incidents and shared learning across teams and the trust.
  • Caseloads sizes were continually being monitored and caseload sizes had reduced since the last inspection.
  • Staff provided a range of care and treatment interventions suitable to the patient group, for example, running dialectical behavioural therapy groups for those with a personality disorder diagnosis.
  • Staff were passionate, compassionate, knowledgeable and proud of their work. Teams were cohesive and supported one another.
  • All teams proactively tried to contact patients who had missed scheduled appointments and who were reluctant to engage in the service. Staff made phone calls, sent letters and did cold calls to follow-up with patients who had not made contact with the service following a missed appointment.
  • Managers ensured staff were regularly supervised and appraised. Teams held regular structured and effective meetings such as team, shared care, multidisciplinary and business meetings. Teams were well-led.
  • Managers had clear action plans and were continually working towards improving the service provided to patients.
  • There was an emphasis on improving involvement from patients and carers in the development of the service.

However:

  • Not all of the teams were adhering to the trust’s safeguarding policy and making safeguarding referrals directly to the local authority. Procedures for making referrals to the local authority differed across teams. The procedure was particularly unclear at the Southampton teams.
  • Patients on clozapine, an anti-psychotic medication which requires regular physical health monitoring, did not always have a relevant medication care plan.
  • Care plans were not always person-centred, holistic and recovery-orientated. Some patients did not have a care plan.
  • Care plans were difficult to access on the electronic patient record system as staff did not save the document in the correct place and used various formats.
  • We could not find evidence that patients had always been offered a copy of their care plan or were involved in their care planning. Some patients we spoke to were not aware of their care plan.
  • Managers were not using supervision sessions to ensure staff improve the quality of patient’s’ care plans.

21 May 2018 to 05 July 2018

During an inspection of Wards for people with a learning disability or autism

 

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

  • Patients were at the centre of all the care provided on the wards. Staff made a holistic assessment of the patient’s needs and capabilities and built this into a care plan centred around the patient’s goals. Staff listened to the patient’s views and reflected these in their plans. They also explained the care plan to patients in a meaningful and clear way.
  • This spirit of inclusion and communication was echoed in the wards’ safe practices of observation, ensuring that patients’ views and wishes were considered while keeping them safe. The layout of the wards was designed to give staff unrestricted views of the ward, and used mirrors where needed to accomplish this. The trust had included patients and carers in designing a new build for the Ashford unit, and this was due for completion in October 2019.
  • There were good systems in place to ensure that staff logged and reported information such as incidents, and the use of restraint. There was high reporting of restraint on Willow ward. When we looked into this, we found that the staff were reporting all instances of de-escalation and low-level restraint, such as a ‘guiding hand’ as an incident of restraint. We concluded that staff were committed to using least restrictive practices where possible and all staff had been trained in how to use restraint.
  • There had been a reduction in the number of vacancies on the wards, but the forensic outreach team still had some vacancies.
  • Staff were experienced and had received specialist training from the trust to enable them to do their jobs effectively. Patients had access to therapies recommended by National Institute for Health and Care Excellence and national guidance about the use of antipsychotic medicine was followed. Staff regularly met as a group to discuss patients, and changes in national guidance was highlighted to them.
  • From the time that patients were admitted, staff were focused on helping them to recover enough to be discharged. This was well-planned and staff helped prepare patients for discharge by ensuring they kept in contact with the people they valued and engage in activities and groups in the community. Where patients were waiting for discharge this was because of a lack of suitable placements in the community.

21 May 2018 to 05 July 2018

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

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

  • The wards calculated the required numbers of staff within safer staffing guidelines but these numbers were not always met. Staff told us that this impacted on patient care due to a reduction in patient one to ones and escorted leave having to be cancelled occasionally, not always having enough staff to hand to deliver safe interventions with patients and therefore a higher level of incidents taking place.
  • The lack of staff also impacted on the ability of managers to provide adequate supervision to all staff. However, most staff members informed us that they were able to raise concerns, share information and gain development through other means, such as reflective group sessions attended by psychologists, peer support and handovers.
  • Not all wards held regular team meetings. This impacted on staff support and patient care, as concerns are not raised, learning is not shared with ward staff and may affect morale. For example, Hamtun Ward had very low staff morale, due to inconsistent leadership and lack of staff meetings.

However:

  • All the wards were well-maintained, clean and had appropriate furnishings. The wards were undergoing renovations to ensure there were appropriate anti-ligature fittings.
  • The wards shared learning from incidents. The environmental risk of patients absconding from Kingsley ward via the garden roof had been resolved and the trust had added anti-ligature and anti-climb rollers on the roof-ends. These measures had also been installed at Elmleigh ward.
  • Staff were caring and compassionate. Staff communicated well with patients and introduced new initiatives such as the ‘normalised care’ on Hawthorn which aimed at making the environment as non-clinical as possible. All items presenting risk were not necessarily locked away (such as television cables) but rather managed effectively through staff and patient engagement, observations, activities and relational security on the ward. Patients praised staff for this initiative.
  • Patient risks were assessed, monitored, updated and managed appropriately. Risk changes were identified immediately and discussed in weekly multi-disciplinary team meetings. Patients were involved in the risk updating process, as seen by audits ensuring the patients signed the risk assessments. The risk and patient assessments were comprehensive enough that the wards did not have to apply blanket restrictions.
  • We saw evidence of good physical healthcare of patients on all the wards. Patients were regularly assessed in weekly or fortnightly physical health checks. All the wards had access to dedicated staff leading physical health clinics and providing general care.
  • There was good multi-disciplinary work among nurses and other professionals on all the wards. All staff, including healthcare support workers, peer support workers, advocates and social workers felt involved in patient care and were invited to the patient review meetings.
  • Effective clinical audits were taking place on all the wards. Staff were involved in a number of audits, including hand hygiene, care planning, physical health assessments and wound audit. However, there were some inaccuracies in the Mental Health Act paperwork on Hamtun ward. This was raised with the managers on the ward at the time of the inspection and they informed us that they would carry out further audits of all MHA paperwork to ensure compliance.
  • There was considerable improvement in the care records on all the wards (since our last inspection). Care records were comprehensive, holistic and personalised.
  • We saw good examples of patient and carer involvement. On Kingsley ward staff were very passionate about ensuring that carers felt involved in their loved ones’ care and had introduced a number of support groups and sessions for carers.
  • The trust had introduced some training and development workstreams in care planning and effective team meetings on the wards to wards in delivering the best outcomes for staff and patients.
  • Staff felt that they had good opportunities for personal and professional development and that the trust encouraged career progression.
  • Most staff spoke highly of their managers and management teams, and felt supported and listened to.

21 May 2018 to 05 July 2018

During an inspection of Forensic inpatient or secure wards

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

  • Staff had built good relationships with patients. Staff gave patients information about the service and the treatments available. The information was provided in different formats and was freely available.
  • The service had regular fortnightly ward rounds that focused patient care, outcomes and on working with multidisciplinary teams.
  • New staff were provided with induction and a personal development program with regular reviews from managers and supervisors.
  • Staff assessed the needs of patients. Assessments were updated regularly by the multi-disciplinary team.
  • Staff assessed and managed physical health through weekly monitoring.
  • Patients said staff were kind and caring. They felt safe on the wards.
  • Staff had access to services in the trust and external services to meet patients’ needs. These included regular visits by an independent Mental Health Act advocate.
  • Staff understood safeguarding, what to report and how to seek advice on safeguarding issues. Staff followed the trusts safeguarding policy.
  • Staff received supervision and yearly appraisal but this was not always documented in line with trust policy.
  • There was good leadership from ward managers.

