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Provider: Berkshire Healthcare NHS Foundation Trust Good

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Good

Updated 2 October 2018

Our rating of the trust stayed the same. We rated the trust as good because:

  • Since the last inspection in 2016, the trust has continued to make improvements. We inspected seven services and carried out a well-led review.
  • We engaged with a range of staff from a variety of professional groups through a series of focus groups with staff from community health and mental health services. Staff were proud to work at the trust and spoke positively about their colleagues and managers.
  • Following this inspection twelve core services were rated as good overall and two were rated outstanding. In rating the trust, we took into account the previous ratings of the seven services not inspected this time.
  • The trust board was strong and confident in performing its role. The executive team were stable and succession planning had been embedded over the last five years. The chair and non-executive directors were committed to ensuring that patients received the best care possible and used their wide range of skills and experience to challenge the executive directors to deliver quality services.
  • The trust had made further progress in the use of a quality improvement methodology. We saw that this methodology gave genuine opportunities for staff and patients in wards and teams to identify areas for improvement and make changes. The use of quality improvement was widespread throughout the trust, both staff and patients were very positive about the potential for improvement.
  • Community Nursing had adopted the Quality Management Improvement Programme (QMIS) and had developed team skills to take a `bottom-up’ approach to problem solving. Examples of improvements included: improvements to low morale through a range of well -being initiatives; and the use of “driver metrics” to focus on harm free care which had seen a reduction in rates of pressure ulcers.
  • Learning summits, led by the Deputy Director of Nursing, were held for all pressure ulcers within community health and mental health inpatient units. All staff involved in the patients’ care are invited to attend and supported by Tissue Viability Clinical Nurse Specialists. Themes and learning from all Learning summits are shared across the organisation via Patient Safety Quality meetings.
  • The trust had addressed most of the areas where improvements were needed from the last inspection.
  • In the wards for people with a learning disability staff had received training in positive behaviour support, patients had individualised behaviour support plans and staff were supporting patients, who had challenging behaviours, appropriately.
  • The trust had strong governance systems supported by good quality performance information. This meant that at all levels of the organisation staff and members of the board had access to useful information that enabled them to gain assurance and make improvements where needed. This enabled the trust to achieve a balance between assurance and improvement work.
Inspection areas

Safe

Good

Updated 2 October 2018

Our rating of safe stayed the same. We rated it as good because:

  • We rated thirteen of the core services as good for safe, one was rated requires improvement. This takes into account the current ratings of the seven services not inspected this time.
  • Significant improvements had been made to the ward environments, including new seclusion room facilities on the psychiatric intensive care unit and improvements to the security of the fences throughout the hospital. The trust had an ongoing maintenance and capital build programme in order to mitigate ligature risks on the wards and gardens, such as the fitting of anti- ligature fixtures and fittings.
  • The trust ensured that ward staff were committed to only using restrictive interventions, such as restraint and seclusion, as a last resort and had an effective system to identify and review restrictions implemented in inpatient services. The trust had arranged for a specialist senior nurse to work alongside the staff on the psychiatric intensive care unit to reduce restrictive practices. This was part of the trust’s quality improvement programme.
  • The ward for people with a learning disability had 10 incidents of rapid tranquilisation in the 12 months leading up to the inspection. There were no incidences of rapid tranquilisation being used in the seven months from May 2017 to November 2017- this is the use of medication, usually intramuscular if oral medication is not possible or appropriate, when urgent sedation with medication is required. Patients were supported using verbal de-escalation techniques and personalised plans developed by the intensive support team.

  • Staff worked with patients to assess their individual risks and to develop plans to manage risks. Each patient had contributed to a safety plan which detailed their risk triggers and interventions they found helpful and effective.
  • Staff were alert to changes in risk and made sure that management plans were updated as necessary.
  • Learning summits, led by the Deputy Director of Nursing, were held for all pressure ulcers within community health and mental health inpatient units. All staff involved in the patients’ care are invited to attend and supported by Tissue Viability Clinical Nurse Specialists. Themes and learning from all Learning summits are shared across the organisation via Patient Safety Quality meetings.
  • The chief executive had set clear procedures for staff on implementing a zero suicide approach and associated guidance on information sharing with family and friends to preserve life.
  • There was a great deal of respect & pride in the trust’s safeguarding advice line

Effective

Good

Updated 2 October 2018

Our rating of effective stayed the same. We rated it as good because:

  • Thirteen of the fourteen core services were rated as good for effective, one was rated outstanding. This takes into account the previous ratings of the seven services not inspected this time.
  • Staff on the ward for people with a learning disability provided good quality care that was in line with best practice and national policy. All patients on the ward for people with learning disabilities had Positive Behavioural Support plans that followed guidance by the Department of Health. Clinical staff on the ward for people with learning disabilities demonstrated a commitment to ensuring that patients were not over-medicated. For example, a patient receiving a long term high dose of antipsychotic mediation had their medication gradually reduced and adjusted in response to their changing symptoms over the course of their admission. This is in line with a national initiative to stop the overmedication of people with learning disabilities.
  • The ward for people with learning disabilities worked closely with the intensive support team to ensure that admissions to hospital were avoided where possible, were well planned, and no longer than necessary. This was in line with the national Transforming Care agenda, which seeks to ensure people with learning disabilities are supported in the least restrictive way possible. Care plans were in an accessible format with photos and images directly linked with those on the case management system to ensure consistency. The electronic care plan included a trust learning disability outcome measure (LDOM), which measured a patient reported outcome measure on the impact of their care plan. The service also monitored outcomes using a recognised ratings scale (HoNOS), administered pre-admission and post discharge
  • The physical healthcare needs of patients across community health and mental health services were assessed and managed. Staff ensured patients could access specialist health support when this was needed.
  • Care plans on mental health inpatient wards for older people and working age adults were developed with the patient and reflected their views. Where patients chose not to contribute, or were too unwell to do so this was recorded and reviewed. The care plans were recovery focused, holistic and demonstrated good practice. The care plans had set goals and monitored progress. Patients told us that they were included in the planning of their care although there was no record of patients who had been given their care plan.
  • As a combined trust the trust was able to support patients’ physical and mental health needs through integrated programmes. For example, the Heart Failure team had received funding to pilot a dedicated Assistant Clinical Psychology post to support patients with heart failure who had high levels of anxiety and depression. Other funded posts were introduced to support patients with complex long term conditions who were also experiencing anxiety and depression.
  • The clinical pathways and policies used by the Minor Injuries Unit were based on national guidance and evidence. Effective pathways were in place for the referral of patients to specialist services, this included physiotherapy, virtual fracture clinic and the knee clinic.
  • Community Nursing had adopted the Quality Management Improvement Programme (QMIS) and had developed team skills to take a `bottom-up’ approach to problem solving. Examples of improvements included: improvements to low morale through a range of well -being initiatives; and the use of “driver metrics” to focus on harm free care which had seen a reduction in rates of pressure ulcers.

