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Provider: Hertfordshire Partnership University NHS Foundation Trust Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 15 May 2019

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.
Inspection areas

Safe

Good

Updated 15 May 2019

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

  • The trust had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff received and were up to date with mandatory training. Specialist training and leadership training was available.
  • Overall, all wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff could clearly see all areas of the ward and knew about any ligature anchor points and actions to mitigate risks to patients who might try to harm themselves.
  • Staff used recognised risk assessment tools. Staff completed holistic risk assessments on admission and updated these regularly and after incidents. Staff responded to changes in patient risks. Staff completed and updated risk assessments for each patient and used these to understand and manage risks individually. Staff minimised the use of restrictive interventions and followed best practice when restricting a patient.
  • Staff understood how to protect patients from abuse and were aware of the requirement to work well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Overall, staff had the appropriate level of safeguarding training for the services they delivered. However, not all staff were up to date with safeguarding training for children. Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
  • Overall, staff followed best practice when storing, dispensing, and recording medication. Staff regularly reviewed the effects of medications on patient’s physical health.
  • The trust managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. We saw evidence of changes to practice following lessons learned.
  • The trust had developed robust personal safety protocols, including lone working practices, and we saw evidence that staff followed them. The trust ensured there was safe staffing in place across the service to ensure patients care and treatment needs were met. Overall, staff had access to alarms they could use to call for assistance.
  • The trust ensured risks to safety from service developments, anticipated changes in demand and disruption were assessed, planned for and managed effectively. Plans were in place to respond to emergencies and major situations. All relevant parties understood their role and the plans were tested and reviewed.

However:

  • We found some environmental concerns that required attention. For example, the assessment room used by the metal health liaison team at Lister Hospital had lightweight furniture and was not soundproof. 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. 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. The trust had plans for refurbishment, to commence in August 2019.
  • We found some concerns related to privacy and dignity and the management of mixed sex accommodation within older peoples’ inpatient wards. In this service, environmental risk assessments were not always detailed or accurate. Not all adult community teams had adequate environmental risk assessments in place, particularly in relation to the management of ligature risks in public toilets.
  • On Oak ward, staff did not consistently complete physical observations following administration of rapid tranquilisation, in line with the National Institute for Health and Care Excellence guidance. We observed some sub-optimal practice related to safe disposal of medicines in one crisis and home treatment team.

Effective

Good

Updated 15 May 2019

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

  • Managers made sure they had staff with a range of skills need to provide high quality care. They supported staff with appraisals, supervision, opportunities to update and further develop their skills.
  • Staff had knowledge of the Mental Health Act and Mental Capacity Act and applied the principles well in their work. Staff explained rights under the Mental Health Act to patients, regularly and in a way they understood. Staff ensured patients were able to take their Section 17 leave as agreed. Instances of staff cancelling leave were rare. When leave was cancelled, patients received an explanation and leave was rearranged.
  • Staff supported patients to make decisions on their care for themselves. They understood the trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly. Staff ensured consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004. When patients aged 16 and over lacked the mental capacity to make a decision, ‘best interests’ decisions were made in accordance with legislation. The process for seeking consent was appropriately monitored.
  • Overall, staff developed comprehensive care plans that met the needs of the individual patients, were up to date, personalised, holistic and recovery orientated. Staff carried out annual physical health checks and checks of physical health at regular intervals.
  • Staff held daily multidisciplinary meetings. Patients, carers and families were invited regularly to multidisciplinary team meetings. Teams worked closely with external parties, such as GPs and other service providers.
  • Most services had a full range of mental health disciplines and workers who provided input into patient care. Clinicians in the trust worked collaboratively with each other and with other external providers in the area to ensure patients received person-centred care, and received that care at the right level and in the right place.
  • Policies were aligned and referenced to national guidance, such as National Institute for Health and Care Excellence (NICE) guidelines. Staff had access to a full range of policies and procedures to support them in their roles and knew who was responsible for providing their national clinical guidance.

