Hertfordshire Partnership University NHS Foundation Trust

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

The service managed safety incidents well and learned from these to improve practice. Staff assessed and managed risks to people who used services and themselves well. Staff supported people through their care and treatment, including when they transitioned to other services. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. All service buildings were safe, clean, well equipped, well furnished, well maintained and fit for purpose. The service deployed sufficient numbers of suitably qualified and supervised staff. Systems were in place to control and prevent risks of infection. The service did not always use systems and processes to safely prescribe, administer, record and store medicines.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The trust had an overarching safety strategy in place supported by the Patient Safety Incident Responsive Policy and Framework (PSIRF). The service reported a total of 1,990 incidents in the past year, with the majority being incidents relating to safeguarding of adults. The trust used an electronic incident reporting system for recording all incidents and those under the PSIRF investigation framework.

Staff knew what incidents to report and were aware of the duty of candour. Staff could give examples of times when they had written to service users and families to explain when something had gone wrong and apologised. Staff recorded duty of candour on the trust incident reporting system to ensure compliance was monitored. The trust intranet included training and support resources for staff completing duty of candour.

Staff held a ‘swarm’ meeting after each safety incident to debrief staff and identify any initial learning. Incidents and lessons learned were discussed at a number of meetings including team meetings, local incident reviews, quality and risk management meetings, and the trust wide learning from deaths group. The service had identified 7 key themes from incidents that included risk assessment and formulation, carer involvement, multi-agency working and physical healthcare and medication safety. The service had action plans in place to address these themes.

Staff were aware of learning and actions taken following incidents and gave examples such as better multi agency working for service users who had substance misuse and debt issues.

Most people using the service and their carers did not know how to raise any concerns about the service but had not felt that they had needed to.

The trust worked with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. They ensured continuity of care, including when people move between different services.

The service had clear referral processes and accepted self-referrals as well as referrals from the single point of access which provided a 24 hour, 7 days a week telephone helpline. Referrals also came from internal teams such as crisis and inpatient wards, and external agencies including the police and general practice (GP) surgeries. Teams also ran a duty worker system so that anyone who visited the service in person or called the duty number would be seen and assessed on the same day.

The service had a clear criteria for referral acceptance and completed a triage assessment for referrals. When people didn’t meet the criteria to be taken onto the caseload staff could refer them to the Primary Care Team or Talking Therapies team provided by the trust, or to external teams including drug and alcohol team or Mind.

Staff completed an initial triage of people on referral that was shared with any other teams that staff signposted people to, so that people didn’t need to repeat their stories.

Staff worked closely with other teams to deliver safe and effective transitions between services, including crisis teams, child and adolescent mental health teams, older people’s mental health teams and inpatient wards. Staff attended review meetings and discharge meetings for patients in acute inpatient wards.

Social workers attended the Hertfordshire transition to adulthood panel, working alongside partner agencies to increase co-ordination and transition planning.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service’s processes promoted people living free from abuse, neglect, and avoidable harm. There were clear systems, policies, and practices in place to ensure people were protected. We saw evidence of a comprehensive local safeguarding procedure and a range of policies designed to safeguard both adults and children from harm.

The trust held quarterly safeguarding strategy meetings and adult community mental health services specific safeguarding meetings.

Staff knew how to raise a safeguarding concern and who to contact within the trust for any safeguarding queries, and each team had a designated safeguarding lead. The service had raised 304 safeguarding concerns and enquiries in the 3 months before inspection. The most common concern was domestic abuse and as a result the trust offered a programme of prevention, awareness, support and governance initiatives including specific domestic abuse training for staff.

Staff gave examples of safeguarding concerns they had raised for people using the service and their children.

Staff advised people using the service not to bring children to the service location when attending appointments or clinics, however we saw at Saffron Ground that people had brought children with them. The trust confirmed that they had published a safety bulletin regarding the presence of children within service premises.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 22 care records and saw that staff involved patients to complete a through, individualised risk assessment which was reviewed regularly. Most care records contained up to date risk management and safety plans that people using the service had a copy of, which included how to access support in a crisis.