However:

  • Although managers ensured that most staff received regular individual supervision, this was not the case in a small number of teams. This was a particular issue in wards for older people with mental health problems. However, all staff had access to reflective practice and the quality of supervision was good.

Caring

Good

Updated 2 October 2018

Our rating of caring stayed the same. We rated it as good because:

  • We rated twelve core services as good and two core services as outstanding for caring, this takes account of core services we did not inspect at this time.
  • The staff across all the community health and mental health services we inspected showed a caring attitude to those who used the trust services. Feedback from people using services and their relatives and carers was highly positive. Staff in all services were kind, compassionate, respectful and supportive. People who used services were appropriately involved in making decisions about their care.
  • Staff and managers consistently spoke to and about patients with warmth and positive regard, showing a knowledge of their individual likes and dislikes as well as their clinical presentations.
  • People who had experience of using services were involved in recruitment panels in mental health services.
  • The embedding of the carers’ strategy had led to more effective involvement for carers in mental health services. This was well established in the crisis and home treatment teams and the early intervention in psychosis service, and work had begun in the acute wards for adults of working age.

Responsive

Good

Updated 2 October 2018

Our rating of responsive stayed the same. We rated it as good because:

  • We rated twelve of the core services as good for responsive, one was rated outstanding and one was rated requires improvement.
  • The trust’s inpatient services, including wards for people with a learning disability or autism, had a clear approach to discharge planning which ensured that discharges were safe and that people did not spend more time in hospital than they needed to.
  • Patients told us how staff helped them to achieve the goals set in their discharge plans. Examples included staff accompanying patients back to their homes to assess what additional support they may need to aid their recovery. Staff actively assisted patients towards their discharge.
  • A bed management and referrals meeting, facilitated by the crisis team, was held daily and was attended by key clinical and managerial staff. This meeting oversaw the inpatient care pathway. The bed management meeting monitored and tracked appropriate bed usage and identified any pressures on the system. The bed management meeting also monitored all actual and potential inpatient delayed discharges.
  • Services met the needs of patients from diverse backgrounds. Staff could access interpreters and information for patients and carers was available in community languages.
  • The specialist diabetes team have developed specific education courses and cookery classes to meet the needs of the Asian community, who have an high incidence of diabetes.
  • Patients and carers using all services told us they were aware of the trust’s formal complaints procedure. Feedback from informal and formal complaints was used to learn lessons and make any necessary improvements.
  • The trust was the only mental health provider in the sustainability and transformation partnership footprint to be given the funding to run an Individual Placement Service, supporting patients back into paid or voluntary work. The trust would identify potential employers, support the patient into the role and then support the employer to manage them. This scheme had been running for three years in the early intervention in psychosis service, and Reading and Slough community mental health teams (CMHT) and they had just been given funding to roll this out to all of the remaining CMHTs.

Well-led

Outstanding

Updated 2 October 2018

Our rating of well-led improved. We rated it as outstanding because:

  • We rated twelve of the core services as good for well-led, two were rated outstanding.
  • Managers at all levels in the trust had the right skills and abilities to run services providing high-quality sustainable care. Succession planning was in place throughout the trust.
  • Leadership development opportunities were available, including opportunities for staff below team manager level. Staff told us they attended an ‘excellent managers programme’ which provided managers tools to support employee health and wellbeing. The course was not limited to managers and staff told us that other team members, band six and above, had attended the course and found it useful.
  • The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.
  • We saw evidence of a commitment to quality improvement and innovation in all the services we inspected. The leadership were promoting and supporting continuous improvement and staff were accountable for delivering change.
  • We saw many examples of strong local leadership, for example the Director for Community health services for children and young people produced monthly newsletters.
  • The Ward for people with a learning disability had signed up to the standards set out by the Royal College of Psychiatrists Quality Network for Inpatient Learning Disability Services, and had been successfully accredited in February 2018. The service had been assessed as meeting all 164 standards, and had acted upon some recommendations for improvements.
  • The Ward for people with a learning disability was involved in work to benchmark it’s performance with the NHS Benchmarking Network. Outcomes for patients compared well with other trusts. The trust had developed a model of care that reflected national best practice outlined in Building the Right Support (NHS England 2015).
  • The trust had invested in a ‘top to bottom’ Quality Improvement programme. This programme was unique in its implementation in community dispersed teams in both mental and physical health services.
  • The trust had strong governance systems supported by good quality performance information. This meant that at all levels of the organisation staff and members of the board had access to useful information that enabled them to gain assurance and make improvements where needed. This enabled the trust to achieve a balance between assurance and improvement work.
  • The chief pharmacist provided the leadership necessary to allow the pharmacy team to improve and promote medicine safety and to support clinical service delivery.
  • The trust leadership team had a comprehensive knowledge of current priorities and challenges across their community health and mental health services and took action to address them. The chair enabled the non-executive directors and the council of governors to participate fully in the business of the trust.
  • Governors felt well supported in their role by the chair and the trust secretary. They were able to appropriately challenge the non-executive directors and the council of governors was able to have input on changes in policy.
  • There was a programme of board visits to services and staff fed back that leaders were approachable. Rigorous and constructive challenge from people who use services, the public and stakeholders was welcomed and seen as a vital way of holding services to account.
  • The trust demonstrated openness, honesty and transparency when responding to incidents and complaints. All the incidents and complaints we viewed demonstrated an open and honest approach, including where the service had not performed to the required standard. The trust was aware of and had systems to ensure compliance with the requirements of the duty of candour, we saw this demonstrated in the correspondence with patients, carers and relatives who had made complaints or were involved in the investigation of incidents.
  • Staff were proud of the organisation as a place to work and spoke highly of the culture. There were consistently high levels of constructive engagement with staff, including all equality groups. Staff at all levels were actively encouraged to raise concerns.
  • The specialist diabetes team had been shortlisted for the 5th year running for the XPERT – Diabetes Type 2 Education National Awards.
  • The trust was one of seven NHS trusts delivering mental health services in England to be named as a Global Digital Exemplar for transforming patient care and engagement through new technology. The board had invested resources into the development of technology to promote mobile working for community teams and to provide online support forums for families and patients in several different services. This included families of young people with eating disorders; families of young people with autism awaiting an assessment and new mums with mental health difficulties.
  • The trust had also participated in one of four successful bids to provide a new model of care for forensic secure adult mental health services in Buckinghamshire, Oxfordshire, Berkshire (East & West), Hampshire & Isle of Wight, Dorset and Milton Keynes.
Checks on specific services

