• Organisation
  • SERVICE PROVIDER

Hertfordshire Partnership University NHS Foundation Trust

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

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

Latest inspection summary

On this page

Overall inspection

Outstanding

Updated 30 March 2022

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

  • We rated safe, effective and responsive as good and caring and well led as outstanding. In rating the trust, we took into account the previous ratings of the five services not inspected this time. We rated the trust overall for well led as outstanding. At this inspection, we rated two core services as outstanding, and four core services as good. Therefore, four of the trust's 11 services are rated as outstanding and seven as good.
  • The trust responded in a very positive way to the improvements we asked them to make following our inspection in January 2018. At this inspection, we saw significant improvements in the core services we inspected and ongoing improvement and sustainability of safe, good quality care across the trust. The senior leadership team had been instrumental in delivering quality improvement and there was a true sense of involvement from staff, patients and carers towards driving service improvement across all areas.
  • We were particularly impressed by the strength and depth of leadership at the trust. The trust board and senior leadership team displayed integrity on an ongoing basis. The board culture was open, collaborative, positive and honest.
  • The trust’s non-executive members of the board challenged appropriately and held the executive team to account to improve the performance of the trust. The trust leadership team had a comprehensive knowledge of current priorities and challenges and took action to address them. The board were seen as supportive to the wider health and social care system. The trust’s chief executive had led on the Hertfordshire and West Essex sustainability and transformation plan (STP) for the region between August 2016 and January 2018. Reports from external sources, including NHS improvement and commissioners were consistently positive about the performance of the trust. The trust had a clear vision and set of values with safety, quality and sustainability as the top priorities. The trust benchmarked their ‘business as usual’ against the vision and values and kept the message at the heart of all aspects of the running of the organisation. Local leadership across the trust was strong, visible and effective. Staff were particularly praising of the chief executive, the medical director and the chief nurse. Succession planning was in place throughout the trust, aligned to the trust strategic objectives.
  • The trust strategy and supporting objectives and plans were stretching, challenging and innovative, while remaining achievable. The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders. The trust’s strategy recognised the need to be inclusive through established networks and partnerships. The trust had a clear vision and set of values, developed in collaboration with over 800 patients, carers and staff, with safety and quality as the top priorities. We were very impressed at how the trust’s vision and values were embedded throughout services and at board level and informed how the senior leadership team operated.
  • Leaders showed an inspiring positive culture with a shared purpose towards the vision, values and strategy, and modelled and encouraged compassionate, inclusive and supportive relationships between all grades of staff. The trust ensured staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Overall, staff received appropriate training, supervision and appraisals to support them in their roles. The trust had introduced a new data management system which had provided greater oversight to staff compliance with mandatory training and supervision. All staff and managers had access to the system, although some managers were awaiting training.
  • Staff showed caring, compassionate attitudes, were proud to work for the trust, and were dedicated to their roles. We were impressed by the way all staff in the trust embraced and modelled the values. The values were embedded in the services we visited and staff showed the values in their day-to-day work. Throughout the trust, staff treated patients with kindness, dignity and respect. Consistently, staff attitudes were helpful, understanding and staff used kind and supportive language patients would understand. The style and nature of communication was kind, respectful and compassionate. Staff showed strong therapeutic relationships with their patients and clearly understood their needs. Staff offered guidance and caring reassurance in situations where patients felt unwell or distressed, confused or agitated. Overall, positive feedback was received from those patients, families and carers spoken with about the care and treatment received from staff.
  • Patients told us they felt safe across the trust. The trust promoted a person-centred culture and staff involved patients and those close to them as partners in their care and treatment. Staff provided positive emotional support to patients.
  • Staff felt respected, supported and valued. The trust promoted a culture of openness, transparency, support and learning in a blame free environment, with safety as a top priority. Staff morale across all teams was consistently high.
  • Patients could access services when they needed to. The trust had robust and effective bed management processes. With few exceptions, patients could access a local bed and beds were available for patients when they returned from periods of leave. The trust reported low numbers of out of area placements for their acute inpatient and psychiatric intensive care wards. There were no out of area placements reported for the wards for children and young people or wards for older people.
  • Staff kept clear records of patients’ care and treatment. Patient confidentiality was maintained. Care and treatment records were clear, up-to-date and available to all staff providing care. The trust provided care and treatment based on national guidance. Staff ensured the needs of different people were taken into account when planning and delivering services. Patients had access to a range of staff with the appropriate skills, experience and knowledge to support care and treatment.
  • Staff completed Mental Health Act paperwork correctly. There was administrative support to ensure these records were up to date and regular audits took place. Staff understood and worked within the principals of the Mental Capacity Act. Systems for the safe management and administration of medicine were in place. Incidents and errors within the pharmacies were reported and investigated and outcomes and learning shared with staff.
  • The trust had effective bed management processes. We were particularly impressed with recent changes to remove all shared accommodation and reduction in lengths of stay for children and young people within the CAMHS inpatient wards. The trust prioritised reducing the length of time patients spent as inpatients by investing in community teams, home treatment teams and robust care pathways.
  • Staff ensured patients had access to opportunities for education and work, including referring patients to a wellbeing college which was delivered in in partnership with the third sector (MIND).
  • The trust proactively worked alongside partners to provide joined up healthcare for the local population. Commissioners and other stakeholders confirmed the trust was responsive to challenge and worked collaboratively with stakeholders, other local NHS trusts and the third sector to deliver services to patients. The trust demonstrated a clear priority for involvement of patients, families and carers, which was particularly impressive and demonstrated real involvement.
  • The trust’s governance arrangements were proactively reviewed and reflected best practice. The trust had robust systems and process for managing patient safety. Staff recognised when incidents occurred and reported them appropriately. The board had oversight of incidents, and themes and trends were identified and acted upon. Managers investigated incidents appropriately and shared lessons learned with staff in a number of ways. The trust applied the duty of candour appropriately, when things went wrong, staff apologised and gave patients honest information and suitable support. We were particularly impressed with new systems for reviewing incidents, implemented since our last inspection, demonstrating a drive to understand and learn from incidents to improve the safety of services and outcomes for patients.
  • We were also impressed by the trust attitude towards innovation and service improvements. The delivery of innovative and evidence based high quality care was central to all aspects of the running of the service. There was a true sense of desire to drive service improvement for the benefit of patients, carers, and the wider system, evident throughout the inspection. Staff included patients in service improvement and used their feedback to change practice. The trust actively sought to participate in national improvement and innovation projects and encouraged all staff to take ownership, put forward ideas and remain involved throughout the process. We saw many examples of innovation and projects that had been trialled and then implemented in the trust.