Staff also involved the families of people using the service in risk assessment and management where appropriate.

The Trust had an up-to-date clinical risk assessment and management policy in place and had implemented riskassessmentand managementimprovement initiatives.

Teams had started holding risk formulation meetings at least once a fortnight, with the psychosis: prevention, assessment and treatment in Hertfordshire (PATH) teams holding twice weekly meetings. These meetings included multi-disciplinary team discussions about higher risk and more complex people using the service to support better risk mitigation and safety planning.This process was supported by a Risk Formulation Meeting Protocol.

Teams had introduced an audit of clinical quality of risk assessments, which involved senior clinicians reviewing 10 risk assessments in detail. Themes from these audits were reviewed and changes were being made to the assessment process as a result.

The trust had implemented an enhanced risk assessment service, which offered support and training to teams and could help develop risk management plans for people using the service with higher risk levels.

The trust had introduced a programme of risk conversations, following learning from national reviews. They had produced a booklet to support staff practice on ‘Let’s talk about risk to others’. 95% of staff were up to date with clinical risk assessment training.

Staff ensured that patients could access advocacy.

The trust completed regular risk assessments of each team’s environment including ligature risk assessments.

We reviewed the environments at Saffron Ground, Centenary House, Oxford House and Holly Lodge which were all clean and well furnished. Waiting rooms had sufficient chairs for people to sit and wait, with information boards displaying details of local resources, advocacy contact details, and information on how to give feedback including quick response (QR) codes. Staff at Centenary House had redecorated the waiting room with input from people who used the service to make it more inviting and relaxed.

Staff booked rooms to see people for appointments and clinics, and staff at Saffron Ground and Holly Lodge told us that it was sometimes difficult to find a room available. The trust confirmed that room availability was on the risk register and that following our inspection a new room booking system was piloted.

The trust held fortnightly space utilisation meetings to review accommodation requests and discuss emerging space requirements across the estate and ensured site rooms were prioritised and protected for urgent and outpatient appointments. Staff could rent bookable rooms in community partner settings to support additional room space required.

At Saffron Ground anyone could enter the front door of the building and access either the stairs or lift up to the offices on the higher floors. We were not assured that a member of the public would not be able to enter the office spaces by tailgating a member of staff through the secure doors into the offices. The service did not have any way of observing the staircase to ensure the safety of people accessing the building.

Following the inspection the trust confirmed it had agreed with the building landlord to make improvements to access with immediate work to upgrade access control to limit access to common parts, lifts and stairs.

Staff all had access to alarms and lone worker safety devices, however at the time of inspection not all staff were carrying their safety devices at all times. This would cause a delay in the event of them needing to call for assistance. We raised this with the trust during the inspection and they sent a communication out to all staff reminding them of the lone worker device policy. Following our inspection the trust confirmed that lone working device compliance was monitored and was currently 79% and that leaders would follow this up in team meetings, huddles and supervision where there was persistent non-use by an individual staff member.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs

At the time of the inspection the vacancy rate was 5% with 65 vacancies. Staff caseloads were manageable with care co-ordinators having caseloads of average 25 across the adult community mental health teams and up to 20 for PATH teams.

The sickness rate for the service was low at 5% but slightly above the trust target of 4%, due to some long-term sickness. Staff turnover was at 12% with Oxford House identified as a turnover hotspot and the trust had implemented recruitment and retention plans as result.

Staff had received and were up to date with appropriate mandatory training with 92% of all staff across the service having completed all mandatory training sessions. Mandatory training sessions included Safeguarding Adults, Safeguarding Children and the Oliver McGowan learning disability and autism training.

Managers provided new staff with a full induction, and all staff received regular supervision and an annual appraisal. At the time of the inspection 84% of staff were up to date with supervision and 96% had an annual appraisal in place.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Staff adhered to infection control principles, including handwashing. The trust had an infection prevention and control governance policy in place.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

The service had appropriate arrangements in place to support the safe use of medicines in community mental health services.

