All inspections: Berkshire Healthcare NHS Foundation Trust

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.

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.

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.

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.

Our rating of end of life care services improved. We rated it as outstanding because:

All staff demonstrated a strong, visible, person-centred culture. Staff were highly motivated and inspired to offer care that was kind, compassionate and promoted patients’ dignity. Staff followed national guidelines on the ‘priorities for care’ from the Department of Health’s ‘one chance to get it right’. This was reflected in the way staff interacted with patients, in patients care records, from consistently positive patient feedback and observations of the way staff discussed patients in multidisciplinary meetings.
Patients were active partners in their care. Staff were fully committed to working in partnership with patients and supported patients to make decisions about their care and their environment for themselves. Feedback from all patients and carers was overwhelmingly positive and all felt staff went the extra mile.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They 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, such as the national audit of care at end of life in which the service scored higher than the national summary score in six of the eight categories.
Patients’ individual preferences and needs were central to the planning and delivery of tailored services, such as where they preferred to receive their end of life care and who they wanted involved. The involvement of other organisations and the local community was integral to how services were planned and ensured that services met patients’ needs. There were innovative approaches to providing integrated patient-centred pathways of care that involved other service providers, such as the close working relationships between local hospices and the nursing teams. Local hospices were directly involved in the care and treatment of patients and staff worked hard to maintain these relationships. There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that met these needs and promoted equality. This included people who were in vulnerable circumstances or who had complex needs, such as services set up for a growing homeless population and tailored services for ex-armed forces patients.

There were high levels of staff satisfaction across all wards. Staff were proud of the wards as a place to work and spoke highly of the culture. Leaders had an inspiring shared purpose and strived to deliver and motivate staff. There was strong collaboration between staff, patients and leaders. This was demonstrated by the trust’s roll out of a quality management improvement system which staff contributed to daily.
Leaders strived for continuous improvement and safe innovation was celebrated. There were clear proactive approaches to seeking out and embedding new and more sustainable models of care, such as ensuring standard work incorporated the ‘five priorities of care’ from ‘one chance to get it right’; a department of health document which sets out actions to improve care in the last days of life.
The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well and had clear guidelines to manage infection after a patient had died. 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. Managers were able to pull incident type themes which meant learning could be established. For example, tissue viability related incidents were recorded and a theme was noted that categorisation was often delayed and this meant that the incident breached time frames. The team at Wokingham brought in tissue viability nurses to deliver training so that staff nurses could sign off the category, thereby allowing them to close the incident.
Staff collected safety information and used it to improve the service. Staff working with end of life patients had raised concerns about syringe pumps which were old and would shortly need replacing. The trust responded and acquired new syringe pumps. However, these were not fit for use in the community as they only had a 24 hour battery life. The trust recalled all of the new syringe pumps and were currently looking for alternatives as a result.
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 these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

However:

Although end of life training was available to staff, it was not mandatory for staff providing this service.
Although end of life information was detailed in progress notes, end of life careplans were not embedded within teams or used by community nurses. Some care plans lacked evidence of being updated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

We inspected the safe, effective and well led key questions and found the following areas of good practice:

Senior staff had reviewed and amended governance systems, such as environmental audits and care record audits to make them more effective and enable them to successfully mitigate risks.
Staff had completed detailed risk assessments and risk management plans. Staff were committed to embedding improvements in practice.
Staff told us that despite the challenges they had faced on the ward, in terms of the two serious untoward incidents, they felt part of a strong, supportive team.
Patients and staff had positive comments about other staff members including senior managers. During our visit, staff were kind and caring when interacting with patients.

However, we also found the following issues that the trust needs to improve:

Keys for the controlled drugs cabinet were kept on the same bunch of keys for medicines cupboards. Adrenaline vials were kept unsecured in the emergency grab bags.
Staff did not always record patient’s refusal of physical health interventions and the recording of food and fluid intake in paper records was inconsistent. There was a potential for information to be overlooked due to paper records being kept in several different places in addition to the electronic records.

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.

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.

We inspected the safe, effective and well led domains and found the following:

Staff did not report every incident which meant they could not be reviewed, investigated and monitored to ensure action was taken to remedy the situation, prevent recurrences and ensure improvements were made as a result.