However:

  • Staff working within the older people’s inpatient service were not in receipt of regular, good quality supervision. Where records were available, they were of poor quality.
  • We found some environmental concerns that required attention. For example, the assessment room used by the mental health liaison team at Lister Hospital had lightweight furniture and was not soundproof. Two acute wards for adults of working age did not have nurse call bells in patient bedrooms. The health-based place of safety located on Oak unit needed cleaning and some changes to the physical environment. We found some community team bases for children and young people were not clean or well-maintained and in one team, staff did not have access to a suitable alarm system. At one site, there were insufficient rooms available for staff to meet with patients.
  • We found some minor concerns related to privacy and dignity and the management of mixed sex accommodation within one older people’s inpatient ward. The trust took immediate action to rectify this. Environmental risk assessments were not always detailed or accurate. Within the community adults’ teams, some interview rooms did not promote privacy and dignity for patients; due to lack of soundproofing. Not all adult community teams had adequate environmental risk assessments in place, particularly in relation to the management of ligature risks.
  • On Oak ward, staff did not consistently complete physical observations following administration of rapid tranquilisation in line with the trust policy and National Institute for Health and Care Excellence guidance. Staff did not complete wellbeing care plans for all patients in the community adults service.
  • Within some acute wards for adults, there was a lack of psychological therapies as recommended by the National Institute for Health and Care excellence. However, this was due to temporary vacancies and the trust was recruiting psychologists at the time of inspection. Staff assisted patients to access psychological therapies in the community, where possible.
  • The trust did not always ensure patients detained under Section 136 of the Mental Health Act were assessed within 24 hours. Between October and December 2018 8% (19 out of 231) of Section 136 detentions exceeded the 24 hours. Out of the 19 cases exceeding 24 hours, staff completed extension forms for 7 detentions. Where delays had occurred, the trust completed incident forms and advised all individuals in writing of the reasons for their delay and follow up actions they could take.
  • We found some trust policies had not been reviewed in line with documented timescales.