Wards for people with a learning disability or autism

Outstanding

Updated 2 October 2018

Our rating of this service improved. We rated it as outstanding because:

  • Patients were not on any high dose antipsychotic medication or multiple medications for psychosis. The clinical team worked to reduce the use of medications alongside other interventions. This meant that patients were not being overmedicated.
  • All patients had a positive behaviour support plans, in line with the Positive Behaviour Support (PBS) Approach recommended by Department of Health.

  • The ward worked effectively with the Intensive Support Team (IST)

  • There was occupational therapist input and daily schedules of activities for patients including art, cookery, music, bowling, games, and local walks.

  • Staffing levels were safe and staff morale was high. Temporary staff tended to be familiar with the ward. Staff reported feeling well supported and the training and professional development of staff was a high priority.

  • We observed positive interactions between staff and patients and a caring culture on the ward. Staff understood behaviour that challenged to be a form of communication and worked sensitively to support patients.

  • All carers we spoke to were complimentary about the attitude and approach of the staff towards their loved one, with several commenting on the calm and caring approach to patients helped them to feel calm and safe.

  • Staff consistently used the least restrictive options when caring for patients and we saw no evidence of blanket restrictions used on the ward.

  • All patients had comprehensive risk assessments and risk management plans, which showed a positive approach to risk taking. Incidents were well reported and learning was shared with staff.
  • The electronic case management system was accessible to staff, with key information available in accessible formats in line with the Department of Health Accessible Information Standards.
  • Seclusion was very rarely used and a local protocol was in place to ensure the safety and dignity of patients requiring this intervention.
  • Staff were receiving regular clinical supervision, and staff meetings were well attended.

However

  • The ward environment was not autism friendly, which may have created stress for patients with an autism diagnosis or certain sensory needs. The ward did not have a sensory area or quiet spaces, and at times could become noisy.
  • Around half the staff team were trained in Makaton, and we observed some staff struggling to communicate with patients who used this as their main way of communicating.
  • Some carers told us that they had not received care plans and that communication with the ward had not always been clear.

Community urgent care services

Good

Updated 2 October 2018

We rated this service as good because:

  • A healthy reporting culture existed where incidents were reported and learning from them was shared with all staff. Staff understood their responsibilities to raise concerns and there were effective systems for monitoring risk, incidents, and safeguarding vulnerable patients.
  • The environment was suitable for the service provided. Equipment had recently been safety checked and was in good condition. Medicines were well-organised, stored safely and at the right temperature.
  • Patient records were completed to a high standard.
  • Mandatory and safeguarding training targets had been met. All staff had received an appraisal within the last year.
  • There was a positive and caring working culture. Staff respected the patients, their colleagues and managers. They responded kindly if patients were afraid or distressed. Staff understood the need for some patients to have privacy or a quiet space.
  • Clinical leaders were respected by staff. They were knowledgeable about quality issues and priorities, understood what the challenges were and took action to address them.

However

  • Staffing levels were reduced due to maternity leave, which prevented the service from providing cover for all shifts.
  • The recognition of patients who should be categorised as more urgent was not consistent with all receptionists.

Community health services for children, young people and families

Good

Updated 2 October 2018

Our rating of this service stayed the same. We rated it as good because:

  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service had systems for identifying, reporting, and managing safeguarding risks. The safeguarding team provided good support to staff across CYPF services through supervision, training, monitoring of incidents and advice via the trust’s safeguarding team.
  • Staff understood their roles and responsibilities under the Mental Capacity Act and Gillick competency framework with respect to issues of consent and capacity.
  • People using the trust’s community CYPF services were treated with dignity and respect. People felt listened to by health professionals, well informed and involved in their treatment and plans of care

However:

  • There were some inconsistencies with management of clinical waste in some clinics and adherence to policy regarding hand-washing.

Mental health crisis services and health-based places of safety

Good

Updated 2 October 2018

Our rating of this service stayed the same. We rated it as good because:

