Berkshire Healthcare NHS Foundation Trust

Updated 26 March 2020

Not used

Updated 26 March 2020

Our rating of the trust improved. We rated it as outstanding because:

• We rated the trust outstanding overall because over the past four inspections we have seen a consistent pattern of progressive improvement in the quality of core services that is reflected in the ratings of these services.
• Since the last inspection in 2018 the trust has continued to make considerable improvements, building on many of the high quality services it delivered.
• In rating the trust, we have taken into account the previous ratings of the eight mental health and community health core services not inspected this time as well as the six we did inspect.
• We rated safe, effective and caring as good and responsive and well led as outstanding. Following this inspection four of the trust’s fourteen services were rated outstanding and eleven were rated good.
• The trust had made the majority of the improvements we said that it should make following our last inspection.
• We found that the trust had a highly skilled, strong, stable and experienced senior team, including the chair and non-executive directors. Leaders had the skills, knowledge, integrity and experience to perform their roles and had a good understanding of the services they were responsible for delivering. There was compassionate, inclusive and effective leadership at all levels. Leaders were visible in the service and approachable to patients and staff.

• The trust had created a positive culture where people, patients, carers and staff could share their experiences and concerns and where there was a really genuine commitment to learning and making improvements. Staff across the trust felt valued and there was a real focus on doing what was best for people, both staff, patients and carers and a real commitment to the delivery of good quality patient care at every level. Staff at all levels of the trust were proud to work there and morale amongst staff was good. Both the Council of Governors and the trade union representatives were very positive about how the trust leaders worked with them in an open and transparent way.

• There was a clear vision, underpinned by a set of values that were well understood by staff across the trust. Staff were consulted and felt included in strategic changes and developments. We noted some really clear thoughts and developments around aligning with partners across the health and care economy to further develop services that put patients at the centre of care. The trust was taking a leading role in a number of the system wide developments and was a key partner in two exemplar integrated care systems, the board was visibly engaged in and supportive to the work of the wider health and social care system.
• The involvement of patients was central to the work of the trust. Patients were supported to express their wishes and to be active participants in meetings where their care was discussed. The involvement of patients and carers in the wider work of the trust had developed further since the last inspection with some excellent examples of coproduction work. For example, children and young people, parents and carers were actively involved in the design and delivery of the service and patients had been involved in quality improvement in acute wards for adults of working age and psychiatric intensive care units. This had resulted in a reduction in staff assaults and patient restraint.
• Staff put patients at the centre of everything they did. Staff treated all patients with compassion, respect and kindness. The privacy and dignity of patients was maintained. Staff worked in partnership with patients to ensure they were supported to understand and manage their care and treatment.
• The end of life care services and community adults services provided innovative approaches to integrated person-centred pathways of care that involved other service providers, particularly for patients with multiple and complex needs. The services were flexible, provided informed choice and ensured continuity of care.
• Staff assessed and managed risks to patients well and followed best practice in anticipating and de-escalating volatile situations. There had been a reduction in incidents of violence and aggression across the inpatient wards. In acute wards for adults of working age and psychiatric intensive care units a positive risk panel was held weekly, staff could discuss particularly complex, high risk patients with senior clinicians in order to agree an effective care plan and to review risk. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The trust had very strong staff networks in place for people with protected characteristics and network leads had some protected time to develop these further. These were the BAME network, LGBT & Friends network for LGBT staff and allies and the newest of these networks was the Purple Network for people with disabilities, long term health conditions or caring responsibilities, with a membership of 300 people. The trust recognised that the work to further develop their commitment to equality, diversity and human rights was ongoing and there was passionate support for this at board level, for example, reverse mentoring with staff from all three staff networks. Each network had an executive champion and worked in partnership with other staff networks, allies and over 100 champions across the organisation. The Diversity Steering group was chaired by the executive director of corporate affairs.
• The trust had made further progress in their quality improvement methodology. We saw that this methodology was embedded throughout the trust and was championed at all levels from ward to board, gave genuine opportunities for staff and patients in wards and teams to identify areas for improvement and make changes. The trust consistently encouraged and supported staff to innovate and develop new ideas. For example, in CAMHS an online peer-support based system, Support Hope and Recovery Online Network (SHaRON), had been developed. This provided a confidential space for children and young people and their families to access support and the hydration project on Henry Tudor ward which had introduced several initiatives that encouraged and promoted hydration, such as a drink station pit stop which provided a visual reminder for patient to drink. This successful initiative was being rolled out across the trust.
• The trust had strong governance systems supported by high 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 trust had continued to build on its innovation as a Global Digital Exemplar, sharing learning and supporting other trusts to make improvements in technology. Innovation was at the core of the trust strategy, with the use of approaches such as True North goals and Listening into Action to engage with staff and empower them to make changes quickly and with board support
• The chief executive had taken a lead in the national benchmarking for mental health and community health.

