All inspections: Sussex Partnership NHS Foundation Trust

We carried out an inspection of the acute and psychiatric intensive care units of Sussex Partnership NHS Foundation Trust on 7, 8, 9 October 2025. We undertook this inspection following information of concern we had received about the low staffing levels, excessive use of restraint so that patients would take their medicines, staff not always involving patients and their families in their care at both Langley Green and Mill View Hospitals and cleanliness and poor maintenance of the premises at both Mill View and Meadowfield Hospitals.

We visited 3 locations and 7 wards in total. We visited 3 wards at Mill View hospital which included Palmeira ward (a female only acute ward), Pavilion (a male psychiatric intensive care unit) and Falmer ward (a mixed gender acute ward for adults). At Meadowfield Hospital, we visited 2 wards which included Rowan ward and Maple ward (both mixed gender acute wards), and Langley Green Hospital which included Jade (a mixed gender acute ward) and Amber ward (a mixed gender psychiatric intensive care unit). Meadowfield Hospital was last inspected in 2016 and rated requires improvement. We carried out a focused inspection at Mill View Hospital in May 2024, which the service was rated requires improvement. Langley Green Hospital was last inspected in April 2021 where we carried out a follow up inspection to assess whether the warning notice we issued in February 2021 had been complied with. This inspection was not rated.

At this inspection we found the service to be requires improvement. The service was in breach of Regulation 10 (Dignity and respect). The wards did not always comply with the Mental Health Act Code of Practice in relation to eliminating mixed-sex accommodation. We found the service to be in breach of Regulation 12 (Safe care and treatment) because the trust did not always manage medicines safely and when patients were administered medicines for rapid tranquilisation, staff did not always carry out the required physical health assessments which put patients at risk of harm on both Amber and Flamer wards. On Jade and Maple ward there was no system in place for patients to ask for help in an emergency. The service also did not manage ligature risks appropriately. The service was also in breach of Regulation 13 (Safeguarding service users from abuse and improper treatment) because we found that blanket restrictions which was in place on Rowan, Mapel, Jade, Amber, Palmiera and Falmer wards were not proportionate to the risks posed to service users and were not effectively monitored.

The service was also in breach of Regulation 18 (Staffing). The provider did not always meet the required staffing establishment for the wards to keep patients safe. We identified a breach of Regulation 17 (Good governance) because the trust’s own governance systems in place were not robust and failed to identify where improvements were required, including those that CQC had identified at the time of inspection.

The trust had not ensured that the service appropriately recorded and monitored the use of blanket restrictions. At Mill View hospital, issues identified at the last inspection continued to persist such as the unsafe and inappropriate administration of medicines. The trust had not always completed and recorded physical health checks and physical health monitoring of patients following the administration of rapid tranquilisation. Post-dose monitoring following rapid tranquilisation was incomplete in several cases.

The trust still did not always detect and manage potential ligature risks in the care environment. We found ligature risks on Amber ward that had not been recorded on the ward’s ligature risk assessment.

The service did not have enough staff to provide safe care and treatment to patients. Patients, staff and carers felt the staffing establishment on all wards was not adequate to provide safe care.

The service did not have a clear system of accountability and good governance processes in place. The provider’s blanket restrictions policy was not regularly reviewed and was not part of the provider’s governance arrangements. The provider’s own oversight audits failed to identify areas for improvement that we had identified during our inspection or failed to enact improvement. The length of stay for patients varied on different wards.

However, the service ensured that staff reviewed do not attempt cardiopulmonary resuscitation (DNACPR) decisions on admission and involved patients in the decision.

Carers were involved in the care of their relatives when appropriate.

Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients.

Patients’ needs were met through good organisation and delivery. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as work, education and family relationships.

Staff helped patients with advocacy. The service acted on concerns and complaints, investigated them and learned lessons. The service made it easy for patients to share feedback and ideas, or raise complaints about their care, treatment and support.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Sussex Partnership NHS Foundation Trust provides a Tier 4 inpatient Child and Adolescent Mental Health Service (CAMHS) at Chalkhill. It has one ward, which is 12-bedded mixed gender ward where young people are admitted if they require assessment and treatment for acute mental health needs. The service is registered to provide the following regulated activities: Diagnostic and screening procedures; Assessment or medical treatment for persons detained under the Mental Health Act 1983; Treatment of disease, disorder or injury.

We carried out this assessment to review progress against the warning notice that was issued to the trust following our inspection in June 2023. We also received information of concern from whistleblowers, relatives, stakeholders and staff which raised serious concerns about the safety and quality of care provided to young people on the ward. The concerns included the safety and wellbeing of young people, incidents leading to harm, not enough skilled and competent staff, concerns observations of young people were not completed correctly and poor leadership oversight.

During this inspection we assessed if the service was safe, effective, caring, responsive and well led. We found the service had not made sufficient improvements. The trust had not met the required actions set out in the previous warning notice or the breaches of regulation. Because of this, we issued further warning notices due to significant and ongoing concerns in relation to Regulation 12 Safe care and treatment and Regulation 17: Good Governance.

Before the inspection, the trust already had an improvement plan in place to address concerns raised by NHS England, who commission the service. However, during this inspection, some of these concerns remained, and previous actions taken by the trust had not sufficiently reduced the risks to young people on the ward.

We identified significant concerns about the safety and wellbeing of young people on the ward. We shared this feedback directly with senior leaders at the trust. The trust responded to this feedback and took immediate action to review and address these risks.

The trust agreed to suspend new admissions to the ward and identified alternative placements for young people whose needs could be better met elsewhere. The trust provided us with updates which enabled us to closely monitor the service and engaged with us regularly as part of this monitoring process. On the 05 December 2025, the trust confirmed that all young people had been safely transferred or discharged from Chalkhill. The trust temporarily closed the service so they could focus on making the required improvements. The trust plans to reopen the service in Autumn 2026 once the necessary improvements have been completed.

The Trust has provided us with an Action Plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

Staff understood and carried out their roles and responsibilities under the Mental Health Act 1983 and the Code of Practice. They received regular training and demonstrated a good understanding of the Act, Code of Practice, Gillick competence and guiding principles.

Staff ensured they explained young peoples’ rights in a way they could understand. Staff repeated this as needed and clearly recorded it in the young peoples’ care records. Information about rights was displayed in communal areas, including information for informal young people about their right to leave the ward.

Staff knew how to access support from the trust’s Mental Health Act administrators and spoke positively about the guidance provided. The trust completed regular audits to monitor the correct application of the Mental Health Act and used learning from these to improve practice. Staff requested second opinions from a Second Opinion Appointed Doctor when required and stored detention paperwork securely and accessibly.

Young people had access to independent mental health advocacy, and advocates visited the ward regularly. Young people said the advocate was nice and tried to help them.

Staff supported young people to take Section 17 leave. This leave allows young people who are detained under the Mental Health Act to leave the hospital for agreed periods, with permission from their responsible clinician. However, young people reported delays to their leave due to staffing shortages and pressures on the ward.

Mental Capacity Act

Staff supported young people to make decisions on their care for themselves. They understood the service policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for young people who might have impaired mental capacity. Staff received and kept up to date with training in the Mental Capacity Act. Staff told us they regularly discussed capacity and consent during meetings about the young peoples’ care and treatment. They also said they would speak to the ward manager or another clinician if they had concerns around capacity.

We saw evidence of capacity and consent recorded in care plans, with capacity to consent to treatment obtained at admission and evidence of this being regularly reviewed. We also saw evidence in care plans of staff attempting to support and engage young people in decision processes before deciding that a patient did not have the capacity to do so. When staff assessed young people as not having capacity, they made decisions in the best interest of young people and considered the young person’s wishes, feelings, culture and history. Staff told us that they held a best interest meeting which would involve the young person, the nursing team, the consultant(s) and the young person’s next of kin, where appropriate.

Staff also demonstrated a good understanding of Gillick competencies, which means they knew how to assess whether a young person (under 16 years of age) had the maturity and understanding to make their own decisions about their care and treatment.

Sussex Partnership NHS Foundation Trust provides mental health crisis services and health-based places of safety as part of the trust’s mental health services. The service offers emergency assessment and intensive home treatment as an alternative to hospital admission. The service provides support for adults over the age of 18 who are experiencing a mental health crisis and who may require assessment under section 136 or 135(1) of the Mental Health Act 1983.

Section 136 is an emergency power which allows for the removal of a person who is in a place to which the public have access, to a place of safety, if the person appears to a police officer to be suffering from mental disorder and to be in immediate need for mental health assessment.

A section 135(1) warrant is issued to approved mental health professionals by the courts. It allows them, with the police, to enter private premises to remove a person to a place of safety if there are concerns for their, or others, safety resulting from their mental state. A mental health assessment can then be arranged to assess their needs. A section 135(2) warrant provides police officers with a power to enter private premises for the purpose of removing a patient to be taken or returned to hospital.

Sussex Partnership NHS Foundation Trust has six crisis resolution home treatment teams based at:

Oaklands Centre for acute care, Chichester
Meadowfield Hospital, Worthing
Mill View Hospital, Hove
Langley Green, Crawley
Department of Psychiatry, Eastbourne
Woodlands Hospital, Hastings

The trust has five health-based places of safety (HBPOS)/ s136 suites at:

Meadowfield Hospital, Worthing
Mill View Hospital, Hove
Langley Green, Crawley
Woodlands Hospital, Hastings (has two s136 suites)

The health-based place of safety for children and young people located at Chalkhill, Haywards Heath has been decommissioned since June 2022, as it is being used as an extra care area for a patient.

A health-based place of safety is a place for patients detained under section 136 of the Mental Health Act. They are taken to the place of safety by the police from an area where the public have access, if they believe that the person is suffering from a mental health disorder and are at risk due to their mental state. Once in the suite, the individual is assessed by mental health professionals to establish if treatment is needed.

The trust also provides a 24 hours 7 days a week community-based mental health crisis service called Havens. The Havens operates as an alternative to the emergency department (AE) for patients who are experiencing a mental health crisis but has no acute physical or medical issues. The Havens accepts referrals from adult teams (excluding dementia services) within the Trust, Sussex Police and British Transport Police, the ambulance service and other emergency services within Sussex. Any person who is resident in Sussex, has a GP in Sussex or has been detained on S136 in Sussex may be referred to the Havens. Patients cannot self-refer to the Havens unless they have a bespoke crisis plan or they have attended the Havens for a crisis assessment and have been discharged within the previous 24 hours.

The mental health crisis service and health-based places of safety at Sussex Partnership NHS foundation trust, was last inspected in January 2019 where it was rated requires improvement overall. This was because staff did not ensure that they completed comprehensive and holistic risk assessments and patients did not always have a care plan. Staff did not ensure that medicines were managed well. Staff did not ensure records were properly kept including records around consent to treatment. The service had not ensured that emergency grab bags were checked regularly. The service did not always have sufficient medical cover, and leaders did not ensure that governance processes were robust enough to ensure the service ran safely.

