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Provider: Northumberland, Tyne and Wear NHS Foundation Trust Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 26 July 2018

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

  • We rated effective, caring, responsive and well-led as outstanding, and safe as good. We rated nine of the trust’s 15 services as outstanding overall and six as good. In rating the trust, we took into account the previous ratings of the services we did not inspect this time.
  • We rated well-led for the trust overall as outstanding. The leadership, governance structures and culture within the trust were used to effectively drive and improve the delivery of high quality person-centred care. Leaders had a comprehensive understanding of the challenges faced by the trust and worked collaboratively to develop solutions.
  • Leaders strived to continually review and improve services. The collective leadership model and operational locality delivery structures meant that staff were empowered to drive improvement at all levels of the organisation. Innovation and new initiatives were celebrated both within the trust and externally.
  • The quality of performance data was outstanding. Staff at all levels had access to a wide range of real time data which was used to actively inform and shape how services were delivered and how care was provided. Staff on child and adolescent mental health wards used data to change practice. This had resulted in reduced use of restrictive physical interventions for patients.
  • Staff maintained high compliance rates for mandatory training.
  • There was an open incident reporting culture. Staff knew how to report incidents and there was evidence of learning from these. Staff received debriefing after serious incidents. There were comprehensive arrangements and procedures to safeguard children and young people. Staff in all services inspected demonstrated a good understanding of safeguarding and knew how to protect patients from abuse and report any concerns appropriately.
  • Child and adolescent mental health wards and specialist community mental health services for children and young people had a truly holistic approach to assessing, planning and delivering care and treatment to patients. Patients had access to an extensive range of evidence based interventions. Staff worked consistently to ensure patients lived healthier lives and developed individualised approaches to meeting the physical and mental health needs of patients.
  • The trust worked collaboratively with other organisations to ensure the highest provision of care for patients. This included facilitating training by specialists to enable staff on the wards to deliver the best care and treatment possible, particularly for patients with complex needs. Staff on inpatient mental health wards worked closely with community teams to facilitate effective discharge pathways for patients. The trust was working collaboratively with commissioners and staff to design specialist community based services for children and young people to prevent admission to hospital.
  • Feedback from people who used the services, those who are close to them and stakeholders were continually positive about the way staff treat people. People said that staff go the extra mile and care exceeded expectations.
  • There was a strong and visible person centred culture. Staff in all services we inspected were highly motivated to offer care that was kind and promoted people’s dignity. Relationships between staff and people who used services and their carers were supportive and caring.

However:

  • The trust acknowledged there was more work to do to review restrictive practices including blanket restrictions across all inpatient services. The trust identified this was an area of development. Whilst there was evidence of significant reduction in the use of mechanical restraint and every use was based on individual risk assessment and subject to director level authorisation, this intervention in the management of violence and aggression was still being used.
  • Staff appraisal rates were slightly below the trust target. Whilst there was no trust target for clinical supervision rates, some services had lower levels of clinical supervision. There were delays in staff receiving formal written outcomes following disciplinary and grievance procedures.
  • In acute wards for adults of working age and psychiatric intensive care units, staff were not always monitoring the physical health of patients after rapid tranquilisation. Seven of these wards did not have nurse call alarms.
  • Waiting times for treatment in community specialist mental health services for young people did not always meet the trust target of 18 weeks for certain specialist treatment pathways.
Inspection areas

Safe

Good

Updated 26 July 2018

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

  • We rated 14 of the 15 core services as good and one as requires improvement. The rating of the safe domain had improved from requires improvement to good in child and adolescent mental health wards, but the rating had gone down in the safe domain from good to requires improvement in acute wards for adults of working age and psychiatric intensive care units. We took into account the previous ratings of services we did not inspect this time.
  • On child and adolescent mental health wards and wards for older people with mental health problems, there was an impressive use and analysis of incident data which staff used to change practice. This had resulted in reduced use of restrictive physical interventions for patients.
  • Staff on wards for older people with mental health problems managed and administered medicines safely. Wards had dedicated pharmacy support.
  • Staff maintained high compliancy rates with mandatory training.
  • There was an open incident reporting culture. Staff knew how to report incidents and there was evidence of learning from these. Staff received debriefing after serious incidents.
  • There were comprehensive arrangements and procedures to safeguard children and young people. Staff in all services inspected demonstrated a good understanding of safeguarding and knew how to protect patients from abuse and report any concerns appropriately.
  • Staffing levels were sufficient to meet needs of patients and staff had appropriate skills and knowledge. On child and adolescent mental health wards, the level of bank and agency staff usage and shifts left unfilled had significantly reduced since our last inspection.
  • In community specialist mental health services for children and young people there were effective lone working procedures embedded.
  • Staff assessed and identified mental and physical health risks and put plans into place to manage these.