However:

  • There was no adapted bathroom or toilet facilities for people with physical disabilities at either site.
  • Patients’ care plans did not contain patients views and although staff told us patients were involved in planning their care this wasn’t always clear in care plans at Ravenswood House.
  • Some patients told us that there was little variety in the food served and that portion sizes where small.
  • Some staff at Ravenswood Medium Secure Unit said that they had experienced bullying. This was escalated to senior management and immediate actions were taken.

21 May 2018 to 05 July 2018

During an inspection of Long stay or rehabilitation mental health wards for working age adults

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

  • The wards were tailored to meet the needs of individual patients. Both wards were recovery orientated and planned discharge from the point of admission.
  • The wards were clean and well maintained. Environmental risks were identified and managed. Clinic rooms were clean, contained sufficient equipment and had access to emergency medication.
  • Staff were caring and compassionate towards patients. Patients told us staff were respectful towards them and supportive. Staff were experienced in rehabilitation and understood the needs of patients well. Staff completed risk assessments and updated these regularly. Staff were knowledgeable about how to identify a vulnerable person was at risk and how to raise a safeguarding alert.
  • We saw evidence of good physical healthcare of patients on both wards. Patients were assessed on admission and monitored regularly. The wards operated a staged self-administration of patient medication.
  • Staff knew how to report incidents and provided examples where learning from incidents had been implemented. Learning from incidents was disseminated to teams in meetings.
  • Care records were holistic, recovery orientated and discharge focused. Care plans covered all areas of well-being. Patients were involved in the development of their care plans from admission, could contribute their views and preferences and had copies of the plan.
  • The wards both had a good multi-disciplinary team and worked collaboratively. Staff were experienced in rehabilitation and understood the needs of patients. Staff were up to date with mandatory training.
  • The wards actively engaged with families and carers. Families and carers were invited to meetings, provided with detailed information and told us they were involved in the care of their relatives.
  • Patients could access meaningful activities on the ward and were encouraged and supported to engage in activities in the local community. Activities were available seven days a week.
  • Patients were provided with vast amounts of information. Patients received a welcome pack on admission and there was lots of other information leaflets available on the wards.
  • Both wards had clear admission criteria and worked with patients towards discharge planning. The average length of stay on the wards was between six and nine months. Patients were rarely readmitted to the service.
  • The wards had clear admission criteria and completed initial assessments to measure a patient’s suitability for the service. The wards were tailored to meet the needs of individual patients.
  • The wards had strong local leadership which provided stability and consistency in the quality of care. Staff felt supported in their roles and received regular supervision and appraisals. Morale among staff was high and they described the culture as open and transparent. Staff knew how to raise concerns and felt able to do so.
  • There were good governance arrangements in place to monitor the quality of care provided. Governance and performance management arrangements were proactively reviewed and reflected best practice.

However;

  • There was limited input from clinical psychologists available to patients on both wards.

21 May 2018 to 05 July 2018

During an inspection of Community urgent care services

  • Patients at both MIUs were seen quickly, assessed, treated and discharged within the national set target of 4 hours.
  • The service had enough staff with the right qualifications and experience to keep patients safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff treated patients and those close to them with dignity and respect. Patients felt supported and provided positive feedback.
  • Staff responded compassionately to pain, discomfort and emotional distress in a timely and appropriate way.
  • The trust board had determined and kept under review the information it required to monitor performance, set priorities and make decisions through a local reporting system.
  • Safety was a priority at all levels. Staff took an active role in delivering and promoting safety, learning and improvement.
  • Safety performance included waiting times for assessment and treatment, adverse incidents, complaints and compliments, which were monitored continuously and were reported to the board. We reviewed safety data from April 2017 to March 2018 and found no serious issues.
  • There was a positive culture and a very good supportive team working amongst staff. Staff at both MIU spoke enthusiastically about their department and the support they received.

However:

  • The Petersfield MIU was small with two clinical areas and was not fit for purpose due to the workload and this had been acknowledged by the trust. There were plans in place to reconfigure the area to increase to five clinical spaces. The present arrangements did not breech the privacy or dignity of patients.

21 May 2018 to 05 July 2018

During an inspection of Community health services for children, young people and families

  • There were sufficient numbers of skilled staff to deliver the service and staff had regular appraisals and training.
  • Staff completed and updated records of people’s care and treatment, and delivered care based on best practice guidance.
  • The service had systems for reporting incidents, complaints and risks and staff used these to improve care and practices.
  • Staff showed kindness and compassion and were committed to providing a good service to children, young people and families in the community.
  • There was an effective leadership and governance structure and a positive culture within the service. Staff understood the service aims, priorities and performances.
  • Staff understood the needs of the families in the local areas where they worked. They monitored non-attendance at appointments and acted to engage people who might to vulnerable.

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.

21 May 2018 to 05 July 2018

During an inspection of Community health inpatient services

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

  • Staff across all sites followed professional guidance and applied this in their treatment to provide safe and effective care to patients.
  • The trust was taking action to recruit and retain staff to ensure sufficient numbers of suitably trained staff were either employed or about to start at the trust to meet patients’ needs. There were effective selection, deployment and support processes in place along with succession planning.
  • Staff had completed training and were knowledgeable about responding to and treating risk. There were effective handovers at shift changes and safety briefings to ensure that staff could manage risks to people who used the services.
  • Safeguarding adults, children and young people at risk was given sufficient priority.
  • People’s care and treatment was planned, delivered and monitored in line with current evidence-based guidance, standards, best practice, legislation and technologies. People had assessments of their needs, which included pain relief, mental health, physical health and wellbeing, and nutrition and hydration needs.
  • Expected outcomes were identified and care and treatment reviewed and updated. Appropriate referral pathways were in place to make sure patients’ needs were addressed. The service monitored the effectiveness of care and treatment and used the findings to improve.
  • Staff were consistent and proactive in supporting people to live healthier lives. There was a focus on early identification and prevention and on supporting people to improve their health and wellbeing.
  • The leadership, governance and culture promoted the delivery of high-quality person-centred care.