We carried out a scheduled comprehensive inspection of Sussex Partnership NHS Foundation Trust’s Mental Health Crisis Services and Health Based Places of Safety on 17, 18 and 19 June 2025. We informed the trust of this assessment 24 hours before the first day of our site visit to ensure that the teams we needed to speak to would be available.

We rated the mental health crisis service and health-based places of safety as Requires Improvement. We found 4 breaches of the regulations in relation to person-centred care, safe care and treatment, safeguarding and good governance.

On this inspection we identified significant concerns that related to poor medicines management, ineffective systems and processes in place to manage risk to patients using services and the health-based places of safety as well as a lack of person-centred care for patients who visited the Havens.

Following the assessment, we served the trust a Warning Notice under section 29A of the Health and Social Care Act 2008 relating to the mental health crisis services and health-based places of safety. We serve S29A Warning Notice when we identify concerns across either the whole or part of an NHS trust or NHS foundation trust, and we decide that there is a need for significant improvements in the quality of health care.

We have asked the provider for an action plan in response to the concerns found at this assessment. The provider has since sent an action plan on how they would make the required improvement.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The trust had relevant policies and procedures that reflected the most recent guidance.

Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy. Although during our inspection, one patient who was detained in the 136 suite had not been provided with information about advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded when they had done it.

Staff stored copies of patients' detention papers and associated records correctly and so that they were available to all staff that needed access to them.

The trust did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Millview hospital is part of Sussex Partnership NHS foundation trust which provides care and treatment for adults with acute mental health needs to aid recovery and wellbeing. The hospital had 5 wards at the time of this assessment, but we inspected Caburn and Regency wards which were female and male acute admissions wards respectively. The hospital was last rated as requires improvement and the report was published in December 2016 based on CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed using Care Quality Commission’s (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 29 and 30 May 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. We carried out this assessment as we had received information giving us concerns about the safety and quality of the service. During this assessment, we reviewed 28 quality statement across 2 key questions. As we assessed most quality statements in the key questions, safe and well-led, the rating for these key questions reflects the findings from this assessment. As we did not assess the quality statements from the key questions effective, caring and responsive, the rating from the previous inspection will be used to rate this key question. The service was found to be in breach of regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was not manging medicines appropriately. We found that there was high use of medicines to reduce anxiety, agitation, and aggression on both wards. The service did not always detect and manage potential risks in the care environment. We found ligature risks in the bathrooms on Regency ward. The service did not have clear responsibilities, roles, systems of accountability and good governance processes in place.

Chalkhill delivers a Tier 4 Child and Adolescent Mental Health Service (CAMHS). Chalkhill is run by Sussex Partnership NHS Foundation Trust and is a 16-bedded mixed gender inpatient unit where young people are admitted if they require assessment and treatment for acute mental health needs. Chalkhill is a sole Mental Health facility in the grounds of a general acute hospital, exclusively for 12–17-year-old young people. They offer assessment and treatment of a wide range of mental health difficulties and needs, as well as support for eating disorders and disordered eating.

Chalkhill was last inspected in December 2016 and was rated as Good overall with Outstanding in Caring.

We carried out this unannounced focused inspection because we received information of concern regarding the safety and wellbeing of the young people, high levels of incidents leading to harm, staff training and competence, low staffing numbers, ineffective observations of young people and poor leadership and support. Before the inspection the trust along with the commissioners of the service had identified some safety concerns and had an action plan in place to address. However, the action plan had not been fully implemented and some of these areas remained a concern during this inspection.

We inspected safe and well-led. Following this inspection, the ratings for safe and well-led went down from good to requires improvement. This meant that the overall rating for the service also went down from good to requires improvement.

Following this inspection, we served the trust with a Warning Notice, because we found that significant improvement was needed to ensure that there was effective oversight of processes and practices, staff competence and support and risk assessing the health, safety and welfare of young people. The Warning Notice required the provider to make improvements to meet the legal requirements set out in the Health and Social Care Act by 11 August 2023. In response to the warning notice, an updated action plan was provided, which set out the actions they had taken to immediately address the safety concerns and the actions they planned to take to mitigate remaining risks.

Prior to the inspection, the trust had capped the occupancy levels at 12 beds. This was to ensure a safe patient to staff ratio during the recruitment of clinical staff. Following our inspection and feedback, the trust paused any new admissions and worked to safely discharge some of the young people where appropriate. Post inspection, the trust continued to provide us with information about the detailed actions being taken that allowed us to monitor the service. The trust had regular engagement with us as part of that monitoring process.

Our rating of services went down. We rated them as requires improvement. Our key findings were:

The ward was not always safe, clean or well-maintained. Staff did not always assess and manage risk well. The environmental security checks and the documentation used to support this did not always capture risks or enable appropriate mitigation to be put in place. Repairs to the ward were not carried out in a timely manner which added to the clinical pressures on the service.
Staff were not always able to keep young people safe from avoidable harm. There were high levels of repeated incidents which caused harm and potential harm to young people where injury was sustained. Staff did not always identify and report all incidents or near misses of incidents. Incidents were not always reviewed and investigated by competent staff. Incidents were not consistently monitored, and action was not always taken to remedy the situation, to prevent further occurrences and to make sure improvements were made as a result.

Staff did not always manage risk well. Although staff completed daily environmental checks of the service environment, they did not always identify, remove or reduce risks that were evident on the ward.
Staff did not always assess and manage risks to young people and themselves. Risk assessments did not always identify or address all a young person’s needs.
Staff did not always develop care plans that appropriately reflected young people’s assessed needs. Care plans were not always personalised, holistic and recovery oriented. Staff did not always use the information in the care plans when delivering care to young people.
There was not enough staff deployed with the skills, expertise and experience to meet the needs of the young people. There was a reliance on agency and bank staff, especially at night. There was no assessment of staff competence and some of the staff did not know how to safely support the young people. Staff told us they were not receiving regular supervision and did not feel supported by the service management to carry out their role.
Staff from the different disciplines did not always work together effectively and this resulted in gaps in the young people’s care.
There were indicators of a closed culture at the service. The trust did not ensure practice at the service was open and transparent. Staff and young people told us they did not always feel safe or supported to raise concerns. Staff reported exceptionally low morale.
Staff did not always follow the trust’s policy and procedures on the use of enhanced support when observing young people assessed as being at higher risk of harm to themselves and others.
Blanket restrictions were evident on the ward which restricted the young people’s movement around the service.
Feedback from young people and relatives and carers was negative. Young people did not always feel safe on the ward.
The governance processes did not always operate effectively. Risks were not always managed well, with oversight, monitoring and learning from incidents being poor. The trust processes for reporting and reviewing incidents was not effective. Despite the trust already having an action plan in place, the trust did not have adequate assurance mechanisms in place. They had not identified that young people were not always receiving safe care and had not acted to make improvements in a timely manner.

However:

All staff spoke positively and, in a kind, caring and respectful manner about the young people. Our observations of interactions between most staff and young people also reflected this.
The mandatory training programme was comprehensive and met the needs of young people and staff.
Staff completed risk assessments for each patient on admission, using a recognised tool.
Young people eligible to take leave were able to take this with the support from staff.
There had been successful discharges where young people had been supported to move on from the service.
There had been recent positive changes to the management of the service.
The service had access to a range of specialists including nurses, occupational therapists, physical health nurses, psychologists and social worker.

What people who use the service say

Young people told us they did not always feel safe on the ward. They told us staff were varied in their approach, and whilst there were certain staff they described positively, they also spoke about staff who they felt did not know them well and did not listen or help them when needed.

What carers and relatives of people who use the service say:

Relatives told us they did not feel their young person was safe or well looked after at all times at the service. They told us about communication concerns, specifically when incidents and investigations happened and not being informed or kept updated. They felt they had to always phone and request information repeatedly as key workers were not always keeping them up to date with their young persons care and their lives whilst they were at the service. They felt there was a lot of agency staff who did not know the young people and their needs well. One relative did say they were invited to multidisciplinary team meetings to discuss their young person’s care and they felt the service was welcoming when they attended.

We undertook an unannounced, focused inspection of Langley Green Hospital to see if the provider was now meeting the requirements of the warning notice that we served (under section 29a of the Health and Social Care Act 2008). Following our previous inspection in February 2021. The warning notice required the provider to make urgent improvements to ensure that patients who had physical healthcare needs were monitored appropriately and had their needs met to keep them safe.

We also looked at whether the provider had ensured that there was always enough nursing and support staff on all wards, at all times to provide safe, good quality care to patients.

Langley Green is a hospital for people with acute mental health problems. The teams provide assessment and treatment for people across four wards;

Amber ward, 12 bed psychiatric Intensive Care Unit (PICU),
Coral ward, 19 bed acute wards for working age adults
Jade ward, 19 bed acute wards for working age adults and
Opal ward, 19 bed mixed sex, integrated care for working age adults and older people

We visited all four wards to check whether the provider had made the required improvements to the safety of the service. This inspection was a focussed inspection so therefore did not provide a change to the existing rating.

We did not rate this service at this inspection. The previous rating of requires improvement remains.

We found:

The service now had enough nursing and support staff to keep patients safe. Since our last inspection, the provider had address staffing levels on all wards and employed agency nurses on a longer-term basis. The trust had also changed the working hours of senior staff to cover 24 hours a day.
Staff had received training in how to meet the physical health needs of patients and each ward had two physical health champions identified. The physical health team visited the hospital twice a week. Staff reviewed the physical health needs of patients at every handover and at the daily safety huddle.
Since the last inspection, the provider had reviewed all patients’ physical health needs, to ensure that were met and monitored. Staff had developed care plans for each identified physical health need and included them in the patient’s risk assessment.
Staff knew how to escalate concerns about physical health. Staff had correctly completed food and fluid charts on Opal ward. Staff on Amber and Opal ward had competed physical health monitoring following rapid tranquilisation correctly.
Managers had introduced a physical health audit, to ensure that they had oversight of the needs of patients and ensure the needs were being met.

However:

Staff told us they had enough staff to manage on the wards but still felt that there was not always enough staff on wards if they had to support other wards during incidents.
Food and fluid charts on Jade ward did not include a target amount and staff had not calculated the total amount of fluid consumed by patients. On Jade ward staff had not calculated the total National Early Warning Score on post rapid tranquilisation charts. We reported this to senior staff during the inspection and they agreed to take immediate action to address these issues.
Doctors had not reviewed do not attempt cardiopulmonary resuscitation (DNACPR) decisions on admission to the hospital. Staff did not always discuss DNACPR decisions with patients. The provider took immediate action to address this.
The physical health audit had not identified that staff were not routinely assessing patient’s risk of venous thromboembolism on admission (in line with National Institute for Health and Care Excellence guidelines). The provider has now updated the audit to include to address this.

