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

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 good. At this assessment the rating has changed to outstanding. Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The unit team included or had access to the full range of specialists required to meet the needs of patients on the unit. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. This meant the service used new evidence-based approaches that went beyond standard practice. The service always worked well across teams and people were supported to maximise their independence.

This service scored 88 (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 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.
We reviewed 11 care records during the inspection. Staff completed a mental health assessment of each patient either on admission or soon after. All patients received a mental state assessment by a doctor on admission. This included an assessment of the patient’s capacity to consent to admission and treatment.
Patients had their physical health assessed on admission and regularly reviewed during their time in the service. Some staff were physical health leads on the units, there was a physical health team and GPs visited patients at the service. Staff could refer patients on for any specialist treatment they required.
Staff developed a care plan for each patient that met their needs. Each patient had a main care plan and a therapy goals and outcomes (TGO) plan. These plans were to be read in conjunction with one another. Care plans were personalised and recovery orientated. Plans for treatment set out the patients’ goals, as well as how their goals would be achieved.
Care plans were personalised to the individual. Patients were involved in the development of their care plans and on an ongoing basis. The patient voice was evidenced throughout the records we reviewed. There was also some evidence of carer involvement. Care plans were written in a way that was easy for people to understand.
Staff did not always make sure patients’ care plans contained up to date information. One patient had been discharged from their section, however the care plan and risk assessment stated that the patient was detained under section. One patient had commenced trial leave at a placement, but this was not reflected in the care plan.Following the inspection, the trust informed us that all care plans and risk assessments were reviewed and updated where necessary to ensure patients’ current circumstances were reflected.
Some of the main care plans we reviewed were not detailed. For example, activities were not included in one patient’s care plan, but staff told us about the patient’s hobbies and interests, and there was a planned activity that took place the day of the inspection. Staff did not always include discharge planning in patient’s main care plans. We raised these concerns with leaders who provided evidence of this in patients’ therapy goals and outcome plans. Leaders told us they would review all care plans to ensure they more clearly referenced the goals and progress identified within the TGOs.

We scored the service as 3. The evidence showed a good standard. The service 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 and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well
Staff provided a range of care and treatment interventions suitable for the patient group. The service used multiple interventions and approaches that positively impacted the care being delivered to patients. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE). Care and treatment involved prescribing medicines, therapeutic activities, individual psychology and group therapy. Staff supported patients to develop a better understanding of their condition. This included support to help patients identify and prevent relapse in their mental health condition. Some patients attended groups to help them develop their skills for independent living, such as monthly health and wellbeing sessions that were modified for the rehabilitation pathway. Patients were supported to access education and employment opportunities. One patient started a university course.

The service used a number of new evidence-based approaches that went beyond standard practice. For example, the service implemented a trauma informed care project to support staff to recognise the impact of trauma, use supportive language, build safe and trusting relationships and reduce the risk of re traumatisation for patients.
Leaders led an improvement programme focused on bowel health monitoring. The project led to improvements in bowel health monitoring across the service including standardised documentation and stronger escalation pathways. The improvements had a direct impact on patient care as they had led to earlier detection of concerns.
Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. The service had access to an on-site physical healthcare team and physical health was regularly monitored.
Managers ensured that staff had access to regular team meetings. Team meetings had a set agenda including risk management, wellbeing, training and lessons learnt. Staff documented any actions resulting from meetings. Managers ensured important information was communicated effectively to staff.
Staff used technology to support patient care. This included video calls with relatives and external professionals during meetings about patient care.
Staff took part in clinical audits, benchmarking and quality improvement initiatives. The service conducted numerous monthly audits which included safeguarding, section 132 rights and review of capacity assessments. Areas for improvement and good practice were documented and shared with staff.