However:

  • At Romsey hospital the geography of the wards did not facilitate the delivery of safe care and treatment at night time.
  • At Romsey hospital the privacy and dignity of patients was not always maintained as bed spaces were less than the recommended guidelines.
  • Safe records management was not consistent across all the hospitals. In some ward areas at Lymington hospital records were stored in an unlockable drawer.
  • Medicines management was not always provided safely. In some areas medicines were not stored safely in line with the manufactures guidelines and in some cases reused which was not in line with hospital policy

21 May 2018 to 05 July 2018

During an inspection of Community end of life care

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

  • Staff providing end of life and palliative care were appropriately trained and understood their responsibilities to keep people safe and what to do if they needed to raise a concern. There was improved oversight of end of life training and competencies.
  • Caseloads in the specialist palliative care team were planned and reviewed to ensure people received safe care and treatment at all times.
  • Risk assessments for care and treatment were used for patients receiving end of life and palliative care. There was timely access to advice, initial assessment care and treatment and, diagnosis or urgent treatment. Advice could be accessed at different times of the day.
  • Staff prioritised care for vulnerable patients with the most urgent care needs.
  • All wards and buildings we inspected were visibly clean. Staff followed infection prevention and control procedures and routine standards of cleanliness and hygiene were maintained.
  • The trust had improved the quality of patient records since the last inspection in 2017 to ensure information was included in a person centred manner.
  • There was a positive reporting culture within the trust, themes from patient safety incidents were identified monthly through the patient safety group and quality and safety committee.
  • Policies and procedures were developed in line with national guidance, and were accessible to staff to support their practice. The trust had recently commenced The National Audit of Care at the End of Life a three-year internal audit, specific to end of life and palliative care.
  • Improvements had been made in the use of individualised end of life care plans since our previous inspection and there were systems to record patients preferred place of death and to monitor outcomes.
  • Staff worked together to deliver effective care and treatment through multi-disciplinary teams.
  • Patients and those close to them told us they were treated with kindness, dignity and respect while they received care and treatment including during physical or intimate care. We saw staff show an encouraging, sensitive and supportive attitude to patients and those close to them who used the services.
  • Staff communicated clearly and knowledgably with patients so that they understood their care, treatment and condition.
  • Staff ensured that when a person was in the last days and hours of life they had an individual plan of care, which included food and drink and symptom control.
  • The trust worked with several clinical commissioning groups to understand and plan end of life and palliative care.
  • Some community hospitals had side rooms that could be used when available for patients at end of life such as Anstey ward at Alton community hospital.
  • The trust had an interpreter system and sign language specialists available. All community hospital wards had ‘dementia link’ nurses and had undertaken dementia awareness training.
  • Wherever possible, the trust ensured the same nurses visited the same patients to provide continuity of care to enable easier identification of changes in a patient’s wellbeing.
  • People who used the service knew how to make a complaint or raise concerns, and they were encouraged to do so.
  • The leadership and culture of staff reflected the vision and values of the organisation. The trust had a vision to provide high quality, safe end of life care. The governance framework was clear. Quality, performance and risk was, managed and leaders could identify the actions needed to address challenges to quality care.
  • The strategy was aligned to the National Palliative and End of Life Partnership’s Ambitions for palliative and end of life care and the values of the trust.
  • Services had continuously improved since the last inspection. The trust had reviewed progress of the implementation of the four-year end of life strategy (2017).
  • Staff felt respected and measures were taken to ensure staff were safe when lone working. Staff received support after working in distressing situations.
  • Leaders we spoke with at all levels of the organisation described staff as passionate about end of life care and said staff provided high levels of care.
  • Leaders prioritised the participation and involvement of most staff. Staff views and experiences were gathered by a series of ‘your voice’ staff engagement events.

However:

  • When we reviewed seven sets of records we saw that do not attempt cardio pulmonary resuscitation or DNACPR decisions were still not always recorded appropriately and in line with national guidance.
  • A number of improvements were still required for the recording of patient information in patient records, particularly related to timings of entries and level of detail in medical notes and clear rationale for prescribing decision.
  • At May 2018 there were three community teams still below the 60% target set for syringe driver training and competence.
  • Complaints received by the trust were not routinely able to be recorded under end of life care. The introduction to the electronic system for incidents of a means to do so was under review.
  • The availability of information for patients and those close to them had been the subject of a thematic review which identified improvements were required in this area.
  • There was no non-executive director lead for end of life and palliative care and the roles of leaders for end of life care were not clear from the intranet.
  • Not all relevant staff felt engaged in creating the strategy for end of life care.
  • The trust did not have a mechanism to explicitly gather experiences and opinions from those who had experienced the trust’s end of life care provision.
  • The trust did not participate in the Gold Standards Framework (GSF) Accreditation process.

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

We found the following areas of good practice:

  • The trust had taken significant steps to address the serious concerns raised at the last inspection to address the issues within the seclusion room at Antelope House. The trust had invested considerable resources to re-design the seclusion room and high care area and bring it in line with the requirements of the Mental Health Act code of practice. The layout and décor of the seclusion room and the high care area had been well considered and constructed to be as non-threatening an environment as possible for unwell patients.
  • Patients were very complimentary with regard to the level of care they received from the staff and the atmosphere on the wards at the time of our inspection was calm and we saw very positive interactions between staff and patients.
  • The staff we spoke with were knowledgeable about the patients on the ward and the staff team were passionate about achieving positive outcomes for the patients.
  • The senior management team had committed resources to analysing the issues of concern on the ward and there was clear planning with regard to driving improvements across the hospital, this included increasing the numbers of restraint trained staff on the wards, increasing staffing levels and skill mix across the wards too.
  • The trust was adopting innovative ways to attract new staff into the service and was also offering developmental opportunities to existing staff.
  • The ward environments were clean and well presented.

However, we also found the following issues that the service provider needs to improve:

  • There were some concerns with regard to examples of poor communication between the senior management team and staff on the wards; this included a lack of clarity with regard to the number of restraint trained staff that should be present within the hospital, and a significant change of plan with regards to the re-opening of Hamtun ward following the redesign of the seclusion room. Staff told us that they felt the trust had been dishonest in its behaviour around the re-opening of Hamtun ward and that their concerns for staff and patient safety had not been heard by the senior management team. Despite the lack of understanding by staff of the number of restraint trained staff considered by the trust to be safe on the wards; the trust was working within the policy by having five PRISS trained staff on duty across the site.
  • The seclusion records at Elmleigh were not completed correctly, the rationale for the seclusion was not always in line with the Mental Health Act (MHA) code of practice and where patients had been secluded more than once in a short time period it was difficult to follow the processes and to be sure that reviews had taken place appropriately. The records did not always state the legal status of the patient, the trust initially told us that where there was no information with regard to the status of the patient on the form then the patient was an informal patient and not detained under the MHA. However at a later visit to the trust we were told this was a recording error and staff had not completed the forms appropriately.
  • The trust was using the place of safety 136 suite at Elmleigh for seclusion of patients. This is contrary to the MHA code of practice and is contrary to the trust seclusion policy.

27 March to 31 March 2017

During an inspection of Community end of life care

We have not rated community end of life care services for Southern Health NHS Foundation Trust

Overall we found:

  • The trust end of life care strategy was due to be launched in April 2017, shortly after the inspection. This included the introduction of the individualised end of life care plan for use by community teams for people living at home. Although, on inpatient wards in the trust’s community hospitals an individualised end of life care plan had already been implemented and had been in use since 2016.
  • At the time of inspection no evaluation of the provision of end of life care had taken place.
  • Staff were familiar with the incident reporting process, however, not all staff we spoke with could confirm if incidents relating to care of end of life patients had been reported. The trust analysed and reported incidents but there was no analysis of end of life care incidents or complaints.
  • There were delays in the provision of beds for end of life patients. The trust had identified equipment issues on the divisional risk register and was working to improve the situation.
  • There was no single patient record to enable all community staff to access patient information in one record, this meant staff did not always have access to up to date information.There was a delay in updating records and inconsistency in the use of paper and electronic records between community teams. We saw care plans and risk assessments were not always up to date.
  • Although medical support out of hours was available at the community hospitals, staff at Romsey hospital said timely medical intervention was not always available when needed We found not all do not attempt cardio-pulmonary resuscitation (DNACPR) forms we reviewed were fully completed in line with national guidance.
  • Staff said they had undertaken end of life care training and syringe driver competency training. However, the competencies were stored on staff personnel files and the trust did not collate data centrally to monitor how many staff were required to complete the training and what proportion had completed the training.
  • Appraisal rates for community nursing staff was lower than the trust target, 65% against 90%.