How we carried out the inspection

During this inspection, we interviewed 17 staff including managers, doctors, nurses and healthcare support workers. We spoke to seven relatives of patients, reviewed nine patient care records, looked at a variety of documentation relating to patient care and other documents relating to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke to seven carers and they told us that communication from the hospital could be improved. They told us that it was difficult to get through to the wards on the telephone and staff did not always call them back or call when they were supposed to. Carers told us that when they complained about staff not calling back, staff told them they were busy. Carers told us they were not involved in the care planning for their relative, even when staff had told them they would be, and therefore did not know what care and treatment they were receiving. Most carers told us they did not know what physical health support their loved one was receiving or how staff were supporting their relative with hospital appointments. However, carers felt most staff were friendly and polite and that their relative was safe at the hospital.

Langley Green is a hospital for people with acute mental health problems. The teams provide assessment and treatment for people across four wards;

Amber ward, 12 bed psychiatric Intensive Care Unit (PICU),
Coral ward, 19 bed acute wards for working age adults
Jade ward, 19 bed acute wards for working age adults and
Opal ward, 19 bed mixed sex, integrated care for working age adults and older people

We undertook an unannounced, focused inspection at this hospital because of concerns raised due to recent serious incidents at the hospital. These included concerns around poor risk assessments, inconsistent physical health monitoring, poor risk management, poor care planning, inconsistent therapeutic observations and inadequate staffing including the high use of agency staff.

We identified a number of concerns on this inspection and so served the provider with a letter of intent under Section 31 of the Health and Social Care Act 2008, to warn them of possible urgent enforcement action. We told the provider that we were considering whether to use our powers to urgently suspend, impose variation or remove their registration. The effect of using Section 31 powers is serious and immediate. We told the provider to submit an action plan within five days describing how it would ensure there were always enough staff with the right skills on all of the wards on every shift to meet the needs of all patients and keep them safe and describe how it would ensure that patients physical health care was monitored appropriately, that all staff were aware of their role in relation to monitoring the physical health care of patients and that there was clear oversight of this.

The provider submitted the action plan on time. Following review of the action plan, we felt assured that the provider had sufficiently addressed the concerns around staffing. However, we still had concerns about how well staff monitored the physical health care of patients and whether this was recorded appropriately. Therefore, we served the provider with a Warning Notice under Section 29a of the Health and Social Care Act 2008, telling the provider that it must ensure that it reviewed all risk assessments and care plans of all patients with physical healthcare needs by 10 March 2021 to ensure these appropriately captured and reflected the needs and actions required and that it must audit all care plans and risk assessments by 31 March 2021 in order to ensure physical health care monitoring was completed as required. We will undertake a follow up inspection in due course to see if the provider has met the requirements of the warning notice.

Following our inspection, the trust told us that the reduction of some third-party sector and social care provision during the covid-19 pandemic have had an impact on their services, which had contributed to some of the concerns we saw on inspection. For example, during the covid-19 pandemic, there had been an increase in acuity of patients with mental health needs, increased demands for beds, patients staying longer in services because they could not be discharged when ready as they could not always access the care and support required in community, resulting in increased pressures on staff. Other factors such as social distancing and restrictions in relatives and friends visiting have also impacted on services. The trust reported they had successfully managed covid-19 positive admissions and contained a number of outbreaks, avoiding wide-scale impact upon patients, staff and the service.

On this inspection, we focused on specific aspects of the key questions; are services safe, are services effective and are services well-led.

Our rating of services went down. We rated the core service as requires improvement because:

There was not always enough staff with the right skills on all of the wards on every shift to meet the needs of all patients and keep them safe. Staff at all levels told us they had concerns about staffing levels, the skill and experience of some staff and felt staff could not always respond adequately when the needs of patients changed rapidly. Patients told us their leave had been cancelled on several occasions because there was not always enough staff to facilitate this.
Staff did not always ensure that patients who had physical healthcare needs and therefore needed their physical healthcare monitoring closely had appropriate care plans and risk assessments in place. For example, two patients had put on significant amounts of weight within a very short period of time and staff did not proactively review them or escalate concerns. Staff did not escalate concerns about patients’ poor fluid intake to the multidisciplinary team. Staff did not undertake a specific risk assessment for a patient who was known to be at risk of falls. There was no care plan related to falls so staff were unaware that they needed to observe the patient, record falls and escalate to the multidisciplinary team accordingly so any required action to keep the patient safe could be taken.
Staff did not consistently complete post rapid tranquilisation physical health monitoring for all patients in line with trust policy and national guidelines.
The trust’s clinical quality audit process was not robust enough to always mitigate or minimise patients’ risks. Although audits of patient records had been completed these had not picked up gaps in risk assessments, care plans and other patients records that we identified on the inspection. This could mean gaps in patient care were missed, required action may not have been taken and required improvements in care may not have been made.

However;

All staff we spoke with were enthusiastic and passionate about working at the hospital and wanted to do a good job. Staff were caring and kind to the patients they looked after. The wards had a new team of managers who could explain clearly how teams worked together to care for patients. Ward managers were supported by senior leaders to perform their roles and there were development opportunities for staff at all levels.
Staff felt respected, well-supported and valued. They were positive and proud about working for the trust and their teams.
Staff knew how to report incidents and what incidents to report. Staff received feedback after a serious incident.
Patients received a comprehensive mental health assessment on admission and staff regularly reviewed them. Staff from different disciplines worked together as a team to benefit patients. Staff held regular multidisciplinary meetings.
The trust had an improvement plan for Langley Green hospital and had deployed senior leaders within the trust to provide cover for service leads and to support ward managers in their roles as part of their business continuity plan. Since January 2021, the trust had implemented a programme of Enhanced Monitoring for the hospital to ensure there is executive oversight and to support the improvement programme.

The ratings for caring (outstanding) and responsive (good) remain the same as we did not inspect these key questions on this inspection.

The service is registered for:

assessment or medical treatment for persons detained under the Mental Health Act 1983,
diagnostic and screening procedures and
treatment of diseases, disorders and injury.

How we carried out the inspection

During this inspection, we interviewed 29 staff including managers, allied health professionals, doctors, nurses, healthcare support workers and non-clinical staff. We spoke to 10 patients, reviewed 11 patient care records, looked at the environment and patient care areas and reviewed policies and procedures and other documents relating to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

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

We rated four key questions as good (Safe, Effective, Caring and Well-led) and one key question as outstanding (Responsive).
The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors and ward managers could adjust the staffing levels based upon the acuity on the wards. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
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.
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 multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff planned and managed discharge well and liaised well with services that would provide aftercare.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

Not all patients prescribed high dose antipsychotic medicine had their physical healthcare appropriately monitored. High dose antipsychotic medication is medicine that is prescribed in excess of the upper limits recommended by the British National Formulary
Fir ward at The Chichester Centre was storing patient bank cards and money in the medicine cupboard temporarily. This was inappropriate and posed a risk to the security of the cards. The service immediately rectified the issue when we highlighted it to them.
Ash and Hazel wards had items in their clinic rooms that were past their ‘use by’ date. These included oral syringes, urinalysis test strips and disposable tourniquets. This was immediately rectified when highlighted to the service.
On two wards, staff were not ensuring that medicines were stored at the correct temperature. Fir ward’s fridge temperature was consistently recorded as above eight degrees celsius whilst storing patient medicines. This posed a risk to the efficacy of the medicines. This was immediately rectified when highlighted to the service who moved the medicine into a different medicine fridge. The trust advised us that this was a recording error by staff reading the thermometer temperatures. Additionally, Hazel ward’s clinic room was consistently recorded as above the maximum temperature threshold stated in trust policy. The ward had ordered an air conditioning unit and the pharmacy team reduced the medicine expiry dates in accordance with trust policy in response to the raised temperatures.

Sussex Partnership NHS Foundation Trust provides wards for older people with mental health conditions who are admitted informally or detained under the Mental Health Act 1983.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led?

Where we have a legal duty to do so, we rate the quality of services against each key question as outstanding, good, requires improvement or inadequate.

We plan our inspections based on everything we know about services, including whether they appear to be getting better or worse.

Where necessary, we take action against registered service providers and registered managers who fail to comply with legal requirements, and help them to improve their services.

At the last comprehensive inspection of this core service in October 2017, we rated the wards as good for the five key questions (safe, effective, caring, responsive and well-led). We re-inspected all five key questions during this inspection.

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

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding
Staff developed a 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.
The ward teams included or had access to the full range of specialities 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 multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
The service managed beds well in most wards and many patients were discharged once their condition warranted this.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

Although we concluded that staff actively involved patients in their care, on St Raphael ward the plans did not contain patients’ preferences including their likes and dislikes around their care. Also, there were no accessible or easy read care planning tools available for patients who might need them on most wards including St Raphael, Opal and Brunswick wards.
Due to high demand for admissions, patients on Heathfield ward did not always have beds available to them when returning from leave.
Heathfield and St Raphael wards had shared sleeping arrangements where more than one patient had to sleep in the same bedroom. The four dormitories on Heathfield ward had only one sink each.
The dining room on Grove ward was very enclosed and was not decorated in dementia friendly colours.

Our rating of this service went down. We rated it as requires improvement because:

We had very significant concerns about the crisis team based at Millview.
The amount of medical cover varied across services as most of the consultants worked part time. Staff told us that there were sometimes problems because the junior doctors that provided cover were sometimes reluctant to prescribe medicines because they didn’t know the patients.
There was evidence that the low morale, resistance to change and culture of the crisis team at Mill View Hospital was having a negative impact on the care and treatment that some patients received. Care plans and risk assessments were not kept up to date to ensure patients were receiving the care and treatment they needed.
The care records reviewed across the four teams varied with respect to their quality and level of detail. The risk assessments and care plans at Meadowfield, Chichester and Langley Green were comprehensive, holistic and recovery orientated. At Mill View, of the six risk assessments reviewed, one had no risk assessment and five contained limited information that did not accurately reflect the current clinical presentation of the patient. In four of the six records reviewed care plans were missing in two of these patients with high risk and complex needs were identified. The remaining two records that had care plans, were not holistic and did not reflect the full range of needs of the patients. Staff did not always act on review of overdue care plans that had been flagged on the whiteboard. An investigation into a serious incident at Mill View in December 2017 had identified the lack of a crisis personalised care plan as a contributory factor. The investigation into the incident recommended that all patients should have an individualised care plan in place by March 2019.
Staff from the places of safety did not always record the time that the approved mental health professional and section 12 doctor had been requested. This meant that the nurse could not accurately calculate the time from request to completion of assessment.
Staff told us that there were sometimes delays in accident and emergency due to a place of safety not being available, approved mental health professionals and police said there were sometimes delays in identifying an available place of safety because of the referral process involved a pager, which then delayed a response to initial contact. Staff said that because ambulances did not always meet the trust policy’s agreed response time, an alternative health ambulance company was used to transport patients to the place of safety.

