Hertfordshire Partnership University NHS Foundation Trust

We found that Hertfordshire Partnership University NHS Foundation Trust was performing at a level that leads to an overall judgement of good.

We found a great deal that the trust can be proud of.

We noted that people’s needs, including physical health needs, were assessed and care and treatment was planned to meet individual need. Staff had good opportunities for learning and development and showed a good practical understanding of the Mental Health Act and the Mental Capacity Act including Deprivation of Liberty Safeguards.

Caring was consistently of a good standard and we found staff to be dedicated, kind and patient focused. The CAMHS substance misuse team deserved recognition in terms of the care and treatment offered but also the responsiveness of the services provided to patients. The services at Logandene and Elizabeth Court had improved greatly since previous inspections. We also observed some good caring practice in the community services for people with a learning disability or autism.

Despite staffing pressures in some areas, staff were generally responsive to the needs of the patient group. The trust’s facilities and premises were generally appropriate for the services that were being delivered. The modern and purpose built facilities at Colne House, Seward Lodge and Kingfisher Court demonstrated an organisation that is proactive with regards to the rationalisation of its estate.

We found the trust to be well-led at board level. The trust’s vision and values were visible in most of the services provided and the work that the leadership team were undertaking to instil these throughout the organisation in order to promote a caring, transparent and open culture was notable. The executive team impressed us both individually and collectively. They demonstrated cohesion and a determination to improve and enhance the quality of care provided to those who use services within the Trust. The inspection team also noted the important role that non-executive directors and the board of governors performed in implementing quality and value throughout the trust.

The executive team met weekly and discussed ongoing issues and board challenge. This enabled the trust board to address any identified issues in a timely manner. The executive and non-executive directors regularly visited services as a way of staying in touch with staff, families and people who used services. Front line staff told us that these visits were much appreciated.

However:

We found areas of concern. In the CAMHS Section 136 suite at Kingsley Green. The privacy and dignity of young people was compromised as a result of the location of the suite. However, the trust acted immediately to remedy this and relocated the suite to a more appropriate environment.

Recruitment of staff was an area that required improvement by the trust in order to reduce reliance on bank and agency staff that were less familiar with the patient group. Staff morale was low in some areas following a trust wide transformation of services. However, we found evidence that the trust was taking action to address these issues.

We will be working with the Trust to agree an action plan in order to improve and address the areas of concern.

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.

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.

We rated the CAMHS inpatient service as good because:-

• The CAMHS unit had a risk register and action plan. This fed into the overall risk register. The main risk identified was staffing and its impact on continuity of care due to high agency usage.
• Young people received mental and physical health assessments and participated in their clinical ward rounds. National institute for clinical effectiveness (NICE) guidance was used to underpin treatment, therapy and pathways. There was a wide range of therapies available for young people and their families.
• The service has seen an increase in the severity of illness amongst young people being admitted in the past year. Young people with disturbed behaviour affected other young people on the ward. Increased observation levels were required. The senior management recognised the pressures the unit was under. Managers reviewed and increased the established staffing levels to meet the dependency levels of the young people.
• The multidisciplinary team worked effectively. Outcome measures were used to measure progress.
• There was an active youth council involved in a variety of projects including complaints and the review of CAMHS services, as well as staff interviews.
• The unit had achieved the Royal College of Psychiatrist quality network for inpatient CAMHS accreditation. The trust had also given staff awards for good practice .The trust was participating in Hertfordshire wide reviews relating to CAMHS and children’s' services.

However:

• The unit had 9 vacancies and depended on high levels of bank and agency staff. The impact of this resulted in fewer activities, nursing staff being unable to keep up-to-date with mandatory training and supervision. Despite the pressures the unit faced, staff treated young people with respect and dignity.

We rated Hertfordshire University Partnership NHS Foundation Trust community-based mental health services for adults of working age as Good because:

• Staff had completed safeguarding training and could explain safeguarding procedures and examples of recent safeguarding concerns. There were good examples of multi-disciplinary working across the teams including collaborative working between professions.

• There was a good range of psychological therapies available including dialectical behaviour therapy, cognitive behaviour therapy, drama and art therapy. Most staff were up to date with their supervision and appraisals and could access specialist training.