Child and adolescent mental health wards

Inadequate

Updated 30 March 2022

Hertfordshire Partnership University NHS Foundation Trust provides child and adolescent services throughout the county. There are approximately 250,000 children and adolescents (under 18 years) in Hertfordshire. For the core service child and adolescent mental health wards, Hertfordshire Partnership University NHS Foundation Trust has one location.

Forest House is a 16-bed unit that provides specialist inpatient care and treatment for young people living in or outside Hertfordshire, aged 13 to 18 years, requiring admission as a Tier 4 provision. The unit is based at Radlett in Hertfordshire and the beds available are for female, male and non-binary gender young people. At the time of inspection three of these beds are specifically for young people with eating disorders.

The service aims to help young people and their families cope with psychological, social, emotional and behavioural problems. Young people have access to a school on site to support educational needs during their admission.

At the time of inspection, the unit had reduced the bed numbers to 13 to enable additional building works on the High Dependency Unit (HDU) area. A further decision to reduce the overall capacity to 10 beds was made before 25th December 2021. The 20th January 2022 was when Forest House had two further discharges and were, therefore, able to reduce the overall capacity to 10. It was not safe or appropriate to discharge earlier in consideration of the individual young people.

During 2020 and 2021, the Forest House service encountered a significant increase in the acuity of the presentations of the young people who were admitted to it. This was in part as a consequence of the pandemic, and the well-publicised deterioration in the mental health of some individuals. At the same time, half of the General Assessment Unit beds in the East of England region (both NHS and Private) were closed to new admissions for young people, which meant more reliance on the Forest House unit and less availability to other alternatives to access an inpatient bed, and to treat and care for more young people. Additionally, young people suffering from eating problems and needing access to trust services had risen by 50%, with a corresponding increase of admissions required, but there were insufficient specialist inpatient beds within the region and nationally to admit these young people to. The impact of this change in the volume and presentation of the client group at Forest House, meant that the young peoples’ length of stay had increased in many cases and the risk that young people presented with had also increased, with more incidents of self-harming, increased violence, aggression, verbal and racial abuse as well as behavioural difficulties. Staffing challenges arose as a consequence of the above changes, as those presenting required more safe and supportive observations and expert care.

Forest House was last inspected in March 2019 and was rated as outstanding overall.

We carried out this unannounced focused inspection of Forest House unit because we received information giving us concerns about the safety and quality of the service. We visited the ward on 25 November 2021 and 9 December 2021 and carried out remote interviews of young people and staff between 7 December and 30 December 2021. We primarily focused on specific key lines of enquiry within the safe and well-led domains and some key lines of enquiry within effective, responsive and caring domains.

Following this inspection, the trust was served with a Section 29A warning notice as the Care Quality Commission formed the view that the quality of health care provided at the trust’s inpatient service for children and young people required significant improvement. The trust was required to take immediate action to make improvements at this service.

We rated the safe, effective, caring, responsive and well led domains.