Some areas of the ward (cinema room, patients’ kitchen, laundry room, storeroom and staff room) were visibly dirty and had an unpleasant smell. Staff had no key on the ward to access the locked servery room in the event of an emergency. Fixtures and fittings were not maintained to a satisfactory standard.

The quality of patients’ risk assessments varied and at times the risk assessments were too brief. Four patients’ risk assessments had not been updated following significant events or incidents. This included physical health assessments. Not all patients had the service user safety plan of the care records completed.

The ligature risk assessment did not have detailed action plans identified, which meant staff did not adequately manage or remove the risks.

Care records contained limited information around decisions taken under the Mental Capacity Act and the Mental Health Act.

Staff had not disposed of some controlled medicines for patients who had been discharged. These were still stored in the locked cabinet and checked daily by staff.

Governance systems were not consistently applied and not always effective in highlighting risk. This meant risks could not be mitigated or reduced. Examples included omissions in the ligature risk assessment, omissions in the service risk register, incomplete or inaccurate patients’ risk assessments and the unsafe storage of food in three ward fridges.

However:

Staff kept the ward clinic room clean and in good order.

There were sufficient staff and the vacancy level for Bluebell ward had reduced significantly. Progress had been made in staff recruitment since our last inspection in December 2016.

All of the staff we spoke to knew how to raise a safeguarding issue or concern.

Staff felt part of the organisation and were able to discuss the philosophy of the ward confidently. Staff told us the vision and values of the organisation were discussed regularly in team meetings, supervision meetings and appraisals.

The ward’s senior management team had regular contact with all staff and patients. The senior management and clinical teams were highly visible and staff said that they regularly visited the ward.

Bluebell ward had accreditation for inpatient mental health services (AIMS). AIMS sets out standards and national guidelines which staff on wards should be achieving. AIMS is an initiative of the Royal College of Psychiatrists Centre for Quality Improvement.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We inspected the safe, effective and well led domains and found the following:

Staff did not report every incident which meant they could not be reviewed, investigated and monitored to ensure action was taken to remedy the situation, prevent reoccurrences and ensure improvements were made as a result.
Some areas of the ward (cinema room, patients’ kitchen, laundry room, storeroom and staff room) were visibly dirty and had an unpleasant smell. Staff had no key on the ward to access the locked servery room in the event of an emergency. Fixtures and fittings were not maintained to a satisfactory standard.
The quality of patients’ risk assessments varied and at times the risk assessments were too brief. Four patients’ risk assessments had not been updated following significant events or incidents. This included physical health assessments. Not all patients had the service user safety plan of the care records completed.
The ligature risk assessment did not have detailed action plans identified, which meant staff did not adequately manage or remove the risks.
Care records contained limited information around decisions taken under the Mental Capacity Act and the Mental Health Act.
Staff had not disposed of some controlled medicines for patients who had been discharged. These were still stored in the locked cabinet and checked daily by staff.
Governance systems were not consistently applied and not always effective in highlighting risk. This meant risks could not be mitigated or reduced. Examples included omissions in the ligature risk assessment, omissions in the service risk register, incomplete or inaccurate patients’ risk assessments and the unsafe storage of food in three ward fridges.

However:

Staff kept the ward clinic room clean and in good order.
There were sufficient staff and the vacancy level for Bluebell ward had reduced significantly. Progress had been made in staff recruitment since our last inspection in December 2016.
All of the staff we spoke to knew how to raise a safeguarding issue or concern.
Staff felt part of the organisation and were able to discuss the philosophy of the ward confidently. Staff told us the vision and values of the organisation were discussed regularly in team meetings, supervision meetings and appraisals.
The ward’s senior management team had regular contact with all staff and patients. The senior management and clinical teams were highly visible and staff said that they regularly visited the ward.
Bluebell ward had accreditation for inpatient mental health services (AIMS). AIMS sets out standards and national guidelines which staff on wards should be achieving. AIMS is an initiative of the Royal College of Psychiatrists Centre for Quality Improvement.

