During a routine inspection

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.

During a routine inspection

We found that the provider was performing at a level which led to a judgement of Outstanding because:

• The trust had a clear vision and values which were incorporated into all aspects of the trust’s business and supported by a set of strategic objectives which were developed with the involvement of patients, carers and staff. Staff felt involved in most changes and empowered to contribute to the development of services. Staff were given the autonomy to provide services based upon the needs of their service users and to develop innovative practice. Staff we spoke to told us that the trust leadership was approachable, accessible and encouraging.
• Feedback from patients and carers regarding their care and treatment was consistently positive. Staff were professional, thoughtful and caring when supporting patients and their carers throughout all the services we visited. Staff supported each other, many staff told us of the strength of teamwork and the support they received from their colleagues. Staff recognised the contribution of families and carers in supporting patients and sought and valued their views.
• Assessment of patients’ needs was holistic and identified potential risks. Care plans were developed with patients and carers to meet the identified needs. Multi-disciplinary teams with a range of professionals worked together to support patients in their recovery and achievement of goals through evidence based care and treatment.
• The trust was open and transparent about safety and staff were encouraged to report incidents. Processes were in place to keep adults and children safe and safeguarded from abuse. Staff were able to describe what action they would take to safeguard a patient if they had a concern. Data provided by the trust showed each pressure ulcer, fall, catheter associated urinary tract infection and venous thromboembolism reported was fully investigated and identified the cause.
• The trust supported the physical healthcare of patients and mental health nurses were trained in tissue viability to meet the needs of patients on the ward. A physical healthcare practitioner provided expert advice, guidance and support to mental health nurses and acted as a liaison with acute hospitals, to ensure that patients’ physical healthcare needs could be fully met before being transferred to a mental health hospital.
• Where services provided care and treatment to patients detained under the Mental Health Act, this was found to meet the requirements of the Code of Practice in most areas. The Mental Health Act office in the trust provided support to clinical areas to ensure relevant documentation was completed correctly, reviewed and appropriately stored.
• Discharge planning started from the point of admission. Outcome measures were used to inform the assessment process and measure the success of interventions and treatment outcomes. Staff worked flexibly to adapt care and stretch existing boundaries to meet the needs of individual patients and their carers.
• Staff were enthusiastic and generally very positive about working in the trust. Staff had pride in the care and treatment they provided and looked for opportunities to improve the experience of patients receiving services. The trust encouraged personal and professional development in all roles within the organisation and the inspection team saw many examples of staff who were continuing to develop their career with the trust.
• External stakeholders found the leadership within the trust to be proactive. The senior leadership could clearly articulate the strategy and the key issues and challenges they faced, and how they were responding to these. Working in triumvirates, clinical leads worked with senior managers to ensure clinical engagement and involvement in operational management.
• Governance within the trust was robust with clear ward to board structures and process in place. An electronic dashboard accessible to all staff within the organisation supported this. The board assurance framework included principal risks linked to the trust’s strategic objectives.
• The trust use values based recruitment to ensure that it recruited staff that shared its values and vision of delivering services and held the required knowledge and skills. Staff at service level confirmed this process resulted in people with the right attitudes and values joining the trust.
• The trust exceeded the majority of its internal targets. Medical revalidation rates were 100% for the trust as a whole. The overall mandatory training rate was 92%, exceeding the trust target of 85%. The average rate for clinical supervision across all 155 teams was 90% in the period 1 May 2015 – 30 April 2016.
• The trust had systems in place to monitor its services against national guidance. Staff in core services participated in clinical audit which led to improvements in services. The trust participated in research and had a director of research, innovation and clinical effectiveness who led in this area.
• The trust looks to work collaboratively in the delivery of all services. The trust worked with a neighbouring trust to provide considerable improvement to a region-wide eating disorders service, with two key, senior staff members seconded to the other trust. The trust participates in external peer review and accreditation schemes and services from around the trust had gained accreditation in these schemes.
• The trust’s ‘Positive and Safe Strategy’ led by the executive director of nursing and operations, aims to reduce the use of restrictive practices in response to managing challenging behaviour, aggression and violence.
• All wards and community team bases were found to be clean and mostly well maintained. The patient led assessments of the care environment score in relation to cleanliness in 2015 was 99%. Environmental risk assessments were completed in all areas and where risks were identified action was taken to remove or reduce these risks. The trust has an estates strategy in place to improve the environment for patients, visitors and staff. A number of projects were due to start or complete around the inspection period.
• However, the environment at Alnwood did not support children and young people’s recovery and linked to high levels of mechanical restraint.