Hertfordshire Partnership University NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question as good. At this assessment the rating has changed to outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 100 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 4. The evidence showed an exceptional standard. The provider always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 9 care records during the inspection. We saw there was a consistent and high-quality approach to assessing, and reviewing patient’s health, care, wellbeing and communication needs with them. Staff completed a comprehensive assessment of the patient in a timely manner as part of the admissions process. Staff gained all relevant information from community teams, including communication needs, and existing care plans to create a comprehensive care plan.

Staff assessed patients’ physical health needs in a timely manner after admission. During the first 24–72 hours of admission, staff gathered comprehensive information from community teams, including physical health assessments, health action plans and medication history. This ensured that all known external health needs wereidentifiedat the outset and acted upon promptly.We saw an example where staff identified a patient who had undiagnosed heart problems on admission and, unbeknownst to anyone, had suffered a heart attack in the community. Staff intervened swiftly which resulted in him having an urgent appointment with a cardiologist and subsequently having a pacemaker fitted.

MDT members such as Nursing, Psychiatry, Psychology, Occupational Therapy and Speech and Language Therapy, reviewed assessments and initiated referrals based on their specialist roles. This supported service users to access the full range of external health professionalsrequiredfor their care.

All patients had an annual physical health review and an annual Learning Disabilities review with a local GP service​. We saw evidence in care records these were up to date for all patients. Managers carried out audits of physical health assessments and reported monthly to the trust Physical Health Committee and attended Physical Health Oversight Group meetings. We saw evidence of recent audits which showed 100% compliance with physical health assessments.

Care plans were highly personalised, comprehensive, updated in a timely manner and showed good evidence of family engagement. Staff took account of individuals’ communication preferences and needs, ensuring that patients could understand and engage with their care planning including providing easy read care plans and finding ways to communicate and present information in a way it could be understood. Discharge planning was clearly documented in the care plan section of patient’s files.

Communication needs and preferences were clearly recorded. Staff spoke passionately with us about the importance of explaining patients’ treatment to them even if they had limited understanding. Where necessary, staff adapted their approach using various methods to improve the patient’s understanding and involvement. All care plans were updated as part of the multidisciplinary team meeting.

We scored the service as 4. The evidence showed an exceptional standard. The provider always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE). These included medication and psychological therapies, activities, education and occupational therapy intended to help patients acquire living skills. We saw that patients had varied trips into the local community, attended football matches, education classes and went shopping and gardening for example.

Patients had timely access to physical healthcare support and were referred to specialists if required. Each ward had a commissioned GP service which visited once a week to support patient's physical health needs.Staff referred patients to external professionals, such as physiotherapists, dentists, and speech and language therapists, when higher-level interventions were required. These teams collaborated closely with the GP and physical health nurses to establish appropriate care routines and escalate concerns as required. ​

​Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration including referral to specialist dietary support where needed. Staff could adapt the menu to meet any requirements or preferences. Staff supported patients to learn cooking skills; one patient, who was cared for in long term segregation, cooked lunch once a week for staff, including senior managers who regularly attended.

Speech and language and physiotherapy staff had collaborated and undertaken published research into dysphagia (difficulty or discomfort with swallowing). People with learning disabilities are at a significantly higher risk ofdysphagia which causes severe health risks, including choking,aspiration pneumonia, malnutrition, and premature death. The resultant Dysphagia and Respiratory Pathway (DARP)integrateddysphagia and respiratory care into a single, coordinated pathway for patients. Staff ensured all patients were screened for swallowing and respiratory risks, including factors associated with community‑acquired pneumonia. Staff provided practical support tools, developed with staff and carer feedback, to ensure recommendations were clear, usable and consistent across teams, aligning with national communication standards such as the Accessible Information Standard.

The team included or had access to the full range of specialists required to meet the needs of patients in the service. As well as doctors and nurses, patients had regular support from occupational therapists, psychologists, speech and language therapists and social workers. Psychologists provided support to patients and staff. They undertook assessments and provided group and individual sessions for patients as well as consultation and training for staff. Staff offered arts psychotherapy and demonstrated positive outcomes.; For example, we saw a case study which demonstrated effectivenessthrough the patient meeting most of her therapy goals and showing improved emotional regulation, engagement, and capacity to explore complex relational themes through art‑making.Occupational therapists offered a range of support including completing sensory assessments for patients and supporting them with activities both within and outside the hospital. Patients chose the activities they took part in. These were part of their care plan and supported people to achieve their goals and aid their recovery.