However:

  • In acute wards for adults of working age and psychiatric intensive care units, staff were not always monitoring the physical health of patients after rapid tranquilisation.
  • In acute wards for adults of working age and psychiatric intensive care units, we found a number of blanket restrictions on some wards within this service and these were not being routinely reviewed. Seven of these wards did not have nurse call alarms.
  • Whilst there was evidence of significant reduction in the use of mechanical restraint and every use was based on individual risk assessment and subject to director level authorisation, this intervention in the management of violence and aggression was still being used.
  • Whist there was an effective process of triage, which enabled the trust to identify higher risk referrals, there was no system for routinely monitoring the risks of young people on the waiting list for treatment.
  • Some risk assessments on wards for older people with mental health problems were brief and not dated.

Effective

Outstanding

Updated 26 July 2018

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

  • We rated seven of the 15 core services as outstanding and eight as good. The rating of the effective domain had improved from requires improvement to good in wards for older people with mental health problems, and from good to outstanding in child and adolescent mental health wards. The rating of the effective domain remained outstanding in community specialist mental health services for children and young people and good in acute wards for adults of working age and psychiatric intensive care units. We took into account the previous ratings of the services we did not inspect this time.
  • Child and adolescent mental health wards and specialist community mental health services for children and young people had a truly holistic approach to assessing, planning and delivering care and treatment to patients.
  • Patients in child and adolescent mental health wards and specialist community mental health services for children and young people had access to an extensive range of evidence based interventions. Staff worked consistently to ensure patients lived healthier lives and developed individualised approaches to meeting the physical and mental health needs of patients.
  • Staff supported patients with complex needs on child and adolescent mental health wards by facilitating training by specialists to enable staff on the wards to deliver the best care and treatment possible.
  • Staff on child and adolescent mental health wards and in specialist community mental health services for children and young people worked collaboratively with each other and with patients and their families. Young people were actively involved in reviewing their progress towards goals and outcomes.

However:

  • On acute wards for adults of working age and psychiatric intensive care units staff were not consistently documenting assessments of mental capacity and best interest decisions.
  • Staff on wards for older people with mental health problems did not always add written recordings of patients’ physical health checks and dietary intake to the electronic patient care record in a timely manner.
  • Staff in specialist community mental health services for children and young people assessed the competency of young people; however this was not always easily accessible within patient records.

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Caring

Outstanding

Updated 26 July 2018

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

  • We rated eight of the 15 core services as outstanding and seven as good. We found caring had improved from good to outstanding in wards for older people with mental health problems. The rating for the caring domain remained good for acute wards for adults of working age and psychiatric intensive care units and child and adolescent mental health wards. The rating for the caring domain remained outstanding for community specialist mental health services for children and young people. We took into account the previous ratings of the services we did not inspect this time.
  • Feedback from people who used the services, those who are close to them and stakeholders was continually positive about the way staff treat people. People said that staff go the extra mile and care exceeded expectations.
  • There was a strong and visible person centred culture. Staff in all services we inspected were highly motivated to offer care that was kind and promoted people’s dignity. Relationships between staff and people who used services and their carers were supportive and caring.
  • Staff knew patients well and the emotional and social needs of patients were valued by staff and informed care and treatment.

However:

  • Staff on child an adolescent mental health wards involved young people in their care and treatment, although this was not always reflected in care plans. On acute wards for adults of working age and psychiatric intensive care units, some care plans contained medical terminology which meant these may not be easily understood by patients.

Responsive

Outstanding

Updated 26 July 2018

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

  • We rated six of the 15 core services as outstanding and nine as good. The core services we inspected this time remained rated as good. We took into account the previous ratings of the services we did not inspect this time.
  • Staff in mental health inpatient services worked collaboratively with community teams to support discharge planning. Staff worked closely with families or community teams prior to discharge to ensure the needs of patients were understood.
  • Patients had access to a range of activities, including during evenings and weekends.
  • On child and adolescent mental health wards, patients had good access to education provision.
  • Patients knew how to raise concerns and submit complaints. They reported that staff were supportive and helped them to resolve issues.
  • The trust was working collaboratively with commissioners and staff to design specialist community based services for children and young people to prevent admission to hospital.

However:

  • Waiting times for treatment in community specialist mental health services for young people did not always meet the trust target of 18 weeks for certain specialist treatment pathways.
  • On child and adolescent mental health wards, records showed evidence of discharge planning and discussions but formal discharge plans were not present.
  • Four acute wards for adults of working age and psychiatric intensive care wards had dated environments. The trust had recognised this and was implementing an improvement plan.

