South West Yorkshire Partnership NHS Foundation Trust

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

• The ward environment was autism friendly and supportive of the sensory integration needs of people with autism. There was a sensory room and other quiet, uncluttered areas for patients to use. Bedroom doors had tactile door surrounds to assist with room recognition.

• Staffing levels were appropriate to meet patients’ needs. Staff were able to spend 1:1 time with patients.
• There was a person-centred culture in which individual patients' needs were prioritised. We saw that staff identified and met patients' emotional and social needs. There was a range of activities available to patients.
• Care records were holistic, recovery-focussed and up to date. Care plans were very detailed and clearly described interventions, enabling a consistent approach from all staff.
• Patients had comprehensive physical assessments on admission and physical health care needs were being met.
• All patients had a positive behaviour support plan which aimed to improve their quality of life. Plans included details of behaviours of concern, triggers to these behaviours and early warning signs.
• Staff received mandatory training and annual appraisals. There was clear learning from incidents.

However:

• Not all information for patients was accessible. The ward team were aware of this and we saw an action plan for improvements to be made.
• Centrally collated data regarding the use of restraint and seclusion was not accurate.
• Mental Health Act and Mental Capacity Act training was not mandatory but was classed as core training for staff on the ward. The recording and monitoring of what staff had had training at ward level was not effective.
• The ward did not have junior doctor cover and some staff felt access to the medical cover which was provided was a concern.
• Missing medication doses were not always being recorded as incidents.

We rated community health services for children, young people and families as good because:

• Services were safe and people were protected from harm. Staff knew how to manage and report incidents. We saw there had been learning following serious case reviews. Risks were actively monitored and acted upon. We found that there were good safeguarding processes in place.
• We found that there was enough staff with the right qualifications to meet families’ needs.
• The clinics and health centres we visited were clean.
• Services were effective. We found good evidence that the service reviewed and implemented national good practice guidelines. The trust had also successfully implemented evidence based programmes, such as the family nurse partnership programme.
• We also saw that patient outcomes and performance were monitored regularly, and that all staff received regular training, supervision and an annual appraisal. There was good evidence of multidisciplinary and multi-agency working across the services.
• Services were caring. Children, young people and parents told us that they received compassionate care with excellent emotional support.
• Services were responsive. We found the service planned and delivered services to meet the need of local families. Parents, children and young people were able to quickly access care at home or in a location that was appropriate to them.

• Services were well led. Staff we spoke with told us the patient was at the centre of what they do, they were positive and proud about working for the organisation. There was an open culture in the service, and staff were engaged in the process of service improvement. Staff reported being supported by their line managers and teams within the organisation.
• Staff worked with national and regional partners to share good practice. The service had been recognised by the Department of Health for their information sharing procedures and also received recognition from the Institute of Health Visiting and NHS England following the development of the health visitor caseload weighting tool. All managers were very proud of their teams.

Overall we rated the trust as good for community end of life care services because:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons were learned and communicated widely to support improvements.

• High performance within the service was recognised by credible external bodies.

• Staff in the community and on the wards of the community hospitals demonstrated a consistently good level of knowledge of end of life care issues.

• The palliative care team was multi-disciplinary with medical, nursing, social work, occupational therapy, physiotherapy and dietetic membership.

• The end of life care lead for the trust was also the end of life care lead for the locality and the trust had a significant role in contributing to the shaping of end of life care services.

• We saw that staff would find ways of making the experience of care as easy as possible for people and that there was a commitment to end of life care at all levels ofthe community service.

• 84% of patients known to the Specialist Palliative Care Team achieved their preferred place of care at the end of life.

• The integrated multidisciplinary model adopted by the palliative care service supported the development of responsive care packages in the community, including the management of a supportive care at home service.

• There was a clear vision, strategy and values for end of life care with well-defined objectives that were reviewed as part of a district end of life care steering group.

• We observed strong leadership from the Specialist Palliative Care Team (SPCT) and senior staff in the community.

• There was a commitment and culture for providing high quality end of life care that was patient focused.

• Innovation was apparent across the SPCT as a whole.

