Rotherham Doncaster and South Humber NHS Foundation Trust

We rated wards for people with learning disabilities at Bungalow 2 as good because

The ward was clean and tidy. Durable material covered walls and surfaces making them safer for the patient.

Staff were skilled and trained in safeguarding.

Care records were up to date, there were comprehensive care plans in place.

Due to the specific needs of the patient, there had been three independent assessments of the patient. This was to look at their treatment pathway and suggest interventions.

The ward had significant staffing issues following the unavailability of some staff following a safeguarding incident in February of this year. This however had been temporarily resolved and some senior staff had been brought in to ensure support, consistency and oversight of the service.

Government policy and the department of health’s document ‘positive and proactive care’ endorsed positive behaviour support. Key staff had attended training to facilitate this approach and further ‘train the trainer’ training was planned for September 2015.

However

• Incidents of restraint in this area were the highest in the trust between 01 November 2014 and 30 April 2015 272 incidents were recorded. The provider and ward staff were aware of this and were working hard to reduce this amount.

• Whilst staff supervision figures showed a steady rise, they were below the trusts expected target.

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

We rated Rotherham Doncaster and South Humber NHS Foundation Trust (the trust) as Requires Improvement because:

• Community mental health services for people with learning disabilities or autism at the Ironstone Centre did not have enough staff to meet the needs of people who used the service. We also identified shortages of community nursing staff in some locations.
• Medication management was not overseen effectively and different systems had been allowed to evolve in different areas of service. The community-based mental health teams did not have regular pharmacist support to ensure safe and effective administration of medicines. This had been identified as ‘high risk’ by the trust on the pharmacy risk register. In the community-based mental health services for adults of working age there was no consistent approach to medication management to support safe practices. In the substance misuse service, staff who were not suitably trained or competent administered medications in the social detoxification service at New Beginnings. The service had no consistent approach to recording medicines patients brought with them on admission and no clear protocols for stock control and storing patients’ own medicines. There was only limited oversight of the process and it was not audited.
• Staff did not consistently monitor the physical health needs of patients of mental health services,which could result in some people’s physical health needs not being met. In the community health inpatients service, Hawthorn and Hazel wards did not complete venous thromboembolism risk assessments in line with guidance from the Nationial Institute for Health and Care Excellence (NICE) relating to adults admitted to hospital as inpatients.
• Not all risk assessments were completed, up to date and of good quality. Some lacked relevant information and important detail.
• At the time of the inspection, the percentage of staff completing mandatory training averaged 77% compared with the trust’s mandatory training target of achieving 90% by 31 December 2015. Compliance with compulsory training, appraisal of work performance and managerial supervision was inconsistent across services and the trust was not meeting its own targets. Trusts should ensure that staff maintain their skills knowledge and training to carry out their roles safely and effectively and are up to date with changes to best practice. Staff who had not completed mandatory training could have been unaware of important changes in the trust’s policies and procedures.
• The trust’s senior management team were aware of the poor compliance with mandatory training and inconsistencies in recording which staff had completed some or all of the training. They had started to deal with these issues and recognised deficiencies in appraisals and were introducing changes. However, poor compliance with mandatory training had the potential for a negative impact on patient care and safety.
• The trust was not fully complying with its responsibilities under duty of candour and people did not always receive a timely apology when something went wrong. The trust did not provide enough guidance for staff on their responsibilities under the duty of candour.

However :

• There was a culture of collective responsibility between teams and services, and openness and transparency in communicating generally.
• People who used the trust’s services were supported and treated with dignity and respect and were involved as partners in their care. Feedback provided by people who use the trust’s services was generally positive. Staff were caring, engaged and supportive towards patients. People and staff were working together to plan care and there was evidence of shared decision-making and a focus on recovery.
• We rated the responsiveness of the community health services for children, young people and families as outstanding. The service planned and delivered care that met people’s needs and was responsive to the changing needs of the local population. They also used innovation in care to meet the needs of local people and hard-to-reach groups.
• The trust handled complaints to a good standard, with managers and staff listening and responding to complaints and concerns and resolving issues quickly where possible.
• While in some clinical areas staff had problems with recording information on the trust’s IT system, such as mandatory training, there were systems to monitor performance information.
• The chief executive had been in post for only three months at the time of the inspection, but had received a handover from the previous chief executive and demonstrated an understanding of what the key issues were for the trust. She was improving quality and staff across the organisation were clear about how the trust should develop. The board and senior team had the experience, capacity and capability to put the trust’s strategy into effect. The trust leadership team actively engaged with staff, people who use the services, their representatives and stakeholders.