However:

Staffing numbers were based on caseload and patient needs. Managers used regular bank staff who knew the patients and service well. The service provided mandatory training in key skills to all staff and made sure everyone completed it.
Staff discussed risks and safeguarding concerns during regular handovers. Staff held meaningful discussions and spoke about patients in a respectful and caring manner. Staff had access to psychiatrists, to ensure all risks from patients on their caseload were safely managed. Staff saw all patients daily for the first three days and then reviewed frequency of visits. We saw evidence that staff saw patients twice a day where risk was considered high.
There was a range of disciplines in the crisis teams which included doctors, nurses, psychologists, occupational therapists and social workers. All staff we spoke with were appropriately experienced and qualified to meet the needs of patients.
Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned. The trust sent a bulletin to all staff with information about recent incidents and any learning identified. Staff had access to debrief sessions after serious incidents that were facilitated by senior managers and psychologists.
We saw effective multi-agency working with a variety of services including the police, ambulance services, approved mental health professionals, rapid response team, street triage and in-patient wards.
Patients at Langley Green could access the day service for daily group therapy in a range of psycho-social interventions Monday to Friday. Groups offered included mindfulness, managing anxiety and art therapy.
We observed staff from the mental health telephone service who were supportive, kind and caring in their conversations with callers.
Patients from the crisis teams spoke positively about the support they had received. They said that staff were responsive, listened and were easy to talk to and they had found the support invaluable. People who had used the places of safety said that staff had treated them with kindness and respect and had done their best to make them feel comfortable.
The trust had introduced initiatives including a pilot to improve the referral process in Chichester and the introduction of an early discharge nurse to bridge the gap between wards and the crisis teams.
An urgent care lounge had recently been opened at Langley Green to provide a calm environment for patients waiting to be assessed. The trust planned to open a psychiatric decision unit at Mill View in April 2019 which will cover the whole of the county.
The managers and team leaders demonstrated the skills, knowledge and experience to perform their roles. All leaders showed a good understanding of the service and could clearly explain how to provide high quality care.
A lead nurse for quality and compliance had been in post since October 2018. They were responsible for standardising processes and improving services to patients in the places of safety. Staff reported an improvement in clinical practice and cascading information since they had been in post.

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

We rated safe, effective, responsive and well-led as good, and caring as outstanding. We also took into account the current ratings of the seven services not inspected this time.
We rated the four core services of acute wards for adults of working age and psychiatric intensive care units; wards for older people with mental health problems; community-based mental health services for adults of working age; and specialist community mental health services for children and young people as good. We had rated all of these as requires improvement at the previous inspection; which demonstrated clear improvements had taken place across the services.
The adult social care location at Avenida Lodge was rated good.
We rated well-led at the trust level as good. The senior leadership team changes had brought with it a new, invigorated and open approach to the direction of the trust and culture in which the staff worked. Staff were excited about the changes and empowered to make improvements to their services. Staff felt valued and felt proud to work for the organisation and engaged effectively with managers.
The management of waiting times had improved. Teams used innovative ways to monitor and manage risks of adults and young people on the waiting lists.
Patients and carers all gave positive feedback about the care they received. They said they were involved in decisions about their care and that staff considered their well-being and experiences as a patient, as well as their physical health needs.
There was improved sharing of when things had gone wrong and learning from incidents across the trust.

However:

Improvements were needed to ensure that the premises and equipment were safe at all times across the acute wards for adults of working age and psychiatric intensive care units.
The adult social care location at Lindridge was rated as requires improvement.
There were some gaps in the staff understanding of their responsibilities under the Mental Capacity Act 2005.
There were some mandatory training subjects that did not meet the trust’s compliance target of 85%.
The trust was still in the process of implementing its action plan to ensure that serious incident investigations were completed to the timelines within their policy.
The trust needed to make some improvements to ensure that evidence of occupational health screening for all executive and non-executive directors was obtained.
There was more work to do to ensure the trust data management systems accurately reflected the supervision and appraisals that were taking place in services.
Although patients leave from the wards was managed well, feedback from the approved mental health professionals was that there was not always a bed immediately available to patients recently detained under the Mental Health Act.

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

One domain was rated as outstanding (Caring) and four domains were rated as good (Safe, Effective, Responsive and Well-Led).
The service had addressed and managed the concerns raised at the last inspection.
Clinician’s caseloads were continually monitored and managed. Risk to patients on waiting lists was well managed and mitigated.
All patients entering the service had thorough risk assessments and management plans in place. There were excellent safeguarding policies, procedures and lead practitioners in the service.
Supervision was happening regularly in line with trust policy. On inspection, we saw that supervision completion rates were much higher than data submitted and had significantly improved since the last inspection.
The service appropriately monitored and managed patients physical health needs. We witnessed excellent working relationships with partner agencies to arrange for further physical health testing when required. Multidisciplinary and interagency working across the service was excellent. We saw the service engaging with many partner agencies to benefit their patients.
The service delivered a range of evidence-based specific treatment pathways and therapeutic interventions for patients.
We observed many positive and engaging interactions between staff and patients and staff demonstrated a caring attitude towards patients. Patient and carer feedback on staff attitudes was excellent. Patients and carers felt involved with the delivery of their care and felt that their voice was heard.
The service provided an advice consult experience (ACE) for patients and carers to join and become involved in service projects and give feedback on staff recruitment panels.
The service delivered a variety of additional campaigns, workshops, events and support groups to equip patients and carers with skills and tools to deal with their mental health in the community, reduce stigma and encourage social interaction.
Sites were within target times for assessment, except for the Hampshire locations where we saw clear and effective plans in place to reduce the waiting times. The service was on average within national target times for referral to treatment.
The service was managing the risk of their waiting lists well and were constantly engaging with patients, parents and carers to assess any changes in circumstances and risk. There was a consistent and effective approach across the service to dealing with crisis and emergency situations.
There was clear leadership direction from senior members of staff within the service with sufficient leadership training and opportunities for all staff. Staff were extremely proud to work in the service and for the trust and morale was generally high amongst all staff.
The service undertook a variety of staff wellbeing activities and days to support staff wellbeing and contribute towards the services recruitment and retention plan.
Local management and systems of supervision and appraisals was appropriate and monitored regularly at all locations. There were regular audits in place to monitor for regularity and quality of supervision by senior leadership.
Innovation within the service was excellent. The service had a culture of driving positive change from the bottom.
Front-line staff had the confidence, support and encouragement to suggest and try new ideas.

However:

There were no alarm systems in place for Chichester and not all therapy rooms had alarms in Eastleigh. Staff did not carry personal alarms at either of these sites.
Not all patient risk assessments were updated within six months, as per trust policy. We found this in 13% of the care records we reviewed.
As at December 2017 the core service was just below the trust’s target for mandatory training (at 84% compared to the target of 85%) and five mandatory training courses were below 75% completion. The service submitted an action plan to us which showed how they planned to ensure all staff completed mandatory training by March 2018.
Some sites did not have enough therapy rooms. This impacted on the delivery of care at one location where appointments were either not being made, shortened or cancelled at the last minute.

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

All wards were clean, well-furnished, and were accessible with a number of disabled adapted rooms on each ward with adapted accessible bathrooms.
Staff carried out comprehensive assessments and physical health assessments with all patients following their admission.
The trust was a smoke-free environment and staff supported patients with smoking cessation groups, use of ecigarettes, and nicotine replacement therapy.
We spoke with 58 patients during our inspection and all said they found staff to be kind, polite and treated them with respect. Staff interacted with patients in a caring, supportive, and compassionate way and respected the personal needs of patients from the lesbian, gay, bisexual, transgender community.
All wards held monthly carers’ support groups. Ward managers made contact with carers and ensured they were supported to contribute to their family members’ treatment by attending reviews and commenting on care plans. Wards had family rooms to ensure that patients could meet with family, children and friends.
All wards had psychologists and occupational therapist input. Occupational therapists offered daily schedules of activities for patients including art, cookery, pottery, music appreciation, table tennis, exercise, smoothie making sessions, pamper sessions, games, mindfulness, movie and pizza nights. Patients in Langley Green Hospital were able to spend time with a therapeutic dog who visited with a volunteer during the week.
The trust held an award ceremony in November 2017 to recognise and award staff members for outstanding contributions in their work. The Langley Green Hospital team won a gold award for the significant and continued improvements being made to patient care across all areas of the hospital. The matron at Langley Green Hospital won a gold award for being an amazing role model to both staff and patients, for being an inspiring nurse and for leading their team from the front with humility, tenacity and commitment. Coral Ward in Langley Green Hospital won a silver award for work undertaken to champion physical health through the National Early Warning Score policy and safety book.
The service manager at Langley Green Hospital implemented the ‘Leader Leader’ model at the end of 2016. This model encouraged staff and patients to adopt leadership roles in the everything they did, for example nursing staff and patients contributed towards ward improvement initiatives.

However:

The trust did not ensure that premises and equipment were always well maintained. Staff on Woodlands ward did not always complete environmental risk assessments for the month of September, nor did they use a check list to conduct assessments when they were undertaken. There was an uncovered gap in a window on Amber ward when it was open. The seclusion room on Amber ward did not allow clear observation, did not have closed circuit television, and the two-way communication intercom was broken at the time of our visit. We re-visited the seclusion room in December 2017 and found that the room had been closed so that renovation works could take place. Staff in Meadowfield Hospital did not regularly check their resuscitation equipment weekly in April, May and August 2017 and Rowan ward during June, July, August and September 2017 on Maple ward.
The service’s compliance for mandatory and statutory training as of 31 July 2017 was 86%, however four courses did not achieve the trust target of 85%.
We found that some patient paperwork was incomplete. One out of six risk assessments we reviewed on Maple ward had not been updated to include risks from numerous incidents involving a patient in September 2017. On Rowan ward, one out of 17 patients’ medicine records we reviewed noted that staff did not record physical health observations post administration of rapid tranquilisation as the patient was ‘volatile’. On Maple ward there was no record that physical health observations were carried out for one patient who received rapid tranquilisation. The trust implemented a new non-contact physical observation post rapid tranquilisation protocol immediately after our inspection. This provided staff with clear guidelines and recording materials for use during non-contact observations.
Medicine records across all the wards were generally well completed. However, on Rowan ward six out of 17 records contained recording errors. All of these issues had been addressed when we reviewed the records during a visit in December 2017. Not all care records for patients in Woodlands Hospital, Caburn, and Maple wards had been updated following incidents and not all care records on Rowan ward were personalised and recovery focussed.
Staff completed a physical health care plan for each physical health condition patients presented with to ensure they received appropriate care. On Rowan ward we found that two out of six physical health care plans were incomplete. On Woodlands ward one out of five physical health care plans we reviewed did not include details of a patient’s physical health issue requiring treatment.
Not all staff received regular supervision or annual appraisals.