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

Following our inspection in December 2015, we rated the service as good for effective, caring, responsive and well led.

During this most recent inspection, we found that the service had addressed the issues that had caused us to rate safe as requires improvement following the December 2015 inspection.
The child and adolescent mental health wards were now meeting Regulations 9 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We rated wards for older people with mental health problems as Good because:

Following our inspection in December 2015, we rated the service as good for caring, responsive and well led. Since that inspection we have received no information that would cause us to re-inspect these key questions or change the ratings.
During this most recent inspection, we found that the trust had addressed the issues that had caused us to rate safe and effective as requires improvement following the December 2015 inspection.
The wards for older people with mental health problems were now meeting Regulations 12 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We rated wards for people with a learning disability or autism as good overall because:

During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe, caring, responsive and well led as requires improvement and effective as inadequate following the December 2015 inspection.

The wards for people with a learning disability or autism were now meeting Regulations 10 and 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

However:

The multidisciplinary team lacked substantial input from key disciplines, particularly occupational therapy and speech and language therapy.

We rated acute ward for adults of working age and psychiatric intensive care units as good overall because :

Following our inspection in December 2015, we rated the service as good for effective, caring, responsive and well led. Since that inspection we have received no information that would cause us to re-inspect these key questions or change the ratings.

During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe as requires improvement following the December 2015 inspection.

The acute ward for adults of working age and psychiatric intensive care units were consistently following their own policy and the Mental Health Act 1983 accompanying code of practice to ensure that the rights of those people subject to long-term segregation were being met.

However:

Over the last 18 months the trust has had two very serious incidents which are still under investigation. We observed good evidence that the trust was taking the right steps to improve risk assessment and management plans however this requires further embedding.
The risks associated with the garden access door on Daisy ward were not fully assessed and managed.
There were hooks attached to the walls of the courtyard area outside Rose ward. Senior managers told us the purpose for these were for securing ladders to the walls to allow maintenance work to take place. These hooks could be used as ligature points and the risks associated with them had not been assessed and managed.
Not all emergency medication was stored together and not all wards had the same medication available.

We have given Berkshire Health Care NHS Foundation Trust a rating of good and this was because:

We rated all community and inpatient health services as good. Of the nine core services we inspected in mental health we rated seven as good, one as outstanding and one as requires improvement.

The trust has much to be proud of and also some areas that need to improve. The trust was well led with an experienced and proactive senior leadership team and board. There were also many committed and enthusiastic senior staff throughout the organisation working hard to manage and improve services. The trust responded in an open and honest way to the findings of the inspection team. They responded to put things right immediately where we had raised concerns. They were open, transparent and not defensive.

The main areas that were positive were as follows:

The wards and clinical team bases were clean and well maintained.
There was good evidence that medicines were well managed across the trust.
Staff made good use of best practice guidelines and outcome measures.
There was a strong culture of multi-disciplinary working. Professionals, teams and agencies worked well together.
Staff recognised and understood their responsibilities in relation to safeguarding. Staff were aware of how to raise an incident and there was a good culture of learning post a serious untoward incident.
Patients and their carers were positive about the care and treatment they received and felt they were treated with dignity and respect.
Staff enjoyed working for Berkshire Health Care NHS Foundation Trust. They told us that the board were visible and approachable. They also spoke positively about the opportunities for professional development and told us that managers encouraged them to attend external training and conferences.
The trust had taken on some challenging services, particularly in primary medical services, one of which had been placed in special measures. They had managed to turn this service around and it is now rated as good.
Community health services were all rated as good across the board.

There were two core services that required improvement. These were the wards for people with a learning disability and the Circuit Lane medical centre. The main areas for improvement are as follows:

There was poor management of ligature points on the learning disability inpatient wards and the child and adolescent inpatient ward. A ligature point can be used by people experiencing suicidal thoughts to harm themselves. On the learning disability inpatient wards the trust had identified numerous potential ligature points, and proposed an action plan to mitigate each. However, staff did not maintain the required level of patient observation; there were an insufficient number of ligature cutters given the physical layout of the ward; and, staff had not received training in the use of ligature cutters.