However,

  • Data showed that between February 2017 and April 2017, 93% of patients who died, achieved death in their preferred place of care, and this exceeded the trust target of 80%.
  • In the year April 2016 to March 2017, 92 patients required an end of life assessment in the same period and 100% had these completed. Ninety six per cent of patients at end of life were seen within the trust target of two hours where a rapid response was needed.
  • Staffing levels in the specialist palliative care home had improved since the previous inspection.
  • Staff we spoke with felt they were engaged with in a meaningful way through discussion with their line managers, divisional leaders and at governance meetings.
  • End of life care was delivered as part of the governance framework within the integrated service division, education and training was integral to the delivery of the strategy. Staff had access to a wide range of end of life care training.
  • Risks in the provision of community services which impacted on end of life care were recorded and monitored in the divisional risk registers.
  • We observed effective multidisciplinary working and staff attended Gold Standards Framework meetings at GP practices to plan the care for end of life patients.
  • On the wards we visited and in patients’ homes we observed compassionate and caring staff who provided dignified care to patients who were at the end of their lives.
  • Staff followed guidelines on prescribing and administration of anticipatory medication including pain relief to patients at the end of life.

27-30 March 2017

During an inspection of Community health inpatient services

We have not rated the community in-patient services provided by Southern Health NHS Foundation Trust.

Overall, we found:

  • Staff provided care and treatment that took account of nationally recognised evidence based guidelines and standards. Staff managed patients’ pain effectively, and patients’ varied dietary and nutritional needs were met.
  • There was a strong emphasis on multidisciplinary working across all inpatient wards. Patients were involved in making decisions about their care and treatment. Admission criteria supported patients to be admitted to the ward that met their individual needs. There was evidence the trust used learning from complaints to improve the quality of care.
  • Arrangements were in place for safeguarding patients and staff were confident in raising any concerns to protect patients.
  • Staff monitored risks to patients, and arrangements were in place to access medical advice and support when needed.
  • In the endoscopy unit clinicians reviewed all referrals to ensure the patients’ suitability for the procedures to be undertaken. The unit had received joint advisory group (JAG ) accreditation.
  • In the endoscopy unit, there was a single sex list to ensure patients privacy and dignity were protected.

However we found:

In Gosport War Memorial Hospital in particular:

  • Staffing in some areas was not in place to meet the assessed needs of the patients on Sultan Ward.
  • That medicines were not always stored or administered in line with manufacturers guidelines
  • Staff did not follow effective infection control procedures in particular when dealing with and disposing of infected materials.
  • Not all equipment was checked to ensure they were safe for use.
  • The governance process for identifying risks was not consistently applied and may impact on care.
  • Staff knowledge relating to mental capacity assessment was variable and may impact on care delivery and best interest of patients.

Throughout the service:

  • Staff were not compliant with mandatory training targets such as basic life support which may impact on patients’ safety.
  • The quality of records was variable and these included care plans which had not been developed when patients’ risks were identified.

27-30 March 2017

During an inspection of Community health services for adults

Overall rating for this core service

  • The trust had many examples of responsive teams working collaboratively to meet their patients’ needs. They provided care close to or within the patients’ home environment, thus reducing hospital admissions. Staff used comprehensive holistic patient risk and care assessments, to identify and respond to risks including the safety, health and wellbeing of patients in the community within their care.

  • Each team and area was involved in delivering the trust’s strategy and goals. Each team developed its own set of objectives that were in line with the trust’s vision and strategy.The trust staff followed process and set procedures to report safety incidents and manage risks. However, because most staff did not use their laptops when delivering care in the community, there were sometimes delays in reporting incidents.The teams used a dashboard system to monitor serious incidents, staffing information and patient feedback. Most staff had learning from incidents shared with them.

  • Staff had a good understanding of their responsibilities toward the Duty of Candour requirements. Patient and their families received compassionate, focused care, which respected their privacy and dignity. They told us they were involved in planning their care and without exception, patients we spoke with praised staff for their kindness, caring and empathy. Most formal patient feedback was positive, although where there were complaints; clear action plans were in place.Community services for adults provided care based upon the latest national guidance from the National Institute for Health and Care Excellence (NICE). There was multidisciplinary team (MDT) working across all the teams we visited, including working with health and social care professionals form other organisations. Staff had mandatory training and most had had appraisals and access to personal development.Most staff felt supported, listened to and well supported by their immediate line managers and the executive team.

However

  • The geographical differences in the location of services and in their commissioning and delivery meant that there were differences in the delivery of care across both areas.Some community teams had significant registered nurse vacancies. The safety of patients could be affected while they were waiting for visits and staff were concerned that their workload was too high to care for patients properly.

  • Staff did not always update patient records in a way that kept patients safe. The trust had invested in products to help staff complete electronic records in the community and at patients’ homes. However, staff chose not to use these tools. This meant records were not made at the point of delivery of care, which posed a risk of incorrect information being recorded. This was the same as our findings during the inspection of community services for adults in October 2014. In many patient homes, their plans of care were not their current plan of care.

  • There were significant delays in the provision of wheelchairs and repair service through an external provider, which affected the safety and well-being of many patients receiving adult community services in different localities. Staff told us about vulnerable patients being kept in bed at home because of a lack of appropriate seating.

  • There were delays for some patients accessing outpatient clinics and services, with between 11% and 14% not having an appointment within the trust targets..

  • There were some examples of poor medicine management, lack of understanding about safeguarding and infection prevention practices. However, these were generally isolated incidents rather than systemic issues.      

27 – 30 March 2017

During an inspection of Community-based mental health services for older people

We did not rate the service on this inspection.

  • We found that all six services we visited had a sufficient number of staff and that the staff received training, supervision and appraisal. Staff morale was good, apart from the Gosport team, and staff felt supported by their managers. Staff knew about the organisation’s vision and values. Staff had been involved in developing improvement actions for their individual teams. However, staff caseloads in the Gosport team were not equitable.
  • The teams we visited had systems in place to assess and manage risk. There was clear learning from incidents and measures had been put in place as a result of learning. Each team had good communication systems, a local risk register and understanding of safeguarding procedures. Managers were able to monitor the completion of risk assessments using an electronic dashboard. Patient notes were comprehensive and structured across all six services. There were processes in place to assess risks within team meetings and psychiatrists were available at short notice.
  • Patients and carers told us they were satisfied with the services they received and were complimentary about staff.