Patients had excellent access to education. For example, at Astley Court the service contracted an external educational service who provided a team of three staff, including a qualified teacher and an arts tutor. The education teams worked with patients by offering bespoke educational packages based on an individualised assessment of needs, including basic maths and English skills, and delivered individualised literacy sessions, focusing on reading and writing for both practical and life skills as well as with the aim of potentially earning a qualification.Teachers were valued and well-integrated into the multi-disciplinary team and worked closely with them to complement the work they were doing with patients. For example, using writing, art and music to complement the anti-racism project and education on healthy relationships and sexuality to complement the work being done around sexual safety. During the inspection we observed a discharge meeting which was attended by staff from the patient’s school (young people with a learning disability can continue to receive support with education and training up to the age of 25) to ensure continuity of education support.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group and new staff, including bank staff, were provided with appropriate induction.

Managers provided staff with supervision and appraisal of their work performance. At the time of inspection, the percentage of staff that received regular clinical supervision was 94% for Elm ward and 100% for Astley Court and Lexden Hospital.The percentage of staff who had their yearly appraisal was 100% for Elm Ward, 97% for Astley Court and 96% for Lexden Hospital.

Managers ensured that staff had access to regular team meetings. Team meetings had a set agenda including incidents and challenging issues, safeguarding and lessons learnt. Staff documented any actions resulting from the meeting including noting the person responsible for the action and updates from any previous actions.

Managers identified the learning needs of staff and provided them with excellent opportunities to develop their skills and knowledge. All the staff we spoke with told us they had excellent opportunities for personal and professional development. Staff attended monthly service development days across all three wards which focused on staff development, training, teambuildingand innovation. Senior nurses attended quarterlydevelopment days for all charge nurses across the division. These sessions focused on priority development areasidentifiedby managers and Charge Nurses and promoted interactive learning, peer discussion, and sharing good practice. Staff had good opportunities to progress their careers within the trust – we spoke to many members of staff who had been supported to progress. For example, a ward manager who had begun their career as a student nurse and a senior healthcare assistant who had started as a cleaner on the ward. Four staff had successfully completed the research internship scheme for NHS staff.

Managers dealt with poor staff performance promptly and effectively. We spoke with a charge nurse who explained clearly the steps they had taken to deal with poor performance from a new member of staff.

Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

We scored the service as 4. The evidence showed an exceptional standard. The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Staff held regular multidisciplinary meetings to discuss patients and improve their care. These meetings were attended by a range of staff from different disciplines, including healthcare assistants, and were effective in discussing a range of issues including changes to patients’ presentation, risk, incidents and medication. Speech and language therapists assisted patients to contribute their views and family members and other relevant professionals, such as staff from schools, were invited.

The teams had effective working relationships, including good handovers, with other relevant teams within the organisation. We saw seamless working and excellent collaboration between community teams and inpatient wards.

Staff followed a 12-point discharge plan with areas to cover when a patient was clinically fit for discharge. This included a transition plan developed for the patient in a meaningful format with a social story, photos of the person’s new staff and new home, a daily or weekly calendar of visits and activities, visits to the new home and shopping for new items with new staff and existing staff.

The service had effective working relationships with teams outside the organisation, for example, commissioners, the local authority, GPs and secondary health services. A local GP was commissioned to visit the wards once a week and ward staff had established effective contacts and communication with other secondary health providers.

We received excellent feedback from commissioners for the service who told us that they were fully involved in all aspects of patients care and everyone worked collaboratively to provide high quality care and manage risk on the wards and in the community. One stakeholder told us about an excellent piece of joint working between ward staff and the Offending Behaviour Intervention Service (OBIS) to support a patient who was involved with the criminal justice system.

The manager and senior leaders attended regular regional meetings. The divisional core management team had huddles 3 times a week to catch up and support one anotherinformally.The core management team formally metin persontwice a quarterto manage the business of the divisioni.e., project tracking, performance tracking, new developments, hotspots, finance, HR, businessplanningand any other business.Oncea quarter, the extended management team from the division metface to face. This was made up of both clinical and operational managers to managethe business of the division and for development and networking.

We scored the service as 4. The evidence showed an exceptional standard. The provider always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff identified patients’ physical health needs and recorded them in their care plans. Staff conducted physical health checks regularly and made sure patients had access to physical health specialists as required. Physical-health monitoring included a focus on early recognition of deterioration and completion of core physical-health checks. Staff undertookdysphagiaand nutrition screening, National Early Warning Score (NEWS2) observations, and Venous thromboembolism (VTE) risk assessments.Patients were seen promptly by a doctor when they felt unwell. The service used easy read information to support patients to understand relevant health information and procedures.

The trust provided a Female Hormone Clinic for women with learning disabilities and /or Autism. Staff providedassessmentand management of female hormones conditions such as menopause,perimenopauseand Polycystic Ovary Syndrome. Staff also reviewed the impact of oral and injectable contraception use on mental health and behavioural challenges in patients.