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

There were sufficient numbers of staff in each team. Staff vacancies were low and were covered by appropriate use of bank or agency staff. Team leaders reviewed caseloads regularly with practitioners to ensure these were manageable.
Staff could access a consultant psychiatrist for routine or urgent appointments.
We reviewed 51 care records of people using services. Staff had completed a risk assessment for each at the point of initial assessment. Staff updated risk assessments regularly and after each reported incident. Each team had a duty system to respond to changes in risk or deterioration in the health of people using services.
Staff had completed safeguarding training and demonstrated good awareness of safeguarding issues. Teams within West Sussex and Brighton and Hove had integrated social workers who took the lead role in any safeguarding inquiry. Within East Sussex the social workers were co-located which helped facilitate communication with the local authority.
All staff knew how to report an incident on the trust reporting system. Staff received feedback and learning from incidents at team meetings and via the trust patient safety matters newsletter. We saw evidence of a change in practice following incidents which resulted in more joined up care for people using services.
All care records of people using services we reviewed had a comprehensive needs assessment. Assessments were person centred, holistic and recovery focused. Care plans reflected the needs identified in the initial assessment.
The early intervention service had a physical health champion to ensure staff were meeting the physical health needs of people using the service, and over 90% of all people using the service had received their annual physical health screening.
Staff monitored the effects of medicine on the physical health of people using services and reviewed this regularly in physical health clinics. This was in line with guidance from the National Institute for Health and Care Excellence.
The trust had a duty of candour policy to which staff adhered. This ensured that staff were open and transparent with those using services and their families and carers and kept them informed of any incidents that might have affected them. The duty of candour policy clearly set out the steps staff must take when informing others following an incident.
Teams offered a variety of treatment options to people using services including National Institute for Health and Care Excellence approved interventions such as family therapy for those experiencing psychosis and cognitive behavioural therapy for anxiety and depression. Each team was multidisciplinary and included nurses, doctors, social workers, psychologists and occupational therapists as well as peer support workers.
Staff received regular supervision in a variety of ways. Staff could access clinical, management and peer supervision as well as reflective practice sessions and support from risk circles. Annual appraisals were completed or booked and staff reported these were meaningful and appropriate to their role.
All teams had good relationships with other teams within, and external to, the organisation. We saw good evidence of joined up working between crisis services, inpatient services and the community teams. Staff had good links with the local authority and teams in West Sussex and Brighton and Hove had employed social workers.
People using services reported that staff treated them kindly, with respect and maintained their dignity. Staff worked with people using services to help them understand their condition so that they could manage these themselves more effectively.
We saw evidence in care records of involvement of the people using services in their care planning. Care records showed that staff discussed care plans with those using services and offered them a copy of their care plan.
Carers we spoke with told us they were kept informed and up to date with any changes in the care for the person receiving the service. Carers were invited to attend review meetings and care programme approach meetings.
The trust had a set target time for referral to assessment and referral to treatment times. Each service across the trust was meeting these timescales. Each team had a duty system which could see urgent referrals on the same day, or within five days as appropriate. All routine referrals were seen within 28 days.
The Glebelands service had developed an integrated service with people using services and non-statutory organisations in the area called the Pathfinder Alliance. This was a co-production between the trust, people using services and the third sector and was only one of three in the country.
The Ifield Drive service had developed a service to provide mental health support to armed services veterans. The service could take referrals directly from veterans, or from their GP. The service aimed to support veterans transition into civilian life and had specialist practitioners who had an understanding of military culture and what the veterans may have been through.
Staff provided people using services with information on how to make a complaint as part of the initial information pack. People using services told us they knew the process for how to make a complaint.
All services had a wide range of rooms to see people using services, including clinic rooms. These were all soundproofed to maintain confidentiality. Each waiting area had a suitable supply of information on local community groups, advocacy and medicine information.
There were clearly defined roles for team leaders and service managers within each team inspected. Team leaders demonstrated a clear understanding of the service they were providing and how it connected to the wider community service.
All staff we spoke with said they felt proud to work for the team they did, and all emphasised the strong working relationships in the teams. There was an open culture of honesty amongst the practitioners and all staff felt they could offer constructive challenge to one another.
The trust was involved in numerous pieces of research for people using services, their carers and staff. Staff were encouraged to be involved in service development and quality improvement work.

However:

Staff at Linwood did not follow the trust lone working policy. Staff at Linwood made arrangements to buddy up with another practitioner at the start of each day. This meant that no one practitioner had oversight of these arrangements. We raised this with the trust during the inspection who gave us assurances that they would ensure staff at Linwood followed the lone working policy.
Not all mandatory training was up to date across all teams. We raised this with the trust who provided a plan for when this would be completed.
Staff did not always record on the electronic system why a care plan may not have been provided to the person using services. Some care plans for people using services were detailed in consultant letters, but this was not always recorded.

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

The wards provided safe care. Staff on each ward carried out a daily ‘safety huddle’ which is a nationally recognised good practice initiative to reduce patient harm and improve the safety culture on the wards. The meetings involved all available staff to discuss specific patients’ risks and any potential harm that may affect patients. Staff on all wards followed the trust’s observation policies and procedures to manage risk from potential ligature points.
The number of nurses identified in the staffing levels, set by the trust’s safer staffing tool, matched the number on all shifts across all wards. All staff told us there were sufficient staff to deliver care to a good standard and the staffing rotas indicated that there were sufficient staff on duty. There had been an ongoing programme of recruitment which had seen a recent reduction in staff vacancies across the wards. Staff told us senior managers were flexible and responded well if the needs of the patients’ increased and additional staff were required.
Staff knew how to recognise and report incidents on the providers’ electronic recording system.
All of the staff we spoke with knew how to raise a safeguarding issue or concern. All staff were aware of who the trust safeguarding lead was and how to contact them. The safeguarding team contact details and flow charts of the safeguarding procedure were placed in all of the wards both in the nurses’ office and also on the patients’ notice boards. Over 94% of staff had up to date safeguarding children and adults training. Staff worked together to provide effective care.
All patients had detailed and timely assessments of their current mental state, previous history and physical healthcare needs. The care plans were recovery focused. Staff described how they developed complex physical health care plans and effectively managed physical health care needs. The trust’s physical health care nursing team had offered training and advice across all of the wards. Staff assessed patient’s nutrition and hydration needs and developed care plans if needed. Health care assistants had received specific training to enable them to effectively monitor nutritional and hydration needs.
Staff were consistently caring. 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. Patients told us they had been treated with respect and dignity and staff were polite, friendly, and willing to help. Patients told us staff were pleasant and were interested in their wellbeing.
There was evidence of patient involvement in the care records we looked at and all patients had either signed a copy of their care plans or said they did not want to sign the plans. Staffs’ approach was person centred, individualised and recovery orientated. Patients reviewed their care plan at least once every week with the multidisciplinary team. Patients told us that their families were included in their care planning. Each ward had an information board for carers that included, for example, information on how to raise a concern.
Patients had access to psychological, educational and social groups and training courses which had a focus on education, recovery and rehabilitation. Staff encouraged patients to develop and maintain relationships with people who mattered to them, both within the service and the wider community. Staff supported patients to maintain contact with their families and carers. For example restrictions on visiting times had been removed on all wards and on Iris ward pet dogs were actively encouraged to visit their owners.
The wards were well led. Ward managers and matrons had the skills, knowledge and experience to perform their roles to a high standard. The wards’ senior management team had regular contact with all staff and patients. The senior management and clinical teams were visible to staff and staff said senior management regularly visited the services.
All staff and patients knew who the senior management team were and that they felt confident to approach them if they had any concerns. Staff knew who the trust’s executive team were and said they visited the wards.
The trust’s vision, values and strategies for the service were evident and on display on information boards throughout the wards. Staff we spoke to understood the vision and strategic objectives of the organisation. 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. Staff were proud about working for the trust.

However:

The trust did not comply with the Department of Health eliminating mixed sex accommodation requirements. Over the 12 month period from 1 August 2016 to 31 July 2017 there were three mixed sex accommodation breaches within this core service, one on St Raphael Ward, one on Orchard Ward and one on The Burrowes.
Chairs on St Raphael ward were not clean.
On St Raphael ward there were no privacy blinds in the bedroom dormitory windows. This meant, throughout the ward, people in neighbouring office buildings could see into the ward both through the bedroom windows and in one of the bathrooms.
Patients on Heathfield ward did not always have timely access to a tissue viability nurse specialist.
Staff did not always undertake mental capacity/best-interests assessments for decision-making other than consent to treatment (such as medication) and admission. For example, for personal care delivery.
There was no escalation process for monitoring patients for whom Deprivation of Liberty Safeguard (DoLS) assessments have been requested by the local authority but not carried out.
Staff supervision did not achieve the trust compliance rate on all wards.

The service had taken most of the action that we required them to take following the September 2016 inspection. The most notable exception was that the trust had not ensured that all staff had undertaken mandatory training.

We found the following issues that need to improve:

All staff had access to mandatory training. However this core service did not meet the trust’s own 75% mandatory training compliance target in four out of 22 subjects. The trust monitored training through a RAG (red, amber green) rating scale to monitor progress across all mandatory training subject areas for all trust services.
Wards generally followed National Institute for Health and Care Excellence guidance and the trust’s rapid tranquilisation policy when monitoring patients’ physical health after administration of rapid tranquilisation. However there were gaps on three physical health monitoring records across Coral, Amber and Pavilion wards, so these did not demonstrate that these checks had been carried out.
Although medicines management practice was generally satisfactory across all of the wards, on Amber ward an audit carried out in March 2017 indicated that in 33 (48%) of the medicine administration charts there was an error.
Eleven out of 12 wards we inspected demonstrated learning from incidents. However, a patient had set fire to their room on Woodlands ward in December 2016. During our inspection we observed patients of Woodlands using their own cigarette lighters smoking in the courtyard. Staff we spoke with told us they did not encourage or enforce patients to hand in lighters following leave from the ward, or carry out searches, which did not demonstrate learning from this incident. Of all the wards we visited, Woodlands ward was the only one that had not implemented the trust smoke-free and smoking cessation policy, in place since 8 March 2017.
The seclusion room on Amber ward in Langley Green Hospital did not have a mirror or closed circuit television to enable staff to monitor the blind spots in the room. The seclusion room mattress could be used by patients to block the window or the door. However, the trust had a plan in place to renovate this seclusion room.
Staff on Maple ward did not record what patients were wearing prior to them leaving the ward on escorted or unescorted leave. This could have assisted staff to identify a patient if they went absent without leave in the community. This was a recommendation in the trust’s leave of absence policy.

However, we also found the following areas of good practice:

The wards had good observation policies and procedures to minimise risks to the safety of patients. Risk assessments and risk monitoring of patients had improved and was good across all the wards.
All 12 wards had developed detailed ligature risk assessments that clearly identified the risk areas and mitigation in place to minimise risks. A ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. All wards developed a risk footprint ward map. These maps were colour coded to indicate the risks in the environment, such as ligature points and levels of staff observations required in these areas to maintain patient safety.

All 12 wards were generally clean, well furnished and well maintained. Wards carried out regular infection control and prevention audits. The clinic rooms across all the wardswere clean, fully equipped with functioning equipment and emergency medicines.

The trust undertook a focussed recruitment drive and wards across the core service were becoming permanently staffed. All ward managers told us that they were able to increase staffing levels daily to meet the changing needs of the patient groups across the wards, for example when there was increased risks and need for increased patient observations.
Staff told us that there was adequate medical cover on all wards day and night to attend quickly if there was a medical emergency.