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.
  • Staff did not complete wellbeing care plans for all patients in the community adults’ service.
  • The trust was not consistently meeting targets for referral to treatment in the adult community team and community team for children and young people. However, the trust had robust systems to maintain contact with patients and manage risk whilst patients waited in both services.
  • Within some acute wards for adults, there was a lack of psychological therapies recommended by the National Institute for Health and Care excellence provided, due to short term vacancies. However, we were assured that some psychological therapies, such as mindfulness, were happening and the trust were actively recruiting into psychology vacancies.
  • The trust did not always ensure patients detained under Section 136 of the Mental Health Act were assessed within 24 hours.

Caring

Outstanding

Updated 15 May 2019

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

  • Staff across the trust truly respected and valued patients, families and carers as individuals.
  • The trust had an impressive strong, visible and person-centred culture. Staff were highly motivated and delivered kind and compassionate care; which respected the individual choice of patients and protected their dignity. Staff recognised and respected the individual needs of patients, including cultural, social and religious beliefs.
  • We were struck by how well staff treated patients and carers. Staff were discreet, respectful and responsive in all their interactions with patients. Patients told us staff were always kind, compassionate and incredibly supportive. Staff supported patients to understand and manage their care and treatment or condition in a very sensitive manner. Staff provided patients and carers with information about their condition and treatment and followed up with further explanations when needed.
  • Staff always communicated with patients sensitively and compassionately, so they understood their care and treatment. They used a range of methods of communication including using signers, easy read leaflets and by seeking support from carers and families where appropriate.
  • The trust ensured patients, families and carers had the opportunities to be active partners in their care. Staff across the organisation worked in partnership with patients and those close to them in an integrated approach. We saw this had a positive impact on patient care.
  • Patients could give feedback on the service they received in a number of ways, for example via ‘having you say’ feedback forms, and the trust shared this information with teams. The wards held regular meetings with full patient involvement. Staff and managers told us patients were involved in recruitment, service development and were active in planning their care. Staff held patients at the centre of everything they did. We found the trust values were embedded in staff behaviours with patients across all services.
  • The trust had excellent links with external partners, including the local acute NHS trust to promote good quality care for patients. There were many examples of coproduction and partnership working to promote good quality and sustainable care for patients.
  • Staff knew how to raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes without fear of the consequences and knew this would be acted upon. We saw evidence that staff were increasingly raising concerns openly and incidents of anonymous contacts to the freedom to speak up guardian had reduced. This evidenced an open and transparent culture was fully embedded.
  • Staff ensured patients could access advocacy, both within the trust and from an independent advocacy service. Carers were provided with information on how to access a carer’s assessment. Carers felt supported by staff and involved appropriately in their relatives care and treatment.

However:

  • On acute wards for adults of working age, not all care plans demonstrated patient involvement or that patients had been offered a copy of their care plan. However, most patients told us they felt involved in their care planning.

Responsive

Good

Updated 15 May 2019

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

  • 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.
  • The 18-week target from referral to treatment was usually met. Managers proactively managed patients who were awaiting treatment. In community mental health services for adults, data showed patients waited, on average, for 67 days for allocation to treatment.
  • We were particularly impressed with the new care pathways model introduced for the inpatient service for children and young people, which had reduced the average length of stay for patients from 80 days to 15. Staff worked closely with community teams and crisis teams to ensure patients were supported throughout the process of admission. The service also had access to a home treatment team on site. The home treatment team supported ward staff to facilitate discharge for patients, so they did not spend any more time in hospital than was necessary. Crisis assessment and treatment team staff utilised the acute day treatment units and the host family scheme which provided an alternative to an inpatient stay.
  • Within the mental health community teams, the trust had robust processes for monitoring patients on waiting lists. The approach varied across teams, but consistently involved regular contact with patients and continued assessment of risk and need. We were assured staff monitored waiting lists effectively. The crisis services did not have waiting lists.
  • Patients were given flexibility in when and where they could see staff. Teams took a proactive approach to engaging with patients who found it difficult or were reluctant to engage with services. The needs of different people were taken into account when planning and delivering services.
  • Staff ensured patients had access to opportunities for education and work, including referring patients to a wellbeing college which was delivered in partnership with the third sector (MIND).
  • Staff helped patients to stay in contact with families and carers. Wards had quiet areas for patients and rooms where they could meet visitors. Staff and patients across most services had access to a full range of rooms to support care and treatment.
  • Patients told us they knew how to complain. Staff encouraged patients to raise concerns and attempted timely local resolutions. Staff knew how to record and escalate complaints. Managers investigated local complaints in a timely way and staff received outcomes and lessons learned via many routes. Patients had access to information leaflets in a variety of languages and there was access to a translation service.
  • There were activities across the week for patients, including weekends. There was access to spiritual support, including within some community teams. Patients had access to drinks and snacks throughout the day.