Patients had access to a joint complex epilepsy clinic for people with learning disabilities,epilepsyand mental health conditions. This enhanced MDT care improved outcomes and management of complex epilepsy and associated co-morbidities in people with learning disabilities.

Ward activities and information helped promote a healthy lifestyle for patients – for example easy-read educational materials were available covering topics such as heart health, diabetes and calories in common food. Staff provided educational sessions for patients on healthy living. On Elm Ward, staff ran a regular Healthy Eating Group, co-facilitated by Dietitians, Speech Language Therapy,OTand ward staff. Meetings occurred monthly and included structured educational sessions, covering topics such as understanding food groups, tasting healthier snacks, traffic light education, and activities to support healthy choices.Staff incorporated structured health-promotion activities into daily routines, encouraging regular movement and achievable exercise, including initiatives such as the “mile-a-day” challenge and charitable wellbeing events.

Smoking cessation support was provided through routine physical health assessment and health promotion interventions. We saw an example of a patient who was smoking approximately 20 cigarettes per day prior to admission and who had been supported to reduce this to 6 cigarettes per day. Vaping had been introduced as an alternative in line with the trust’s No Smoking Policy.

Lexden Hospital had close links with ‘Sport for Confidence’ an Essexcommunity-basedorganisationwho provided patients with unique sportingand physical activityopportunities in mainstream leisure facilities. The sessionsprovided anopportunityfor peopleto try differentphysical activitiesin a safe and supportive environment with skilled sports coaches and occupational therapists, providing attainment of new skills,building confidence and social interaction with others.

We scored the service as 4. The evidence showed an exceptional standard. The provider monitored all people’s care and treatment to continuously improve it. Theyensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

People’s outcomes were monitored using recognised rating scales. Staff used a standardised set of outcome measures to ensureequitableassessment, improved oversight and to demonstrate evidence of patients’ progress.Staff had developed a learning disabilities outcome dashboard tomonitorcompliance.The 3 wards used Health of the Nation Outcome Scales for People with Learning Disabilities(HoNOSLD) asthe primaryoutcome measure as well as a range of clinician-reported, patient-reported and co-produced outcome measures such as, LifeStar, Therapy Goals and Outcomes (TGO), and Clinical Global Impression (CGI). At the time of inspection, all wards had 100% compliance with HoNOS LD.

Behaviour and riskwerereviewed daily through collated data on frequency of incidents, incident reporting, restrictive practice use and ABC data. This data was then used toidentifypatterns, evaluate PBS plans and reduce restrictive interventions.Functional skills were reviewed, and information collated daily on personal care, communication, activities of daily living and community access. These measures were then reviewed and used to inform and shape occupational therapy and speech and language support required and to inform how best to support someone in preparation for their move back home.

Staff demonstrated a strong focus on quality of life, ensuring engagement in meaningful activities, choices, socialskillsand relationships. Simple Quality of Life scales, with easy read versions were used to support this.

We saw many examples of positive outcomes for patients. For example, a patient was admitted having needed the support of 4 carers when in the community due to behavioural challenges. Following his treatment and discharge, he was able to live independently in the community with minimal support and a greatly enhanced quality of life. We saw another example where a patient had not been outside of his family home for many months due to trauma and anxiety but was regularly enjoying accessing the community and taking part in activities following his admission and treatment.

We scored the service as 4. The evidence showed an exceptional standard. The provider always carefully explained to people what their rights around consent were, made sure they fully understood them and always fully respected these when delivering person-centred care and treatment.

Staff took all practical steps to enable patients to make their own decisions. For patients who had impaired mental capacity, staff assessed and recorded capacity to consent appropriately on a decision-specific basis regarding significant decisions.

Staff complied with the Mental Health Act 1983, ensuring patients’ rights were upheld and clearly communicated in a way patients could understand, including the right to appeal. Consent to treatment forms (T2 and T3) were present, well-organised, and accurately completed. No concerns were identified in the records reviewed.

Staff had recognised that Mental Health Review Tribunals can be particularly challenging for people with learning disabilities and autism, who may struggle to attend, communicate,understandand follow proceedings. Doctors and other staff, worked collaboratively with other professionals, health access champions and experts by experience to co-produce “easy read” guidance for both face-to-face and virtual tribunals to make the process clearer, more inclusive and aligned with the Equality Act (2010). This guidance has since been adopted nationally by the Royal College of Psychiatrists’ Faculty of Intellectual Disability and HM Courts and Tribunals Service,demonstratingwider system impact and improving fairness,accessibilityand patient involvement in tribunal hearings.