• Staff demonstrated a good understanding of people’s individual needs. Most people who use services and their carers we spoke with gave positive feedback about the care and support they received.

However:

• There was a high number of vacancies and use of agency staff across the teams we visited that impacted on people’s continuity of care.

• We found a high number of cases that had not been allocated a care coordinator within 28 days. People who use the services experienced a delay in allocation and high frequency of change in care coordinators.

• All staff did not have lone working devices, or were not aware of what the lone working procedures were.

• Following a serious incident at Hertford County Hospital, all staff were not aware of the learnings or outcomes. Staff at Hertford County Hospital and Waverley Road also were not all provided with a debrief after serious incidents.

• In the care records we reviewed, risk assessments did not always identify people’s risk including histories of self harm. People’s care plans were not always up to date. They also lacked evidence of how the person who uses the service and/or their carer were involved with the person’s care and treatment. We also found that people did not always have a completed physical health assessment.

• Staff we spoke with found the trust’s electronic database system difficult to use and they could not access people’s information easily.

• Staff were unhappy with the recent transformation and this affected their morale. However, they felt supported by their team and manager. Despite issues with staffing, we observed staff providing high quality care to people who use services.

We rated Hertfordshire Partnership University NHS Foundation Trust wards for older people with mental health problems as Good because:

• Care and treatment was delivered in a person centred, kind, respectful and considerate way
• Care Programme Approach and ward reviews were carried out in a timely manner
• Patients and their carers were involved as partners in their care
• Patients told us they felt safe and were satisfied with the care they received
• There were care plans and risk assessments in place for patients
• There was a culture of staff managing patient behaviours effectively and only using medication when they needed to
• Patients had routine and regular contact with a range of health professionals to promote their physical health and well-being
• Different professions worked effectively together to assess the needs of patients and to support the discharge process
• There was an active occupational therapy team and they developed individual plans and therapeutic activities with patients.
• Patients and their carers told us that staff treated them with kindness, dignity and respect.
• There was an active chaplaincy service which supported patients with their spiritual needs
• Staff showed a clear understanding of the Mental Health Act and the Mental Capacity Act including Deprivation of Liberty Safeguards.
• Staff told us they felt valued and supported by the Trust and felt confident they could report their concerns without fear of reprisal.
• There was an active training plan in place for staff to enable them to keep up to date with their clinical or leadership skills and to develop these further
• There were robust systems in place to record incidents and learning from incidents was routinely shared
• Morale amongst staff we spoke to was generally good and staff were clear about their roles and responsibilities
• Local leadership was available and supportive to staff

However:

• Arrangements for medication management did not keep all patients safe. Some patients did not receive the recommended monitoring they should have received following administration of “as needed” or PRN medications for agitation and one patient received an inhaler that was not prescribed for them. There was no involvement from pharmacy staff in medicines reconciliation and covert medication plans were not always reviewed in line with the Trust’s own policy or signed by a pharmacist.
• Care plans were not completed in a personalised way which meant they did not reflect the person centred way that we saw staff delivering care. Records did not reflect that patients or carers had been involved in developing their care plans or had been given a copy, though most people told us they had been involved. Risk assessments and care plans were not all up to date.
• A number of staff told us that the introduction of a new shift pattern meant that they were often unable to take their breaks in a timely manner and some staff told us they were often unable to take a break. Some staff told us that they were anxious about some of the reorganisation of the service and were uncertain about the future of some units.

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.

We rated Hertfordshire Partnership University NHS Foundation Trust as good because:

• Patients were protected against the risk of abuse because staff were trained in safeguarding and how to report any form of abuse they saw.
• Patients care plans described the care and treatment needed to meet their needs.
• Patients’ rights under the mental health act were always explained to them with regular reminders of their rights.
• Patients were treated with respect and had access to advocates
• Visitors were well catered for with dedicated visitor bedrooms for families travelling long distances
• Patients were offered psychological assessment and occupational therapy.
• The acute wards and PICU were well-led and morale was good amongst the staff.