However:

  • Staff working in the community teams for children and young people did not have sufficient rooms available to meet with patients. Within the community adults’ teams, some interview rooms did not promote privacy and dignity for patients; due to lack of soundproofing.

Well-led

Outstanding

Updated 15 May 2019

Our rating of well-led improved. We rated it as outstanding because:

  • 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 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, with the chief executive having chaired the Health and Care Partnership Board (STP) between 2016 and 2018. Reports from external sources, including NHS improvement and commissioners were consistently favourable.
  • Local leadership across the trust was strong, visible and effective. We were particularly impressed by the leadership demonstrated by the leaders of the three trust strategic business units and the lead for safeguarding. We were also impressed by the clear focus and priority for providing safe and high-quality care consistently demonstrated by the finance director. Staff consistently and particularly praised the chief executive, medical director and chief nurse. The trust reviewed leadership capacity and capability on an ongoing basis. 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 was working with other local health economy stakeholders with an intention to improve the sustainability of the care the system delivered to the population of Hertfordshire. This was particularly evidenced by the commitment and involvement of the trust’s chief executive through leading the regional sustainability and transformation plans. 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 at board level and informed how the senior leadership team operated. We saw the trust values were embedded throughout the trust through recruitment, new initiatives, staff appraisals and staff wellbeing. 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. The board culture was open, collaborative, positive and honest.
  • The trust proactively worked alongside partners to provide joined up healthcare for the local population. For example, the trust worked alongside the local community NHS trust in The Marlowes Health and Wellbeing Centre in Hemel Hempstead and the New Leaf Wellbeing College, co-produced by organisations and individuals across the spectrum of mental and physical health in Hertfordshire. Staff working in the psychiatric liaison service worked in partnership with two local acute trusts, with joint working protocols and escalation processes in place. 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.
  • 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. Leaders had an inspiring shared purpose and strive to deliver and motivate staff to succeed. The trust ensured staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Any staff shortages were responded to quickly and adequately.
  • We were particularly impressed with the caring and compassionate attitudes of staff across all services we visited. Staff consistently demonstrated that patients were at the heart of every interaction. This included working collaboratively with families, carers and outside agencies. Staff felt respected, supported and valued. Across all services, staff reported exceptionally supportive relationships with colleagues and local managers. Staff showed pride and talked passionately about their roles. In some services staff went over and above to provide the best care possible. We felt this was due in part to staff feeling recognised for their hard work and the quality of the care they delivered.
  • Staff morale across all teams was consistently high. This was evidenced during the core service inspections and via focus groups, involving nearly 300 staff. he trust encouraged staff inclusion, including staff with protected characteristics, via a number of network groups; including BAME, disabled, staff carers, mental health, women’s and LGBT.
  • The trust promoted a culture of openness, transparency, support and learning in a blame free environment, with safety as a top priority. We saw a number of practices to support staff and promote learning, for example, SWARMs, Swartz rounds and ‘safety huddles’. Staff spoke positively of the support they received, and the trust focus on shared learning. The trust appointed a new freedom to speak up guardian in August 2018. Staff spoke positively about this role and confidence in the role was demonstrated by increasing numbers of referrals no longer anonymised. The trust applied the duty of candour appropriately. We reviewed serious incident investigation reports and saw the trust contacted families and carers for their views and kept them informed. We also saw robust evidence of application of duty of candour within trust responses to complaints.
  • The trust demonstrated a clear priority for involvement of patients, families and carers, which was particularly impressive and demonstrated real involvement. This was evident throughout the inspection across all core services and modelled by the senior leadership team. Examples included the emphasis on involvement in planning services, recruitment of senior staff and service user involvement in board meetings. The trust actively supported a number of carers’ groups and councils. We saw evidence where changes had been made as a result of patient feedback and many examples of co-production, for example, the making our services safer (MOSS) strategy, which involved patients working with staff to improve the impact of restrictive practice.