  • The service had access to safe, clean and well-maintained assessment and clinic rooms to see their patients. Staff kept patients and themselves safe through observations, use of alarm systems and GPS tracking devices.
  • The service had appropriate systems in place to ensure all risks from patients on their caseload were safely managed. Staff completed and referred to risk assessments that allowed them to identify patients with specific risks and respond appropriately. The service worked with patients to produce individualised safety plans.
  • Staff made appropriate safeguarding referrals and involved agencies that supported people at risk of abuse. They used incidents and complaints for learning and service improvement. The recently introduced 360 learning loop allowed involved staff to contribute to the investigation process and take ownership of any learning identified.
  • The service had dedicated crisis teams that carried out comprehensive assessments of patients in crisis within appropriate time frames. They provided referrers with clear guidance on admission criteria and followed checklists to ensure teams who were providing the care and treatment to patients had full knowledge of each patient’s risks and needs. They were updated on bed availability throughout the trust and screened all patients to see if they could be supported in the community prior to inpatient admission.
  • The service provided psychological interventions to individual patients or within a group. They had good links with local agencies where patients could access support with social needs. Patients also had access to a recovery college where they, or their carers, could attend educational courses and training programs to support their mental health recovery.
  • The service employed sufficient numbers of appropriately qualified staff who had high completion rates of mandatory training. Qualified nursing staff were supported to revalidate their registration to the regulatory body. The trust provided information on recommended training that could be accessed to enhance career progression.
  • The service had good links with internal teams and external agencies which supported the patients’ experience. They had daily contact with wards to identify patients who could be supported in the community. Staff from community mental health teams remained involved when their patients were in crisis and the service had developed pathways for patients who were also known to substance misuse services.
  • Staff cared for patients in a supportive and compassionate manner. They knew their patients well and discussed their needs and risks with other members of staff in a positive, non-judgemental manner. Carers had access to an established carers’ group in both east and west Berkshire. Both patients and carers were encouraged to give feedback about the service
  • The service had introduced a triage room in east Berkshire to ensure dedicated staff were available to answer phone calls from patients. Staff appropriately followed up patients who had not attended planned appointments.
  • Staff enjoyed their jobs and felt supported by their colleagues. They felt supported by senior managers who provided staff with bespoke training and opportunities to reflect and debrief on work related issues.
  • The service maintained operational oversight through a well-structured schedule of meetings. The trust used a recognised secure electronic patient record system to ensure that information was readily available to staff. Staff had access to an informative and user-friendly intranet site and the general public similarly had access to a user-friendly internet site.

However:

  • The service did not routinely provide physical health monitoring to patients. They also did not have a system to highlight important information, such as specific risks and safeguarding issues, at a glance.
  • The service did not record temperatures in rooms where medicine was stored and did not have robust security arrangements for medicine cupboard keys. Consultants did not have sufficient oversight of all prescribing within the service as they only received reports every six months.
  • Care plans did not always capture the full range of interventions offered by the service. At times it was not clear if patients had received key information on their care and treatment. .
  • Two health-based places of safety were in close proximity and shared a bathroom area. This had an impact on patients’ privacy and dignity when both were in use.
  • Staff told us they felt disconnected from trust wide senior managers and executive directors and they did not regularly visit teams or give staff opportunities to communicate with them.

Acute wards for adults of working age and psychiatric intensive care units

Good

Updated 2 October 2018

Our rating for this core service stayed the same. We rated it good overall because:

  • Considerable improvements had been made to the ward environments, including new seclusion room facilities on Sorrel ward and improvements to the security of the fences throughout the hospital. The trust had an ongoing maintenance and capital build programme in order to mitigate ligature risks on the wards and gardens, such as the fitting of anti-ligature fixtures and fittings. All wards were clean, well maintained and had good furnishings and fittings.
  • Significant improvements had been made with assessment processes and the quality of the documentation in the care records. Risk assessments were completed for all patients and were detailed, complete and comprehensive. The care plans were recovery focused, holistic and demonstrated good practice. Patients told us that they were included in the planning of their care.
  • Patients had access to a full range of psychological therapies. These were delivered via one to one sessions and in groups.
  • Staff developed complex physical health care plans and effectively managed physical health care needs. Staff supported the integration of mental and physical health and staff developed comprehensive care plans that covered a range of physical health conditions
  • Staff engaged in clinical and management audits. Clinical development leads and the nurse consultant oversaw a quality improvement programme called the ‘Quality improvement initiative strategy. .
  • Patients we spoke with on all of the wards were complimentary about the staff providing their care. Patients told us they got the help they needed it.
  • For the 2017 patient-led assessments of the care environment (PLACE) assessment Prospect Park Hospital scored better than similar trusts for the quality of food assessment, scoring 98.9% compared to 91.5% nationally. Patients told us the quality, range and quantity of food was good.
  • Ward staff provided clinical quality audits, human resource management data and data on incidents and complaints.
  • Staff told us they felt respected, supported and valued in their work. They commented in particular about the support they received from their ward managers and the next in line managers. Staff were proud to be working for this trust.

However:

  • The communal lounges had an excess of wires for the TV which presented an additional ligature risk.
  • Patients did not have their own key and had to request that staff lock their bedroom. This meant that bedrooms might be accessible to other patients.
  • There were inconsistencies in the cleaning standards and records in the clinic rooms.
  • We observed two searches on Daisy ward being carried out in the corridor area and not in private.
  • There was no written record of patients’ de-brief following an incident.

Community health services for adults

Good

Updated 2 October 2018

Our rating of this service stayed the same. We rated it as good because:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance and monitored the effectiveness of care and treatment, and made improvements where needed. They compared local results with those of other services to learn from them.
  • The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

Wards for older people with mental health problems

Good

Updated 2 October 2018

  • The service completed annual ligature risk audits and staff understood the risks on the wards well. Staff managed high risk areas well and knew those patients who were most at risk. Risk assessments were all up to date and thorough. We saw clear risk management plans in place in addition to crisis and contingency planning. The service had good falls risk assessments and management plans in place and current quality improvement work looked to reduce falls further.
  • Physical healthcare was closely monitored in the service with basic monitoring, electrocardiograms, body mapping, food and fluid monitoring and referrals to various primary healthcare professionals.
  • Staffing was appropriate across both wards and we saw ward managers changing the staffing numbers to respond to the acuity on the ward. We saw the service deploying their staff in innovative ways to ensure wards were well staffed and could manage when levels of acuity increased. The wards had sufficient medical cover 24 hours a day.
  • A full range of physical and mental health assessments were conducted on admission. Nationally recognised screening tools were used and clinical leads undertook regular audits. All patients had a current and up to date care plan. Care plans were holistic and management plans reflected the needs identified. Patients and carers reported feeling involved with their care plan and updated on their treatment.
  • There was good multidisciplinary input for the service. We saw two weekly multidisciplinary meetings on the wards and recent quality improvement work had improved the structure and function of the meetings.
  • We saw many positive examples of engaging and respectful interactions between staff and patients. Staff spoke in a kind, caring and patient manner to patients and supported them to manage and understand their care.
  • Patients had access to a range of social groups ran externally and we saw staff facilitate patient’s attendance. On Rowan ward we saw an innovative pub club group held weekly whereby the dining room was transformed into a replica pub that served alcohol free beverages to patients, carers, family members and staff.
  • There was good morale noted amongst all staff members and staff felt proud to work for the trust. There were no performance issues, staff suspensions or grievances ongoing.
  • The service undertook appropriate investigations into serious incidents and demonstrated clear learning and change of practice from previous incidents. There was sufficient auditing of various aspects of patient care to ensure good oversight and management.
  • The service had recently completed tutoring of the Quality Management Improvement System that was in place and the wards had quality improvement projects ongoing to improve patient care. Staff reported an excitement regarding leading quality improvement works from the ward level.