Neither the child and adolescent inpatient ward or learning disability inpatient wards met the requirements set out by the Department of Health guidance ‘Privacy and Dignity, the elimination of mixed sex accommodation’. This states that hospitals should provide accommodation which ensures that men and women are separated and have access to their own facilities, such as toilets and bathrooms. This was also a concern at the high dependency unit at Prospect Park hospital.

Staff did not monitor people’s physical health needs adequately for people with a learning disability.

Some staff were not communicating well with people with a learning disability, as they lacked the necessary skills and training to do this.

The trust had not implemented or monitored changes needed in the appointment system in response to patients’ at the Circuit lane surgery. This surgery also needed to ensure that they improved access by telephone to the GP practice.

We were concerned about the quality and safety of care on the older people’s mental health inpatient units. Not all staff were aware of the risks that individual patients faced, nor of the level of observation and support they needed to keep them safe. Not all staff knew how to prevent or care for pressure ulcers. Not all staff on these wards were receiving regular supervision.

We issued the trust with a warning notice in respect of the high dependency unit at Prospect Park Hospital. This was because the trust had failed to ensure that the rights of those people subject to long-term segregation were being met. This breached their policy and the Mental Health Act 1983 accompanying code of practice. We returned to the high dependency unit at Prospect Park on the 11th of February 2016 and were pleased to report that the trust had resolved the concerns raised in the warning notice and were fully compliant with the law.

In December 2016 we undertook a follow up inspection to find out whether Berkshire Healthcare NHS Foundation Trust had made necessary improvements to the four core services we had rated as requires improvement for the Safe key question. At the comprehensive inspection in December 2015 we issued the trust with five requirement notices that affected these four core services.

• Wards for people with learning disabilities

• Wards for older people with mental health problems

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

• Child and adolescent mental health inpatient ward

These related to the following regulations under the Health and Social Care Act (Regulated Activities) Regulations 2014:

• Regulation 9 Person centred care

• Regulation 10 Dignity and respect

• Regulation 12 Safe care and treatment

• Regulation 17 Good governance

• Regulation 18 Staffing

We returned in December 2016 and we found that Berkshire Health Care Foundation Trust had acted to meet the requirement notices we issued after our inspection in 2015.

We therefore rated the Safe key question as Good overall.

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.

Overall rating for this core service GOOD l

Overall, this core service was rated as good. We found community services for adults was good for all the key questions of safe, effective, caring, responsive and well-led.

Our key findings were:

Staff recorded incidents on the electronic reporting system with shared learning across the service. There was a strategic approach to reducing harm where there were concerns, as in the case of pressure ulcers.
Staff adhered to infection prevention and control procedures, the trust used an audit programme to monitor and improve practice.
Staff were able to identify safeguarding issues and followed the safeguarding procedures to report concerns.
Staffing levels had improved across the service in recent months and community nursing teams worked collaboratively to share referrals, prioritise workloads and meet demand.
Risk assessment was used to inform care; however, we found there were inconsistencies in staff practice in the frequency of review some assessments, such as for pressure ulcers.
Care plans were evidence based with patient centred outcome goals.
Staff were competent for the roles they undertook and the majority of staff had received an appraisal in the last year. Supervision was available but the uptake varied across the teams.
There was excellent multi-disciplinary working. Staff worked collaboratively to understand and meet the needs of patients, particularly those with long-term conditions.
There were appropriate systems and processes in place for the referral, transfer and discharge of patients from services.
Consent was sought from patients prior to care or treatment being provided. Not all staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
Patients received compassionate care that respected their privacy and dignity, with patients involved in decisions made about their care.
The planning and delivery of services took into account the diverse needs of the local population and those in vulnerable circumstances. The reconfiguration and integration of some services had taken place for the trust to be able to be more responsive to patients with complex needs.
Delayed transfers of care were a priority area for the trust to address. Work was taking place with partner agencies to improve the situation.
There was a clear vision and strategy for community health services for adults, in line with the trust vision and goals. Most teams had developed their own business plans to correspond with the directorate plan.
Clear management and governance structures were in place through meetings to monitor performance and service risks. There was good local leadership throughout the various teams with an open, caring and supportive culture.
The trust used feedback from patients to monitor the quality of the service and to inform change.
There were good examples of innovation to improve patient care and wellbeing. Cost improvement programmes were in use to ensure sustainability of services

Overall, we rated this core service as good. We found each of the five domains of safe, effective, caring, responsive and well led were good. People we spoke with were complimentary about the services they received and the attitude and competency of staff.