• The service proactively engaged staff and patients to ensure their views were heard and acted upon, including the use of volunteers to obtain patient and family feedback.

We rated community inpatient services as good because:

• The service prioritised patient protection and there were defined systems, processes and standard operating procedures to keep people safe and safeguarded from abuse. We saw evidence of open and transparent culture in relation to incident reporting. Opportunities were available to learn from investigations and staff were comfortable reporting their concerns or any near misses. The duty of candour process and practice was in place across all community inpatient locations. Complaint and concern responses were provided in a timely way with improvements made to the quality of care as a result.

• The department was clean and there were infection control and prevention audits, which showed high scoring outcomes. We found that medicine management and recording of information was to a good standard and well maintained.

• Training levels were in line with trust targets as a whole and staff competence was apparent during inspection. All safeguarding training took place as part of the trust’s mandatory training programme and nursing staff demonstrated a good level of knowledge in relation to safeguarding triggers, forms of abuse and processes.

• Risks to people who use services were assessed, monitored and managed on a day-to-day basis. Risk assessments were person-centred, proportionate and reviewed regularly. The service applied national early warning scores to identify when the escalation of care needs was appropriate.

• Feedback from numerous patients across both of the community locations was very positive. We heard that staff responded compassionately to patients’ needs and were skilled in dealing with vulnerable individuals with complex physical and mental health needs. Relatives said they felt involved and had the opportunity to speak with medical and nursing staff when required.

• We observed the treatment of patients to be compassionate, dignified, and respectful throughout our inspection. Ward managers were available on the wards so that relatives and patients could speak with them as necessary. Staff were hard working, caring and committed to delivering a good quality service. They spoke with passion about their work and were proud of what they did.
• We found that the trust’s contribution to local and national audit was in line with the national average, and evidence of changes made by specialities in response to their outcomes was available and had been actioned.
• Planning and delivery processes were in a place to enable services to meet the needs of the local population. The importance of flexibility, choice and continuity of care was evident within each service. The needs of different people were taken into account when planning and delivering services and reasonable adjustments were made to remove barriers when people found it hard to use or access services.

• There was evidence of competent, responsive, multidisciplinary working between all professionals. They worked closely with the local authority when planning discharge of complex patients and when raising safeguarding alerts.

• The behaviours and actions of staff working in the division mirrored the trust values of ‘patients’ first, safe and high quality care, and responsibility and accountability’ of which we saw multiple examples of during our inspection.

We rated this core service as good because:

• Systems to manage and report incidents were in place, safeguarding procedures were robust and records were up to date.
• Medicines were stored and administered appropriately. Equipment was readily available and cleanliness and infection control procedures were followed.
• Risks to the delivery of care for patients were managed and action taken to mitigate them.
• Services were mainly fully staffed, mandatory training was up to date and staff development was supported.
• Care and treatment followed evidence based guidance.
• Care pathways were coordinated, multidisciplinary working was effective and outcomes for patients were evidenced and audited.
• Patient’s consent to care and treatment was documented.
• Care was delivered with compassion and staff treated patients with dignity and respect. Patients were involved in decisions about their care and treatment and received emotional support.
• Community services had a clear vision focussed on the patient at the centre and the needs of patients influenced the planning and delivery of services, including care for patients with diverse cultural needs.
• Patients had timely access to services, with minimal waits for most services. Few complaints were received by the service.
• Governance arrangements supported the delivery of care for patients. Performance measures were used which were monitored and action was taken when issues were identified.
• The service demonstrated a positive, focussed culture.
• Community services operated in an environment that encouraged improvement and innovation.

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

• Some of the community nursing teams were co-located and managed within local authority community learning disability services. These teams utilised the local authority electronic recording systems to create and maintain patient records. Although these staff could access Rio, the trusts electronic recording system, they were not all able to update the records and could not easily share the information held on the local authority system. Staff that used Rio told us the system did not enable them to input and upload some assessments which they had to store on a network drive. This resulted in staff from other teams being unable to directly access all the relevant information on a patient’s record.

• We saw evidence that patients risk was assessed as part of their initial assessment however risk assessments were not always reviewed routinely, unless there was a known change in a patient’s needs.

