Berkshire Healthcare NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question as good. This meant people were safe and protected from avoidable harm. At this assessment it remains as good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality Statement Score: 3
We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Care plans were mostly comprehensive and well written however we noted that some observations were carried out every 15 mins rather than random times. This means that patients maybe able to predict the times staff would observe them and risks increase because of this.

We reviewed 5 care records which were held in a secure password protected computer system. Care plans were generally detailed, personalised and reflected people's individual needs, strengths, preferences and circumstances.
Staff demonstrated knowledge of the people they supported and were able to describe changes in presentation, risks and support needs.
Care records demonstrated a detailed assessment of a person with autism and moderate learning disability who had transitioned from living with elderly parents into supported accommodation. Staff demonstrated a clear understanding of communication needs, mental health presentation, social inclusion, family involvement and the impact of this significant life transition.
Care plans demonstrated use of first-person language, detailed life histories, comprehensive risk formulations, person-centred interventions, strong understanding of communication needs and clear evidence of family involvement.
Staff demonstrated knowledge of the people they supported and were able to clearly explain support arrangements, risks, progress and future plans. This reflected continuity of care and strong therapeutic relationships. We noted that falls risk assessments were comprehensive. Family members participated in initial care plan meetings and their views were reflected in a care plan. Patients’ views were documented in the safety plan section of risk management plan. This included strengths and protective factors. Patients had an enhanced observation care plan in place which covered the rationale for enhanced observations, identified triggers or early warning signs of distress, strengths and self-soothing techniques, patient's preferred interventions, patient's interests and key therapeutic engagement strategies.

However, we observed one care plan did not have a carers care plan. We also noted that some observations were carried out every 15 minutes rather than at 4 random times within an hour. This meant that patients may be able to predict the times staff would observe them and risks increase because of this.
Despite these recording issues, which were resolved during the assessment the care plans reviewed demonstrated that people's needs were understood, regularly reviewed and responded to appropriately.
 

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.
Care plans demonstrated use of recognised evidence-based approaches including Positive Behaviour Support (PBS), Occupational Therapy (OT) interventions, Speech and Language Therapy (SALT), mental health pathways and person-centred planning.
Staff provided examples of supporting acute hospital staff to better understand the needs of people with learning disabilities. This included education around communication, routines, environmental adaptations and individual support needs.
One Occupational Therapy intervention plan reviewed used strengths-based language throughout and clearly identified practical support needs. The plan focused on promoting independence whilst ensuring support remained personalised and appropriate.

Mental Health Act

On the day of our inspection, 95% of staff on Orchid ward had received training in the Mental Health Act. Ninety-three percent of staff on Rowan ward had completed training.
Staff explained to people their rights under the Mental Health Act in a way that they could understand, repeated them as required and recorded that they had done so.
People had easy access to information about independent mental health advocacy and written information was available.
We checked 7 entries on a group leave form on Orchid Ward – they were all fully completed however, the last 2 entries from 30/6/26 did not state time back in or have a staff signature. Staff confirmed both patients returned as expected and that one of the patients had been escorted by a staff member who knew they had safety returned. The sheets were audited on a weekly basis.

Quality Statement Score: 3
We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

We observed a MDT meeting on both wards. Families could join via weblink link if unable to attend in person. The meetings were well structured and demonstrated effective multidisciplinary working. They were informative, had good engagement from multiple disciplines, embedded use of IT systems for handover and good team communication. Both physical and mental health were considered and reviewed.
Staff worked collaboratively with acute hospitals, Adult Social Care, care providers, families, police services and advocacy organisations. Discussions demonstrated positive working relationships across agencies.
Managers reported good multidisciplinary engagement across teams and partner organisations. Specifically, we observed status exchange meetings where both clinical and other sector partners contributed to provide support to the wards and managers, giving them a platform to bring forward concerns to partners for patient care.
 

Quality Statement Score: 3
We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.
Care records demonstrated involvement from a range of specialist services including Medical, Speech and Language Therapy (SALT), Occupational Therapy (OT). Patients also had access to physiotherapists and dieticians. This demonstrated a holistic approach to meeting people's health needs.
The workforce consisted predominantly of Registered Mental Health Nurses (RMNs) and Adult Nurses. Leaders described how this skill mix enabled the service to respond effectively to both physical and mental health needs.
Staff demonstrated a strong understanding of significant physical health risks alongside mental health and learning disability needs. Physical health considerations were integrated into assessment, care planning and review processes. A GP attended the ward weekly to offer medical support.
Staff described collaborative working.
Staff supported people to access healthcare specialist services where required. Examples were provided of staff working collaboratively to overcome barriers to healthcare access. Relatives described being part of long-term planning and being involved in planning meetings. On Rowan ward a patient they were supporting was struggling to access a brain scan appointment, however staff were working collaboratively with the patient and their family to support the patient in gaining the appointment.

Quality Statement Score: 3
We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.
Staff used recognised tools to assess and record risk, symptom severity, and clinical outcomes.
Staff we spoke with demonstrated a clear focus on achieving positive outcomes for people. Outcomes were monitored through a range of review and oversight processes like Montreal Cognitive Assessment (MoCA) and Addenbrooke's Cognitive Examination (ACE-III) to test for cognitive impairment, and national early warning score (NEWS) to test physical deterioration.
Staff described a structured approach to monitoring outcomes through reviews and MDT meetings. These processes enabled professionals to review whether support remained effective, identify changes in need and agree actions where outcomes were not being achieved.
Care records evidenced ongoing review of wellbeing plans, risk assessments and support arrangements. Records demonstrated that outcomes were monitored through changes in presentation, levels of support required, placement stability, risk management, physical health oversight and engagement with services. We observed in multi-disciplinary meetings that staff were able to articulate progress, deterioration and changing needs during case discussions, indicating that outcomes were being considered as part of routine clinical practice.
 

Quality Statement Score: 3
We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person centred care and treatment.
Care records demonstrated consideration of the Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS) and Best Interest (BI) decision-making processes. Legal frameworks were clearly reflected within records reviewed.
Community DoLS applications were evidenced within records and staff demonstrated understanding of their responsibilities in relation to legal restrictions and safeguarding people's rights.
Staff demonstrated a good understanding of capacity assessment and least restrictive practice. Discussions reflected an emphasis on supporting people to make their own decisions wherever possible.
Family members, advocates and relevant professionals were involved in Best Interest decision-making processes where appropriate. Staff recognised the importance of collaborative decision-making when people lacked capacity to make specific decisions. Relatives consistently described effective care planning.
Staff described multidisciplinary Best Interest processes for people requiring healthcare interventions where capacity was lacking.
The wards evidenced practical application of Mental Capacity Act principles to support access to healthcare whilst ensuring decisions remained lawful and person-centred.