SUMMARY OF FINDINGS

  • Access to a clinical psychologist was limited to young people which reduced the ability to provide therapeutic interventions in line with best practice.
  • There were a number of vacancies within the therapy team and the ongoing refurbishments had also impacted on room availability to enable therapists to conduct therapy sessions.
  • Staff did not consistently enforce the unit’s mobile phone policy to ensure the safety and wellbeing of all young people on the unit.
  • The unit did not have effective systems in place to ensure staff administered and recorded administration of medication to young people in accordance with their prescription charts.
  • Staff did not adhere to the trust guidelines when completing physical healthcare checks for young people following administration of medication administered for the purpose of rapid tranquilisation.
  • There was insufficient management and oversight of the running of the service to ensure all policies, procedures and local governance arrangements were maintained, monitored, accurately documented and effective.
  • There were not always enough suitably trained, competent, skilled and experienced staff to deliver safe care and treatment and develop therapeutic relationships with the young people. Compliance with key training requirements did not meet the trust target.
  • Some young people told us they did not always feel listened to and did not feel safe on the unit due to bullying by other young people and felt this was not managed appropriately by staff.
  • Staff morale within the unit was poor. Some staff described low morale due to significant staff changes, increased level of acuity of young people accessing the service, incidents of assault, the impact of major refurbishment within the unit and difficulties with maintaining staffing levels.
  • Most parents and carers were dissatisfied with the level of care and treatment offered to young people and there were delays in the response from the trust to formal complaints.

However:

  • Staff knew about potential ligature anchor points and mitigated the risks.
  • Most regular staff worked hard and showed compassion and kindness to the young people they supported.
  • Whilst risk management plans were not always up to date, we found overall the risk assessment and care plans to be holistic and person centred.
  • The trust had taken the decision to keep Forest House operating to the maximum capacity possible, despite recent challenges, in order to provide appropriate placements for young people and support the wider healthcare system. At the time of the inspection, all other similar units across the East of England had either closed to admissions or had significantly reduced their bed numbers.

How we carried out the inspection

During the inspection we:

  • Spoke with the clinical director and interim senior service line lead
  • spoke with head of nursing and service line lead for tier 4 children and adolescent mental health services
  • spoke with a total of ten staff which included the modern matron, team leaders, lead therapist, counsellor, psychologist, nurses and health care workers
  • spoke with six young people
  • spoke with eight parents & carers
  • spoke with one external social worker
  • reviewed eight care plans and risk assessments
  • reviewed three care records and 4 observation records
  • observed a daily handover meeting
  • reviewed a range of policies and procedures, data and documentation 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 with six young people who said they felt there were enough staff present on the unit but two told us that often staff were busy. Three young people said there had been incidents or bullying on the ward and this was not managed appropriately by staff, they felt unsafe on the ward and not listened to by staff. Three young people said there was a lack of therapeutic interventions, including psychology, although another young person said they had accessed art therapy three times per week. One young person told us staff were respectful and polite but three did not and that their concerns were not always addressed, some staff lacked empathy and there was lack of consistency with staffing. One young person told us they felt their complaints were disregarded and another said a lot of the time their views were not heard. However, one young person said a number of staff were helpful.

One young person told us activities were often cancelled due to staff shortages. The current refurbishments on the unit also impacted on the ability to access quiet space areas.

We spoke with eight parents who said that overall, the quality of care for their children was very poor. They cited that communication between staff and themselves was poor and they were not always consulted regarding their child’s care or there was a delay in them being updated following an incident on the unit.

The parents of one young person told us there was no single point of contact for families to alleviate a lot of the confusion around the care and running of the unit. Most parents did not feel their children’s needs were being met and there were significant delays in response to complaints they had made. Three parents told us their child’s self-harming behaviour had increased since admission to the unit. Some parents said they were frustrated at the lack of therapeutic support available to their child and there was a lack of psychiatrists and consistent staffing within the unit. Some expressed a lack of meal support and expertise from staff for young people with a diagnosis of an eating disorder.

Community mental health services with learning disabilities or autism

Good

Updated 8 September 2015

We rated the Community Learning Disability Services as good because:

  • Staff undertook a risk assessment for every person who used the service and this was reviewed regularly. There were excellent lone working policies and all staff followed these to ensure their safety and that of people who used the service.
  • Comprehensive personalised and holistic assessments were completed in a timely manner. The team included or had access to the full range of health professionals required to care for the people who used the service.
  • Staff were polite, kind and treated people who used the service with respect. People and their relatives told us that staff were compassionate and cared about them. People were actively involved in their care planning and participated in their clinical reviews.
  • The teams were able to assess urgent referrals quickly and non-urgent referrals within an acceptable time. Where possible, people had flexibility in the times of appointments. There was easy access to interpreters and signers. People who used the service knew how to complain.
  • The team’s objectives reflected the trusts values and objectives. There were good and effective governance systems ensuring good quality and safety. There were opportunities for leadership development. Staff were offered the opportunity to give feedback on services and input into the service development.