• The teams integrated within local authority services were not governed by any key performance indicators and were not required to provide performance data to enable the trust to monitor the quality and safety of service provision.

• Psychology teams were not always meeting the services target of 18 week treatment pathway and some people had been waiting 13 months to access the treatment.

However,

• Patients had holistic care plans based on individual need, including care plans in easy read formats. Staff demonstrated a strong person centred culture through their knowledge of the patients they supported.

• Teams held weekly meetings to review new referrals and waiting lists, where patients presented to be in crisis the service would prioritise their need for support.

• Staff were supported to make suggestions for innovative ideas. The service had supported the development of the ‘cook and eat’ books, a range of easy read cook books designed for use by people themselves and within therapy sessions.

• The service had a robust process in place to record incidents, learn from incidents was reviewed at management level and disseminated through to teams. Staff were all aware of their responsibility under the duty of candour and this had been incorporated in to the incident reporting system.

We rated Community Mental Health service for older adults as requires improvement because:

• There were long waiting times from referral to treatment. Access to psychological therapies was limited causing long waiting times in some areas.

• Not all services had a full multidisciplinary team complement.

• It was difficult for staff within teams to ensure records all held the same information as some services used paper and others used computerised systems. in addition, the use of different systems meant there was duplication of work when recording information.

• Some patients’ care records did not reflect the involvement of the person and their wishes for care and treatment.

• Trust wide learning events were carried out following incidents however attendance at these was not mandatory.

• There was no crisis service for older people.

However:

• Managers were able to asses required staffing levels and ensure enough staff were available to provide care. Staff knew what their responsibilities were in relation to safeguarding and what they needed to do to keep themselves and patients safe.

• Staff we spoke with understood the Mental Capacity Act and we saw evidence of this put into practice. Best interest meetings were carried out when required and documented in care records. Regular multi-disciplinary team (MDT) meetings were carried out and were used to discuss patients’ care and any concerns that may have arisen since the last meeting.

• Staff treated patients and carers with dignity and respect. Appointments were rarely cancelled and patients told us that staff were very accessible. Staff made time to speak with patients and their carers. Patients were encouraged to ask questions and participate in their care and treatment decisions.

• Staff knew about the duty of candour and were aware of the types of incidents that should be reported. Learning events were carried out following incidents and staff were given debriefs and support.

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

• the service was using a combination of electronic and paper records and some information was being stored in the clinical records and some on restricted access shared drives

• waiting lists for treatment were long and unless someone contacted the service for assistance it was not possible to monitor any changes in risk. The trust were not able to provide accurate information about how long children and young people were waiting for treatment after they had been assessed

• a procedure was in place for safe visiting, which included staff carrying a personal safety device, but staff were not fully following this which put staff at increased risk of harm from others.

• the trust required clinical staff to have basic life support training but the compliance with this was significantly below trust target, this meant hat staff who were not trained were unable to provide basic life support in an emergency situation.

• the trust could not provide accurate up to date information on waiting times and average caseloads of the teams.

• Clinical audits were not being regularly undertaken to ensure quality standards were in place.

We rated South West Yorkshire NHS Partnership Foundation Trust as good because :

• The environment of the health based places of safety (136 Suites) were adequate and in line with Mental Health Act guidance. It optimised patient dignity, safety and comfort.
• The crisis teams had robust monitoring of medication and had rapid access to psychiatry; patients could be seen within the day. We saw examples of the crisis team learning from incidents and implementing changes within their practice. Staff across all the teams were up to date in their adult and child safeguarding training.
• All the teams worked alongside external stakeholders to respond to people in crisis effectively. This was in line with the trust’s responsibilities under the crisis concordat.
• All initial assessments are carried out by a band 5 or band 6 nurse. If a band 5 nurse carries out the initial assessment, this is always discussed with a band 6 nurse. We saw initial assessments were comprehensive and detailed. Staff across all the teams had a good understanding of the Mental Health Act and Mental Capacity Act. They understood the guiding principles and were able to give examples of how they could apply it in practice.
• We observed meaningful, compassionate and person centred care delivered by dedicated staff. Patients were positive about their experiences with the crisis teams.
• Staff within the crisis teams met their targets to complete initial assessments within four hours of referral. We observed flexible working around patients’ needs. Staff adjusted their schedules so that patients could attend their appointments. Crisis teams utilised a range of resources which increased the quality of the service they delivered, for example, self-help leaflets and interpreting services.
• We saw effective use of auditing which provided oversight of team performance. These enabled team leaders to plan work and identify gaps. We saw teams shared good practice across the different regions, learning from each other’s experiences. Staff had good morale and were happy about how they were managed. Staff felt valued and that their thoughts mattered.

