Hertfordshire Partnership University NHS Foundation Trust

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

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

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

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

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

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

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

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

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

SUMMARY OF FINDINGS

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

However:

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

How we carried out the inspection

During the inspection we:

• Spoke with the clinical director and interim senior service line lead
• spoke with head of nursing and service line lead for tier 4 children and adolescent mental health services
• spoke with a total of ten staff which included the modern matron, team leaders, lead therapist, counsellor, psychologist, nurses and health care workers
• spoke with six young people
• spoke with eight parents & carers
• spoke with one external social worker
• reviewed eight care plans and risk assessments
• reviewed three care records and 4 observation records
• observed a daily handover meeting
• reviewed a range of policies and procedures, data and documentation relating to the running of the service.

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

What people who use the service say

We spoke with six young people who said they felt there were enough staff present on the unit but two told us that often staff were busy. Three young people said there had been incidents or bullying on the ward and this was not managed appropriately by staff, they felt unsafe on the ward and not listened to by staff. Three young people said there was a lack of therapeutic interventions, including psychology, although another young person said they had accessed art therapy three times per week. One young person told us staff were respectful and polite but three did not and that their concerns were not always addressed, some staff lacked empathy and there was lack of consistency with staffing. One young person told us they felt their complaints were disregarded and another said a lot of the time their views were not heard. However, one young person said a number of staff were helpful.

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

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

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

We carried out an unannounced focused inspection of Warren Court because:

We received information giving us concerns about the safety and quality of the services at Warren Court from stakeholders, members of the public and staff who worked at the service. Concerns related to the safety of patients, the management of safeguarding, the use of restrictive practice, staffing levels and the levels of assaults against patients and staff.

As this inspection was focused, we only visited Warren Court and did not look at all key lines of enquiry.

Warren Court is part of the Eric Shepherd Unit and is a service for people with a learning disability who require specialist or forensic healthcare. The service provides medium secure assessment and treatment services for men with learning disabilities, additional mental health needs and a history of offending behaviour.

The service’s admission criteria included males aged between 18 and 65 years with a learning disability with a history of offending behaviours and where their mental state required conditions of medium security. All admissions were under the Mental Health Act. Warren Court was divided in to five houses. House 1 to 4 had five beds and house 5 had 10 beds and was the assessment and treatment house where patients were initially admitted. However, at the time of our inspection, managers had decided to just use five beds on house 5, due to the level of acuity. Newly admitted patients continued to be assessed prior to admission to determine the most appropriate house for admission and in consideration of their individual need.

We did not rate this service at this inspection.

We found:

• The service did not ensure that all seclusion records were completed in accordance with the Mental Health Act Code of Practice. We found gaps in several sections in one record relating to care and health needs. We also reviewed medical reviews for episodes of seclusion which lacked detail in some records.
• Patients we spoke with told us they did not always feel safe in the service due to the level of physical assaults between patients. Due to high levels of acuity, and to support safeguarding plans, patients were often moved between the houses, which they found unsettling. Staff did not ensure patients had access to regular patient forum meetings.
• The service did not ensure duty rotas accurately reflected movement of staff across the service and observation allocation sheets were not always fully completed.
• The service could not demonstrate that staff were in receipt of specialist training to support them in their roles and team meetings did not regularly take place.
• Staff morale within the service was variable. Some staff described low morale due specifically to increased acuity, incidents of assaults on staff and difficulties with maintaining staffing levels. Some staff did not feel that senior managers were visible, or that they could raise concerns without fear of reprisal.

However:

• The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received mandatory training, supervision and appraisal.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

How we carried out the inspection

During the inspection visit, the inspection team:

• visited all houses at Warren Court, looked at the quality of the house environments and observed how staff were caring for patients;
• spoke with five patients and six carers or family members of patients who were using the service. Interviews with patients and carers were completed by telephone;
• spoke with 15 staff members; including managers, doctors, registered and non registered staff;
• attended and observed one care programme approach meeting and one risk assessment meeting;
• looked at seven care and treatment records of patients.
• reviewed the seclusion and long-term segregation records for one patient.

What people who use the service say

We spoke with five patients. Some patients said they felt unsafe when there were incidents of aggression between patients and were not happy about being moved between houses when this occurred. All patients we spoke to were positive about the staff who they said were kind and supported them well. Patients said if there were things they were unhappy about they were able to raise these with the service. However, they did not feel their concerns were always acted upon in a timely way. Overall, patients wanted increased opportunities to access fresh air and had fed this back to managers.

Patients did not have access to regular patient forum meetings. We were concerned that patients did not have significant opportunities to share their collective views around the running of the service, or the opportunity to suggest improvements or receive feedback. Patients said they spoke with advocacy staff if they needed to.

We spoke with six relatives of patients. Relatives spoke positively about the hospital and the quality of the care that their relative received. Relatives and carers felt they were kept informed of and involved in the care received by their family member at the service. The majority of relatives felt that the needs of their family members were being met. The majority of relatives and carers were aware of how to complain and examples were given where complaints had been made and acted upon.

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.

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

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

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

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

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

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

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

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

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

• 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.

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

We found the following areas of concern:

• There were three incidents of physical restraint where staff used techniques which were not taught for this environment. This could compromise both the safety of staff and patients, and was undignified for the patients involved. We identified that these three incidents were not reported to the local safeguarding team until we bought this to the trust’s attention. We were not assured that the safeguarding was effective for the patients.
• Staffing levels impacted negatively upon patient care. The hospital regularly worked below the recognised optimum staffing levels. Some patients escorted leave had to be cancelled, some planned activities were cancelled, and planned visits from family on one occasion had to be postponed.
• The one seclusion room across the hospital did not meet the Mental Health Act Code of Practice. There was no effective two way communication system, the light could not be dimmed, and the temperature was cold. We were not assured that staff controlled the temperature to maintain patient comfort while in seclusion. The location of the seclusion room did not ensure that privacy and dignity of the patient was maintained at all times.
• We observed that there were poor lines of sight across all wards. Mirrors in place did not mitigate this risk. The up to date risk assessment did not actively identify what actions the staff had to take to minimise the risk of a patient using a ligature. There was not enough staff to always ensure that communal areas had a staff presence.
• The clinic used a risk assessment tool which reflected the risks of patients. Not all incidents were transferred to the risk assessment in a timely way.
• Not all care plans were representative of the patients’ current needs. Two patients who were on a medication which required close physical health monitoring due to potential serious side effects, did not have a care plan in place to reflect this.
• Staff were not receiving regular clinical or management supervision in line with the trusts policy.
• Some areas of mandatory training fell below 75%.
• We observed some building works being undertaken at the time of inspection. We saw that patients who had unescorted leave could have accessed an area which contained numerous tools and building equipment.

However:

• The clinic rooms were fully equipped, with accessible resuscitation equipment and emergency medications which were checked regularly by staff.
• The wards were clean, had adequate furnishings and were well maintained.
• There was adequate medical cover throughout the 24 hour period.
• Staff undertook a comprehensive assessment of all new patients upon admission.
• The use of rapid tranquillisation was kept to a minimum, and was always clinically indicated.
• There was good medications management across the clinic, with good pharmacy support.
• There was good access to physical healthcare for the patients who required this.
• Staff had received annual appraisals.
• Staff had a good working knowledge of the Mental Health Act and the Mental Capacity Act.

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 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.

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 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.