However:

  • The most recent month of supervision demonstrated completion rates of 75% (Orchid) and 25% (Rowan). Completion rates were consistently below 75% for each ward for the past 12 months. Staff commented that they did not always receive their one-to-one supervision and staff were unaware of the senior level oversight of supervision.
  • Staff on Orchid Ward had not maintained documentation of checks on emergency equipment in a consistent manner. There were some gaps of up to one month between February and March. Staff consistently recorded the clinic room on Orchid ward as slightly above the ideal temperature stated by policy, however no mitigating action had been recorded to reduce the temperature.
  • Staff did not always review as and when required medicines in line with National Institute for Health and Care Excellence guidelines on Orchid ward.
  • Mandatory and statutory training for the service had a 78% completion rate. Of the training courses listed, 16 failed to achieve the trust target and 10 failed to score above 75%
  • Patients on Rowan ward did not have free access to their rooms. Bedroom doors were routinely locked on the ward and staff held the keys for them. This restrictive practice did not appear on the trusts list of restrictive practices and therefore was not routinely reviewed.

Child and adolescent mental health wards

Good

Updated 31 August 2017

We rated child and adolescent mental health wards as good overall because:

  • Staff had carried out a detailed and thorough ligature risk assessment. All risks identified had been mitigated and the risks reduced effectively. Staff spoke confidently about managing ligature risks and they reviewed the risks at every shift handover. Staff carried out thorough and relevant risk assessments for patients and staff. Staff updated risk assessments regularly and ensured risk management followed through into care plans. Staff kept the ward clean and they maintained comprehensive cleaning schedules and audits to ensure the staff cleaned to the required standard.

  • The trust ensured sufficient staff were available to deliver care to a proficient standard. Where agency and temporary staff were used, they received a thorough induction and in most cases these staff were familiar with the service and patients. Over 93% of staff were up to date with their mandatory training. Staff were confident in reporting incidents and were familiar with the trust’s procedure for doing so.

  • Patients had access to advocacy services. Patients met with the advocate as a group every two weeks. Managers told us that areas of concern and themes were fed back to them. There was information about the advocacy service and leaflets about the independent mental health advocacy service.

  • Staff on the ward understood the vision and direction of the service and wider organisation. Staff at every level felt very much a part of the service and were able to discuss the philosophy of the unit confidently. Staff told us that staff morale was good and that they were being supported in their professional development.

  • The service manager and ward manager maintained a series of clinical audits, data about staff and data on incidents and complaints. The information was summarised and presented clearly. The ward was organised and well-led. There was evidence of clear leadership at a local level.

However:

  • Patients had raised safeguarding issues at a meeting. Although staff had seen the minutes of the meeting, they had not raised these issues formally as safeguarding concerns. When we raised our concerns, trust managers spoke to the meeting facilitator to ensure that any safeguarding issues would be raised in future. In addition, the senior managers formally raised the safeguarding concerns for investigation.

  • Staff understood the concept of parental responsibility as set out in the Mental Health Act Code of Practice. However, we were unable to locate evidence that patients had given consent to share information with their parents in all six of the care records we reviewed. This was despite the trust reporting in January 2017 that a consent form for sharing information should be completed for all patients on admission to the unit.

  • The quality of documentation in the care records in regards to capacity to consent to treatment was of a variable standard.

  • Staff did not always record capacity or competence to consent appropriately. For example, there was no reference to Gillick competency in the care records and no record of the nature of the assessment against Gillick principles. This was despite the trust reporting in January 2017 that a Gillick competency template would be developed in April 2017. Gillick competence is a term used in medical law to decide whether a child (under 16 years of age) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge.

Community mental health services with learning disabilities or autism

Good

Updated 30 March 2016

We rated community mental health services for people with learning disabilities as Good because:

  • People referred to the service were safe because good systems were in place to ensure the people with the most urgent needs were seen first and that people who waited longer were monitored while they waited.

  • The teams were responsive to the needs of the local populations and found innovative ways to meet the needs of people who use services.

  • Staff sought people’s views on the care that they received.

  • Staff were motivated to provide good care by a strong leadership team.

Community-based mental health services for older people

Outstanding

Updated 30 March 2016

We rated Berkshire Healthcare NHS Foundation Trust as outstanding because:

  • All of the teams we visited were located in settings that were clean and in a good state of repair.
  • All of the interview rooms and areas where patients had access to were comfortable and well maintained. Each staff member was provided with a portable alarm system. This provided the GPS location of the staff member and could be used to call for help.
  • Caseloads of each staff member were managed and reviewed in supervision. All staff were up to date with supervision.
  • Arrangements were in place to cover sickness, leave and vacant posts.
  • All teams had a duty system in place that could respond quickly if a patient had a sudden deterioration in health or in times of crisis. The duty system operated on a rota basis.
  • All of the records we reviewed had evidence of thorough risk assessments being in place. There was analysis of risk and crisis and contingency plans. Patients were assessed at initial contact with the service and regularly thereafter.
  • Each team had a safeguarding lead and staff in all teams were able to identify the lead. Safeguarding training was mandatory. Staff demonstrated good awareness of how to identify and escalate safeguarding concerns.
  • The Trust held monthly locality Patient Safety & Quality Meetings (PSQ) where cases were reviewed, learning from incidents discussed and Service Managers fed back the information to OPMH multi disciplinary business meetings. Wokingham OPMH team held Plan, Do, Study, Act (PDSA) meetings to review provision and plan service improvements. Staff found both meetings supportive.
  • We found evidence in care records that physical healthcare needs of patients were routinely reviewed. Ongoing physical healthcare needs were addressed as required.
  • Staff were extremely positive about the opportunities for professional development offered by the Trust. Staff members told us they had been funded by the Trust to undertake higher education courses and had gained qualifications at masters level.
  • All teams had arrangements in place to report and learn from incidents. Each team kept incident logs and staff were able to tell us what should be reported on DATIX. When incidents were reported the team manager investigated and learning was disseminated to staff in team meetings. There was an extremely proactive approach to learning from incidents.
  • Two of the memory assessment clinics we visited had undergone successful accreditation with the memory service national accreditation scheme (MSNAP). The other two teams were working towards gaining accreditation.
  • All interactions we observed between staff and patients were respectful, kind and considerate. Patients and carers told us they felt supported by staff in each service and staff involved them in their care. We were told that staff were kind and respectful.
  • The trust offered a six week “understanding dementia” education course to relatives and carers. The course provided a range of information to assist relatives and carers to support them when caring a person with dementia. We were told by carers this course was valued and beneficial.
  • The trust had developed a “Dementia Handbook for Carers”. The handbook provided detailed information for carers across the West of Berkshire about a range of subjects including locally available services, day to day living, an A-Z of symptoms and legal and money matters. A Newbury OPMH Consultant led the project to develop the handbook in partnership with the University of Reading. Several groups of carers had been consulted throughout each stage of its development.
  • The trust maximum target time for referral to treatment (RTT) is 126 days. Memory Services are currently compliant with a Quality Schedule target requiring at least 70% of people referred to memory clinics to be assessed within six weeks. At the time of the inspection 78% of people referred to all BHFT Memory clinics since April 2015 had been assessed within 6 weeks.
  • The Wokingham team had established the Young People with Dementia (Berkshire West) charity. The charity was formed due to a shortage of local support and helped to meet the needs of people who develop dementia at an early age. The charity also supports relatives and carers of young people with dementia. Older peoples teams and the charity collaborate to provide a seamless pathway for young people with dementia and their carers
  • The Trust had developed a specialist assessment form. The assessment form was developed with input from psychiatry, social work, community mental health nursing and psychology. The assessment form incorporated NICE guidelines. The assessment form was in use by all older people’s services in the Trust to enable the standardisation of assessment. The assessment form also had questions specific to the responses of the carer or relative of the patient which gave a holistic assessment.
  • All of the services visited offered a range of information to patients and their families. Waiting areas had leaflets and posters which provided information about mental health problems, physical health issues, local services, patients’ rights, help lines, how to complain and local advocacy services.
  • All of the services visited could access leaflets in different languages if required.
  • Morale was extremely high in each of the teams visited and staff spoke highly of their team and the support available.
  • Staff in all services had received mandatory training. Mandatory training included safeguarding, conflict resolution, equality and diversity, fire awareness, infection control and manual handling. There were high levels of completion of training across the service.
  • Staff were extremely positive about the quality of the supervision they received. All of the teams staff members had high completion rates for supervision.
  • Each team worked well together and listened to each staff member’s views. We saw evidence of this in multi-disciplinary team meetings in each of the services.
  • Staff were aware of the Trust’s complaints procedure and information was available to patients and carers about how to complain. We saw evidence of instances where staff had learned from complaints in a positive way.
  • Staff we spoke to told us that the trust management visit were visible and approachable. Staff spoke highly of the management.
  • The feedback we received from staff, patients and carers evidenced that services were very patient centred and provided individualised and holistic care

Community-based mental health services for adults of working age

Good

Updated 30 March 2016

We rated community based mental health services for adults as good because:

  • All of the teams we visited were situated in buildings that were clean and in a good state of repair.

  • All of the interview rooms and areas that patients had access to were comfortable and equipped with a wall alarm. Each staff member was issued with a lone working device that was GPS enabled and connected to the device’s management incident centre when activated.

  • Arrangements were made to cover for sickness, leave and vacant posts. There was a duty rota in place in each team to cover this work.

  • Some of the teams we visited had short term teams who saw people in a crisis for a short period of time. Where these teams were present, the number of people on the waiting list for a care co-ordinator was reduced. In the teams that had a waiting list we saw that measures had been put in place to monitor and act on any risks to people waiting to use the service. This included regular contact by the duty team.

  • All the teams had a duty system in place to support people who did not have or were waiting to be allocated a care co-ordinator. Staff were able to respond promptly to a sudden deterioration in people’s health using a red, amber and green rating system to identify any changing risks to people in the care of the service.

  • In the 23 electronic care records we looked at we saw evidence of thorough and clear risk recording across all of the teams and risks were updated regularly with robust crisis relapse and contingency planning was in place.

  • The Trust held a monthly ‘positive risk panel’ with senior management where clinicians can bring cases that are causing concern to discuss the way forward. Staff found this to be very supportive.

  • Each team had a safeguarding lead and staff across the community mental health teams was able to identify this lead and demonstrated good knowledge of how to identify and escalate any safeguarding concerns.

  • We observed an excellent pharmacy led clozapine service in place across the community mental health teams with six clinics per week. The nurse or pharmacy technician was always available to give the patients information about their treatment. Patients were very happy with the service.

  • We observed good practice of recording route of administration and dosage within British National Formulary (BNF) limit and in line with National Institute for Health and Care Excellence (NICE) guidance.

  • There was good evidence that patients’ ongoing physical care needs were being monitored and this was reviewed at least six monthly at out-patient appointments or care programme approach meetings.

  • The psychology department in the community mental health teams offered many of the therapies recommended by National Institute for Health and Care Excellence (NICE) including cognitive behavioural therapy.

  • Staff were extremely positive about the opportunities for professional development in particular the trust’s commitment to non-psychology staff training in cognitive behavioural therapy techniques, such as graded exposure, behavioural activation and problem solving.

  • Staff spoke and behaved in a way that was respectful, kind and considerate. Patients we spoke to told us that they were treated with dignity and respect by staff.

  • Patients told us that they felt able to make choices about their treatment and felt very involved in their care. They felt they had a say in all aspects of their care and their opinions on medicines and other treatments were sought and respected.