We rated community mental health services for people with learning disabilities and autism as requires improvement because:

• Staffing levels at the Ironstone Centre were not adequate to meet the needs of people who used the service.

• Risk assessments had not always been completed or updated at the Ironstone Centre and Rotherham community learning disability team (CLDT).

• Care plans and physical health checks were not always reviewed and updated at the Ironstone Centre.

• Clinic rooms at Rotherham CLDT presented a risk to staff and service users. Psychiatrists only had access to personal alarms across all the locations. There was no environmental risk assessment at the Rotherham CLDT.

• Staff understood the mental capacity act but people’s care files did not contain mental capacity assessments.

• Responsibility for ensuring mandatory training was up to date was held by staff, and there were systems in place to ensure managers at location level monitored this.

• Not all risks identified locally were recorded on the learning disability business division risk register

• Staff morale was not consistently good across the CLDTs.

• Issues raised during our inspection had not been identified by senior managers of the trust.

• Governance was not effective and robust with regard to the Ironstone Centre

However:

• Staff were able to confidently describe safeguarding policies and procedures and knew how to report any concerns. Incidents were recorded and actioned appropriately.

• Care planning was carried out in conjunction with people who used the service. Recruitment of staff involved people. Services either had staff trained as best interest assessors or had good access to best interest assessors.

• Multi-disciplinary teams worked cohesively and consisted of qualified nurses, psychiatrists, psychologists and various allied health professionals involved in people’s care.

• People we spoke with told us staff were kind and respectful. The confidentiality of people using the service was maintained and respected.

• People who used the service and their carers told us they knew how to complain and felt their concerns would be taken seriously.

• There were a range of facilities available to people requiring disabled access and where facilities were not available, reasonable adjustments had been made.

• The trust’s vision and values were displayed on notice boards and staff understood the vision and values and how to implement them.

• A dedicated 117 service had been piloted in the community.

We rated the end of life care services at Rotherham Doncaster and South Humber NHS Foundation Trust hospital as good for safe, effective, caring, responsive and well led.

There were sufficient staff for the number of patients at the hospice. Community nursing had challenging caseloads and often had to prioritise their work. Bank staff were used to backfill sickness and absence. Staff were aware of incident reporting and there was evidence that lessons had been learnt and improvements have been implemented to maintain safety. The hospice and the day care centre were visibly clean, tidy and staff worked bare below the elbow to reduce the spread of infection.

We found staff attendance of mandatory training was slightly less than the trust expected level of 90%. This has been identified by the management and action is being taken to improve it. There was sufficient equipment to deliver care in a safe manner. The hospice had a bariatric bed. Two bedrooms had been designed to support patients with dementia.

There was good evidence that staff were aware of the most up to date guidance, such as the five priorities of care. They explained that the guidance ensured that people and their families are at the centre of decisions about their treatment and care.

We saw patients were regularly assessed and appropriate pain relief was administered in a timely manner by staff at the hospice and in the community. If a patient was not receiving adequate nutrition or hydration by mouth, even with support, the doctor considered other forms of clinically assisted nutrition or hydration, such as intravenous fluids, to meet the patient’s needs. The managers were working collaboratively with the service commissioners to improve the monitoring of the services to demonstrate progress.

Patients and family members told us that staff understood their needs, treated them with respect and maintained their dignity and privacy. We observed several examples where staff treated the whole family with care and compassion. This was especially the case when young parents with children required palliative and EoLC. Patient’s records showed that when patients experienced physical pain, discomfort or emotional distress staff had responded compassionately and appropriately.

At meetings, staff addressed each patient’s holistic wellbeing by discussing physical, psychological, social and spiritual needs. This meant that that they were able to understand the needs of the individuals and involve them and their family members in the plan of care. Patients and relatives were empowered and supported by staff to manage their own health, care and wellbeing to maximise their independence. The hospice worked closely with different religious groups and had twenty-four hour access to support groups for different religious needs.

There were arrangements in place to ensure patients and their families were able to access the appropriate care without delay. People who used the service knew how to make a complaint or raise concerns. Patients and relatives told us that staff encouraged them to make constructive comments and they felt that staff listened to them.

Patients were admitted to the hospice between 8.30am and 4pm between Monday to Friday. This meant some patients who were eligible for admission were delayed or were admitted to other NHS wards. However, there was on call out of hours cover for patients.

We visited the living well team and found them to be the hub for outreach engagement. They had a membership of multicultural staff and had links with diverse groups of people within the serving population. Independent interpreters were used to help patients and families to help staff meet patient’s needs. The facilities at the hospice were focused on Christian worship and staff acknowledged there was work to be done around providing multicultural facilities for people.