Well-led

Outstanding

Updated 26 July 2018

Our rating of well-led stayed the same. We rated it as outstanding because:

  • We rated nine of the 15 core services as outstanding and six as good. We found the well-led domain had improved from good to outstanding in child and adolescent mental health wards and in specialist community mental health services for children and young people. The rating for acute wards for adults of working age and psychiatric intensive care units and wards for older people with mental health problems remained rated as good. We took into account the previous ratings of the services we did not inspect this time.
  • The leadership, governance structures and culture within the trust were used to effectively drive and improve the delivery of high quality person-centred care.
  • The trust had carried out a significant organisational restructure in October 2017, and invested in high levels of staff engagement during this time. The inspection team were struck by how cohesive the new structures and governance arrangements were, in the short period of time since implementation.
  • The trust had implemented a collective leadership model which supported the aim of devolved decision making. There was a strong desire to ensure that decisions were taken as close to the delivery of care as possible, to ensure the needs of patients and local populations were met. Devolved decision making was supported by a robust accountability framework which managers at all levels understood. New and aspiring managers had a range of development opportunities.
  • Leaders had an inspiring shared purpose and demonstrated integrity and humility in their ambition to continuously improve outcomes for people who used the services and their families and carers. Leaders were visible and approachable and engaged effectively with staff. Staff across the trust spoke highly about senior leaders in the organisation.
  • Leaders had a comprehensive understanding of the challenges faced by the trust and worked collaboratively to develop solutions. We saw examples of a wide range of initiatives developed in partnership with other organisations.
  • The trust had developed a truly collaborative approach to working with staff, people who used the services, families and carers and external stakeholders. The trust strategy for 2017-2022 had been developed through a model of co-production. Annual quality priorities were developed in collaboration with staff, patients, families and carers, governors and other stakeholders.
  • Strategies and plans in place were challenging and innovative and fully aligned with the wider health economy. There was a systematic and integrated approach in place to monitor the progress against plans. Plans were consistently implemented and had a positive impact on the quality of services.
  • Leaders strived to continually review and improve services. The collective leadership model and operational locality delivery structures meant that staff were empowered to drive improvement at all levels of the organisation. Innovation and new initiatives were celebrated both within the trust and externally.
  • The trust was committed to driving and improving the delivery of high quality person-centred care. The trust had a high level of commitment to partnership working to ensure holistic pathways were in place to support patients. The trust was a significant partner in the development and delivery of the local transformation and sustainability plan, leading the mental health work stream.
  • The quality of performance data was outstanding. Staff at all levels had access to a wide range of real time data which was used to actively inform and shape how services were delivered and how care was provided. There was evidence of significant positive impact on patients as a result.
  • The trust identified, monitored and responded to current and future risks. The trust had developed a risk appetite framework which clearly defined the level of acceptable risk to the organisation to meet the strategic aims. Risk management was part of the devolved decision making arrangements, with a clear escalation process in place. This gave managers at different levels of seniority the framework by which to effectively manage risk.

However:

  • The trust acknowledged there was more work to do to review restrictive practices including blanket restrictions across all inpatient services. The trust identified this was an area of development.
  • Staff appraisal rates were slightly below the trust target. Whilst there was no trust target for clinical supervision rates, some services had lower levels of clinical supervision.
  • There were delays in staff receiving formal written outcomes following disciplinary and grievance procedures.