  • There was good feedback from carers. Many told us they had had a carer’s assessment, felt supported and had access to carers groups.

  • Staff told us that they reviewed their waiting lists daily by using the (red, green and amber) RAG rating system and risks were re-evaluated and acted upon as necessary. People on the waiting list were contacted regularly to gauge any changes to their risk and need.

  • There were multi-language leaflets available on the Trust’s intranet which had a link to google translator so that translation could be accessed as and when needed.

  • There were two telephone interpreting services available to Trust staff (Mother Tongue and Pearl Linguistics) which offered telephone and face to face interpretation.

  • Staff were aware of the Trust’s complaints procedure and they told us that they reminded patients and carers how to complain and tried to view it in a positive way.

  • Morale was very good across the teams and the staff across all of the teams said that their team was good to work in and very supportive of each other.

  • Staff told us that the trust management visit the unit and there were regular ‘listening into action’ sessions held by the chief executive which they felt had led to positive change.

  • Staff benefitted from support offered by psychology and the trust’s trauma service after incidents and immediate debriefs in supervision and in their teams.

  • There were opportunities for patients to become peer mentors with a focus on access to groups that were patient led and focussed. We also observed a group for people with emotional instability at Upton hospital, Slough run by (ASSIST) assertive stabilisation service. Patients and carers we spoke to told us how much they valued this service.
  • Based on feedback from staff and patients, the services were very recovery focussed with an emphasis on individualised and personalised care that was not risk averse.

Community health inpatient services

Good

Updated 30 March 2016

Overall rating for this core service Good l

We rated the inpatient service in community hospitals as good for safe, effective, caring, responsive and well-led.

  • The inpatient wards in community hospitals had safe systems in place to prevent abuse or avoidable harm to patients. There was a system to allow staff to report patient incidents and safety concerns. Patient safety information was displayed for staff and visitors. There was a good track record on the prevention of pressure ulcers. Staff knew how to raise incidents. Incidents were investigated and the learning was shared widely. Staff were aware of their obligations under the duty of candour.
  • Medicines were managed appropriately across inpatient wards and in the minor injuries unit. A high percentage of staff participated in mandatory and other training. Inpatient wards were clean and well maintained. There was sufficient equipment to meet the needs of patients, and the requirements of staff to reduce the risk of avoidable harm. There were appropriate systems in place to monitor patients for sign of deterioration. There were sufficient numbers of suitably trained and qualified staff to keep patients safe.
  • Care was planned and delivered in line with national and best practice guidance. There were suitable evidence based policies and procedures in place for staff to follow. Patients received pain relief when they needed it. Patients were offered food and drinks. This was available over 24 hours. Patients that needed it were given assistance to eat and drink. There were systems in place to collect patient outcome data in order to monitor quality.
  • The trust participated in a programme of audit and also contributed data to national audit programmes. Staff received appropriate appraisals and supervision. There was excellent multidisciplinary (MDT) involvement in patients care and treatment. Regular meetings occurred to review patient progress and plan for discharge. All appropriate MDT staff were involved in these meetings. Patient records were securely but accessibly stored in all wards. Staff were aware of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards, and had received training.
  • We observed patients being treated with care and compassion by ward staff. The privacy and dignity of patients was maintained at all times. Patients and those close to them were involved in decisions about all aspects of their care. Patients told us that they were treated with kindness and respect. Staff took time to assess and treat patients appropriately and also to discuss their fears and anxieties. There was support available for patients that required emotional support. There was a chaplaincy service to support patients’ religious needs. This service was able to support patients of all faiths through a network of volunteers.
  • The trust had open relationships and good communication with commissioners. The trust worked with patients and GPs to organise and develop services. Patients were provided with activities in addition to rehabilitation. Patients’ religious and cultural needs were supported. Translation and interpreter services were provided for patients that needed them. Staff participated in safeguarding adults training.
  • Staff were aware of the particular needs of patients that were living with dementia or a learning disability. Patients with dementia or a learning disability were given a priority in the minor injuries unit (MIU). Patients admitted to the community hospitals were seen by nursing and medical staff promptly. Ambulance patients had an initial assessment within fifteen minutes in the MIU. Walk in patients were assessed within one hour. Bed occupancy was high in most inpatient wards. There was a waiting list of patients in acute hospitals that needed to access the service. Patients and relatives were given the information they needed to raise a complaint if they needed to. Changes were made in response to complaints and patient feedback.
  • Staff were aware of the trust’s values, as well as the vision and strategy for the individual wards. Effective governance processes were in place to monitor quality, performance and risk. Patient safety incidents were investigated and the learning shared with staff. Risks to patient safety were identified and recorded on a risk register, along with planned interventions to mitigate the risk.
  • There was an open culture and staff felt confident to raise concerns over patient safety. The trust had effective systems in place to capture patient feedback. This information was used to improve patient care. Staff were engaged and valued the opportunity to be involved in quality improvement projects.
  • In the inspection of the inpatient wards at community hospitals we spoke with 64 members of staff, 27 patients and six relatives. We also reviewed 24 sets of patient records.

End of life care

Good

Updated 30 March 2016

Overall rating for this core service

The end of life care service is delivered along with other general care services, in community hospitals and patients’ own homes.

Overall, we rated this core service as ‘Good’. We found community end of life care services at Berkshire Healthcare NHS Foundation Trust were, ‘outstanding’ for caring and ‘good’ for safe, effective, responsive and well led.

Our key findings are :

  • Services for end of life care were safe and there was a good culture of reporting and learning from incidents.

  • Incidents were reported and process was risk was monitored. The service monitored safety information such as healthcare associated infections, pressure ulcers and medicine errors. There was safety information available, which related to workforce and patient experience.

  • Learning from risks, incidents and near misses was shared with staff. Staff had knowledge of the requirements of the duty of candour.

  • There were systems in place for escalating concerns about potential safeguarding concerns.

  • The environment was clean and well maintained.

  • Equipment was available for patients in their homes and was delivered promptly. Staff were able to order urgent equipment such as hospital beds or moving and handling equipment for patient use within 24 hours to ensure harm free care.