27 – 30 March 2017

During an inspection of Wards for older people with mental health problems

  • All wards were subject to the trusts ongoing environmental improvement plan that included minimising ligature risks. The security arrangements and exit and entrance facilities to Stefano Olivieri were inadequate and there were privacy and dignity issues relating to the bathroom facilities on this unit. We bought these concerns to the attention of the trust who have taken action.
  • We found examples where there were inconsistences and varied practice in the completion of do not attempt cardio pulmonary resuscitation (DNACPR) form on wards at Stefano Olivieri, Berrywood and Beaulieu. Staff told us that they were unclear how best to restrain an older patient when requiring injectable medication, which could cause harm to patients. The trust was currently reviewing their policy to ensure that this intervention could be delivered safely.
  • Despite ongoing challenges related to the recruitment of new staff, the trust had undertaken a safer staffing review of all the wards. This had created additional vacancies due to the trust identifying the need to increase staff numbers, which resulted in reliance on bank and agency staff. We found that all wards were providing local inductions to bank and agency staff, although not all of these included the ligature risks. Most staff we spoke with told us that they were happy at work, that there was a good sense of team spirit and that morale was generally high. Staff described ward managers and other senior staff as being accessible and visible.
  • Serious incidents were reviewed at a 48-hour post incident panel meeting. Systems and processes were in place to review and learn from serious incidents. There were governance processes in place on all wards, which enabled staff to monitor quality and safety aspects of their services.
  • We found overall that patients’ physical health needs were, assessed, managed and reviewed regularly. All staff had completed a physical health workbook that included how to monitor patients’ blood pressure and temperature and assess for neurological conditions.

27 – 30 March 2017

During an inspection looking at part of the service

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.

28th March – 30th March 2017

During an inspection of Community-based mental health services for adults of working age

We did not rate this service on this inspection.

We found the following issues that need to improve:

  • The previous inspection found that there was inconsistent use of risk assessment and crisis planning for patients accessing the service. In addition, the investigation following a serious incident involving the death of a patient identified incomplete risk assessments as a learning point. On this inspection, we found that that assessing and recording of patient risks was not consistent. Staff did not always update risk assessments with new information, and there was poor and inconsistent use of the different crisis plans that the trust had provided staff to use.
  • There was variation in caseloads across the teams. There were particularly high caseloads at the Andover team. Although the trust had undertaken a review of the demand and capacity of the teams, some staff reported that caseloads were not manageable and that they had extra duties that were not taken into consideration.
  • We found that staff morale had been affected by the ongoing public scrutiny and coverage in the media, and the pressures from a recent split with adult social care.
  • There was a lack of recording of the next of kin information in patients electronic care records. This had implications for the duty of candour where staff needed to be able to contact family members in the event of an incident.

However:

  • There was positive use of the trust’s risk register to escalate risks, such as those with the environment and staffing. This ensured that there were both long and short-term plans for the mitigation of risks. Incidents were reported and investigated, and learning was cascaded through to front line staff.
  • There was a positive change in the oversight of the teams’ performance with the continued implementation of the trust`s electronic governance system. This allowed managers to check on key areas of performance within their teams to ensure completion of essential areas of practice.
  • Staff spoke positively of the mutual peer support within the teams; they felt supported through their immediate leadership teams.
  • The recent change to the trust`s executive board had improved top down communication; however, staff felt it was too early for the change in the board to have had a noticeable impact.

13 - 15 September 2016

During an inspection looking at part of the service

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.

19 and 20 January 2016

During an inspection of Wards for people with a learning disability or autism

We found the following issues that need to improve:

  • The trust had not taken appropriate steps to mitigate the risk from ligature points. Ligature points are places to which patients intent on self-harm might tie something to strangle themselves. At Evenlode, we identified multiple ligature points throughout the unit. A considerable amount of work had been carried out at the Ridgeway Centre to remove identified ligature points. However, we identified a number of outstanding and clear risks that needed further work to be more effectively reduced.
  • We asked the trust at the time of our inspection to provide us with an assurance that steps would be taken to reduce the risk of ligatures until the completion of scheduled work. On a return visit to the service on 29 January 2016, we were informed that a number of steps had been taken to mitigate more effectively the risks from ligatures, including: new observation practice, use of safer beds, and electrical cables shortened and clearly identified on individual patient property lists. However, we were concerned that although the provider had taken action when we requested it, they had not engaged or consulted effectively with the patient group or explained the rationale behind the changes.
  • We found the clinic room at Evenlode was unfit for purpose and did not contain appropriate essential resuscitation equipment. Further, the intercom that would allow patients who were placed in the seclusion room to talk to staff outside the room was not working. We asked the trust to put this right immediately. We also identified specific issues with the environment at both services that potentially compromised patients’ privacy and dignity, including a lack of curtains on one patient’s bedroom window at the Ridgeway Centre.
  • The trust had developed an epilepsy map and toolkit, which had been rolled out across north learning disability services in 2013/14. However, a specific ‘Protocol for the safe bathing and showering of people with epilepsy’ was awaiting completion and final sign off by the board more than two and a half years after a much-publicised death by drowning of a young person at one of the trust’s other learning disability services. This patient had drowned while bathing, unobserved by staff, after having an epileptic seizure. Support workers were inconsistent in their explanations of how they would supervise patients when bathing. Staff’s uncertainty and a lack of consistency meant that patients with epilepsy were still potentially being placed at unnecessary risk when bathing. We noted that the protocol was subsequently available from 1 February 2016 on the trust website.
  • We identified a number of concerns about the processes and systems for learning from incidents. Following an incident in July 2015, when a member of staff at Evenlode suffered a serious assault, it was recorded in electronic care notes that staff were concerned about remembering physical intervention techniques. We found that more than six months later, there had been no subsequent investigation and no additional or revised specialist training provided for staff.
  • Staff supervision at both services was poorly managed, inconsistent and infrequent. In addition to the lack of regular and consistent formal supervision, staff meetings had not taken place at Evenlode, which meant that staff had not had appropriate forums in which to raise concerns or to share best practice.
  • None of the staff spoken with at Evenlode felt to be part of the wider trust, and staff at all levels expressed their sense of isolation from the trust. Staff told us there was an ongoing sense of uncertainty as to the future for the service, and that they felt the trust’s senior management team had not effectively supported them.
  • We identified a number of serious failings in relation to the trust’s oversight and governance of Evenlode. Similarly, the trust’s own most recent internal peer review of Evenlode catalogued a large number of concerns in relation to the safety, effectiveness, responsiveness and leadership of the service. The fact that the service had been left without appropriate senior support and oversight for so long, and allowed to deteriorate to such an extent, demonstrated both poor governance and ineffective oversight of the service by the trust’s senior management team.

However, we also found the following areas of good practice:

  • We saw some evidence of positive leadership at a local level. We found there had been improvements, at the Ridgeway Centre, in staff’s morale and sense of being part of the wider trust since our previous inspection. Staff were positive about the changes in the physical environment and the investment that had been made. They also told us that support from senior managers had also increased considerably. It was to the credit of the local level team at Evenlode that staff who had recently joined the service reported to us that they felt it was a strong and supportive team, who helped them and who were positive about patient care.
  • We saw examples in care records to demonstrate appropriate assessments and monitoring of risks were carried out, specific to each individual patient. Staff completed comprehensive, timely assessments of patients’ needs on admission. Care records showed that physical examinations were undertaken and that there was ongoing monitoring of patients’ physical health problems. We saw evidence that staff at Evenlode managed complex patient needs with a therapeutic approach and very low use of psychotropic medication.
  • We saw examples at the Ridgeway Centre of how patients were actively involved in decisions about their own care and treatment. For example, a ward service users group had been set up to look at key issues. At Evenlode, efforts were being made to involve patients more in decisions about their own care and treatment. Therapy sessions and one-to-one sessions with staff were good forums for people to raise concerns or to make suggestions for improvements. The ward community meetings were well attended by patients, and there was tangible evidence that patients felt relatively safe to raise concerns in this setting.