  • The trust’s governance arrangements were proactively reviewed and reflected best practice. A systematic approach was taken to working with other organisations to improve care outcomes. Executives and non-executive directors were impressive in their understanding of their roles and responsibilities. The trust used a systematic approach to continually improve the quality of its services and safeguarded high standards of care by creating an environment in which excellence in clinical care would flourish.
  • The trust had effective structures, systems and processes in place to support the delivery of its strategy and oversight of performance, quality and risk. The trust held patients as a top priority. The trust had an overarching integrated governance committee to which all other governance meetings reported. There was robust scrutiny at board level and non-executive directors challenged decisions where necessary. The trust had a physical health strategy, overseen by the physical health committee. Objectives were incorporated into each strategic business unit’s business plan and a physical health champion nominated from each service area took forward these actions. Interaction between all levels of governance in the trust worked well.
  • The trust discharged its duties under the Mental Health Act efficiently. The trust demonstrated robust arrangements to ensure hospital managers and non-executive directors discharged their specific powers and duties, according the provisions of the Mental Health Act 1983.
  • The trust had a robust and effective complaints process led by qualified and experienced staff. Staff across the trust knew how to support patients and carers to complain, and were not afraid to raise complaints themselves. The board positively shared with staff the importance of reporting things that were not right and were open to apologising when things went wrong.
  • We had high levels of confidence the senior leadership had the focus, ability and drive to make improvements and address issues of poor performance quickly and effectively. For example, improvements at the Broadlands Clinic in Norfolk, subsequently rated outstanding in 2018. When issues were identified, the trust worked quickly to make improvements and shared learning across the organisation.
  • We were impressed with the trust oversight and management of restrictive practices (restraint). The trust had recently reviewed its RESPECT training and commissioned an external review of seclusion practices. Actions included strengthening practice around privacy and dignity, improvements to RESPECT training, strengthening the governance to review seclusion practices and regular audits of seclusion. We saw the trust had robust actions plans to improve practice and safeguard patients. Records showed improvements as a result.
  • The trust demonstrated an impressive commitment to best practice performance and risk management systems and processes. The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust had a comprehensive and regularly reviewed risk register. All staff were able to add a risk to the register and this was then reviewed, along with mitigations, at local meetings and escalated through the governance system.
  • The trust monitored strategic risks via the board assurance framework and reviewed this regularly. We found this document gave robust assurance to the board. However, we identified some further areas for improvement. The trust took immediate action.
  • We were particularly impressed with innovations in information management we observed, and the trust focus on ensuring staff had access to innovative and best practice information systems and processes to support delivery of high quality care to patients. For example, a new information and clinical support system, SPIKE v2, which ensured key information from the electronic patient record systems was easily accessible, and ‘discovery’, a data management system for staff access to training and to record supervision. The trust had introduced virtual meetings via the internet to save staff travel time. Staff in Norfolk were particularly praising of this initiative.
  • The leadership drove continuous improvement and staff were accountable for delivering change. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. For example, on the ward for children and young people, the trust had introduced a new care pathways model which had reduced the average length of stay for patients from 80 days to 15. These pathways included 72-hour urgent admission, and four-week, six week, and eight-week admissions for patients with more complex needs. Staff worked closely with community teams and crisis teams to ensure patients were supported throughout the process of admission. The service also had access to a home treatment team on site. The team supported ward staff to arrange discharge for patients so they did not spend any more time in hospital than was necessary.