However,

• We saw that the staff on the 136 suites did not always review their ligature risk assessments in a timely manner.
• Monitoring for Mental Health Act and Mental Capacity Act training were not always present.
• Appraisals for staff had not been completed equally across the four crisis teams.
• Not all teams provided crisis team leaflets describing their crisis service other than in English.
• Not all teams were commissioned to have police liaison officers.
• The crisis team in Barnsley had high levels of sickness. The sickness levels year to date was 12%.
• Teams felt less confident with the management structure above the team leaders.

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

• patients had risk assessments in place which were reviewed regularly. Risk management was practised in daily and weekly multi-disciplinary meetings

• there were good safeguarding practices in place. Staff knew how to identify abuse and raise concerns

• there were lone worker protocols in place that staff understood and adhered to

• services were engaged in clinical audit. Systems were in place to monitor adherence to National Institute for Health and Care Excellence (NICE) guidance. Action plans were in place to achieve compliance where required

• patients were involved in decisions about their care. Care plans were personalised, holistic and recovery focused

• feedback from patients was positive. We observed patients being treated in a respectful manner and with a caring and empathic approach

• there were processes in place to prioritise referrals and respond to urgent referrals. Teams were able to engage with individuals who found it difficult or were reluctant to engage with services

• there was strong leadership at team and business delivery unit levels.

However;

• there were long waiting times for access to psychological therapies in parts of the service. In Barnsley North community mental health team this was an average of 54 weeks. Provision of psychological therapies to the South Kirklees assertive outreach team was also insufficient

• the ADHD and autism team had a referral to first contact time of 44 weeks. The time from first contact to second contact was 14 weeks. Commissioners were introducing increased funding for the service to help address this

• training on the Mental Health Act and Mental Capacity Act was not mandatory training and not all staff had received training

• electronic systems used to store patient records were unreliable. Contingency plans to use paper records were in place. The issue of electronic records systems was on the trust risk register

• staff expressed concerns about caseload and capacity. They were concerned that teams were reaching, or at their maximum workloads and this would limit the amount of time they could spend with each person who used the service.

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

• All wards were clean, tidy, and well maintained. The clinic rooms were fully equipped and emergency equipment was checked regularly. Staff were aware of how to report incidents and did so via the online incident reporting system. The ward complied with guidance on same sex accommodation by having single en-suite bedrooms and a designated female lounge area. There were good medicines management procedures for recording, dispensing and storing of medication. Staff were aware of the duty of candour and their responsibilities surrounding this.

• All patients had a physical health check on admission and there was evidence of ongoing physical health monitoring. There was evidence that National Institute for Health and Care Excellence guidance was being followed in relation to prescribing of medication and there was a range of psychological therapies on offer to patients. Clinical staff participated in a wide range of clinical audit, including medications, mental health act and care records. Eighty seven percent of staff had received an appraisal in the last twelve months. Mandatory training was at 89% for the core service. This was above both the national average and the trust target of 80%.
• We saw positive interactions between staff and patients. All patients we spoke with told us they were treated in a dignified, respectful and caring manner. The staff we spoke with knew the patients well and this was reflected in the care plans of the patients. Patients all had a copy of their care plan if they wanted one and they were fully involved in developing them. There were weekly community meetings where patients were given the opportunity to give feedback on the ward. Patients told us they were encouraged to join in with activities that were available.