The community staff said their strategy was to lead the way with compassionate care, to be a workforce that reflects the community, and to ensure they provided good quality care. The ultimate vision was for staff to work in partnership with all services, take ownership and be proud of care delivered.

There was a good supportive culture within staff in EoLC and palliative care teams. We also witnessed management ensuring measures were in place to protect the safety of staff who worked alone and as part of dispersed teams working in the community.

Staff were encouraged to bring their ideas forward and action those where appropriate.

There were clear lines of accountability including clear responsibility for escalating and cascading information between senior management team and the clinicians and frontline staff. Staff made comments that feedback from surveys and investigatory outcomes was delayed in reaching them.

Overall we rated this service as good.

Staff reported incidents and there was evidence of learning from incidents in the service. The service had implemented a FallSafe bundle and a multidisciplinary falls risk assessment tool in line with recommendations from NICE (CG161). Care records were comprehensive, individualised and up to date. Wards were clean and tidy and equipment was available for staff to use.

People’s care and treatment was planned and delivered mostly in line with current evidence based guidance and there was participation in local and national audits. Patient outcomes were better than or in line with the national average. There was evidence of internal and external multidisciplinary working.

Staff were caring, they respected patients’ privacy and dignity. Patients were involved in decisions made about their care and treatment. The service met the needs of vulnerable patients. Senior staff held weekly clinics on the wards for patients and relatives to discuss their care.

The service actively worked with stakeholders to ensure that patients’ needs were met through the way services were organised and delivered.

Governance in the service was effective. Risks were identified and managed at ward level. Nursing leadership was good with an open and honest culture where the benefit of raising concerns was valued. Managers engaged with staff and the public and supported improvement and innovation.

Venous thromboembolism was not in line with NICE guidance (CG92) and posed a clinical risk to patients’ care. The service was not assured from the records held that staff had completed the appropriate training and that patients were not put at risk.

There was limited evidence of how the service’s strategy aligned to the trust’s strategic objectives.

The trust had appropriate risk reporting structures in place. The trust investigated and reported incidents in line with an appropriate policy. We saw evidence of the service sharing learning incidents with staff. There were safeguarding systems in place to ensure children and young people were protected from harm. Staff were knowledgeable and experienced in the safeguarding of children and young people, and in responding to patient risk. Staffing levels and caseloads were broadly appropriate for the service being delivered and were in line with commissioned levels. Where shortages in staff were identified this was raised with the local commissioning service to request additional resources.

Staff received mandatory training, although it was not clear whether all staff were up-to-date with their mandatory training. This was due to a discrepancy between data provided by the trust and local data shown to us by managers. There was a broad awareness of the principles of duty of candour and an appropriate policy was in place. Only management level staff had received full training on this at the time of our inspection.

Staff practiced evidenced based care and treatment. The service used technology and telemedicine to keep in touch with potential service users, including those in hard to reach groups. There was good evidence of multi-disciplinary working within the trust and with local networks. Staff were aware of the principles of consent, and we observed them practicing it during their work. There were also clear and easily accessible referral routes into services. We heard good examples of transition planning for children moving between the health visiting and school nursing service.

The trust was not meeting some targets set by NHS England for this year and its Commissioning for Quality and Innovation (CQUIN) target for breastfeeding. However, the service had identified these issues and mitigating action was being taken to address them. There were variable levels of staff appraisal rates throughout the service. It was not clear whether all staff were up-to-date with their appraisals. This was due to a discrepancy between data provided by the trust and local data shown to us by managers.

We spoke with children, young people and families, and observed care taking place. We found evidence that staff practiced compassionate care and provided emotional support to children, families and other professionals. People who used the services told us they felt involved and understood the care and advice offered to them.

The trust planned and delivered services that met people’s needs and were responsive to the changing needs of the local population. It also used innovation in care to meet the needs of local population and hard to reach groups. This included ensuring additional resource was available when the service noted low breastfeeding uptake. This took into account equality and diversity needs and the needs of people in vulnerable circumstances. There was full access to translation and interpretation services, and links with new migrants to the area and the local lesbian, gay, bisexual and transgender (LGBT) community.

Services were easily accessible and children and young people could access services in a variety of ways, in a manner and at a time to suit them. We saw examples of learning from complaints. This included the use of action plans to inform improvements.

There was a clear vision within the service that focused on innovation and placed the patient at the heart of services. Leadership was not a top down process and staff of all levels showed leadership within services. There was a system in place for the local and corporate management and leadership of the children, families and young people’s service. There were systems in place for linking governance, risk management and quality measurement at service level and at board level. We saw examples of how this information was also cascaded to staff.