Checks on specific services

Child and adolescent mental health wards

Outstanding

Updated 26 July 2018

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

  • Staff worked in creative and flexible ways to ensure that patient’s physical health was monitored effectively and that patients lived healthier lives. Physical health care was fully embedded into care and treatment. Where patients had complex needs, staff created graded exposure plans informed by formal assessments to work towards physical health monitoring. Staff worked with patients to enable them to take their own physical health measurements.
  • The services worked in a truly holistic and individualised way to assess, plan and provide care and treatment to patients. This involved where appropriate seeking specialist treatments including input from experts, specialist training for staff and following best practice guidance and recommendations for meeting the needs of patients with eating disorders.
  • Staff committed to an open culture and commitment to reflection following incidents. A dedicated trained responsive oncall debrief facilitator was present on Lennox and Ashby. They responded to incidents and led patient and staff debriefs following incidents. On all wards, debriefs from incidents fed into reflective practice sessions and into patients’ clinical team meetings.
  • The trust had invested in, built and developed a model of care and an innovative bespoke system. Talk First focused on delivering safe and positive care and followed the principles of positive behavioural support, reducing the use of restrictive interventions and worked well with the initiatives Safe wards and Star wards. The system was not burdensome on staff as it generated an automated dashboard to analyse incidents live from incident reporting systems. The data could be reviewed by many different factors. Staff teams embedded individual patient dashboard reviews into patients’ clinical team meetings where they used the information to change practice. Trends and themes from incidents were integrated into ward environmental risk assessments. External lessons learnt were also incorporated into environmental risk assessment to assess dynamic risks.
  • The services had clear leadership and governance structures following the recognised collective leadership model. The trust had invested in training to ensure leaders had the capacity and capability to deliver effective leadership in practice. Staff reported high levels of engagement, satisfaction and morale. They felt confident if they had any concerns to raise these. The services had clear frameworks of meetings with mechanisms to escalate and cascade information from ward to clinical business unit levels.
  • Leaders and frontline staff were working with commissioners to deliver changes in service models in line with the Transforming Care Agenda. This had led to the closure of some beds and more beds were expected to close. The trust was developing specialist community based mental health services aimed at providing effective treatment and preventing hospital admission.
  • Three wards had achieved Full Monty award from Star wards for implementing all 75 positive initiatives. They had also increased the duration of handover time to 30 minutes for all wards and reduced the use of bank and agency staff including the amount of shifts left unfilled.
  • Patients and their carers were meaningfully involved as partners in care and treatment. Staff knew patients and their individual needs very well. Observations demonstrated that staff were calm, positive and responsive to patients’ needs. Patients were involved in local recruitment for some staff vacancies.
  • The trust had invested in improving the environments to ensure these were more therapeutic, recovery focussed and comfortable. This had included work to overcome the environmental challenges of the historical build of Alnwood and the opening of a dedicated area at Ferndene for day service activities to take place.
  • The services had 91% compliance rate for mandatory training.
  • Staff understood and demonstrated their responsibilities in relation to safeguarding, Mental Health Act and the Mental Capacity Act.

However:

  • Although the trust had invested in and made a significant commitment to reducing the use of restrictive interventions including reducing mechanical restraint by 68%, there were 84 uses of mechanical restraint between January to December 2017. All use of mechanical restraint was subject to individual risk assessment and subject to director level authorisation.
  • We found some ligature points that the trust could remove on Fraser and Riding wards to further reduce risk.
  • Care plans did not always reflect patient involvement and patient views that staff had sought. Although staff discussed discharge and made plans, care plans did not contain information on discharge planning.

Specialist community mental health services for children and young people

Outstanding

Updated 26 July 2018

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

  • Care records contained up to date individual risk assessments and management plans. Staff could review complex cases in a multidisciplinary risk meeting and seek support and guidance to ensure risks were appropriately managed.
  • Staff worked collaboratively with young people and their family/carers to efficiently deliver care in an outcomes based approach. Young people were actively involved in reviewing their progress towards their goals and outcomes.
  • Staff were trained in an extensive range of therapeutic interventions in line with National Institute of Health and Care Excellence recommendations.
  • Care plans captured the voice of the young person and placed them at the centre of their care.
  • Managers and commissioners were working together to reduce waiting lists and ensure the service met the needs of children and young people locally.
  • Key performance indicators were embedded within the service and effective governance processes were in place to monitor the quality of the service provided.

However:

  • Assessment of Gillick competence was not easily accessible in young peoples care records.
  • The service was not always meeting the trusts target of 18 weeks from referral to treatment for certain specialist treatment pathways. Whilst there was an effective process of triage, which enabled the trust to identify higher risk referrals, there was no system for routinely monitoring the risks of young people on the waiting list for treatment.

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

Good

Updated 26 July 2018

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

  • The service was providing effective care. All patients had a care plan which was regularly updated. Patients had access to a range of care and treatment options which were in line with national guidance. Staff were supervised effectively and had access to additional specialist training. Staff understood and implemented the Mental Health Act and Mental Capacity Act effectively.
  • Staff were caring. Feedback from patients and carers was consistently positive about staff attitudes. The service was organised in a way that ensured staff focussed on interacting and engaging with patients as opposed to administrative tasks. Care records showed evidence of ongoing patient involvement and engagement through regular one to one sessions with nursing staff. Carers told us that they felt appropriately informed and involved in the care provided by the service.
  • The service was providing care in a way that was responsive to people’s needs. Beds were managed appropriately to ensure that people could access the service when they needed it. Wards had a range of facilities to promote comfort, privacy and dignity. Most wards had good accessibility. The service could access interpreters, translators and other services designed to meet individual needs.
  • The service was well-led. There was a stable management team with managers at all levels who had the skills, knowledge and experience to perform their roles. Ward managers and senior managers were highly visible on the wards and staff told us that managers at all levels were approachable. Almost all staff we spoke to told us that they felt respected, supported and valued. There were good systems and processes in place to assess and monitor quality and safety on the wards.