However:

• staffing levels on some wards were insufficient to keep patients safe
• there was high usage of bank and agency staff
• There were unmanaged ligature risks in some of the acute wards

We gave an overall rating for mental health crisis and health based place of safety of Good because:

• Staff within the crisis teams we inspected demonstrated a good knowledge and understanding of people using the service. In the shadow visits we undertook, it was clear that staff had an understanding of people’s needs. We observed examples of very sensitive information being discussed with the visiting professionals and being handled in an empathic and supportive way with choices being offered on how to guide and direct people to support their own independence.

• The crisis teams were responsible for gatekeeping 100% of all inpatient beds. They did this effectively. The teams maintained close working links with the outpatient and inpatient services across their geographical areas which enabled this effective level of gatekeeping.

• Staff morale was high in all of the teams we visited. Staff told us they were proud of the job they did and felt well supported in their roles.

However:

• At the North West CATT four of the eight medication cards we checked contained errors in administration recording. There were gaps in administration of medications and medicines had been given when dates showed they had not been prescribed. This meant that people’s medication was not always being administered in a safe way. This was reported at the time through the trust incident reporting system.

• At the North West CATT the medication cupboard temperature was not being recorded. This meant that medication was not being stored in a safe way. This was discussed with the manager at the time of the inspection and a system had been put in place by the time we left the service.

• All the crisis teams we inspected were aware of the risks associated with lone working but there was no consistency of approach across the crisis teams in how they were managing the risks. The trust had a lone worker policy however staff did not always appear to be following this.

• The section 136 suites at Lister Hospital and Kingsley Green children’s 136 suite did not provide a safe and/or suitable environment for the assessment of patients detained under section 136 of the Mental Health Act 1983.

• In the crisis teams out of the 15 sets of support plans we looked at, only four sets had recorded that the person receiving the service had been given a copy of their care plans and there was no documented reason as to why this had not been done. We spoke to 8 people receiving care from the crisis teams and four of those people were not aware of or had not received a copy of their care plan.

We gave an overall rating for long stay/forensic/secure services of ‘good’ because:

• Senior managers were aware of the risks in their areas and had identified actions to reduce them.
• Staff had risk assessed areas of improvement for wards including high risk ligature points. Staff managed these with relational security measures such as use of observation. Refurbishment work was scheduled for 2015/16 to ensure a safer environment.
• The majority of patients felt safe on their ward and told us that staff reacted promptly to any identified concerns.
• Patients had multi-disciplinary assessments in place and care plans with evidence of physical health checks and monitoring by staff.
• Staff provided a range of therapeutic interventions in line with National Institute for Health and Care Excellence (NICE).
• Staff reported they received support through induction, training, supervision and appraisals and for managers to monitor compliance with this.
• Staff treated patients with respect and dignity and we found patients were encouraged to be involved in their treatment and give feedback on the service provided.
• Units were well equipped to support treatment and care and had links with adult education, vocational and voluntary organisations and encouraged community engagement.
• The trust had governance processes in place to manage quality and safety.
• Managers had data on their area to compare their service with others. Where performance did not meet the expected standard, action plans were put in place.
• Staff were positive about the support they received from their manager and that they felt free to raise concerns and that they would be listened to.
• At Broadland Clinic staff morale appeared lower than at other units. Concerns included the trust consultation relating to staff shift patterns and the electronic staff rota. Managers were aware of these concerns and explained actions taken.
• Peer led assessments took place to improve the quality of the service provided such as from the quality network and Patient-Led Assessments of the Care Environment (PLACE).

However:

• There were nursing vacancies across each site and at Broadland Clinic staff and patients said this had a detrimental effect on the care given. Some professionals reported high caseloads which were above national standards for medium secure units. Patients and staff said the quality of the service provided had been affected by this.
• Improvements were required for seclusion and long term segregation rooms relating to ensure dignity.
• Across sites we observed staff had difficulties locating information on the electronic patient record
• Some improvements were needed relating to the MHA 1983 and MCA 2005 documentation, such as recording discussions regarding consent to treatment and when informing patients of their legal rights.