We rated community-based mental health services for older people as good because:

Staff were providing a safe service. Staff were aware of the risks for individual people who used the service, medication was managed well and staff had a good understanding of safeguarding. Staff were able to see people who used the service in a timely manner and prioritised people who needed urgent support.

Practice reflected current guidance and there was good access to a wide range of interventions. There was good use of outcome measures to monitor if services were effective. Audits that were specific to the service were carried out to provide assurances of robust care with improvements made where needed.

Staff were consistently caring and showed warmth, kindness and respect to people who used services and their carers. They provided practical and emotional support. Staff went the extra mile to care for people in a person centred way and involve carers and people who use the service in their care. Groups and accessible information was provided for people and carers. The needs of carers were assessed and support groups were provided.

Staff morale was good. They were well supported with access to training and other opportunities to reflect and learn. There were opportunities for leadership training and career progression.

The teams worked well with GPs, the local authorities and other local services and groups.
People who used the service, carers, staff and external stakeholders were encouraged to give feedback through a range of mechanisms and these were used to make improvements.

We rated adult community mental health services as requires improvement because:

However:

The quality of risk assessments varied across teams.We reviewed 46 records and found six risk assessments missing. However, we observed staff regularly discussing risk during meetings in all teams visited.
The quality and detail of care plans were inconsistent across the teams.In some of the records reviewed, it was unclear if the person was subject to a care programme approach of if a lead practitioner had been allocated. There was little evidence of staff explaining rights to people on a community treatment order.
We reviewed the training records for six teams which showed an overall compliance with mandatory training. However, compliance with some training including the Mental Health Act, Mental Capacity Act and safeguarding adult’s level two was low. Staff told us that it was difficult to access face-to-face training and they did not receive protected time to complete mandatory training.
Staff told us that learning was not consistently shared across teams.
There were effective internal meetings to monitor risk and discuss people with complex needs.The caseloads of the teams were monitored regularly in meetings and individually in supervision.
The single point of access triage nurse booked new referrals into pre-arranged assessment slots, based on need and priority.The trust had met their target of referral to assessment and treatment times between April 2015 and March 2016.
Staff were committed to creatively improving services to meet local need. This included the employment of peer support workers and employment advisors and the introduction of a daily clinic so that staff could respond quickly to people in crisis.
The trust was a partner in the Sussex recovery college which offered mental health recovery focused educational courses to adults of all ages.

We rated specialist community mental health services for children and young people as requires improvement because:

Staff had failed to consistently assess and document risk for young people in the carenotes system. There was poor reporting of lower level incidents within the service.This meant that not all incidents involving young people were escalated accordingly. Care Quality Commission had taken enforcement action through the issuing of a warning notice due to the failings in the recording of risk assessment.
Some of the sites were not clean. Toys were not regularly cleaned.
There were extensive waiting times for young people needing to access therapies in some geographical areas. These waits were outside of the target set by commissioners and impacted on you people needing to access vital services.
Care plans were not always completed for young people and some young people had not received a copy of their care plan.
Whilst staff did say they received supervision, there was poor oversight of supervision which meant that managers could not guarantee that all staff received regular supervision. Appraisal rates were below the target set by the trust.

However:

On the 7 December 2016 we carried out a focussed inspection to follow up the warning notice. At this inspection we identified that the trust had responded positively to the findings in the warning notice and significant improvements had been made. The trust had developed an action plan to ensure compliance with the trust target of 95% of risk screens completed. We looked at a random selection of 127 care records from 19 teams across Hampshire, Kent and Sussex. Out of the 127 care records we found only 4 risk screenings were missing, this equated to a 97% compliance rate for the care records we viewed. The trust target was 95%. This demonstrated a significant improvement from our findings in September 2016, where we found only 43% of risk screens having been completed.
There was good investigation into serious incidents that ensured the trust fulfilled its duty of candour. There were robust arrangements for staff to make safeguarding alerts that included strong oversight of the safeguarding process. Staff received mandatory training. Physical monitoring equipment was available.

There were evidence based care pathways and staff trained in therapies approved by the National Institute for Health and Care Excellence (NICE). Outcomes were recorded in order for staff to improve practice. There were effective relationships with external services.
Young people were treated with dignity and respect. Efforts were made to include young people in the running of the service. Communities and schools were educated in mental health problems and coping skills. Groups were available to young people and their parents and carers.
Staff responded to changes in risk through referral to urgent help services. There was a proactive approach to young people that did not attend appointments. Complaints were dealt with effectively.
There was good morale amongst the staff teams and they were aware of who the senior managers within the trust were. There were robust systems in place to ensure performance was measured.

We rated Sussex Partnership NHS Foundation Trust mental health crisis services and health-based places of safety as good because:

People had access to safe and clean environments that were accessible by wheelchair users. Teams were well-staffed and had access to appropriate alarms systems that ensured people using the service and themselves were kept safe.
Psychiatrists were available to all teams across the service. They had the flexibility to carry out medical reviews in people’s homes. The service had systems in place to allow staff to medically support people in the absence of a doctor. Staff had access to equipment that allowed them to monitor people’s physical health.
Crisis teams had systems in place to safely manage people’s risk. They were able to assess people quickly and followed clear procedures that ensured other work did not get overlooked.
Crisis teams worked with people and their carers to collaboratively produce care plans that were meaningful and specific to their individual needs. Care plans were holistic and addressed people’s physical, psychological and social needs. Carers were well supported by the service and staff routinely offered carers assessments.
Teams used lessons learnt from incidents to improve practice and inform meaningful audits. Staff embraced duty of candour and were open and honest with people following incidents. Staff were supported by senior managers to ensure everyone involved was included in the outcome of incidents.
Teams had effective handovers to allow them to efficiently manage their caseloads. They also had regular meetings where clinical and business issues could be discussed. Teams had effective links with services they worked closely with and this improved the experience of people using the services.
People who used the service were treated with compassion, respect and dignity. People in HBPoS were offered refreshments and toiletries to keep them comfortable. Staff promoted people’s independence whenever possible. People were involved in their care and kept informed of any delays and appointment changes. People were able to give feedback and teams used this information to improve their practice.
The Sussex mental healthline was accessible 24 hours a day, seven days a week, to support people with mental health issues. People presenting at accident and emergency with mental health issues in East Sussex had access to the urgent care lounge, which offered a calm place to wait for assessment. Positive feedback had led to the trust securing funds to replicate this facility across the other four sites.
Street triage, an initiative whereby mental health professionals work alongside police officers, had been responsible for significantly reducing the amount of people, with mental health issues, being taken into police custody. They had also reduced overall use of HBPoS by providing people with less restrictive ongoing care plans.
Teams had sufficient administration support and made use of hot desk facilities in other trust locations to cut down on travelling time. This gave them more time to deliver direct care to people. Teams had systems in place to ensure staff could easily identify when important direct care interventions, such as supporting carers and monitoring physical health, had been completed.
Staff embraced the trust’s vision and values. They enjoyed their work and had no concerns with bullying or harassment. They felt supported, and listened to, by managers who were visible and fully involved in the day to day delivery of clinical care.

However:

Staff were not consistently up to date with mandatory training requirements due to some courses having reduced availability.
Crisis teams did not always offer people individual crisis plans or relapse prevention plans. The crisis information that was available was generic and consisted of useful contact numbers; however, some information was conflicting across teams. In addition, at night people only had access to the Sussex mental healthline. People requiring urgent support would need to make their own arrangements to get to accident and emergency.
Crisis teams across the trust did not effectively share their practice. This led to teams approaching established crisis team roles, such as supporting people who were not engaging, and assessing whether people were appropriate for early discharge from hospital, with different levels of efficiency.
People detained in health-based places of safety (HBPoS) occasionally had to wait more than three hours before being assessed due to delays in availability of approved mental health professionals and Section 12 doctors. This timescale exceed recommendations by The Mental Heal Act Code of Practice.
People occasionally remained in HBPoS for extended periods due to lack of bed availability.

We rated Sussex Partnership NHS Foundation Trust as requires improvement because:

At the last comprehensive inspection of the trust in January 2015 we identified a number of areas where improvements were needed across a number of core services, with five of the 11 core services rated as requires improvement.
At this inspection four core services were rated as requires improvement. There were ongoing concerns in the acute wards for adults of working age and psychiatric intensive care units, and wards for older people with mental health problems. Physical health monitoring was not taking place following the intramuscular administration of rapid tranquillisation andpatients were prescribed high dose antipsychotics. On the acute wards for adults of working age and psychiatric intensive care units we also identified concerns in relation to the Mental Health Act records and consent to treatment. In the specialist community mental health services for children and young people we identified that there was a lack of risk assessments for some children and young people using the service. This had been identified at the January 2015 inspection and a requirement notice issued. This was an ongoing issue and so we took enforcement action through serving two Warning Notices on the trust to ensure that action was taken to improve these services.

Some areas identified at the previous inspection still needed to be improved upon from the January 2015 inspection, such as access to psychological therapy for all patients. Progress had been made across the trust to meet the Department of Health guidance on eliminating mixed-sex accommodation. However, on wards for older people with mental health problems there were mixed-sex wards that were not always managed in accordance with Department of Health guidance on mixed-sex accommodation, though risks were being mitigated on a day-to-day basis.
Within the community services there were long waiting times from assessment to treatment within the specialist community mental health services for children and young people, with Hampshire and Kent as the services with the longest waiting times.
There was a high level of bed occupancy across the acute wards for adults of working age and psychiatric intensive care units. Patients did not always have a bed to return to following a period of leave and patients were sometimes moved to other wards for non-clinical need, due to the pressures on beds.
The governance processes had undergone a review and the changes as a result of this were still embedding. As a result of this the systems did not provide sufficient oversight to the board around clinical risks, such as physical health care and medicines optimisation to ensure that patients were not at risk of insufficient care and treatment. It was also unclear how findings from staff surveys, clinical audits and national enquiries were being used to develop the trust.

However:

At this inspection seven core services were rated as good, which was an improvement on the six rated good following the January 2015 inspection. Three core services had moved from being rated as requires improvement to good at this inspection. These were the ward for people with a learning disability or autism, the long stay/rehabilitation mental health wards for working age adults and the child and adolescent mental health ward.
Since the last comprehensive inspection of the trust the trust had developed and implemented an action plan for improvement. During this inspection we found that the majority of actions had been implemented and many improvements made to services and people’s experiences of these. This was particularly noticeable in the ward for people with a learning disability or autism at the Selden Centre and long stay/rehabilitation mental health wards for working age adults, where a number of improvements had been made to make the services safer and enhance the experience of patients.
Since the last inspection in January 2015 the trust had improved staffing levels to ensure that wards were safely staffed. The majority of staff were caring, kind and respectful towards patients, people who use services and their carers, involving them in decisions about their care. This had an impact on the care planning which, where in place, was generally good.
Since the last inspection the trust had improved access to physical healthcare and this was kept under regular review. Most areas had access to good physical healthcare support to meet patients’ needs.

