During a routine inspection

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.

During a routine inspection

• We rated safe as requires improvement and effective, caring, responsive and well-led as good. In rating the trust, we took into account the previous ratings of the seven services not inspected this time. We rated the trust overall for well-led as good. At this inspection, we rated two core services as outstanding, one core service as good and one as requires improvement. In rating the trust, we took into account the previous ratings of the seven services not inspected this time. Therefore, two of the trust’s 11 services are rated as outstanding, eight as good and one as requires improvement.
• 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.
• Staff managed medicines safely in most services. The trust had made improvements in medicines management since the last inspection. Documentation was clear, staff completed competency assessments, and managers implemented systems to manage medication and completed regular audits.
• The trust provided mandatory training, supervision and appraisal. Staff compliance with this in most services was above 75%. Managers discussed the values with staff in supervision, and based team objectives on trust values. Senior staff saw leadership as fundamental to their role and managers were visible and approachable. The trust recognised staff success through individual and team awards and staff were encouraged and supported to develop in their roles.
• Staff completed comprehensive and robust risk assessments and documentation showed clear patient involvement and inclusion. Care of patients focused on their strengths and areas of independence. Staff responded quickly and effectively to the changing needs of patients. Bed management processes were effective and embedded into some services.
• Staff included patients in service improvement, using their feedback to change practice. We saw many examples of innovation and projects that had been trialled and then implemented in the trust.
• Safeguarding and incident reporting were transparent locally and thorough; review and evaluation of this was proactive. Teams shared lessons learnt effectively and in some services shared this learning with patients. There was good evidence of multidisciplinary team working within the services and with external agencies.
• Local leadership across the majority of services was strong, visible and effective. Senior leaders were known to staff and visited services. The board encouraged feedback from all levels of the organisation. The responsiveness of the teams and at board level to issues raised during the inspection was immediate.
• The trust had a robust governance framework and structure. Service managers attended local monthly clinical governance meetings, which fed into the trust wider governance meetings. Local governance meetings discussed ward issues, such as incidents, safeguarding, staffing concerns, and identified and shared learning from incidents.
• Information technology systems and use of technology applications enabled staff to deliver care more safely and efficiently. Quality improvement initiatives had begun to make a difference. The system for agreeing projects to be supported showed commitment to the principles the trust upheld. Staff involved service users in project decision that needed to be made.
• A system called SPIKE gave staff access to monitor performance and leaders saw this as a way to assist data collection and analysis and reduced time on administration tasks. The trust was developing a second version of SPIKE to further improve data management and staff saw this as positive.
• We were provided with a good description of the way in which the trust implemented Duty of Candour, highlighting that it is in the terms of reference for the investigation of each serious incident that the duty of candour is complied with; patients are contacted before, as part of, and at the conclusion of each investigation.

However:

• Low staffing in the child and adolescent mental health ward may have impacted on the frequency of one to one keyworker sessions. In one ward for people with a learning disability or autism, shifts were not always covered with sufficient staff.
• Although staff on the mental health wards had assessed the risks posed by potential ligature anchor points, they had not identified all such risks. Also they had not taken action to fully mitigate the risks posed by some of the potential ligature anchor points that they had identified. The trust took immediate action at the time of inspection to address this and a plan of works was completed by the end of January 2018.
• We identified the use of restrictive practices on the child and adolescent mental health ward. Patients access to mobile phones was restricted and some patients were not allowed full access to the ward garden.
• Seclusion occurred outside of designated seclusion rooms in several services and staff did not always clearly document the reasons for this. Two seclusion rooms had environmental issues identified and were not compliant with the Mental Health Act code of practice. The trust took immediate action to address this.
• Some physical healthcare records lacked detail in care plans and monitoring for long-term health conditions did not take place.
• Supervision compliance was low in two services. Most services had local system to record compliance in the absence of a trust wide system.
• In one service, staff did not feel supported by senior managers and there was a poor working relationship with the education team. The leadership in Albany Lodge was new, the staff team was new and staff felt there was a lack of direction.
• The trust did not follow the NHS framework for reporting serious incidents.

During a routine inspection

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.