However;

• In specialist community mental health services for children and young people we found that the average waiting time for assessment in the county wide attention deficit hyperactivity disorder (ADHD) and autism pathway for children and young people was 33 weeks. In East Berkshire the average waiting time from referral to treatment in the specialist community teams was 23 weeks. This was lower in West Berkshire, where it was 15 weeks. The trust had developed waiting list initiatives to address this, and support provided for waiters and appropriate actions taken for urgent cases. There had been increasing rates of referrals into CAMHS services, and the trust had secured additional funding for early intervention for young people. Waiting lists were a key quality concern and were monitored by the trust board and commissioning groups. There were several initiatives that the teams and trust were involved in to reduce waitlists and ensure risks for children and young people waiting were managed and responded to. The trust had identified a gap in the commissioning of this service and the CAMHs leadership team were engaged in a commissioner-led project to review pathways and services for autism and ADHD and to identify a new service framework based on a comprehensive review of the capacity and demand for these services.
• Patients on the acute wards for adults of working age and psychiatric intensive care units were subject to several blanket restrictions. rules and policies that restricted a patient’s liberty and rights, which were routinely applied, without individual risk assessments to justify their application.
• Some of the ward environments of the child and adolescent mental health ward and acute wards for adults of working age were in need of redecoration. However, the trust does have a rolling programme of redecoration in order to address this.

Updated 26 March 2020

Our rating of community health services for adults service improved. We rated it as outstanding because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent to do their job. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week. For example, community nursing. Services were delivered in line with national guidelines.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually. For example, changing the name of the heart function team.

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.

Updated 26 March 2020

Our rating of community health inpatient services stayed the same. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. Oakwood ward demonstrated high standard of risk assessment and care plans.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff at Henry Tudor ward were leading on the hydration quality improvement project and had multiple drink stations on the ward to encourage and promote hydration. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Staff supported patients with smoking cessation and alcohol withdrawal.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. We saw evidence of positive feedback from patients and carers across all the sites we visited. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
• 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. For example, the consultant on Henry Tudor ward encouraged staff to attend an international conference on hydration. As a result, many initiatives had been put in place on the wards to reduce dehydration in patients.

However:

• Although staff kept electronic records and paper copy of patients’ care and treatment, some records and care plans were generic or not goal oriented. Records were not easily available to all staff providing care as some information was available in electronic format whilst other information was kept in paper format at the bed side of patients. This caused a potential delay in delivering care and treatment.
• Three of the six patients we spoke with on Henry Tudor ward said on a recent occasion staff did not comfort them when they were distressed, but staff understood patients’ personal, cultural and religious needs.

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.

Updated 26 March 2020

• The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health.
• Young people had good access to education and physical healthcare
• Staff treated young people with compassion and kindness. They respected young people’s privacy and dignity. They understood the individual needs of young people and supported young people to understand and manage their care, treatment or condition.
• Staff planned and managed discharge well. They liaised well with services that would provide aftercare and were assertive in managing the discharge care pathway.
• Staff engaged actively in local and national quality improvement activities. All members of staff participated in the work involved in a trust-wide quality improvement system called Quality Management Improvement System.
• Young people’s safety plans were individualised and holistic care plans that were written with the young person.
• Restrictions were reviewed regularly with the involvement of young people.