The trust had clear information about the cultural diversity of populations across the different areas they served and they sought feedback about people’s experience of the care they received and future priorities. The trust had a clear strategy and initiatives to improve people’s experience.
The trust had a patient advice and liaison service that offered advice and support to people wanting to make a complaint.
The trust responded positively and proactively to concerns identified during the inspection and made marked improvements to the services to ensure patients were kept safe from the risks of medicines.
The trust had met the fit and proper persons test and there was very positive feedback about the leadership of the trust. The chief executive had had a positive impact on making staff feel more engaged and improving the culture of the trust. Staff felt positive and incorporated the trust values into their work.
From the 1 - 4 November 2016 we carried out a focussed inspection to follow up the Warning Notice served on the acute wards for adults of working age and psychiatric intensive care units, and wards for older people with mental health problems. At this inspection we identified that the trust had responded positively to the findings in the Warning Notice and significant improvements had been made. The trust had developed an action plan and staff were well aware of this and what they needed to do. The wards were being supported by senior managers, peer review and practice development nurses. The e-learning for physical health monitoring had been updated and all staff were receiving refresher training. The records we viewed showed that consent to treatment paperwork was recorded appropriately. The records relating to physical health monitoring for patients prescribed high dose antipsychotics and following intramuscular administration of rapid tranquillisation medicines demonstrated this was being carried out.
On the 7 December 2016 we carried out a focussed inspection to follow up the warning notice served on the specialist community mental health services for children and young people. At this inspection we identified that the trust had responded positively to the findings in the warning notice and significant improvements had been made. The trust had developed an action plan to ensure compliance with the trust target of 95% of risk screens completed. We looked at a random selection of 127 care records from 19 teams across Hampshire, Kent and Sussex. Out of the 127 care records we found only 4 risk screenings were missing, this equated to a 97% compliance rate for the records looked at. The trust target was 95%. This demonstrated a significant improvement from our findings in September 2016, where we found only 43% of risk screens having been completed.

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

The trust maintained safe staffing levels across teams. Turnover, sickness and vacancy rates were low in the teams we inspected. The trust managed vacancies pragmatically when they arose by discussing the needs of each team and varying staff skills accordingly. Staff in all teams were highly skilled, qualified and enthusiastic about their work. Staff accessed specialist training to improve their skills. Staff morale was high and all staff reported feeling supported by their team, local management and trust management.

Staff completed thorough risk assessments and reviewed risk appropriately. Risk assessments covered all areas. Staff reported manageable caseload numbers across all teams we inspected. Staff raised safeguarding alerts to the local authority competently and knew what to report.

Multidisciplinary and interagency working was excellent. We saw initiatives to improve working with mental health teams, dementia teams, social care and child and adolescent teams. We saw interagency working to promote the Transforming Care Agenda 2015. This aims to improve services for people with a learning disability and a mental health problem or behaviour that challenges. Staff promoted joint working agreements with relevant teams to prevent admission to hospital for people using the service. Staff provided high quality training packages to other teams and providers to raise awareness of learning disability issues and to improve care in these areas.

The service worked effectively with people who found it hard to engage. They provided bespoke packages of care to enable people to live in the community who may otherwise be in hospital.

Staff treated people using the service with respect and sensitivity. Staff really cared about the people they worked with. People using the service and their carers spoke positively about staff and the service they provided. The trust employed therapy assistants to ensure all staff and providers worked effectively with people with learning disabilities. All locations were accessible for people with physical disabilities and all locations provided easy read signage. Information, reports and care plans were all available in easily accessible formats.

The trust was committed to research and evidence based practice. Staff were proactive at trying out new initiatives and being involved in research and development.

However:

Staff did not complete crisis plans routinely. These plans inform people using the service and their carers who to contact or what measures to take in a crisis.

Staff reported incidents but did not always learn lessons from the investigations of these incidents. This meant services missed opportunities for improvement.

The trust recently introduced the electronic database, care notes. However, the trust had not implemented standard operating procedures. As a result, different teams and staff from different disciplines recorded information in different formats and in different sections. This meant it was not easy to find information in the notes as individuals recorded things differently.

Teams did not use outcome measures to monitor effectiveness and progress of interventions.

The teams did not routinely ask people using the service to complete satisfaction surveys. This meant that the teams missed opportunities to improve services in response to feedback.

At our last inspection in January 2015, we found the service required improvement. Since the last inspection the service had improved. This time we rated wards for people with learning disabilities or autism as good because:

Staff supported patients in a safe ward, which was clean.They identified risks in the ward and developed plans to keep patients safe.
Staff completed full assessments for patients, which included their individual needs and risks.They used these assessments and worked with patients to develop individualised care plans, which followed professional guidance.
Staff used safe techniques when restraining patients and reviewed incidents of restraint to see if they could support patients in a less restrictive manner in the future.
The ward multi-disciplinary team had an appropriate range of professional skills to meet patients’ needs. Staff worked well as a team and felt well supported.
Staff supported patients in a kind and considerate manner, whilst maintaining their privacy and dignity. We observed staff being very supportive to patients.The feedback we received from patients and their carers was positive. Staff involved people in the care they received.
The service had clear systems for reviewing quality information and implementing learning.Staff reported when things went wrong and investigated these incidents to identify how they could improve in the future. Staff had developed and completed improvement action plans following our last inspection, which rated the service requires improvement.During this inspection we found staff had implemented necessary changes and made many improvements.

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

During the comprehensive inspection of the trust from 13 – 15 September 2016 we found that patients were put at risk following the administration of intramuscular rapid tranquillisation. This was because staff were not monitoring or recording patients’ physical observations at regular intervals in accordance to ensure that patients were kept safe. We took enforcement action and served a Warning Notice to the trust to take action on this to keep patients safe.
Five of the eleven wards did not always comply with the Department of Health Eliminating Same Sex Accommodation requirements. The Burrowes, Larch, Meridian, Orchard and St Raphael wards. There was no female only lounge on The Burrowes ward and the ward only had one assisted bathroom and two shower rooms. All three of these rooms were on the female bedroom corridor so male patient would have to walk past female patients’ bedrooms to use these facilities. On St Raphael ward female patients had to walk past the male bedrooms to use the bathroom facilities.
Patients did not always have access to prompt specialist nursing services such as nutritional support, tissue viability, podiatry or diabetic services as the trust did not have a service level agreement with the local community NHS trust.

However:

From the 1 - 4 November 2016 we carried out a focussed inspection to follow up the Warning Notice. At this inspection we identified that the trust had responded positively to the findings in the Warning Notice and significant improvements had been made. The trust had developed an action plan and staff were well aware of this and of what they needed to do. The wards were being supported by senior managers, peer review and practice development nurses. The e-learning for physical health monitoring had been updated and all staff were receiving refresher training. The records we viewed showed that consent to treatment paperwork was recorded appropriately. The records relating to physical health monitoring for patients and following intramuscular administration of rapid tranquillisation medicines demonstrated that monitoring was being carried out.
Staff had a good understanding of the legislation they worked with daily such as the mental health Act and Mental capacity Act. They applied this appropriately and worked to the principles of the relevant codes of practice.
Staff across the inpatient wards were kind and respectful and people and their carers gave positive feedback on the care they had received. Staff were aware of the different needs of patients and offered patients support if they wanted to make a complaint.
We found that local leadership was visible and that staff spoke positively about their managers. Managers had the authority to get on with their job and were open and accountable.

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

Families, carers, and most young people spoke positively about those that cared for them. They told us that staff listened to them and informed and involved them in decisions about care and treatment. Care plans reflected this and were very holistic and personalised. Staff gave young people copies of their care plan. Carers told us that the consultant and other staff were accessible. They provided weekly updates and information to help the carer understand the current situation of the young person and their treatment. Staff made changes to the running of the unit in response to the views and opinions expressed by young people.

The unit provided young people with a range of activities and therapies. Young people on the unit had access to occupational therapists and psychologists. Staff also worked collaboratively with local authorities and community services to better understand and meet the range and complexity of the needs of young people.

Staff spoke enthusiastically about their roles and displayed a passion to meet young people’s needs. Staff demonstrated an empathy and understanding about the young people’s varying circumstances and a commitment to offering a professional, accountable service with a real desire to see young people move on in their lives.
Managers supported staff to develop and improve. Staff had good access to specialised training and received regular supervision and a yearly appraisal.
The unit was well-led. Staff felt supported by their managers and staff morale was good. Staff told us that managers were approachable and supported them to develop their role further. Carers spoke very highly of the leadership within the unit and felt this had an impact with the whole team. Carers told us that the unit had improved significantly over the past year.

However:

There was not always regular staff members on shift during the night.
There was a Mental Health Act Review visit in February 2016 that identified areas of improvement that needed to be addressed. An action plan for these improvements had been put in place.

We rated as forensic inpatient/secure services as good because:

Staff considered patient safety throughout their admission to the service. Each ward had a comprehensive ligature risk assessment and audit. Staff undertook environmental risk assessments regularly to ensure the continued safety of patients. Staff completed a comprehensive risk assessment for all patients at the point of admission and updated these at regular intervals. Patients were involved in their own risk assessment. Staff used recognised risk assessment tools such as the historical, clinical risk management-20.
Ward managers adjusted staffing levels to take account of busier periods on the ward. Each ward covered their vacancies with regular bank staff as far as possible. Use of agency staff was minimal. Managers ensured that the rotas allowed for patients to receive regular one to one sessions with their named nurse.
The service had good physical health provision. The Hellingly Centre employed an on-site GP and practice nurse and the Chichester Centre had a GP in attendance twice a week. The Chichester Centre also had a diabetes nurse specialist providing education to nurses and patients there about the management of diabetes. The wards used the monitoring early warning signs scale to ensure physical health checks were kept up to date.
The service had learnt from incidents and had introduced a new approach to ensure staff followed the observations policy as a result of a previous incident. Staff now completed a knowledge and skills assessment before they were able to complete observations on the ward. The observation policy now ensured staff interacted with the patient under observation, so they could monitor changes in a patient’s mental state and act accordingly.
The service had good governance systems in place. This was reflected in the high rates of mandatory training, staff appraisals and supervision. Safeguarding training compliance rates were 100% across the service other than on Ash ward which was 91% for safeguarding children, and Hazel ward which was 86% for safeguarding adults.
Patients were involved in their care on the ward and had opportunities to be involved in service development. Each ward held a daily community meeting which gave patients the opportunity to raise issues on the ward. Patients were involved in working together groups with staff, where staff and patients discussed service developments. Patients participated in their care planning and care plans were holistic, personalised and recovery focused.
Each ward had a full complement of mental health professionals. These included psychologists, social workers, occupational therapists, nurses, nursing assistants, and doctors. Each ward was supported by the pharmacy service at each site. The psychology service and occupational therapy service ran a full range of therapies and activities which were provided in groups or individually. Each team had regular team meetings and each ward had protected staff time for meetings and reflective practice sessions. Ward managers met on a regular basis to share learning and discuss service developments. Staff from the low secure and medium secure services could offer joint assessments to ensure patients were admitted to the most appropriate ward rather than having to be transferred at a later date. The wards each had a full range of rooms to support patients’ care. Each ward had a clinic room, therapy rooms and activity rooms. Each site had a gym and multi-faith room for patients to use. Patients on both sites had access to outside spaces. The garden areas had exercise equipment for patients to use. Patients were encouraged to be involved in maintaining the garden area and in the planting of flower beds on both sites.
The wards ran a ‘moving in/moving on’ group for patients who were due to move between wards, for example from the admissions ward to the treatment ward, or from a medium secure setting to a low secure ward. Patients could spend time on the new ward during the day and then return to their ward in the evening to help with the transition. Staff demonstrated a caring, supportive approach to patients. Staff gave patients one to one time and listened to and acted upon patients’ concerns.
Staff felt well supported by senior managers within the service. Staff reported that senior managers were always available and often visible on the wards. Staff felt they had the support of their manager, matrons, clinical director and service director. There was an open, transparent and supportive culture amongst staff on the wards. Staff reported high levels of job satisfaction and morale. All wards had achieved accreditation with the quality network for forensic mental health services. The service was involved in research and ran a clinical academic group. The focus of the current research was patients’ self-esteem. This area of research was chosen in collaboration with the patients.