Our key findings are:

Overall, premises and equipment were clean, safe and suitable, although the Skimped Hill sexual health clinic in Bracknell was not secure, in a good state of repair or kept clean.
Staff reported incidents and there was a good approach for sharing and learning from incidents. This included incidents or concerns related to safeguarding children and young people.
Staff managed medicines safely. However, in Skimped Hill sexual health clinic systems were not in place to ensure medicines were stored at safe temperatures.
There was an integrated IT system for services, which promoted safe storage and exchange of records. This was not accessible to sexual health services which meant they had to operate ‘workarounds’ to log information safely. Staff created good records in all services.
Staff used technology to promote their services with young people, for example using social media and texting reminders for appointments.
People using services spoke highly of the attitude of staff. They said they were friendly, kind and good listeners. They showed empathy, were skilled in gaining children’s trust and involving them in care programmes. Staff also took people’s emotional wellbeing and family circumstances into account when discussing and planning their care.
There was good multi-disciplinary working within the service. This was supported by the integration of therapy services and a locality based structure. Where there were issues in delivering a responsive service for looked after children, staff were working with partners in social care to improve processes. Staff were optimistic that that joint working with the children and adolescent mental health service (CAMHS) would improve in 2016 with the integration of CAMHS with children’s community health services.
Leadership and management were effective and staff felt supported. Staff were complimentary about the visibility of senior management and the chief executive in particular. Staff were involved in service development, however services were commissioned by a large number of organisations with changing priorities and budgets, and this had caused a lot of service changes. Staff in sexual health services were unsure of their service direction and strategy, due to forthcoming commissioning changes.
Staff had good access to training and professional development and applied evidence based practices. They used nationally recognised assessment tools and care pathways, to deliver good patient outcomes. Care and services were focused on the needs of individual children and young people. Staff met with people in locations that were best for the children, as far as possible, and prepared person-centred care and treatment plans.
Systems were in place to review clinical practices regularly and staff said the trust had a good culture of encouraging improvements in care delivery. Risk registers were mostly up to date and managed effectively and governance arrangements meant staff managed service performance, quality and safety consistently. All staff showed a passion to provide an improving service to children and young people.
The services had received only a few complaints; however, guidance on how to make a complaint was not readily available. Staff managed informal complaints locally and ensured there was learning from complaints as appropriate. Information leaflets were only available in English, which meant they were not accessible to all members of the local population.
Staff monitored the timeliness of assessments, referrals and interventions. Waiting times were mostly within the target timescales. Actions were being progressed in areas that had difficulty achieving agreed waiting times.

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.

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.

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

We rated wards for older people with mental health problems as good because:

Staff delivered care and treatment to patients in a kind, caring manner that respected their dignity.
Patients and their families told us they felt safe and cared for on the wards.
We saw evidence of innovation on both wards as the first wards for older people with mental health problem to have implemented Safewards.
Staff promoted research into dementia care.
Staff had good understanding and awareness of safeguarding. Staff had completed safeguarding training and knew the safeguarding process.
Staff mandatory training was up to date. Staff appraisals were up to date.
Managers reported good relationships with the trust’s senior management.Staff told us that senior managers frequently visit the wards.
Care and treatment was provided by multidisciplinary team working. We observed a thorough and effective patient focussed staff handover.
Patients had access to a wide variety of activities. Patients had a choice of what activities would be available at the weekend. We saw a cinema for patient use on Rowan Ward.
We saw evidence of community meetings taking place for patients on the ward.
We saw Mental Health Act paperwork up to date and fully completed. We saw good evidence of recording and storing of legal paperwork. Staff had a good understanding of the MHA.
Managers were completing the Excellent Manager course.
Patients told us the food was of good quality. We saw evidence of staff catering for a variety of dietary requirements.Soft food and easy chew diets were available.
Staff on the wards told us they felt well supported by senior management within the Trust and that senior managers were a visible presence on the wards.
We observed that the wards were clean, well maintained and clutter free.