• Discharge was always well planned and happened at an appropriate time for that person. There was a full range of rooms to support care and treatment of the patients. Patients had the facilities to make a phone call in private. There was a lot of emphasis on patients accessing local groups for activities. However, there was also a wide range of activities available on the ward seven days a week, including evenings. Staff and patients were able to discuss any issues in community meetings and staff meetings. Information leaflets were available in a range of languages if required. Patients had access to an independent mental health advocate who visited the ward on a weekly basis. Staff were aware of the organisation’s vision and values and used them as a basis for their work with patients’. These were displayed in the communal areas.

• The clinical leadership on the ward was clear and all staff said that they felt supported and listened to. Staff were aware of the trust vision and values and were committed to providing good care in line with this.

However:

• On The Poplars, Ward 19 and Chantry Unit the ward layout did not allow staff to observe all parts of the ward. This was not mitigated by the use of mirrors on Chantry Unit or Ward 19. The use of observations did not include staff being present in those areas on a routine basis and on the day of our inspection staff were not present in those areas. Risk assessments of patients did not refer to the blind spots within the wards when considering the risks to and from that patient. This meant that the ward was not doing all that was practicably possible to reduce the risk of harm to patient s and staff.
• The bedrooms door handles at Ward 19 were a ligature risk. Although this was identified on the annual ligature risk assessment to be managed locally there were no bedrooms without these door handles. This meant that if patients were a high risk of self harm they would need to be nursed on close observations which was not the least restrictive option.

We rated forensic inpatient secure wards as requires improvement because:

• The nursing staff levels on each ward did not match the number of nurses required to facilitate adequate nursing care. This meant that patient’s leave, physical health appointments and ward based activities were cancelled due to the lack of staff.
• The temperature in the clinic room was too high and exceeded the recommended level for the safe storage of medicines. This meant that the stability of medicines was unsafe and that medicines were at risk of being less effective.
• Not all patients with a learning disability or autism had positive behaviour support plans or equivelants in place. This meant that staff would not be providing a consistent approach towards patient exhibiting behaviour which was challenging. This is not in keeping with guidance from NHS England, (Transforming care for people with learning disabilities, 2015).

• Patients were not always receiving 25 hours a week of meaningful activities as recommended by NHS England. This meant that patients were not reaching their potential for recovery and rehabilitation in a timely way.

• Patient care records did not always contain evidence of the patients’ involvement in their care. MHA, Mental Capacity Act (MCA) and immediate life support training was available but was not mandatory training for staff. The training being delivered was variable, inconsistent and accurate attendance figures were not kept by the service. The trust had no oversight regarding staff knowledge and understanding of the MHA, MCA or levels of competency for life support.

• Patients’ rights, the recording of patients’ capacity to consent to treatment and advance decision statements were not consistently recorded in patients care records.

• The care and treatment of one patient in long-term segregation did not meet the standards set out in the MHA code of practice.

• Not all staff had timely access to patients’ electronic care records which could compromise the care delivered.

• Food choice availability was inconsistent.

• There was no system in place to ensure that staff were receiving regular supervision as described in the trust supervision policy. Information was collected at ward level but this was not accessible at trust level. This meant that the trust had no data to provide assurance that supervision was being delivered.

• On two wards, compliance with appraisals was 50% and 46% which was not in line with trust policy.

However:

• Staff showed a good understanding of safeguarding issues and there were good links with the local safeguarding authority.

• The facilities provided by the service were clean, spacious and focussed on promoting patients recovery whilst maintaining appropriate levels of security.

• Family and carers were kept informed of patient’s care when patients had consented to this. Family and carers were invited to review meetings and felt involved in patient care and decisions.

• We found effective multidisciplinary team (MDT) working. Teams were cohesive with good communication between different professionals and agencies.

• There was a range of professionals involved in patient care which ensured a holistic approach was taken towards patient care.

• There was effective psychology provision available to patients with a range of psychological approaches offered. The psychologist was part of the MDT and contributed to the care planning process. This meant that patients needing psychology could access this service directly and that a psychological approach was embedded in the ward philosophy.

• Staff followed the trust’s complaints policy and lessons were learnt from adverse events. This meant that patients’ views were listened to and acted upon.

• Staff were kind and caring and treated patients with respect. This meant that patients felt supported and had a good relationship with their care team.