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We rated long stay/rehabilitation wards for adults of working age as good overall because:

Clincal risk was well managed with risk assessments reviewed and updated in ward round meetings. Environmental risks were identified and addressed regularly and managers ensured that environmental risk assessments were regularly undertaken. These were shared with staff in monthly meetings. There weresystems in place for sharing information with staff around lessons learned

the average Patient Led Assessment of the Care Environment score for cleanliness across all services was 93%; with three of the services scoring 100%
staff on all wards provided patients with a full and comprehensive programme of therapeutic, recovery focussed activities and interventions. Activity plans were patient led and designed around personal needs and choices. All of the services promoted and encouraged positive risk taking within their ethos and actively supported patients towards independence.

there were enough staff to provide patients with regular 1:1 time and staff informed us that leave was not cancelled because of staffing levels. Patients confirmed that leave was regularly facilitated

overall compliance with mandatory training for the services was 81%. This was higher than the trust compliance rate of 65% - 75% in all areas of mandatory training

staff completed comprehensive assessments for all service users in a timely manner. All 30 care records we reviewed were up to date, personalised, holistic and recovery orientated. Records showed that patients had ongoing physical health monitoring, using national early warning scores needs and this was recorded in patient notes.

we observed positive therapeutic relationships between staff and patients at all wards and we observed strong local leadership across the wards, which staff and patients confirmed.

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

On some wards, staff did not always ensure that paperwork to obtain patients’ consent to treatment was complete and accurate. There was also missing information in some Mental Health Act paperwork on all wards except for Maple, Rowan and Oaklands wards. Out of the 126 medicine records we viewed on the initial inspection, 13 of these were incomplete or missing. For example, one patient was prescribed medicine for five months using a treatment authorisation appropriate only for the administration of emergency medicine. We reviewed mental capacity assessments on all the wards. On Jade ward, we reviewed two patient records where staff assessed patients’ capacity. However, the forms did not indicate if patients with capacity consented to receiving treatment. One informal patient on Jade ward was assessed as not having capacity to consent to treatment and was administered medicine on two occasions without appropriate authorisation under the Mental Health Act or Mental Capacity Act. This was also identified at the previous inspection of the trust in January 2015. We took enforcement action and served a Warning Notice to the trust to take action on this.
Patients were put at risk following the administration of high dose medicines and/or intramuscular rapid tranquillisation. This was because staff were not monitoring or recording patients’ physical observations at regular intervals in accordance to ensure that patients were kept safe. We took enforcement action and served a Warning Notice to the trust to take action on this to keep patients safe (included in same Warning Notice as above).
On four wards there were pieces of clinical equipment either missing, not working or out of date.
Patients routinely did not have a bed to return to on the same ward after a long period of leave from the ward. It was trust policy not to keep leave beds empty. This meant that patients did not want to have leave for fear of not having a bed to return to. Also, when patients returned to the ward after leave, they were sometimes referred out of area or to other wards were there was bed availability.

Staff did not always update risk assessments following incidents on the ward.
There were areas of least restrictive practice on Maple, Rowan and Oaklands wards where staff operated open ward environments. However, there was a blanket restriction on Amber ward where patients were unable to use their mobile phones and were supervised when making calls using office telephones.
Not all staff had mandatory training or supervision.

However:

Across all wards, patients were generally happy with the care they received.
From the 1 - 4 November 2016 we carried out a focussed inspection to follow up the Warning Notice. The trust had responded positively to the Warning Notice and made significant improvements. The trust had developed an action plan and staff were well aware of this and what they needed to do. The wards were being supported by senior managers, peer review and practice development nurses. The e-learning for physical health monitoring had been updated and all staff were receiving refresher training. The records we viewed showed that consent to treatment paperwork was recorded appropriately. The records relating to physical health monitoring for patients prescribed high dose antipsychotics and following intramuscular administration of rapid tranquillisation medicines demonstrated this was being carried out.
The majority of staff were kind, caring and built positive relationships with patients, their families and carers.
The psychologist on Caburn ward developed a ‘therapeutic keyring’ containing distraction activities and emergency contact numbers to support patients when they were distressed.

We rated the wards for older people with mental health problems as requires improvement because:

Five out of six wards we visited did not meet the Department of Health guidance on eliminating mixed sex accommodation.
We did not see evidence of regular supervision in the 16 staff files we viewed.

However:

The trust had taken action to address and manage all of the ligature risks identified on the wards. However, the ligature risk assessment tool did not have dates to show when works would start or be completed by.
There was good medicines management on all wards we visited.
There was learning from incidents which resulted in new ways of working in some areas.
All 16 care plans we read were person centred and included information gathered from patients, carers and other health professionals. However, not all care plans were signed or indicated if patients or carers had been offered or received copies.
National Institute of Health and Care Excellence guidelines were followed on Larch Ward when prescribing medicines to patients.
Staff explained patients’ rights to them when they were admitted on to the wards we visited. There were notices inside ward entrance doors explaining why they were locked and that patients could speak with staff to discuss if they wanted to leave the ward.
Section 17 leave records we viewed were up to date.
The paperwork we viewed for patients who were detained was in date and completed correctly.
During our visit, staff were kind and caring when interacting with patients.
Staff told us how they managed care planning in ways which reduced stress to patients with advanced dementia.
During our visit, we spoke with two carers who said that staff involved them very much in planning care for their family members. This was documented in care plans.
Some wards focused on carer involvement in their regular staff governance meetings.
On Burrowes ward, staff offered patients a choice of drinks and food during lunch time.
Feedback gathered from the trust’s patient safety peer reviews and friends and family test showed that carers and patients found staff to be compassionate, caring and kind.

Overall, we rated the trust as requires improvement and this was because;

Two core services were rated as inadequate under safe.
The trust had no plan in place to tackle the high rate of suicide.
There were significant gaps in the flow of information, particularly around learning from serious untoward incidents.
There were significant gaps in training, appraisal and supervision for some staff.
The quality of care planning was inconsistent and did not always demonstrate how people were involved in their care.
The trust lacked strategic direction.
The trust had gaps in relation to providing the board with assurance

However, caring in some areas was rated as outstanding and the trust is a place of innovation and ideas. It also clearly aspires to best practice in many parts of the services provided.

There were inconsistencies in how services were managed and we found that some areas of care in learning disability and older people's inpatient services were inadequate. These services require urgent attention to bring them up to acceptable standards of safety. We asked the trust to close Hanover Crescent (part of their rehabilitation services) to admissions due to an unsafe environment, with poor conditions of hygiene and low levels of staffing. The trust did this immediately.

It was clear that the trust recognised that some areas are facing particular challenges and we found the managers and directors of the service were responsive to our challenge and acted swiftly to put things right.

We have recommended a number of requirement notices to be put into force and these relate to ensuring that standards of hygiene are maintained, that staff are properly supported to receive their mandatory training, that risks are properly identified and that care plans involve people.

There was an elevated risk of people self-harming or committing suicide. Many of these deaths happened whilst people were in receipt of services in the community.

There was an elevated risk of suicide within 3 days of discharge and within 3 days of being admitted to an acute setting. In total there were 80 deaths in the period from 1 November to 31 October 2014. Whilst we recognise that it is not just the trust's responsibility to develop a suicide prevention plan, we would urge the trust to initiate urgent work with public health and community agencies to address this.

We were concerned that staff were not receiving timely feedback in relation to serious untoward incidents. We therefore asked the trust to supply us with details of length of time it took from notification of a serious untoward incident to time the report and action was completed and circulated. From the data supplied to us from the trust, it is struggling to meet timescales, with some investigations taking 220 days from start to finish. This may impact on their ability to close the loop on serious incidents and ensure that learning to avoid / prevent similar incidents from emerging is shared. The current average time taken to of completed reports of from serious untoward incidents is about four approx. 4 months. The trust must work to address this.

The staff survey identified that there was an elevated risk to staff working extra hours and feeling stressed. The trust has a clear action plan to address this. This includes reviewing the staffing levels and skills mix on inpatient units and reviewing the use of three -day 12 ½ hours shift rotas.

At the time of the inspection, the Trust acknowledged that there was not a system in place to clearly identify clearly where ‘agency’ staff were used. The Trust raised this with CQC prior to the inspection.

Overall, caring was rated as good, achieving outstanding in community child and adolescent services and forensic services. This was because staff were found to be compassionate, kind and motivated to go an extra mile for the people they served. We also found good solid evidence that the trust was sensitive to individual needs, taking cultural, religious and spiritual needs into account. They also provided good information to people and this was available in a variety of languages and formats.

The trust is a place where innovation is given priority and this enables them to seek new ways of working and bring about change to service delivery. There is much creativity at a senior level. We would urge the trust to continue to ensure that the quality of more traditional services is are maintained and that the desire to seek new and innovative ways of working is not at the expense of those services.

The senior management team were very positive about the new Chief Executive Officer (CEO). They felt that having been through a difficult and challenging period and that the culture of the board had changed for the better. We found the senior team to be open and transparent in their discussions with us. The CEO was able to describe the challenges facing Sussex.

It was clear that the trust were in a period of some significant change, including a cultural change. We heard from staff and stakeholders that relationships at times with the trust had been difficult to manage at times but that this was becoming more positive. Many felt that the new CEO was responsible for bringing in a more visible and open approach. The trust did not have a clear strategic direction that which was written down and understood by staff. The trust also lacked a framework to which ensured that the board were clear about and understood the more detailed risks and challenges facing the organisation. It had identified the principal principles risks faced by the organisation.

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.

These older reports are from our old approaches to inspection, including those from before CQC was created.

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.

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.

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.

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