  • We were pleased to see the trust had made significant improvements to the identification and reporting of serious incidents. Since our last inspection, the trust had introduced a moderate harm panel which met weekly and had representation across all strategic business units, including, safeguarding, clinical directors, managing directors and deputy directors of nursing, safer care and the deputy medical director. The panel met to ensure incidents reported as moderate harm, severe harm or death were discussed, immediate learning shared and themes identified. The panel liaised with the mortality governance team, and referred cases where appropriate for structured judgment review. The panel also set terms of reference for any serious incident investigations and instigated SWARMs to support staff through reflective practice. We considered the trust had had significantly improved practice in this area, reporting had improved and lessons had been learnt that would otherwise have been missed.
  • The trust had a robust and planned approach to take part in national audits. The trust’s practice audit and clinical effectiveness team led on clinical audit work for the trust, including nationally mandated audits, alongside a variety of audit topics requested internally.
  • 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, we were not always clear on the outcome measures used or timeframes for evaluation. We were concerned the trust would not always have clear evidence to monitor success, or otherwise, of some of the projects and pilots it implemented.
  • The trust had a fully embedded and systematic approach to quality improvement. The trust had a continuous quality improvement agenda which focused on six themes: safety, clinical effectiveness, service user experience, access, workforce and productivity. The trust had an ‘innovation hub’ in which they held regularly scheduled sessions and bespoke workshops. The trust had an innovation fund, launched in October 2016 with 17 panels held to date. The trust identified no upper limit to innovation fund awards.
  • We saw examples of staff at all levels taking personal responsibility for innovation and implementing better ways of doing things, fully supported by their leaders. For example, the introduction of anti-slip (gummy) socks in older people’s inpatient services and a ‘pimp my zimmer’ initiative. Innovations were taking place in services to promote the privacy and dignity of patients. For example, the provision of a dedicated Section 136 suite for children and young people and the elimination of dormitory style accommodation. This supported the Department of Health’s guidance on eliminating mixed sex accommodation.
  • Leaders used key performance indicators to monitor performance. This data fed into a board assurance framework and the integrated governance committee. Team managers had access to a range of information to support them with their management role.
  • The trust demonstrated high levels of constructive engagement with staff, external stakeholders and people who use services, including equality groups. For example, the trust took an active role in the wider health economy relating to system resilience and supported the neighbouring acute NHS trust, to support legislation that applied to patients admitted to those sites requiring MHA assessments. The trust provided MHA training to the acute NHS trust and the police.
  • The trust had implemented a visionary community chaplains project, extending support into community teams. A further 12-month pilot started in 2018, extending the service to Watford.

However:

  • Staff had access to a range of policies and procedures via their intranet. However, we found some policies had not been reviewed in line with documented timescales; whilst others had statements stating the policies remained current. It was not, therefore, always clear whether all policies had been reviewed.
  • We considered the trust should further review the board assurance framework to address some gaps in assurance.
  • Some managers had not received training in the operation of the trust’s new data management system and were unable to operate the system effectively.

Checks on specific services

Wards for people with a learning disability or autism

Outstanding

Updated 25 April 2018

The summary for this service appears in the overall summary of this report.

Wards for older people with mental health problems

Good

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

Community-based mental health services for adults of working age

Outstanding

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

Child and adolescent mental health wards

Outstanding

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

Mental health crisis services and health-based places of safety

Good

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

Specialist community mental health services for children and young people

Good

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

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

Good

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

Forensic inpatient or secure wards

Outstanding

Updated 25 April 2018

The summary for this service appears in the overall summary of this report.

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.

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.