  • Medicines, including controlled drugs (CDs),were appropriately managed. The trust used a single model of syringe driver for the delivery of end of life care medicines and staff had received appropriate training on the use of these.

  • Patients in the last days of life at home or being cared for within a community hospital setting could access medical care out of hours. Staff who were concerned about the deterioration of a patient could access on-call medical advice from the out of hours GP service.

  • Staff provided care to patients based on national guidance, such as National Institute for Care Excellence (NICE) guideline on End of Life Care in Adults and the Priorities for the ‘five priorities for the care of the dying person’.

  • The trust had recently introduced a new end of life care plan to replace the Liverpool Care Pathway, which had stopped being used in England in 2013.

  • There were sufficient staff to provide high quality care in community hospitals and community settings.

  • Staff worked in multidisciplinary teams to coordinate patient care. The local multidisciplinary team meetings (MDTs) held at GP practices and hospices were well attended by community nurses, specialist palliative care staff and hospice staff.

  • The trust used single point of access (SPA) arrangements together with a local hospice to screen referrals into the East Berkshire palliative care service. Staff told us this had helped in reducing the response time in delivering end of life care. Discharges from hospitals were managed efficiently.

  • Patient outcomes were monitored by individual services and information about these outcomes was included in the trust’s clinical governance reports.

  • Staff had access to specialist training courses and had appraisals.

  • Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

  • The ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) documents we reviewed did not always record an appropriate rationale. The trust had not undertaken an audit of DNACPR documentation and were not aware that the recording of DNACPR decisions were poor.

  • Staff involved and treated people with compassion, kindness, dignity and respect. Feedback from patients and their families were consistently positive and included many examples of where staff had gone “above and beyond”.

  • We saw some excellent examples of staff providing care that maintained respect and dignity for the individual. There was also good care for the relatives of dying patients and sensitivity to their needs.

  • Patients and relatives were given the emotional support they required, and felt that they were involved in the planning of their care. Staff in the community gave patients the time they needed, so their visits did not seem rushed, even when the service was under pressure.

  • The trust had audited and were in the process of implementing the standards of the ‘one chance to get it right’ document. The trust had formed an end of life (EOL) care group to support the delivery of end of life across the trust. The trust also participated in an East and West Clinical Commissioning Group’s(CCG) end of life care group which consisted of commissioners, GPs, local hospices.

  • Community hospitals provided appropriate facilities for end of life care. There was provision for people with communication difficulties, this included an interpreter service.

  • The environments in community hospitals were designed to be suitable for patients living with dementia. Vulnerable patients were identified and effective multidisciplinary working ensured their needs were met.

  • Complaints were handled in line with the trust’s policy and were dealt with in a timely manner. Staff were encouraged to be proactive in handling complaints. Staff received feedback from complaints in which they were involved.

  • Although the trust did not have a published end of life care strategy, the service leads had identified priorities around improving the end of life care services across the trust. Staff we spoke with were aware of these priorities and described high quality patient care as a key component of the trust’s vision.

  • The leadership, governance and culture were used effectively to drive and improve the delivery of high quality person-centred care. The leadership for end of life care was strong and empowered all staff to strive to deliver the best possible service.

  • The trust sought and acted on feedback received from patients and relatives.

Specialist community mental health services for children and young people

Good

Updated 30 March 2016

We rated specialist community mental health services for children and young people as good because

:

 

·        

The trust had recently secured funding to increase staffing and capacity in order to reduce the significantly long waiting times for patients.

  • At the time of our inspection the service was in the process of embedding the increased staffing and the extended opening hours for the common point of entry service at Wokingham. New staff had been recruited and the service was in the process of inducting staff on programmes that included shadowing staff in all the care pathways. The service had fully recruited in East Berkshire.

·        

The waiting list was actively managed and this included face to face as well as telephone contact to young people and their families. Patients on all the pathways could be seen quickly based on prioritisation relating to urgency, risk or need. For example, 15% of patients on the autistic spectrum disorder (ASD) diagnostic pathway where waits were longest were seen within 12 weeks based on need.

  • Young people and their families were mainly satisfied with their care although there were concerns in relation to the long waiting times.

·        

There was an active participation group that had contributed to improvements in the service design such as arts and crafts displays and areas for younger children, such as in Slough. The group were in the process of developing CAMHS leaflets and a social networking site to support young people between appointments.

·        

We observed a range of multi-disciplinary meetings and appointments.  Staff were skilled and showed respect and empathy towards young people. There were robust discussions around risk.

·        

There were skilled staff to deliver the service and most staff were up to date with their mandatory and statutory training. In addition, staff received values based appraisal and as part of this they identified their training needs. There was satisfaction expressed about the quality of the leadership training in the trust.

·        

Most staff felt well supported by their manager and were familiar with the senior management team who visited the areas that staff worked in.

·        

There was an open culture towards reporting incidents, bullying and whistle blowing and learning from complaints.

 

However;

 

·        

The ongoing increase in demand and capacity issues for CAMHS services in Berkshire had created long waiting times. For example, 38% of patients on the  autistic spectrum disorder (ASD) diagnostic pathway  were not seen within 12 months , including a wait of more than two years for some young people on the  autistic spectrum disorder (ASD) diagnostic pathway. This had created some dissatisfaction with young people and their families. This was expected to improve significantly as vacancies were filled following the increase in funding. However, at the time of our inspection it was too early to see the effects from the significant improvements in capacity.

·        

In Wokingham care plans records were not well managed and staff at the service found it difficult to find evidence of whether some patients had a care plan. There was also variation in the quality of risk assessment records.

·        

Caseload management tools were not consistently used, although this was being piloted in Newbury.

  • Although there had been no ligature incidents in the community CAMHS buildings, there were multiple ligature risks in the community buildings due to the age of some buildings. Action plans had been developed to mitigate risks but staff were not aware of these.

  • Recruitment had been less successful in Wokingham and West Berkshire where waiting lists were longer and staff felt under pressure; particularly in services were there were more temporary staff.

  • Morale was generally good amongst staff, despite the work pressures. However, at Wokingham where half the workforce were locum and agency staff this had adversely affected morale.