At the Ridgeway Centre, we found the female ward was welcoming and we saw staff engaged freely and positively with patients. When staff spoke with patients on the male ward, the interaction was appropriate and respectful, but was task-focused rather than person-centered. Patients at the Ridgeway Centre were positive about the care and treatment they received and told us they did not have anything about which to complain. However, they also confirmed they knew how to complain and were confident in complaining if they were unhappy about anything. 

18-21 January 2016

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

We previously conducted a comprehensive inspection of acute wards for adults of working age inpatient and psychiatric intensive care (PICU) wards in October 2014; we published the report in February 2015. We found that the trust needed to make improvements. We carried out this inspection to check if it had made these. We found that the trust had made a number of the required improvements, which we have described in the report.

However, it had failed to make sufficient changes to environmental concerns, particularly in identifying and prioritising fixed ligature points (a point that a person could attach a cord, rope or other material for the purpose of hanging or strangulation). Governance arrangements did not facilitate effective assessment, recording or monitoring of actions taken or actions outstanding to mitigate risks. We have taken separate enforcement action against the trust in relation to this.

We had serious concerns about the security and safety of the garden used by patients on Kingsley ward, at Melbury Lodge. A low roof was easily accessible by patients, they could then leave the site or there was a danger that they could access the second storey part of the roof. A patient had sustained serious injury falling from the roof; the trust had taken very little action to effectively address this risk. We requested that the trust took urgent action to maintain patient safety while its estates department undertook an assessment of any required work to make the environment safe.

The trust had failed to make improvements in the following areas:

  • while we found that there had been some work in relation to the management of ligature risks, we were concerned that the trust was unable to clearly identify what action it had taken and how it was prioritising additional anti-ligature works required. It had not addressed ligature risks and blind spots on Kingsley ward at Melbury Lodge

  • no effective action had been takento prevent patients climbing onto the roof of Kingsley ward even though there had been several incidents which could have resulted in potential harm and one incident when a patient fell, suffering serious harm

  • it had not fitted blinds on bedroom doors on Kingsley ward at Melbury Lodge to protect patient privacy and dignity

  • the sluice from the male laundry room on Kingsley ward at Melbury Lodge had not been removed

  • The trust had not made sufficient changes to the seclusion room on Hamtun psychiatric intensive care unit at Antelope House, so it still did not comply with the Mental Health Act 1983: Code of Practice. The trust advised that work was due to commence March 2016.However, the trust had not put in place interim measures to mitigate the impact on privacy, dignity and confidentiality.

  • while staff told us blanket restrictions on Hamtun ward at Antelope House had been removed, patients said they were still not allowed to have a bath after 9pm

  • staff did not always fully record decisions about patients’ capacity

  • patients were not always able to take leave due to staff shortages

  • not all wards provided sufficient patient activities and opportunities for physical exercise

  • staff did not always fully explain to patients their rights under the Mental Health Act

  • staff did not always complete observation records in line with trust policy.

    However, the trust had made the following improvements:

  • begun adding extra bathrooms to comply with guidance on mixed sex accommodation on Hawthorn 2 at Parkland Hospital

  • informed patients about any closed circuit television (CCTV) in communal areas on Hawthorn 2 at Parkland Hospital, and on Kingsley ward at Melbury Lodge when it was highlighted to them on inspection

  • removed the sluice sink and macerator from the patient laundry on Hawthorn 2 at Parklands Hospital

  • ensured staff completed or booked a place on mandatory training and received regular supervision

  • displayed smoking cessation information on all wards and prescribed smoking cessation aids such as nicotine replacement patches for patients

  • improved staffing levels across all wards

  • ensured staff mostly completed risk assessments before patients took section 17 leave

19 - 21January 2016

During an inspection of Child and adolescent mental health wards

Significant improvements had been made to the child and adolescent mental health wards since the October 2014 inspection and the trust had addressed the previous compliance actions. At the October 2014 inspection, we found high levels of staff commitment and enthusiasm in Bluebird House, where young people were involved in all aspects of their care and support. At this inspection in January 2016, we found this was again the case and Leigh House had worked hard to achieve the same high standard.

There were now trust policies in relation to the restraint of young people. Young people were involved in all aspects of planning their care and treatment at Leigh House. Young people had routine health checks in Bluebird House and Leigh House. There was a trust transition policy to support young people transitioning into adult services, and clear care pathways for young people. The discharge of young people was discussed or planned as part of the admission to the service. The staff team ensured that young people at Leigh House did not feel that the service was planned around the needs of the young people with an eating disorder, and that those with mental health needs received the same level of support. Staff in Bluebird House and Leigh House were aware of any trust-wide initiatives to seek feedback from young people and other users of the services or staff.

However, from information provided by the trust, there was a large amount of prone restraint (face down) occurring at Bluebird House. There was a training request for staff to train in supine restraint (face up) submitted in September 2015. During inspection, we were advised that training would be rolled out to staff from April 2016. The trust has since told us that it is developing a programme “which will see staff trained in a variety  of different restraint techniques including supine with the main focus being on reducing the frequency of restraint and its duration when used” and as such the training package will not be implemented in April 2016. Out of hours medical cover was not consistently available at Bluebird House. There were no suitable arrangements to ensure that the trust was made aware of incidents involving a young people’s first medical review, when seclusion was authorised had not been undertaken by the responsible clinician or duty doctor (or equivalent) within one hour of the commencement of seclusion.

18 - 21 January 2016

During an inspection looking at part of the service

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.

18 - 21 January 2016

During an inspection of Community-based mental health services for adults of working age

  • The adult community mental health services provided a range of mental health services for people in Southampton. Patients and carers had raised concerns that there was disjointed provision of crisis services across the area and some people waited a long time for an appointment with the community teams following a referral. The trust and local clinical commissioning group had identified that there were a number of key performance indicators of safety and quality. For example, the trust had benchmarked these indicators and found that there were higher than average complaints and serious incidents, which showed mental health services for people in Southampton were not being performing well.
  • We had a number of continued concerns. These included inconsistent recording in care records in relation to risk assessment and plans, and a failure to follow up patients who did not attend appointments. These were all aspects of care that have been identified as key risk issues in a number of serious incidents that had occurred but had not been addressed, at the time of the inspection, by the trust. We also found that supervision structures were not consistently embedded across the teams and as a result, staff did not always manage their caseloads effectively or monitor the quality of record-keeping.