However:

The provider must ensure that all staff working on the wards are aware of the requirements of individual patient needs and observations.The provider must ensure that these are being carried out appropriately and risks to patients are minimised. This includes physical and mental health issues.
All staff working on the wards must be made aware of the risks of the patients in their care. We found that not all staff were aware of patient risk assessments and the level of observations required to support patients.
The provider must ensure that individual care plans are developed for all risks identified in patients.We found care plans that did not reflect the risk highlighted in the risk assessments.
Staff must receive supervision to ensure they are provided with appropriate support to meet patient needs. Staff did not have regular supervision.

Staff should report all incidents that occur on the ward.
We saw the patient board was not covered in the ward office. The provider should ensure that patient confidentiality is maintained where patient names were displayed in the office on Orchid ward, which could also have been seen from the ward area.
We saw no privacy curtain in the bathrooms. Staff should promote the privacy and dignity of patients through the provision of curtains around the door of the bathrooms on both wards.
Patients should be given more opportunity to be involved in their care plans where able.
Staff should display notices to inform patients not detained under the Mental Health Act 1983 of their rights inside the entrance to all wards.
Staff should arrange a best interest discussion to take place for any informal patients attempting to leave the ward.
Not all staff had awareness of pressure area care and prevention.

We rated the child and adolescent wards as good because:

We carried out an unannounced visit to the ward on 16 December 2015 following our scheduled inspection on 8 and 9 December 2015. Management took urgent steps to ensure that all staff were made aware of the ward’s ligature risks and how to manage them. Staff had started to allocate patients to bedrooms that contained ligature risks only if the risk assessment indicated that they were at low risk of self harm. The ward had made immediate changes to meet the Department of Health’s guidance on Eliminating Mixed Sex Accommodation. This was done by agreeing to cluster the male and female bedrooms at opposite ends of the corridor as new patients were admitted. Furthermore, male and female bathrooms were situated at opposite ends of the bedroom corridor. Patients were asked to wear appropriate clothing when walking from their bedrooms to their bathroom facilities. In addition, a member of staff was available to observe the corridor throughout each night.
The ward was clean and well organised.
Care plans, risk assessments and progress notes were up to date and present in the seven client files we read.
Staff offered patients a wide range of therapies such as drama therapy, cognitive behavioural therapy (CBT) and dialectical behavioural therapy (DBT).
All staff received regular supervision.
Staff demonstrated compassion and caring when they spoke to patients. Patients told us that staff were polite to them and respected their privacy.
The ward had a wide range of rooms for activities and patients had access to a garden when accompanied by a member of staff.
Patients had access to education. Ofsted assessed the education unit as outstanding in 2013.

However:

Staff did not include risks they identified in two of the three inpatient care plans we read. This meant there was no evidence of a written plan describing how staff and patients would manage these risks on the ward or in the community.
Staff completed Health of the Nation Outcome Scales for Children and Adolescents (HONOSCA) and Children’s Global Assessment Scale (CGAS) outcome measuring tools on only three out of seven files we scrutinised. Staff used these tools to measure patient improvement wellbeing while in a CAMHS unit.
Two members of staff said they did not understand Gillick competence. The Mental Capacity Act (MCA) does not apply to young people aged 16 or under. For children under the age of 16, the young person’s decision making ability is governed by Gillick competence. The concept of Gillick competence recognises that some children may have sufficient maturity to make some decisions for themselves.
Patients did not have access to advocacy services on the ward. Advocates can help patients get the services they need and make sure their wishes are heard.
There were unboxed fuse and other electrical boxes on the corridor walls which were not secured. They could be reached by patients to stop power supply to the ward. Fire extinguishers around the ward were not secured. This meant patients could use them to harm themselves or others. There was an unboxed metal pipe and tap on the ward which could be a danger to patients at risk of self harm.

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.

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.