However;

  • There were areas of improvement to maintain safety on the wards. Staff were not monitoring the physical health of patients after the administration of rapid tranquilisation. Several wards had implemented blanket restrictions. The service was not regularly reviewing blanket restrictions. Nurse call alarms were not available in patient bedrooms on seven of the eleven wards. Ligature risk assessments on two of the eleven wards had not identified all potential ligature points in patient accessible rooms.

Wards for older people with mental health problems

Good

Updated 26 July 2018

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

  • There were good patient risk assessments on each ward. The service provided a safe environment and managed risks well. Patients told us they felt safe. Risk assessments included monitoring of existing and potential physical health risks.
  • Staff understood that the use of restraint was a last resort. They used de-escalation and low levels of restraint to manage incidents of aggression wherever possible. Staff ensured they documented episodes of seclusion, restraint, and rapid tranquilisation in accordance with trust policy. The ward took part in the trust restrictive interventions reduction programme and reported incidents of restraint appropriately.
  • Patients had detailed, personalised care plans, which included information about physical health needs. Patients and their carers felt involved in decisions about their care. Staff gathered information from families and carers to complete the Newcastle model of assessment record for patients with cognitive impairment. This reflected a patient’s history and preferences and contributed to their care plan. They used the five P’s assessment tool for patients with a functional mental health issue.
  • There was effective multi-disciplinary team working with regular reviews of patients care and treatment needs. We saw the Mental Health Act, detention papers and associated records completed appropriately. Staff understood the application of the Mental Capacity Act. They recorded best interest decisions including when significant decisions were made for patients who lacked capacity.
  • Patients, families, and carers appreciated and spoke highly about the quality of care and treatment the service provided. Staff involved patients in decisions about their care where possible. They engaged with and supported families and carers where appropriate. Staff contacted families and carers with updates on patient progress, held regular carers meetings, and invited them to reception meetings.
  • The service accommodated patients in trust beds and sent them out of locality rather than out of area, they moved patients back to their local areas as soon as they were able, this meant carers could visit more easily. Staff worked towards discharges from the point of admission and where possible staff visited care homes and/or families to discuss the level of support the patient would need when they left hospital.
  • On the functional disorder wards, activities were structured and planned whilst in the organic wards activities were ad-hoc and individualised. All of the wards had activity workers who worked shift patterns; this meant they were available to assist staff with activities on evenings and weekends.
  • Internal changes within the service had led to a positive change in culture. Staff focused on the needs of the people using their service, providing high quality patient centred care, which reflected the trust’s vision and values. However:

However:

  • On Castleside, there was an unpleasant smell and signage on the doors had been ripped off as well as flooring that had been damaged by a patient.
  • We looked at 32 patient records and each patient had a risk assessment in place. However, some of the information was very brief, a question was answered with a tick and no explanation, and some of the information was not dated.
  • Staff kept written records throughout the day of the patients’ dietary intake, their health checks and how their mood was. This information was added to the progress notes on the computer. However, we saw that these notes were not always added to the record in a timely way.

Long stay or rehabilitation mental health wards for working age adults

Outstanding

Updated 25 July 2018

We did not rate long stay/rehabilitation wards for working age adults at this focused inspection. All ratings shown in this report are from our previous inspection in June 2016.

We found the following issue that the trust needs to improve:

  • Patients identified as being at risk of choking or swallowing on Bridgewell ward did not have this documented in their risk assessment, although these were reflected in care plans.

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

  • Patients’ risks were being assessed, monitored, and managed on a daily basis. Staff recognised changes in risk and responded appropriately.

  • Staffing levels were adequate to keep people safe and effective handovers were taking place to ensure staff were able to manage risks.

  • Staff were raising concerns and reporting incidents. These were investigated appropriately and lessons were communicated widely to support improvement.

  • Patients were receiving a comprehensive assessment of their needs. Care and treatment was delivered through care plans, which reflected their needs.

  • Staff had the skills required to deliver care and treatment. Learning needs were being identified and training was delivered to meet these needs.

  • Staff were working together to assess, plan and deliver care and treatment.

Mental health crisis services and health-based places of safety

Good

Updated 1 September 2016

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

:

  • The service had effective systems to assess, monitor, and manage risks to people who used services. There was a clear pathway for people to access services including those people who referred themselves to the crisis teams.
  • People who used services received care which focused on their needs and was based on recovery. Care records were of a high standard and most people who used services felt fully involved in their care planning.
  • There was good inter-agency working with Northumbria police. The introduction of the street triage service had led to a significant reduction in the number of people detained under section 136 of the Mental Health Act.
  • Staff provided kind and compassionate care and treated people who used services with dignity and respect.
  • Staff provided support to carers and with consent included them in their relatives care.
  • Staff received feedback from incidents and complaints. There were systems in place for learning and sharing from incidents and complaints to be cascaded.
  • Overall compliance with mandatory training was good. Where areas were low managers had actions in place to improve.
  • Staff were receiving supervision and had had an annual appraisal. Managers had taken steps to improve compliance with supervision. The steps taken had made a difference.