However,

  • The area manager and team managers all demonstrated a good understanding of the challenges and risks within the service and were committed to continuing with the implementation of the improvement plan. Staff we met were reflective and supportive of the changes being implemented.
  • The trust board recognised that significant work was required at Southampton in order to ensure safe and effective services were provided. As such, an improvement team had been put in place by the trust, which developed a plan of action to achieve a number of changes. Staff had been consulted on the improvement plan in July 2015 and the first phase of the improvement plan had been implemented in November 2015. The main components of the first phase had been implemented at the time of inspection:
  • A redesigned community pathway had been introduced. The community teams were based across three hubs, central, east and west, delivering all functions of community mental health care, undertaking mental health assessments and, where allocation within the team was appropriate, a range of more specialist assessments and interventions.
  • A redesigned crisis care pathway had been implemented. One 24 hour team had been established, to be available seven days a week to support people who were acutely unwell, and either work with people at home or arrange admission and discharge from hospital where indicated. There was a plan to increase the psychiatric liaison service at Southampton General hospital by March 2016.
  • The plan included a focus on improving the pathway for people who were in hospital, ensuring people did not remain in hospital any longer than they need to and that local beds were available when people need admission
  • The implementation of the improvement plan was being overseen by an area manager who was well respected by all staff we met. It was the first permanent area manager in post for two years. Most staff felt consulted and engaged with the improvement plan and felt it would improve services. While it was clear there were still a number of improvements to be made and changes to be evaluated and embedded, we saw how proposed improvements to the care pathway would reduce the experience of multiple transitions between different teams for patients and had improved communication and joint working between the teams. Weekly project meetings monitored actions.

5th August 2015

During an inspection of Wards for people with a learning disability or autism

Steps had not been taken to address risks with the environment identified by the trust and highlighted in our comprehensive inspection in October 2014. Observation mirrors had not been put in place to reduce the blind spots in the unit, ligature points, such as weight-bearing curtain rails, had not been removed or the risks associated with them effectively mitigated. Bedroom doors had not been changed to anti-barricade. Despite significant ligature risks being identified at the service for more than 12 months, training in identifying and mitigating ligature risk had not been completed by half of the unit’s front-line staff at the time of inspection. We requested immediate actions to be undertaken by the trust and will continue to closely monitor progress with the commissioners for the service.

The unit had recruited to a full complement of staff, and there were sufficient numbers of staff present to support people and meet their different needs throughout the day. We identified a number of minor issues, but overall there were effective systems and processes in place for the safe management of medicines. Staff received support and were debriefed following serious incidents, and reflective practice sessions formed a key part of the subsequent learning process.

Physical observations were being carried out, for example blood pressure and pulse rate checks. Patients had detailed individualised care plans on the electronic patient record system. However, support plans were not written in a format suited to individuals’ different communication needs. Care records we reviewed did not reflect that patients were actively involved in writing or reviewing their care plans .

Multi Disciplinary Team (MDT) meetings were attended by a broad spread of appropriate professionals, including nurses, doctors, occupational therapist, pharmacist, and patients themselves or their representatives as required. The service had an effective MDT decision making process, with an informal and almost flat hierarchy style, whereby eveyone in the team had a say and made a contribution. There was close working with other teams, including the intensive support team (IST), community learning disability team, and assertive outreach team helped to support continuity of care. Mandatory staff training was mostly up to date, and staff were able to get additional training through the trust in order to better meet the needs of people at the service.

5th and 6th August 2015

During an inspection of Forensic inpatient or secure wards

This inspection was a follow up visit from a comprehensive inspection that was undertaken in October 2014. We do not rate services based on the outcome of a focused inspection. The ratings that were awarded at the time of the comprehensive inspection in October 2014 remain.

In summary we found the following:

  • Patients’ at both sites were not routinely having their observation levels and associated risks recorded within a plan of care, although (and with the exception of two patients with the pre discharge flat) the practice of completing observations of patients was being done.
  • The understanding of the differences between seclusion and de-escalation was not clear. The practice of providing bowls to patients for toileting purposes as opposed to appropriate facilities, when in seclusion, was of concern to us. We also found that the current design of the room did not allow for good, clear and effective communication between staff and patients’ held within the seclusion room at Southfields.
  • Nursing staff were not aware whether Flumazenil medicine was stored on the premises at Southfield. At both Ravenswood and Southfield, there was limited knowledge for the use of Flumazenil by registered nurses and whether it was stored on the premises or not.
  • That safety improvements to the environment at Ravenswood had begun, were on schedule, and were due to finish in February 2016.
  • Environmental assessments across both sites were being completed on an annual basis.
  • The Trust had implemented a programme of learning which involved showing staff how to use ligature cutters and how to correctly store and record ligature cutters.
  • Fridge temperature monitoring across both sites for the safe and effective storage of medicines was, on the whole, being completed.
  • The recruitment of Band 5 registered nurses remained a problem for the Trust, however, work continued within the Trust in order to address this.

7 – 10 October 2014

During an inspection of Community mental health services with learning disabilities or autism

We inspected three community learning disability teams, two in Oxfordshire and one in Hampshire. We also inspected two assertive outreach teams in Oxfordshire and Buckinghamshire and two intensive support teams in Buckinghamshire and Hampshire. The community learning disability teams were large  the assertive outreach and intensive support teams were very small. At the time of the inspection the assertive outreach teams were in the process of joining the community learning disability teams. The intensive support team in Buckinghamshire was expanding.

We gave an overall rating for community mental health services for people with learning disabilities or autism of good because:

  • Staff across the service were very committed to providing person centred care to the people using the services and displayed care and compassion. We found some very positive multi-disciplinary and multi-agency work. We heard from people using the services and their relatives about their positive experiences.
  • Staff were working hard to complete comprehensive core assessments and develop care plans and risk assessments. People using the service and their relatives were involved in this process as much as possible. Staff had a good understanding of the Mental Capacity Act although best interest meetings could be better structured.
  • Staff were positive about their work and appreciated the training opportunities they had received. They also felt well supported within the services where they worked.
  • The community teams were responding quickly to urgent referrals. For people referred for non-urgent interventions there were sometimes longer waits for services with 26 referrals waiting for over a year; this needs to be addressed.
  • Staff working in the Hampshire services felt a stronger connection to the trust while the staff working in Oxfordshire and Buckinghamshire felt more removed. The trust had made an effort to address this especially through the use of training, executive and senior staff visits, roadshows, staff briefings and the people development programme. Senior staff acknowledged that there was the continued need to improve contact and communication across all the teams. The divisional director had been promoted from head of service from within the LD service three weeks before the inspection and although he was new to the post he had an extensive knowledge of the service.

7 -10 October 2014

During an inspection of Community-based mental health services for adults of working age

We gave an overall rating for community-based mental health services for adults of working age of good because:

Southern Health NHS Foundation Trust provided good community-based mental health care, treatment and support for people, their families and carers. It offered people a range of community based treatments, psychological support, medication, and advice.

Throughout the services we visited, we found good working arrangements with primary care and third sector providers.

However, the work of the community mental health teams was affected by the lack of available local acute admission beds. This meant some people were being accommodated in hospital beds a long distance from their home. It also meant that there were, on occasion, delays in accessing a bed on an acute admission ward.

We saw good examples of local leadership in all of the services we visited. Staff were aware of the trust’s vision, values and strategies, and of its local management structure.

6 -10 October

During an inspection of Wards for people with a learning disability or autism

We inspected four inpatient learning disability services, two in Hampshire, one in Oxfordshire and one in Buckinghamshire. Two of the inpatient services in Oxfordshire had stopped providing a service shortly before the inspection.The Short Term Assessment & Treatment unit (STATT) closed in December 2013 and John Sharich House (JSH) closed in early 2014.