There was a positive and responsive leadership supported by an open culture. Leaders supported and empowered staff to drive improvements and to develop. There was extensive evidence of engagement with both the public and staff, and we saw clear examples of staff and public feedback and interaction used to drive and improve services. There were many examples of innovation aimed at increasing access to services and educating children, young people, and their families. There were systems in place to ensure improvement and sustainability. We saw good examples of evaluations of projects taking place to ensure that the service understood and could learn from its successes and failures.

Serious incidents were investigated and feedback was given to staff. Staff used safeguarding procedures appropriately and medicines were managed safely. Equipment for patients was supplied promptly. Infection control procedures were followed and community locations were visibly clean. Staff knew how to escalate concerns.

Community services used and contributed to NICE guidance. Pain relief and nutritional needs of patients were addressed. The tele health service had significantly reduced home visits and admissions to hospital. The service consistently achieved performance and outcome targets. Staff were supported to develop their skills. Multi-disciplinary working was well developed. Access to mental health services was straightforward. Staff appraisals were not up to date and the audit programme required development. Not all staff received consistent clinical supervision. Staff did not always assess capacity or fully document consent.

Patients and relatives were treated with respect, dignity and compassion. Confidentiality was maintained. Patients spoke very positively about quality of care they received. Staff offered clear explanations and checked the patient’s understanding. Patients were empowered to engage in self-care. Staff provided emotional support to patients and their relatives and carers.

Services were planned and delivered to meet the needs of patients particularly those with complex conditions. The service met the needs of hard-to-reach groups, the traveller community and bariatric patients. Patients were assessed promptly and referral to treatment times met the 18 week target. Mental health services were accessible. The needs of minority ethnic patients were reflected in service provision. There were few complaints but learning was shared with staff. The needs of patients with dementia were not always considered appropriately.

The leadership of the service was joined up with the executive leadership and staff knew the trust’s vision and values. A risk register was in place for the service. Regular governance meetings were held. Managers and staff felt supported by the trust and the service reflected an open and honest culture. Staff opinions were sought. We found examples of innovative and outstanding practice. We identified some concerns in the supervision of Band 5 nurses.

Compliance with mandatory training, including safeguarding training, was below the trust’s target of 90%. There were shortages in the permanent staffing of community nursing teams; this was on the corporate risk register. Caseloads for community nurses were higher than planned. Capacity and demand information was used daily to support the movement of staff in response to patient workload; this demonstrated a shortfall in nursing hours or units.

There were gaps in clinical risk assessments and insufficient planning for the review or evaluation of care needs. Risks linked with electronic record systems were being addressed.

We rated Rotherham Doncaster and South Humber NHS Foundation Trust as good because:

• The skill mix within the service was sufficient to ensure good quality care and treatment. This led to flexibility across the teams allowing staff to cover essential visits and clinics in the event of unexpected illness or holiday leave.
• Patient risk assessments were updated when new risks were identified and during patient reviews. Staff documented daily any increased risks if a patient’s mental health deteriorated. The care records we reviewed all had up-to-date risk management plans. This meant staff could make changes to the care they gave their patients keeping them safe.
• Multidisciplinary teams managed the referral process, assessments, on-going treatment and care by discussing the best treatment and pathway options for each individual. This meant patients received care and treatment that suited their individual needs.
• Patients gave positive feedback and felt personally involved in the development of their care plans. Staff delivered care to patients and their carers in a compassionate and respectful manner. Support groups for carers were available and staff arranged for respite care when appropriate. Carers consistently told us that staff actively supported them and valued this service.
• Patients took part in national initiatives to raise awareness of the needs of people with young onset dementia. The day care facility attached to the young onset dementia service allowed patients to organise their own activities and therapies. It supported people to live active lives in their community and maintain their day-to-day skills, friendships, hobbies and interests. The memory services either had accreditation or were in the process of achieving accreditation with the Royal College of Psychiatrists’ memory service national accreditation programme. The young onset dementia service in Doncaster was carrying out research in partnership with Sheffield Hallam University. Rotherham memory service was researching a cognitive stimulation therapy project. Staff from North Lincolnshire set up a choir for service users and carers. They were finalists at the recent Alzheimer’s Society dementia friendly awards for best dementia friendly involvement initiative.

However:

• The community mental health teams held caseloads that exceeded Department of Health guidelines.
• Patients’ care plans were not always personalised or holistic and the quality varied across the teams. Some care plans did not consider all aspect of the patient’s wellbeing or support their recovery.