However:

  • The service had an action plan with environmental improvements needed for two of the health based places of safety. There was not a date for completion of some of these required actions.
  • There were conflicting reports from staff regarding how many staff should be available for police to hand over a detained person in the health based places of safety.
  • There was not access to a full range of disciplines in the crisis teams. Staff told us they would like more access to psychology, occupational therapy and social work support.
  • Some professionals reported delays in accessing services via the telephone response service.
  • Staff removed medication from their original containers for people to use in their own homes which constituted secondary dispensing.

Community-based mental health services for older people

Outstanding

Updated 1 September 2016

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

  • There was a truly holistic approach to assessing, planning and delivering care and treatment to patients. Staff were responsive to individual patient’s needs and actively engaged in assessing and managing risk. Staff worked effectively together to share knowledge and deliver evidence-based treatment to patients.

  • Staff empowered patients and carers to have an active role in their care and treatment. Staff developed positive relationships with patients and carers to ensure their needs and individual preferences were reflected in the planning of their care. Patients and carers reported staff went the extra mile and exceeded their expectations.

  • The services were flexible, provided choice and ensured continuity of care for patients. Patients could access services in a way and at a time which suited them. Staff worked collaboratively with other services, within integrated person-centered pathways to ensure they met patients’ needs.

  • Staff were committed to continually developing their skills and competencies to ensure they delivered high quality care. Staff attended additional specialist training to enable them to acquire new skills and share best practice. Staff were encouraged to take an active role in research and innovative practices.

  • Leaders had an inspiring shared purpose which succeeded in developing a strong, visible person-centered culture. Staff were highly motivated to offer high quality care and were proud of the service they delivered.

  • Leaders consistently engaged with staff and actively encouraged them to raise concerns. Staff were open and transparent in reviewing incidents and learning lessons when things went wrong. Staff shared this learning across the trust and this was used to inform service development.

However:

  • Staff caseloads were high in some services and some services felt they did not have sufficient administrative support. Managers were aware of this and were continually reviewing ways to develop systems and processes to address these issues. Managers had sufficient authority to increase staffing levels as required.

Forensic inpatient or secure wards

Good

Updated 1 September 2016

We rated Northumberland, Tyne and Wear NHS Foundation Trust Forensic Inpatient/Secure wards as good because

:

The service was built around a principle of person centred practice, which was representative of the trusts values, this was demonstrated through the interactions we observed between staff and patients. Staff were seen to demonstrate dignity, respect and an understanding of individual needs within their interactions with patients.

There was an open culture in the service and patients were able to approach staff or managers for support at any time. Patients’ views were sought through regular 1:1 time, weekly multidisciplinary meetings and clinical case reviews; these were reflected in patients care planning, individual therapeutic programme and outcome measures. Patients were also encouraged to provide feedback on the service through the use of comments cards and regular community meetings.

The service held a weekly multidisciplinary single point of referral meeting which included representation from NHS England. All new referrals were discussed to decide if the service could meet the needs of the patient and which ward would provide the most appropriate care pathway. Patients received a multidisciplinary pre-admission assessment, which included an assessment of patients’ physical health and any on-going support which may be required following admission.

Patients had the support of a full multidisciplinary team who worked with patients to provide an individualised support package specific to the patients needs including a range of psychological and occupational therapies. Facilities within the service supported this through the provision of therapy rooms, therapeutic kitchen, activity rooms, a gym and an all-weather outdoor sports arena. The service also had links within the community to provide patients access to activities including an allotment and walking groups.

Patient completed both a Functional Analysis of Care Environments and Historical Clinical Risk assessment with staff. These were live documents which were updated as needs changed or a minimum of every three months. Oswin ward had also developed a formulation pathway for patients which included input from the patients and all relevant professionals to ensure the service had a full risk profile of the patients.

The principles of relational security were embedded within the service and all staff we spoke to were able to describe the importance of this. The use of restraint and seclusion was low, this was seen as a last resort and staff used their knowledge of and relationship with patients to identify potential trigger points and de-escalate behaviours before issues arose

The seclusion room on Aidan did not meet the recommended standards for seclusion facilities, the service was aware of this and work had begun on building new ‘Gold standard’ seclusion facilities.