We rated mental health crisis services and health based places of safety as good because:

The trust provided a robust and supportive induction programme for new staff working for the CRHTT. Staff felt supported by management and were encouraged to develop professionally. Staff were in the main qualified at band 5 and above and team leaders were band 7 with team managers being appointed on band 8b. Medical staff were actively involved in patient care.
Our review of case notes showed that CRHTT staff assessed risk and needs thoroughly and created detailed care plans. Staff reviewed care plans and risk assessments on all home visits that we shadowed.
The trust had responded to concerns about the CRHTT. Following an increase in demand, complaints from people using the service and an increase in whistleblowing, the trust had developed a robust action plan. Weekly meetings were taking place to update on progress and £1 million had been invested in these services. A robust recruitment programme was being implemented and 18 new members of staff had been recruited. The trust had introduced a governance lead across both CRHTTs and audits were starting to take place. Mandatory training was being given a priority and supervision sessions were being monitored. All staff were being trained in supervision skills in order to undertake supervision responsibilities for lower banded staff.
HBPoS staff made timely and effective assessments.
The trust had developed robust and thorough interagency protocols and operational policies for the health based places of safety (HBPoS) in line with the new Code of Practice.
CRHTT staff developed supportive and caring relationships with their patients.
CRHTT were improving the way they received feedback from carers and people using the service and this was showing positive results. The patient experience tracker was being used to capture feedback.
CRHTT performed better than the England average in quarter one 2015-2016 for gatekeeping acute admissions. Admission rates were kept at a low level by treating people in the community.
There were good secure systems for record keeping and good lone working policies for staff.
Street triage had been introduced in the west of Berkshire. This had helped to reduce the number of S136 admissions detained in custody and reduced the overall number of S136 applications made in west Berkshire.
CRHTT west had access to crisis beds to prevent acute hospital admission.
CRHTT was in the process of accreditation with the Home Treatment Accreditation Scheme (ATAS). It had won three trust awards and was involved in local research studies.

However:

Following a serious incident in HBPoS one and two in August 2015 a formal investigation was commissioned, following this a recommendation was made to review the environment. This review was not due for completion until January 2016 but remedial measures had been put in place to increase safety in the HBPoS in the interim.
There was no environmental and no ligature risk assessment available for the HBPoS on the day of the inspection. New updated assessments were forwarded within a few days.
HBPoS three had only a basic bolt on one side of the door separating the room from staff areas. This was a security issue and the trust agreed they would change this. Staff informed us that a review of HBPoS three was also due.
Staff in CRHTT including management, recognised the need for a clear referral policy. CRHTT was perceived as having an open referral policy meaning it was difficult to decline inappropriate referrals. This was being implemented through the action plan.
Physical assessments were not robust and often relied on GPs or inpatient wards. The trust recognised this as an area needing improvement.

We rated acute ward for adults of working age and psychiatric intensive care units as good because :

Care plans were holistic, recovery focused and mostly person centred; there was evidence that patients were involved in their care planning. Physical health assessments took place on admission. A general practitioner (GP) attended the inpatient unit and provided sessions for those suffering from existing chronic conditions and for health promotion.
There were a number of professionals working across the wards such as occupational therapists, psychologists, nurses and doctors.
Regular team meetings occurred in which staff were updated of outcomes from complaints, lessons learned from incidents, outcomes of audits and new initiatives.
The Mental Health Act documentation across all wards was generally good. Detention paperwork was up-to-date and available for scrutiny. There was evidence that the teams were endeavouring to adhere to the principles of the Code of Practice.
Effective handovers were in place and digital dictation was piloted on one of the wards to reduce the length of time handovers were taking to enable this time to be spent with patients.
Patients told us that the substantive staff were kind and caring, we also observed positive interactions with patients, and we found that staff were knowledgeable about their patients’ care and treatment needs. Advocacy was widely available and publicised across all the wards.
The carers we spoke to felt that they were involved in their relatives care, particularly in multi-disciplinary team meetings.
Regular community meetings took place on the wards, patients were seen to be able to give their views, and staff gave feedback in a ‘you said we did’ format.
Senior managers and the ward mangers monitored key performance indicators in relation to access and discharge to the acute wards. The ward reported no delayed discharges within a 6-month period. There were regular teleconferences to review the current inpatients and those who were clinically fit for discharge but had social issues that prevented this.
The wards were able to cater for individual dietary and cultural needs. Information was displayed for patients’ regarding how to complain, advocacy, ward information, and the mental health act.
The inpatient unit had a multi faith room, gym and therapy centre which patients’ could access seven days a week.
Staff were aware of the visions and values of the trust, could describe what these were and told us that they were linked to their annual appraisals.
The ward staff conducted regular clinical audits and provided feedback to other staff through email and the ward meetings to improve performance. Staff described good morale and team working on all the wards. All the staff said that they felt supported by their immediate line managers and could tell us who the senior managers were.
All the adult acute wards and PICU were participating in the Safewards initiative, and Bluebell, Rose, Daisy and Snowdrop ward were accredited under the Accreditation for Inpatient Mental Health Services (AIMS) scheme.