We rated Rotherham Doncaster and South Humber NHS Foundation Trust as requires improvement because:’

• Risk assessments on the electronic system were found to be poorly completed, incomplete or missing.

• Care records were found to be missing, incomplete, or poorly completed on the electronic system.

• Electronic records did not reflect the content of paper records, and information had not been scanned, as per procedure, into the electronic system though scanners were available.

• Appraisals for non-medical staff had not been completed.

• Mandatory training figures for the service showed non-compliance with trust targets in relation to equality and diversity and conflict resolution.

• Mental Capacity Act (MCA) considerations did not fully show adherence to its principles.

However:

• The trust had taken positive actions to try to reduce gaps in record keeping by the recent employment of a safeguarding advisor with a remit to ensure that all records in the service were maintained at a high standard.

• Safeguarding supervisors were also in place, offering supervision to staff to help deal with issues relating to record keeping and to support clinical safeguarding decision making.

• Access to psychological therapies was available, and the skill set of staff within the service reflected the needs of the people who used the service.

• The therapeutic relationship between staff and people who used the service was seen to be excellent. The interventions observed were professional and caring.

• Referral to assessment, and assessment to treatment times, had improved. The introduction of a re-configuration of Rotherham CAMHS showed improvements accessing the service.Key performance indicators (KPIs) were closely monitored to ensure that improvement was maintained across the service.

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

There was a skilled multi-disciplinary team. Some staff were trained as best interest assessors and some had undertaken training in cognitive stimulation therapy, wellness recovery action planning and motivational interviewing. The advanced nurse consultant was a Queen’s nurse. The title of Queen’s Nurse indicates a commitment to the values of community nursing, high standards of practice, excellent patient-centred care and a continuous process of learning and leadership. Staffing levels and the skill mix within the teams meant the staff on duty were able to meet patients’ needs.

We saw a number of excellent examples of proactive work to improve patients’ experiences. The teams actively promoted advance decision making so that other people could understand how patients would like to be cared for when they were not well.

In Doncaster, there was a carers’ support worker and a wellness action recovery worker. There was an innovative peri-natal mental health service that provided specialist interventions at home to reduce admissions to mother and baby mental health units.

In Rotherham, there was a dedicated service for deaf patients with mental health problems. They worked with children and young people aged 14-18 as well as adults. They supported patients by promoting their deaf identity, to help them live and work as valued members of the deaf and wider communities.

Rotherham and Doncaster operated a new model liaison and diversion service introduced by NHS England. The service supported patients with mental health conditions, substance misuse problems and learning disabilities who were suspected of committing an offence and came into contact with the police. There was also a street triage team working with the police. This team had significantly reduced detentions under section 136 Mental Health Act 1983 (MHA). This year, the street triage team had won the trust’s award for partnership working and the Doncaster district police diversity achievement of the year award.

At Great Oaks, the acute care service, including the mental health crisis service, had planned a “perfect week”. This was a groundbreaking exercise in mental health services. It focused on organisational development and better patient care, safety and experience.

There was a drive to increase participation in research, such as research into decision making around treatment for patients diagnosed with personality disorders and research into early discharge.

The service had significantly reduced waiting times for mental health assessments for patients with learning disabilities and autism, in line with National Institute for Health and Care Excellence (NICE) guidance.

The referral system enabled patients to access help and support directly when they needed it, 24 hours a day, seven days a week. The mental health crisis services focused on helping patients to be in control of their lives and build their resilience so they could stay in the community and avoid admission to hospital wherever possible. The teams had established positive working relationships with other service providers such as the acute admission wards, GPs and community services and groups. The teams worked with the acute wards and community teams to plan patients’ transitions between services in a holistic way. They ensured discharge arrangements were considered from the time patients were admitted, to ensure they stayed in hospital for the shortest possible time.

All but one patient we spoke with told us they had a copy of their care plan and that they had been involved in formulating it. They said staff sought feedback from them about care planning and their views had been included in the care plan. Carers told us that they had been able to ask questions and the staff responded knowledgeably and informatively. The care plans we reviewed and the care we observed showed that patients’ individual, cultural and religious beliefs were taken into account and respected. Patients were supported to maintain their social networks and independence in the community.

In all the teams, we saw the staff were kind, caring and compassionate and supportive of patients. When we spoke with patients, they were positive about the support they had been receiving and the kind and caring attitudes of the staff team.

All the teams were managed well. There was a good governance structure to oversee the operation of the mental health crisis teams. Staff received appraisal and a range of supervision, managers investigated complaints, incidents were reported and investigated, changes were made when they were needed, staff participated in audits and safeguarding and Mental Health Act 1983 procedures were followed.