When incidents did occur there was a process of providing a debrief for both the staff and patients involved. Incidents were monitored and reviewed; lessons learned were shared across the service and discussed within team meetings. The staff we spoke to were able to articulate their responsibility under the Duty of Candour and provide examples of when they would need to fulfil this responsibility. The trusts electronic incident recording system provided prompts for staff to consider the need for the Duty of Candour.

Staff morale was seen to be high across the service; staff were aware of the trusts visions and values and could describe how these were embedded from the point of recruitment in to supervision and appraisals.

Community mental health services with learning disabilities or autism

Outstanding

Updated 1 September 2016

We rated community based services for people with learning disabilities or autism as outstanding because:

  • A proactive approach to anticipating and managing risks to people who use services was embedded and was recognised as being the responsibility of all staff. This was reflected in the risk assessments and plans.

  • Staffing levels were sufficient to meet the needs of the service. Staffing levels had been estimated by obtaining the advice of staff, carers and other agencies. This model had been implemented in the Sunderland team and was in the process of being rolled out to other teams.

  • Staff knew how to report incidents. All staff were open and transparent, and fully committed to reporting incidents and near misses.

  • There was a team approach to the prescribing of medication. The approach ensured that psychological and social factors were given full consideration before medication was prescribed. This meant that service users were less likely to be prescribed medication unnecessarily.

  • There was a truly holistic team approach to assessing, planning and delivering care and treatment to people who use services. The safe use of innovative and pioneering approaches to care and how it was delivered were actively encouraged. New evidence based techniques were used to support the delivery of high quality care.

  • We found the continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice. This was reflected in the specialist training provided and the effectiveness of multidisciplinary meetings.

  • Staff had close links with external agencies, including them in multi-disciplinary team meetings where appropriate. The systems to manage and share the information that was needed to deliver effective care were fully integrated and provided information across teams and services. This was reflected in the training provided to external care providers and families.

  • Feedback from people who use the service, those who are close to them and stakeholders was continually positive about the way staff treat people. People that staff went the extra mile and the care they received exceeded their expectations.

  • The involvement of other organisations and the local community was integral to how services were planned and ensured that services met people’s needs. There were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs.

  • There were high levels of staff satisfaction across all teams. Staff were proud of the organisation as a place to work and spoke highly of the culture. There were consistently high levels of constructive engagement with staff across all teams. Staff at all levels were actively encouraged to raise concerns.

  • The leadership drove continuous improvement and staff were accountable for delivering change.

  • Safe innovation was celebrated. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. This included working with other agencies to reduce the number of people with learning disability or autism living away from their local communities or in long stay hospitals.

Substance misuse services

Good

Updated 1 September 2016

We rated substance misuse services as good because;

All areas were clean, well maintained and offered good facilities for the service to be delivered. Staff carried personal alarms and adhered to the lone working policy. Clients and staff told us they felt safe using the service. Clients had risk assessments which were comprehensive and up to date. There was a system in place to ensure that incidents were recorded and investigations were undertaken whenever necessary.

Clients spoke positively of the service; they felt involved in their treatment options and told us the staff team treated them with dignity and respect. There was a helpful pack available to clients and carers which described how the service worked and information regarding support available through other agencies.

There were several treatment pathways available to clients depending on their individual needs. Teams took active steps to keep clients engaged in treatment including an initiative for clients new to the service and making contact with clients who did not attend appointments. Staff knew how to support clients in making a complaint and there was information available through the information packs and within all premises informing clients how to make a complaint.

We saw evidence of how the aims of the service were upheld by the staff team. Staff described good working relationships within the partnerships and the other agencies involved, Mandatory training, supervision and performance appraisal was undertaken within all teams.

Staff knew how to report incidents, complaints and safeguarding concerns and the service had developed an APP (software designed to run on a computer) to support staff in getting feedback on incidents, the outcomes and any shared learning or changes to practice. There was a risk register which listed risks, actions, dates and those responsible for taking any action.

However;

In one location services were provided on the first floor of the building and there were no facilities for anyone with physical disabilities to access these areas. Staff told us this could be problematic but this was mitigated by using alternative rooms for clinical interventions or clients manoeuvred the stairs as best they could.

A system for checking medical equipment in one location had recently been introduced but had not been undertaken in the week of our inspection.

The system for checking stocks of prescriptions in one location did not allow for regular reconciliation of unused prescriptions.