Community-based mental health services for older people

Good

Updated 8 September 2015

We rated community-based mental health services for older people as good because:

  • The service operated safely, with sufficient numbers of well-trained staff who were aware of, and used, safe practice such as the lone worker policy and procedures.
  • The needs of people using the service were assessed and responded to promptly and monitored effectively.
  • The teams had a good mix of professionals, nurses, support workers, psychologists, pharmacists, social workers, psychiatrists, occupational therapists, speech and language therapists, who worked together well.
  • People using the service were treated with respect and dignity and their individual needs responded to. They were very complimentary about the service and the staff they came into contact with.
  • There was a low turnover of staff throughout the services. This offered people using the service consistency and experience.
  • Staff were highly motivated, caring and enthusiastic about their work. This was reflected in their contact with people who used the service.
  • Changes to the service had been managed effectively, whereby three out of the four areas had relocated services to central ‘hubs’. Staff working in these hubs had responded positively. One area, the North West, was still to move to a hub.

We also noted:

  • The environments of some memory clinics were not very welcoming for people using them, and there were delays for some people between being referred and receiving an assessment.
  • It was not always clear if people using the service had had mental capacity assessments, which is needed to ensure people are not given treatment they are unable to consent to.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 8 September 2015

We gave an overall rating for long stay/rehabilitation wards of good because:

We found that the wards were kept clean and well maintained and patients told us that they felt safe. There were enough, suitably qualified and trained staff to provide care to a good standard. At Sovereign House, one qualified and one unqualified staff worked each shift; at The Beacon, two qualified and two unqualified staff worked each shift and at Gainsford House and Hampden House, two qualified and one unqualified staff worked each shift. We found that patients’ risk assessments and formulations were robust and person centred. We found the service had strong mechanisms in place to report incidents and we saw evidence that the service learnt from when things had gone wrong. We found, however, that patients were not protected against the risks associated with the unsafe use and management of medicines. This related to the rehabilitation wards not having appropriate arrangements in place for obtaining, recording, and dispensing medicines.

The assessment of patients’ needs and the planning of their care was individualised and had a focus on recovery. We found staff had a good understanding of the Mental Health Act 1983 (MHA), the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice. We saw throughout all of the wards that the multi-disciplinary teams were involved in assessing and delivering patient care. We found motivated and supportive ancillary staff on all of the wards.

We found caring and motivated staff, and, saw good, professional and respectful interactions between staff and patients during our inspection. Patients commented positively about how kind the staff were towards them. We saw evidence of initiatives implemented to involve patients in their care and treatment. These included the recovery STAR tool and daily ward briefings with all patients and staff.

We found bed management processes were effective. Patients were able to access a rehabilitation bed when required and were actively engaged, through a recovery focussed model of care, to prepare for community living. We found a developing service model and care pathway which optimised patients’ recovery, comfort and dignity. We found a varied, strong and recovery orientated programme of therapeutic activities, many of which were making use of the local mainstream, community facilities. These included many community based sporting activities, as well as person centred interpersonal skills training. We noted the service was responsive to listening to concerns or ideas made by patients and their relatives to improve services.

We found all staff to have good morale and that they felt well supported and engaged with a visible and strong leadership team which included both clinicians and managers. We found governance structures were clear, well documented, adhered to by all of the wards and reported accurately. We noted a quality initiative called, “show casing” which identified a particular area of the service where a development or improvement had been identified. This was then advertised and celebrated across the rehabilitation service and the rest of the trust. We saw that this particularly motivated staff and gave them impetus to continue to improve the quality of care and treatment provided.