The staff understood their responsibilities relating to the duty of candour. They knew what a notifiable safety incident was and explained what they were expected to do. They were clear that they would explain and apologise to patients and their families in any event.

The staff we spoke with told us that morale was good. Many staff told us they were proud of the job they did and said they felt well supported in their roles. They felt valued and were positive about their jobs. We saw excellent examples of staff suggestions being implemented.

There was excellent commitment to quality improvement across all the teams and they had developed various services to improve care. However, at the time of the inspection we did not see any formal process for the teams to meet with each other. This meant they may miss opportunities for learning and sharing. We found examples of good or excellent practice in all the teams that could have been shared across the service.

We rated community-based mental health services for adults of working age as ‘requires improvement’ because:

• Not all risk assessments were completed, up to date and of good quality. Risk assessments had information omitted and lacked important detail. There were a high number of people with no valid risk assessment. This impacted negatively on the people who use services and staff’s safety as current risks were unknown.

• Care plans were not always up to date, holistic or recovery-based.

• Monitoring for physical health issues was inconsistent in some teams which could result in some people’s physical health needs not been met. Systems were not in place to monitor service user’s physical health check compliance.

• There was a lack of psychological input in some teams. This meant that whilst some people who used services had access to a psychologist, other people did not.

• Information the trust provided showed that mandatory training completion rates were significantly lower than the trust target of 80% for most teams. Although team managers informed us these figures were inaccurate and completion rates were higher, the trust was not able to provide information to confirm this. This meant it was not possible to determine that staff had received the required training to keep people who used services safe.

• On average, only 16% of staff had received an appraisal in the last 12 months. This is not in line with trust policy.

• Staff members not directly working with the team, did not have easy access to information about people when they needed it.

• The poor quality of the IT system had a negative impact on people’s care including the ability to provide accurate service user information. The IT system would not allow single changes to any part of the card record such as the risk assessment. It would automatically ask for care plan and CPA review information to be updated. This meant that staff would avoid adding small pieces of information due to the extra amount of work and time this created.

• There was no consistent approach to medication management to support safe practices. There was a lack of oversight regarding medication management and different systems had been allowed to evolve.

• Not all interview rooms were fitted with alarms. This meant that staff were not able to call for assistance if needed which could compromise the safety of staff and people who used services.

• Lone working practices were not consistent and there were some gaps in relation to staff safety. Staff were lone working all day and had no contact with the team until 5pm. This meant there was no assurance regarding staff safety for many hours.

However:

• Managers could employ bank or agency staff when there were staff shortages.

• Incidents were reported in line with the trust’s policy.

• We found some areas of good practice, which included effective team working, good links with external organisations, and regular staff supervision.

• Staff were respectful, compassionate and empathic to people who use services. People who use services reported they felt involved in their care and staff were available to them when needed.

• Most staff would recommend the trust to their friends and family as a service to receive care.

• Staff responded to urgent referrals promptly. Staff endeavoured to be flexible in relation to appointment times and dates. Access to consultant psychiatrists was well organised with the availability and flexibility to see service users easily and quickly.

• Detailed information regarding treatment options and care was readily available to service users.

• Staff handled complaints appropriately. They received feedback from complaints following investigations and subsequent findings.

• Team managers were supportive and available to staff members when needed.

we rated older people’s inpatient services as good because:

• The service was safe,because there was a comprehensive governance system in place which minimised the risk of infection. Daily, weekly and monthly checks took place to ensure the standards of effective cleaning on all wards.

• We found the ward enviroments were safe because the service had taken steps to reduce the possibility of harm occurring. Ligature risk assessments were in place, equipment was appropriately maintained and fixutures and fittings on the wards were in good condition.

• There was sufficient staff on duty to ensure patient needs were met and staff had received training appropriate to their roles to ensure high quality care was delivered.

• We examined a sample of records relating to patients and found most care plans and risk assesssments were detailed, holistic and person centered. Although we did note that some improvements were required in relation to the daily nursing notes as they did not always demonstrate the care and treatment which was provided.

• The service used a range of methods to ensure patient care was effective and these methods were inline with recommended best practices. We observed how care was delivered and found staff were caring, compassionate and had a good understanding of the needs of the patient group they were providing care too.

• The service had a comprehensive admission and discharge process in place and many of the wards were under their bed occupancy with very few patients requiring further admissions after discharge.

• Wards optimised patient recovery and their was a wide range of therapeutic and recreactional activities available for patients to participate in.