Wards for people with a learning disability or autism

Outstanding

Updated 1 September 2016

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

  • There was a truly holistic approach to assessing, planning and delivering care and treatment to patients. Staff from different disciplines worked in collaboration and a mutual respect amongst professionals was evident. There was a multi-disciplinary approach to the delivery of treatment at all stages, including the review of referrals prior to admission onto the wards.
  • Patients and carers were active partners in the planning and delivery of care. Patients were generally very positive about their level of involvement in the development of care plans.
  • There were excellent arrangements in place to assess, monitor and review physical health needs of patients.
  • The range of therapeutic activities was excellent. Patients had individualised activity plans that took account of patient preferences, likes and dislikes.
  • Staff knew how to report incidents and used analysis of incident data to inform practice. Learning was based on thorough analysis and investigation. Staff undertook a dynamic approach to using data, including in the reformulation of treatment plans. There was evidence of effective debriefing processes for staff and patients following incidents. The trust had robust mechanisms to disseminate learning following reviews of incidents. All staff were encouraged to participate in learning to improve safety.
  • Staff demonstrated a proactive approach to anticipating and managing risks. Patients and their carers were actively involved in managing their own risks through the use of collaborative risk assessment tools.
  • There were excellent performance management systems in place at service, ward and staff level. Staff were committed to contributing to the achievement of personal and service level targets.
  • Staff delivered treatment in a respectful and caring way and demonstrated an advanced understanding of patient needs. Patient and carers spoke very highly of staff and the quality of care received.
  • Staff were passionate about their work and spoke with pride about the wards they worked on. Staff were proud to work for the trust.
  • Staff were actively encouraged to review practice and identify ways to improve service delivery and patient outcomes.
  • There were sufficient staff working on the wards, providing safe and effective care to patients. Managers could bring in additional staff to meet the needs of patients. Mandatory training rates for staff on learning disability and autism wards were above trust targets. Staff had access to a range of specialist training, that was directly linked to the needs of patients. This included additional training for nursing staff in physical health care and monitoring. Staff received regular supervision and appraisal.

However:

Clinic facilities for the wards on Kenneth Day Unit were limited. Medication was stored and administered from the nursing office. This meant there was limited privacy for patients when accessing medication. Staff acknowledged this and hoped to develop one bedroom on each of the wards as a dedicated clinic room. Seclusion rooms on the Kenneth Day Unit had low ceilings with CCTV monitors, which patients could reach. This presented a potential hazard to patients.

Community-based mental health services for adults of working age

Outstanding

Updated 1 September 2016

We rated community-based mental health services for adults of working age as outstanding because:

There was a truly holistic approach to assessment, care planning and delivery of care to patients:

  • Assessment and treatment of patients was a multi-disciplinary approach and considered the holistic needs of the patient which was incorporated into their care and treatment.
  • Where appropriate patient’s religious and spiritual identity was incorporated in to their recovery journey, care and treatment through access to spiritual therapy which was delivered by the chaplaincy team.
  • Creative care planning was used to meet patient’s needs. A pictorial care plan was created for a person with a learning disability written in basic language with easy read pictures.
  • There was good access to a range of psychological therapies in both group and individual sessions recognised by National Institute for Health and Care Excellence.
  • Patient’s physical health was seen as an integral part of their mental health care and treatment. Robust systems were in place to identify and monitor people’s physical health. Physical health checks and monitoring of medication levels such as, high dose anti-psychotic medication therapies, clozapine and lithium were completed and recorded.
  • Teams used recognised outcome measuring tools to measure patient rated outcome and experiences, clinical rated outcome measures were used, such as perspective on side effects of medication.

  • Patients and staff participated in research. Hexham community mental health team participated in NHS research in a focussed study into the effectiveness of cognitive behavioural therapy in people with a diagnosis of schizophrenia.

There was a commitment to the continual development of staff and their professional development. Professional development of staff was maximised through team training stars developed using evidence based information, considered patient need and team feedback about staff learning needs.

Teleport house was equipped with a private treatment recovery room which was furnished with comfortable furniture and entertainment facilities.

The feedback from patients and their carers was universally positive. Patients and their carers felt that they were an active partner in their care and told us that staff went the extra mile. Patient’s felt that staff understood the totality of their needs from mental health, physical health to spiritual and religious identity.

  • Teams made reasonable adjustments for patients with additional needs.
  • Risks to people were assessed and monitored.
  • Staff reviewed risk assessments regularly to reflect any changes in risk to people. Teams identified and responded to changes in people’s health. Teams were flexible and saw people urgently when needed.

  • Teams used lone worker procedures and equipment was in place to support and protect safety of staff.
  • Feedback from investigations was shared with staff in team meetings and in email communications from the trust.
  • Gateshead community treatment team (non-psychosis) held weekend assessment clinics when needed.
  • The trust’s vision and values were embedded into teams. Staff knew the trust’s values and explained how these applied to their everyday work.
  • There was an open and transparent culture to raising concerns or issues to management and there was good staff knowledge of the trust’s whistleblowing policy.
  • Services were well managed with good governance structures. Staff knew who senior managers were. Staff felt supported by their managers and managers had the authority to make decisions about their service.