However;

• Most of the ward environment was not in a good state of decoration. Bedrooms were particularly in need of updating and the communal shower and toilet room consisted of a row of shabby and highly cramped cubicles. However, the trust had plans in place to move to the Prospect Park site which will enable co-location of all inpatient mental health services and a much improved environment.
• Staff imposed a number of clinically justifiable blanket restrictions on young people, such as a ban on the use of smartphones, although young people were provided with mobile phones to text and make calls. Restrictions were reviewed regularly with the involvement of young people.
• Staff did not always record that they had assessed the mental capacity or competency of young people, or that they had obtained their consent.
• Young people did not have a lockable space within their bedroom, although they did have access to a storage area to lock their belongings in. There were no locks on bedroom doors and no patient control of bedroom door viewing panels.

Updated 26 March 2020

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

• The community child and adolescent mental health service provided safe care. Clinical premises where children and young people were seen were safe and clean. Managers monitored the caseload of individual members of staff, to ensure these were not too high to prevent staff from giving children and young people the time they needed. Staff monitored waiting lists well to ensure that children and young people who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented initial care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the children and young people. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the children and young people. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people.
• Staff treated children and young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of children and young people. They actively involved children and young people and families and carers in care decisions.
• The service used a common point of entry team who used red, amber, green ratings to ensure they assessed and treated children and young people who required urgent care promptly. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
• The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.
• The service was innovative in developing and implementing initiatives to improve the service, children and young people’s experience and multi-agency working. The specialist community teams and common point of entry team had completed training and implemented the Quality Management Improvement Programme (QMIS) and had developed team skills to take a bottom-up approach to problem solving.

However:

• In the attention deficit hyperactivity disorder pathway and autism assessment pathway the waiting time for assessment was up to two years. In the East specialist community team the wait for treatment was over 18 weeks and averaged 23 weeks. The trust had developed waiting list initiatives to address this.
• Staff did not always document care and treatment plan outcomes and reviews in the care plan templates. Staff recorded updates to treatment, goals and outcomes within progress notes, rather than on the care plan document. This made it difficult for staff to track and review progress with the care plan. Following development of their initial care plans, staff did not ensure children and young people were provided a copy of their care plan reviews or updates.
• Staff did not always record consent and capacity or competence clearly. In 4 of the 15 care records we reviewed, there was no reference to capacity or consent. Staff did not always record Gillick Competency within the specified form on the electronic care records.

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.

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

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.

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.

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.

Updated 26 March 2020

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

• The wards had enough nurses and doctors to keep patients safe and meet their needs. Staff generally managed medicines safely and followed good practice with respect to safeguarding. Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Each patient had contributed to a safety plan which detailed their risk triggers and interventions, which patients told us they found helpful and effective. Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that staff received regular training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff treated patients with compassion and kindness, understood the individual needs of patients, and actively involved patients and families and carers in care decisions.
• Staff had empowered patients to raise improvement ideas, three of which had been implemented by staff to good effect, reducing violent incidents, prone restraint and self-harming behaviour
• The trust continued to undertake a quality improvement project which aimed to reduce patients’ average lengths of stay, reduce use of out-of-area placements, and address patient flow between the acute and psychiatric intensive care wards.
• The service was well led, and the governance processes ensured that ward procedures ran smoothly. Leaders empowered staff to address issues using quality improvement methods. Wards adopted the Quality Management Improvement Programme (QMIS) and had developed team skills to take a `bottom-up’ approach to problem solving.

However;

• The acute wards had some issues with the environment. We found tired paint work, graffiti that had not been removed from walls, and not all bedrooms were fully furnished.
• The wards had known high risk ligature points which staff told us they managed by observations. However, some of the ligature points were in areas that were not observed frequently.
• On all wards patients of both sexes could access each other’s bedroom corridors, although staff said they would prevent inappropriate entry. The trust had piloted giving patients their own bedroom keys and it planned to roll out giving patients their own bedroom key in January 2020. In addition, on Rose ward male patients could see through a glass panel onto Daisy wards female corridor. We raised this during the inspection and staff dealt with this immediately.
• Patients were subject to blanket restrictions which were not subject to individual risk assessment and that were not proportionate to individual risks. For example, all patients were searched on their return from leave, had restricted access to aerosols, and patients had their cigarettes, lighters and matches confiscated and not returned until discharge.
• On Bluebell ward, staff did not consistently explain patients’ legal position and rights as required under section 132 Mental Health Act 1983.
• Female lounges were regularly used for meetings and groups which were attended by male patients, this limited the time the lounges could be used by females.

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.