• There had been a limited number of complaints about the service. Relatives we spoke with talked positively about the care people received. We were told by patients and relatives they knew how to complain and there was posters and information packs available to both relatives and patients on each ward.

• We found overall the service was well-led. Staff talked positively about their managers, they were aware of the organisations visions and values and there was a strong commitment to innovation and research within the service in areas such as music therapy for people with dementia.

However we did find some areas requiring improvement.

• There was not an effective multi-disciplinary team. For example they were often nurse and doctor lead with minimal input from other specialist areas such as occupational therapy and psychology.

• Staff had limited knowledge of the Mental Health Act and Mental Capacity Act. We saw examples in records where it had not been used or where it was not used correctly.

• There were restrictions in place for patients who were accommodated on dementia wards. There were blanket restrictions in relation to all doors. With the exception of communal lounge areas doors were locked. This meant patients did not have free access to kitchen areas or bedroom spaces without requesting assistance from staff members.

• Daily nursing notes were not written in a way that reflected the care and treatment patients received and required improvement.

We rated the forensic inpatient/secure wards as good because:

• Staff at all levels of the service we spoke with talked about how they worked with people, listening to and responding to the views and wishes of patients. We witnessed staff using enabling language and positive interactions with patients. Staff spoke about patients in a respectful manner and demonstrated a good understanding of their individual needs.

• Staff carried out comprehensive assessments of patients’ needs. Patients were involved in all aspects of their care planning. Staff had a good understanding of positive behaviour support in the forensic service. There were effective strategies in place to protect patients, including those with more complex needs and to enable patients to be safely involved in the local community.

• There was evidence that the provider and commissioners had good working practices. Discharge was the focus of intervention and care across the service. There were good links with community teams and work was ongoing to reduce the difficulties with moving patients into least restrictive environments in community-based settings. The balance between providing sufficient security to keep those on the wards safe, the least restrictive environment and proactive discharge planning was appropriate for the needs of the patients.

• There was good access to healthcare. All patients had a health action plan in place specific to their individual needs. Patients were encouraged and supported to manage their own health needs.

• There was a range of staff specialities and the team were skilled and experienced in working with this patient group. Staff had a good understanding of the mental health act, mental capacity act, deprivation of liberty safeguards and the corresponding guiding principles.

• Both wards were clean, homely and in reasonably good repair and décor. Regular environmental assessments were undertaken. The service acted on the findings from these in order to achieve a high standard of repair and cleanliness. Patients and carers told us the wards were always clean.

However

• There were difficulties with the environment, such as a lack of child visiting areas, inadequate fencing for two courtyards, lack of activity areas and blind spots in all areas including the seclusion room, which affected observation of patients. These issues were recognised in the trust risk register and staff mitigated against these environmental risks with good relational security.

• Attendance at mandatory training was low however; the trust had plans to address this low attendance.
• Some blanket restrictions were evident with patients highlighting bed times, smoking times and restrictions on mobile phone use on Amber ward.

The five questions we ask about our core services and what we found. We rated long stay and rehabilitation mental health services for adults of working age adults as good because:

• The ward environments were spacious, clean and well maintained. Where there was mixed sex accommodation, this met current guidelines for the provision of segregated accommodation for men and women. Wards had ligature risk assessments and where risks were identified, there were plans in place to mitigate the risk.
• In the last six months restraint had been used 5 times, there was no prone restraint and no reported seclusion. Staff used de-escalation techniques to support patients who reported that staff always made time for them. Risk assessments were present, comprehensive and reviewed on a regular basis.
• Care records were present, up to date, and covered a wide range of needs including physical health care. Patients had been involved in their care and had been offered a copy of their care plan. There were a variety of interventions available to support therapeutic activity on an individual basis and in groups.
• Multi-disciplinary team meetings were held on a regular basis allowing for care reviews and patient discharge to be planned.
• Care records were present, up to date, and covered a wide range of needs including physical health care. Patients had been involved in their care and had been offered a copy of their care plan. There were a variety of interventions available to support therapeutic activity on an individual basis and in groups.
• Staff were aware of the trust values. Each ward had its own mission statement or philosophy of care linked to rehabilitation services. There was a quality improvement plan for part of the service and some of the actions from the plan were in place with other recommendations planned.
• Staff supervision and performance management was in place across the service and records were kept to evidence that this was an on-going process.
• Staff changes on one ward had resulted in some systems and process’s not being embedded, for example a structured format for ensuring multi disciplinary reviews were undertaken on a regular basis for each patient. However, we re-visited the ward the week following the inspection to gather further information and found that this was being addressed.