However,

The en suite privacy curtains in the double bedroom areas on Bluebell and Daisy ward did not provide adequate privacy to the patients occupying these rooms or dignity when they used the shower and toilet facilities.
The high dependency unit (HDU) on Sorrell ward did not meet the same sex guidance or allow the patients their privacy and dignity whilst they were restricted to this area.
Not all staff on Bluebell ward had been issued with keys. This meant that they did not have access to emergency equipment, or to activate the fire alarms.
The wards were unable to increase their daytime establishments to staff the place of safety; this affected the staffing levels of the ward during the day when the place of safety was occupied.
Risk assessments and risk management plans were inconsistent and not reflective of patients’ risks in some areas.
A patient was secluded without the appropriate safeguards and monitoring being out put in place and patients’ movements were being restricted in the HDU without any formal reviews of their care and treatment. These restrictions meant that the trust policy and the Mental Health Act code of practice was not followed
There were blanket restrictions in place around the searching of patients on admission. These did not consider individual risks as to whether the search was necessary.
Staff prevented an informal patient from leaving the ward without any formal review of their legal status.
Staff did not conduct regular monitoring of the physical health of patients that were prescribed high dose antipsychotics.
The wards used bank and agency staff to cover many shifts on the wards. Some patients reported that these staff could sometimes be dismissive and rude to them.
Therapies as recommended by the National Institute for Health and Care Excellence (NICE) were not available for patients to access. There was not a clear strategy for managing those admitted with a personality disorder on the inpatient wards.

One to one supervision did not always occur in line with their trust policy of 4-6 weekly, nor was it always formally recorded when it did occur.

We rated wards for people with learning disabilities or autism as requires improvement because:

Patients’ privacy, dignity and safety were compromised as a result of a breach of same-sex accommodation.

Wards were not always safe and patients’ were not always protected from risk of unsafe or unsuitable premises due to inadequate management plans for ligature risks.

Staff did not always effectively monitor or review patients’ physical health needs.

Staff did not always involve patients in their care planning and did not complete regular reviews to ensure the information was up-to-date.

Staff did not have knowledge or training in specialised areas relevant to the needs of the patient group.

There was limited access to outside space at Campion Unit.

There was a shortage of weekend activity provision at Campion Unit.

There was a lack of written information on display around the wards, which was provided in an accessible form for the patient group.

Absence of most supervision and appraisal records on staff files impacted on the ability of managers to effectively monitor and manage individual performance of team members.

However, the ward environments were clean and tidy and clinic rooms were properly equipped. The use of physical restraint was minimised by the use of proactive de-escalation techniques. There was no record of any serious incidents occurring within the last six months. Some care plans, specifically devised to help staff, were of a high quality. Staff used person centred planning tools in relation to supporting patients to prepare for discharge.

Staff treated patients with kindness, dignity and respect. Most staff had a good understanding of the individual personality traits and emotional support needs of their patients.

The service participated in accreditation schemes and quality improvement programs. Multidisciplinary Team (MDT) members have been involved in conducting and supporting research.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

These reports, under our old approach to inspection, involved us assessing a whole provider against the standards we expect.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

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