We rated wards for people with learning disabilities and autism as requires improvement because:

• There were three patients nursed in long term Segregation. The inspection team felt that the service users care plan within specialist residential services required more detailed information on their Long term segregation management, since our inspection the modern matron informed us that this was now in place.
• There were high rates of seclusion of patients at Lexden hospital. There were 87 episodes in the last six months. At Astley Court and Lexden hospital, patients were secluded in rooms that were not specifically designed to meet the standards of a seclusion room.
• All staff told us they knew what to report and how to report incidents.
• The Mental Health Act and the code of practice were not always adhered to. For example, consent to treatment and capacity requirements were not always followed however we saw evidence that patients had their rights explained to them on admission.
• Mental Capacity Act and Deprivation of Liberty Safeguards procedures were not appropriately followed in specialist residential service and Astley Court. Some staff demonstrated a limited awareness of the Mental Capacity Act. Capacity assessments to consent to treatment were not adequately carried out. Where patients required best interests meeting this was not consistently carried out.
• At Astley Court and Lexden hospital multidisciplinary team meetings did not have regular involvement of full range of other health professionals such as speech and language therapist, occupational therapist, social workers and psychology. These were external professionals from a different trust that provided care to patients but were not involved in clinical reviews.

However:

• There were fully equipped clinic rooms with accessible resuscitation equipment and emergency drugs that were checked regularly.
• Staff were trained in safeguarding and demonstrated a good understanding of how to identify and report any abuse.
• Staff were supervised, appraised and had access to regular team meetings.
• The units involved staff in a regular programme of clinical audits to monitor the effectiveness of the service provided.
• We observed and patients and their relatives told us that staff were respectful, polite and kind.
• Staff demonstrated that they understood the needs of the patients well. Patients and their relative were involved in their care planning where appropriate.
• There were a full range of rooms and equipment to support treatment and care in Dove, Lexden hospital and Astley Court.
• Patients’ cultural and religious dietary requirements were met. Patients also had access to spiritual support through the hospital chaplains.
• Patients’ individual communication systems were used and understood by staff. This meant that each patient was able to communicate their needs in the way they were used to for example, using sign language or pictures.

• Patients knew how to make a complaint and staff processed complaints appropriately. Staff told us that they knew how to use the whistle blowing process and felt free to raise any concerns.

• Staff had opportunities for leadership development, for example, some staff were on the leadership academy programme.

• Staff were offered the opportunity to give feedback on services and input into service development through the annual staff surveys.

• The trust used key performance indicators and other measures to gauge the performance of the team. Where performance did not meet the expected standard action plans were put in place.

We rated the community child & adolescent mental health services as good overall because:

• Due to the shortages in staff, the services relied heavily on bank and agency staff. As such, recruitment of substantive staff was active at the time of the inspection. This was having a knock on effect on key areas of the service such as appointment waiting times, completion of risk assessments and staff morale. Psychiatrists were also found to be carrying higher than normal caseloads. This was in part due to a large number of patients with ADHD who required ongoing medication reviews.
• Staff reported IT problems within the services; most notably at the adolescent drug & alcohol service where they had limited access to the electronic patient record system (BOMIC) for over 6 months.  This issue was being escalated through the county council at the time of the inspection as the solution rests wit the IT provider.

• The team did however find that reporting and learning from incidents was being achieved. We saw evidence of the dissemination of lessons learned throughout the services inspected.

• The services were effective overall. The inspection team viewed evidence of robust risk assessments, ongoing assessments and outcomes being achieved. Regular audits were carried out in order to monitor effectiveness in key areas such as waiting times, infection control and safeguarding and the outcomes of these discussed within the directorate governance meetings. In order to provide safe and cohesive pathways, inter-agency working with local authorities and internal Trust partners was also in evidence.

• Caring throughout the services was of a good standard. We saw evidence of staff showing compassion and empathy towards the young people in their care. Young people and their families were involved in decisions regarding their care.

• Responsiveness within the services was evident and of a good standard. Referrals were received via the single point of access and also internally through the various child and adolescent mental health teams. We saw good examples of the services meeting assessment targets; 88% of young people were being assessed within 28 days of referral and assessments within four hours for those presenting in the emergency department of the local general hospitals.
• The inspection team rated the well-led element of the child and adolescent mental health services as good. This was due to the notable alignment of the services with the trust’s vision and values. The managers that we spoke with provided evidence that they and staff are offered development. We also noted governance systems that robustly monitored performance, risk and quality. Senior management and team leaders provided visible leadership.