However

• We observed blanket restrictions on two wards and discussed the reasons for these restrictions with the ward managers and the modern matron. On one ward there were acceptable reasons for two of the restrictions, which complied with the Mental Health Act code of practice. The restriction on Coral and Goldcrest with regard to how wards give patients access to hot drinks does not comply with the mental Health Act code of practice. We did not see evidence that any of the restrictions are reviewed and evaluated on a regular basis.
• Goldcrest had four locum psychiatrists who had been in post consecutively since November 2014. Feedback from commissioners suggested this had a negative impact on the consistency of patient care.
• A thermometer used for recording the temperature in a fridge storing medication on Coral did not have the facility to measure the lowest and highest temperature range within the fridge. Records demonstrated that the thermometer on Goldcrest was not being reset each day to record the daily temperatures within the medication fridge. This means that medication may not be stored safely within the appropriate temperature range prior to administration and could impact on the effect of the medication on the patient.
• On Coral and Goldcrest bags used for the delivery of resuscitation equipment in the event of an emergency, had tears in them that might allow for items to drop out and not be available when required.
• The information provided by the trust showed that mandatory training in long stay rehabilitation wards was below the trust standard of 90% of staff being trained by 31 December 2015. In some areas, training was showing as 0%.
• There were gaps in medication administration records. It was not clear if patients had been absent from the ward, or if the gaps were missed doses of medication which might impact on patients health and wellbeing.
• The inpatient staffing acuity and dependency profile tool used to calculate safe staffing requirements was not being adhered to on Goldcrest.

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

• the wards had up-to-date environmental risk assessments and good systems and process for keeping the environment safe

• wards had the required skill mix and it was unusual for them to be below their required number of nurses on duty

• staff understood how to keep people safe where there were ligature risks.

• the wards were clean and had good systems for managing the environment, including infection prevention

• there were good quality risk assessments, risk management plans and care plans for the patients and these were recovery focused

• there was good inter-agency working between the inpatient and community teams and staff described good morale within them

• we saw that interactions between the staff and patients on the wards we visited were respectful and professional

• we saw staff acknowledged carers views in meetings, even if the carer was not present.

We rated the substance misuse services as requires improvement because:

• The trust used a risk assessment tool, which had two parts, which were a basic risk assessment and a comprehensive assessment. However, most risk assessments were basic, inconsistently completed and not regularly reviewed. In 14 of the records reviewed, only a basic risk assessment was completed and substance misuse was not identified as a risk factor.
• Mandatory training compliance for most areas was below the trust target of 90% completion.
• The trust had developed a social detoxification facility, New Beginnings. This was in a period of transition and had recently changed registration to become an inpatinet detoxification. However, at the time of the inspection the social model was still in operation. We found that the consultant assessed service users prior to admission and detoxification prescriptions were placed with the agreed pharmacy. Service users would then attend the pharmacy daily to be supervised. However, some service users had been prescribed other medications, which were stored in the clinic room on site at New Beginnings, and although the social detoxification policy stated that service users should be self-administrating their own medication, we saw that support workers who were not suitably trained or qualified gave medications out daily.
• Assessments of service users’ needs were basic, incomplete, or contained within progress notes, this made them difficult to locate on the electronic case management system. Some assessments had been archived.
• Care plans at Sinclair House and Foundations were inconsistent, not recovery focused and not regularly reviewed.
• There was limited involvement of families and carers. Care plans were not always signed by service users and lacked evidence of their involvement.
• Targets set by commissioners, on the number of service users successfully discharged, were not being met. There was limited evidence of discharge planning.
• Audit systems in place at a local level failed to pick up inconsistent risk assessments and care planning.

However:

• Premises were clean, tidy, and well maintained with welcoming waiting areas.
• Staffing levels were appropriate and safe for service users’ needs. There was good reporting of incidents across all services at a local level and effective safeguarding systems were in place.
• The team leader at New Beginnings had completed an environmental suicide and ligature point risk assessment and audit. An action plan was in place for the social detoxification.
• Service users had access to psychosocial therapies and a good range of group work sessions. Staff followed National Institute for Health and Care Excellence guidance for prescribing medications. Good multidisciplinary teams worked in each service and met on a regular basis.
• Staff were kind and respectful to people using the services and there were good and positive interactions between staff and service users.
• Peer mentor schemes had been developed in all services, with good training packages and on-going support. Peer mentors in Doncaster had progressed into paid work with the service.
• All services were well managed at a local level, and service managers supported staff. The assistant director was visible and supported service managers within the substance misuse division.
• All managers attended monthly governance meetings. Performance systems were in place to monitor key performance indicators (KPIs) with regular meetings held between service managers and commissioners from each local authority.