We gave an overall rating for wards for people with learning disabilities or autism of requires improvement because:

  • Whilst staff were working hard to identify and manage individual risks, the inpatient environments needed improvements to make them safer including reducing ligature risks and improving lines of view.
  • Staff were reporting incidents but learning from incidents was not being shared consistently across the inpatient services. External stakeholders in Oxfordshire told us the trust did not have a well-developed safety culture and had previously not reported or investigated serious incidents well in this particular service. It was felt that this was improving but it was too early to be confident about the level of that improvement. Observations by the inspection team across the core services inspected demonstrated that Southern Heath did have a well-developed safety culture in place in respect to incident reporting and management in Hampshire but this was still being embedded into the Oxfordshire and Buckinghamshire services which it had acquired in November 2012.
  • Staff working in the Hampshire services felt a stronger connection to the trust while the staff working in Oxfordshire and Buckinghamshire felt more removed. The trust had made an effort to address this especially through the use of training, executive and senior staff visits, roadshows, staff briefings and the people development programme. Senior staff acknowledged that there was the continued need to improve contact and communication across all the teams. The divisional director had been promoted from head of service from within the LD service three weeks before the inspection and although he was new to the post he had an extensive knowledge of the service.
  • There was poor local leadership at Evenlode as the head of service had not been working for three months and interim management arrangements had not provided the ward manager and staff team with sufficient support.
  • At the time of the inspection Verita were undertaking an independent review into the commissioning, assurance and governance of learning disability services in the Oxfordshire area. This was in response to a tragic death on the Short Term Assessment and Treatment Unit (STATT) unit on the Slade House site in July 2013. A previous external review had found that the death was preventable. Staff and service users were concerned about how the trust was handling the situation as they felt the trust had not been as open and honest as it could have been. This was clearly causing distress and affecting staff morale and unrest with people using services and their families. They felt the trust had failed to communicate effectively and was acting outside of its own values.
  • In addition, there was concern as to whether the trust would continue to deliver the services in the future which was affecting staff morale.

Despite this, we found that staff across the service were very committed to providing person centred care to the people using the services and displayed care and compassion. We found some very positive multi-disciplinary work particularly in supporting people with complex challenging behaviours. We also could see that staff were actively supporting people using a recovery focus with the aim of enabling people to live more independently. We heard from people using the services and their relatives about their positive experiences.

Staff were positive about their work and appreciated the training opportunities they had received although some staff, especially support workers, needed more training to enable them to understand the specific needs of the people they were supporting. 

7-10 October 2014

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

We gave an overall rating for acute wards for working age adults and the psychiatric intensive care unit (PICU) of requires improvement because:

  • Elmleigh acute wards and PICU in particular had insufficient, suitably trained staff covering the unit as a whole, including a health based place of safety that was in use almost every day.
  • There were significant shortfalls in staff training particularly in respect of the safe restraint of people and emergency life support which meant people using the service were at risk of harm in an emergency. Emergency equipment at Elmleigh was kept in the PICU treatment room a significant distance from the acute wards. As a result there was a risk of delay in the event a person collapsed or suffered a cardiac arrest on the acute wards.
  • We found ligature risks on all wards. These were usually known to staff and some wards had taken action to address or mitigate the risks. However, some ligature risk assessments failed to record any action to address risks and Elmleigh ward managers had not implemented, or followed up, actions identified to remove risks that had been highlighted ten months ago.
  • There was a lack of opportunities for physical activity on some of the PICUs.
  • At Elmleigh there was significant shortfalls in areas of training, inconsistent provision of supervision to staff and a poor records on the completion of staff appraisals when compared with other similar services within the trust.
  • We received mixed responses from people when we asked them about their involvement in their care. Some people told us they were listened to by staff and able to contribute to decision making whereas others said they had not been involved in developing their care plan and did not have a copy.
  • The planning and delivery of the service was not always responsive to people’s needs. For example, the seclusion room on Hamtun ward at Antelope House was not fit for purpose. The design did not allow staff to easily observe people in the room. The design of the wards was different at different locations. Some wards were clearly segregated with separate female and male wards and facilities and many bedrooms had ensuite bathroom and toilet facilities. However, we found that some of the bathrooms and toilets at Parklands Hospital were labelled as ‘unisex’ and during our inspection we saw that women used the bathrooms on the male corridor. This was contrary to Department of Health guidance as women had to walk past male bedrooms to get to the bathroom.
  • At Elmleigh it was not clear how the information was being used to improve the service. The monthly performance dashboards for Elmleigh PICU and acute wards for July, August and September showed little discernible improvement on a range of measures, including training and appraisal, and in some areas performance was worse.
  • At Elmleigh most staff did not feel engaged in ward improvements and were disappointed in the lack of support they received from managers.
  • Most wards used performance data and feedback from people using the service to identify areas for improvement and bring about changes in the service except at Elmleigh where the systems in place were not effective in bringing about continuous improvement.

However, most people experienced kind and considerate care from staff and were positive about the support they had received. Carers we spoke with on all wards we visited reported feeling involved in their relative’s care. At Elmleigh a café had been set up on the acute wards where people and their relatives could buy drinks and cakes. There was a small seating area that allowed people to meet with relatives in a more relaxed setting away from the main acute wards. At Melbury Lodge a carer’s guide, containing information about the service, had been developed in conjunction with the carer’s council that was available for friends and relatives.

The diverse needs of people were considered. At Melbury Lodge innovative work had been carried out to ensure that people’s spiritual needs were integrated into their everyday care and treatment. Information on how to complain was available on the wards and most people using the service told us they knew how to make a complaint if they wished.

Most people on all wards had care plans in place that addressed their assessed physical and mental health needs and any individual risks identified. There were a range of meaningful and therapeutic activities available for people on the wards. On some wards an activities programme was provided across seven days.

Staff on some wards were aware of research and developments in acute mental health care and we noted the implementation of new approaches based on evidence and best practice. For example, the ‘safewards’ initiative was being implemented on the wards and considerable progress had been made with this in some areas. At Melbury Lodge the service had developed a spiritual assessment as part of a holistic approach to determining people’s needs. This was based on evidence that people recover faster and recovery is more likely to be sustained when health professionals work with people to explore their spirituality.

Most staff (except at Elmleigh) had completed their mandatory training and received regular clinical supervision.

We saw good examples of multi-disciplinary team working which supported people’s care, treatment and discharge from the wards. Records and information systems mostly supported the effective delivery of care and treatment to people.

Governance structures were in place and in most wards were effective. Staff understood their roles and responsibilities and lines of reporting on the wards. Performance was monitored and key performance indicators included workforce, patient experience, operational measures and quality and safety measures. Performance information was actively used to address shortfalls and bring about improvements in some wards.

Some wards were very well-led. Most staff spoke positively about their line managers and reported feeling able to raise any concerns they had about standards of care. People using the service were asked for their feedback about services and this sometimes led to changes in the service provided. Most wards used performance data and feedback from people using the service to identify areas for improvement and bring about changes in the service except at Elmleigh where the systems in place were not effective in bringing about continuous improvement.

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.

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.