Clinic rooms were clean, temperature controlled, with appropriate secure medicines storage facilities. Depot medicines were stored in locked cabinets with adequate stock maintenance. FP10 prescription pads were stored securely, however, the logging system at Holly Lodge did not ensure that an auditable trail of prescription pads was maintained as more than one prescriber was using the same prescription pad. This would mean the service would be unable to track whether prescriptions were being used appropriately.

Following our inspection the trust undertook a review of prescription pad management, issued a trust wide learning note and updated mandatory training to ensure that a single prescriber per pad approach was implemented across the service. The trust also updated it’s safe and secure handling of medicines audit and introduced a specific FP10 prescription pad audit.

The physical health clinic, clozapine and depot clinics, were well developed and worked proactively to engage with patients, completing health checks for people with severe mental illness (SMI). We saw evidence that staff carried out physical health checks and baseline monitoring for people on antipsychotics and mood stabilisers. Capillary blood testing had been introduced for people prescribed clozapine. This reduced the need for venous sampling and supported compliance with monitoring. We saw that clinics maintained clear spreadsheets to track required monitoring, which helped ensure good oversight. The clinics used nationally recognised tools for monitoring and management of medicines related side effects, including the Glasgow Antipsychotic Side-effect Scale (GASS), to support medicines optimisation. However, the service was not always able to carry out ECG (echocardiogram) monitoring for people prescribed certain psychotropic medicines as per trust guidance. As a result, people were redirected to GPs for ECG monitoring. Follow-up actions relating to these ECGs were not always clear, and it was often uncertain whether investigations had been completed. One person on high-dose antipsychotic therapy had no recorded annual ECGs despite a known cardiac history. This lack of oversight may increase the risk of harm for people prescribed medicines requiring ECG monitoring. Staff told us this clinical risk had been identified by the service and recorded on the service risk register with an action plan in place to address this.

Following the inspection, the trust confirmed that training was available to staff on conducting an ECG test and that an ECG interpretation and reporting service was available for staff to use. The trust also confirmed that they would be setting up mobile ECG clinics as a result of our inspection findings to ensure people had access to the required tests. The trust introduced a test model of ECG provision for 2 healthcare support workers, with clinical oversight from senior nursing and medical staff, carrying out ECGs on set days for people taking high dose antipsychotic therapy, clozapine or before starting any new medicine where an ECG was recommended.

Some people were prescribed olanzapine long-acting injections (an antipsychotic injection with recognised health risks following administration). We saw evidence that the Trust had appropriate guidance in place to support staff with monitoring and recording people’s health after administration. We saw evidence that the Trust has good oversight for people who were non-compliant or disengaged with their medicines.

The service introduced an initiative to help people better understand their medicines. Information was made easy to access using paper copies and QR codes. This encouraged people to ask questions and be informed about their treatment. The Choice and Medication Leaflets available were designed to help service users, carers and family members understand their medicines better, and to make more informed decisions. Printable medication leaflets were available in different languages and easy read.

People were also encouraged to involve family members or carers in discussions about their medicines to support understanding and shared decision-making. A pilot electronic rating scale system was embedded at Saffron Ground. This allowed people to complete medicines-related rating scales remotely and supported clinical review.

We saw evidence that at Saffron Ground staff had removed medicines from 3 people’s homes and stored these at the service, however consent to remove and store people’s own medicines was not clearly documented. Records for signing these medicines in and out of the service were incomplete or inaccurate. We could not be assured there was clear governance and oversight of this process. Where staff supported people with their medicines, medicines reconciliation was not always completed, and staff relied on labelled instructions on medicine boxes with some medicines labelled as dispensed over two years ago.

Following our inspection the trust issued a safety alert on the retention of service user medication by community teams, delivered additional training to teams and updated audit processes to include routine monitoring of any medicines removed from people’s homes.

The trust also increased clinical oversight and medicines management processes by introducing additional pharmacist input to support teams with high-risk medicines including medicines reconciliation, prescribing review, physical health monitoring, and shared decision-making.