We scored the service as 4. The evidence showed an exceptional standard. The service 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 and effective multidisciplinary meetings. All patients were discussed and seen by the multidisciplinary team (MDT) in weekly ward rounds. Patients participated and shared their views about their care and treatment. Carers and external professionals were invited to attend.
Staff shared information about patients at effective handover meetings within the team. Handovers took place 3 times a day, before the commencement of each shift. There was a process to escalate any concerns to leaders. Leaders reviewed safe care levels daily to ensure staffing levels met the needs of the units, and they could organise additional support if required. Staff described feeling supported by their team.
The teams had effective working relationships with other relevant teams within the organisation, for example, staff told us the Mental Health Act Team were supportive. All staff within the multi-disciplinary team (MDT) including nursing staff were complementary of one another and how they worked together to meet the needs of patients.The trust had a longstanding agreement in place with the local authority which meant social workers were fully embedded and worked within the multi-disciplinary teams.
The teams had effective working relationships with other teams outside the organisation. For example, a local GP visited the units on a weekly basis. Staff worked well with external teams involved in patient care such as care coordinators and community mental health teams. Staff maintained links with them while patients were in hospital and invited them to attend ward rounds.There were multiple examples of collaborative working, including a service set up in the community, called Enhanced Rehabilitation Outreach Service (EROS). This was an innovative model of integrated working across inpatient and community settings that supported some patients to be discharged from a hospital setting earlier than they would have otherwise been. The service promoted discharge and supported patients’ integration into the community.
The service received excellent feedback from stakeholders who said the service worked collaboratively with them, which helped improve patient care and outcomes for patients. Stakeholders stated that staff actively listened to patients and strongly advocated for them.

We scored the service as 4. The evidence showed an exceptional standard. The service always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. The service 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 patient records. Staff monitored each patient’s vital signs at least once per week. Staff wrote up detailed progress notes for each day and night covering patients’ compliance with medication, food and fluid intake, leave, personal hygiene and sleep.
Staff made sure patients had access to physical health care, including specialists as required. Patients were seen promptly by a doctor when they felt unwell.
The trust provided patients with a weekly allowance of £50 to shop for food which they prepared for themselves. Staff supported patients to make healthy choices while shopping and Occupational Therapy (OT) staff ran a weekly healthy eating group to educate and support patients.
Unit activities helped promote a healthy lifestyle for patients. For example, OT staff introduced a project called ‘nature prescribing’ to help patients reconnect with nature. Staff recognised this could be powerful to patients suffering with mental illness. The project included those who had low motivation as some ideas were things patients could do while on the units, and others were while they were out on leave. An external company visited the units to provide regular physical activities, sports and games to patients.
OT staff ran a health and wellbeing group on a monthly basis. Staff asked patients for feedback about what they would like these groups to include. Staff ran sessions on topics including anxiety and stress, medication and sleep.
OT staff ran a sexual safety project at Gainsford House to support and educate patients about sexual safety for future relationships they may commence once in the community. Staff provided support on a one-to-one basis. The unit was also a local distribution site for dispensing testing kits and condoms. The service planned to expand the project to the other rehabilitation units.
 

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.
Staff continuously monitored patients’ health, their mental state and well-being. At handover meetings staff noted details of patients’ mental state, food and fluid intake, personal hygiene, compliance with medication, and engagement in activities.
Staff used recognised rating scales to assess and record the severity of patients’ conditions and care and treatment outcomes. For example, clinicians completed Health of the Nation Outcome Scale (HoNOS), which is a scale to measure health and social functioning of mental health patients. Clinicians also used Goal Attainment Scaling (GAS) to assess how far patients’ individual goals were achieved throughout the course of their admission. Outcome measures were monitored by the multi-disciplinary teams and at governance meetings.
Occupational therapy staff followed the Model of Human Occupation (MOHO) model, which is an evidence-based framework that focuses on how occupations are motivated, organised, and performed within daily environments. This model was embedded in written notes and assessments but could also be adapted when needed.
 

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.
Staff assessed each patient’s capacity to consent to admission and treatment on admission. Capacity was monitored and recorded at multidisciplinary team meetings. Consent to treatment forms (T2 and T3) were present in the records we reviewed.
If a patient was detained under the Mental Health Act 1983, the arrangements for their detention and treatment were consistent with the requirements of the Act and accompanying code of practice. Staff supported patients to understand how the Mental Health Act applied to them and supported patients to understand their right to appeal.
Staff took all practical steps to enable patients to make their own decisions. When staff felt a patient may have lacked capacity to make a decision, staff did what they could to support their understanding.
Staff displayed information about how to access an Independent Mental Health Advocate (IMHA). Patients knew how to access an advocate and told us that an advocate regularly visited the units.