• There was an effective discharge planning process in place that involved the MDT. This meant that patients ready to move on from the service were not unnecessarily delayed.

• Staff understood and agreed with the mission and values of the trust and felt they were applicable to their role and reflected in the service objectives.

• The senior management team were a visible presence on each ward.

• Each ward was involved in the safer wards programme to help improve the safety and comfort for patients and staff.

• Staff reported that morale was good.

• Staff had the opportunity to give feedback on services and input into service development.

We rated long stay/rehabilitation mental health wards for working age adults as requires improvement because:

• Staff at Enfield Down did not review the risk assessments that they had undertaken and did not update these to reflect changes in risks associated with changes in patient presentation. This placed patients at risk of harm from incorrect information being held about them, and their current risks not being managed effectively.

• Staff at Enfield Down did not always follow national guidelines and best practice with regards to medicines management. They did not review PRN medication (medication when required) regularly.

• Staff at Enfield Down had prescribed high dose antipsychotic medication for two patients but had not undertaken regular electrocardiograms; despite one patient being at high risk of cardiac problems. This meant patients on high dose antipsychotics where at risk of physical health complications because they were not being monitored appropriately.

• Staff st Enfield Down, did not hold regular multidisciplinary meetings to discuss the care of patients. The service held Care Programme Approach meetings on a three to six monthly basis and this would be when patients would be fully reviewed. This meant that staff might not meet the needs of patients in a timely and efficient manner.

• The services within the trust were led by a team of three senior clinicians.Within the rehab service the governance lead post was vacant and was out to advertisement. At Enfield Down, governance processes had failed to identify that there were insufficient monitoring of patients on high dose antipsychotic medication, that patients were not being reviewed in a timely manner, and that risk assessments were not being reviewed or updated as required.

However

• The average mandatory training rate for the whole service was 93% with both units achieving above the trust standard of 85%.

• Care plans were developed in collaboration with the patients, were holistic and covered a range of areas such as mental health, physical health, drug and alcohol issues and social issues. The occupational therapist also contributed to the care plans demonstrating a multidisciplinary approach.

• We saw interaction between staff and patients that was respectful, thoughtful, considerate, timely, and professional. Patients we spoke to told us that staff members were professional at all times. Staff members were praised by patients for being approachable, caring and always making time to talk.

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

• Some wards had poor lines of sight, which put patients at risk where the trust had not mitigated ligature risks or in some cases identified them.
• Bathroom facilities were not adequate on Beamshaw and Clarke wards.
• Patients on Beamshaw and Clarke wards could not take a bath without staff present. This was a blanket restriction.
• Staff did not routinely carry out monitoring of high doses of medication.
• Managers did not ensure staffing levels were always sufficient to keep patients safe. Escorted section 17 leave was either cancelled or cut short due to staffing levels.
• Staff on ward 18 had either not completed patients’ risk assessment or had not completed them on time.
• Line managers did not provide regular supervision to staff on all of the wards.
• It was not always clear in records whether people had capacity and therefore whether there was any requirement for capacity assessments to be undertaken where necessary. Staff did not always follow the best interest process.
• There was not always a bed available on patients’ return from leave and in some cases beds were put in communal rooms.
• Access to activities was limited at weekends.
• Information on how to complain was not displayed on Trinity 1.
• We observed one example of a patient’s privacy and dignity being compromised.

However:

• We observed staff interacting with patients in a respectful manner and in ways that were appropriate to the needs of the person.
• The provider had introduced a co-production care plan. However, this had not been adopted in all areas.
• Ward rounds involved the patient and patients were very positive about the care they received.
• Patients had good access to advocacy services.
• Patients were given a pack of information on admission to the wards.
• Staff reported good support within the teams and there was a good team spirit on most wards.
• Staff followed duty of candour by being open and transparent and verbally apologising when something went wrong.
• My physical health and my mental health documents had been introduced on some wards.

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 found that the provider was performing at a level which led to a rating of requires improvement. We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

We rated the trust as requires improvement overall because:

• Staffing levels in some of the inpatient areas did not always meet the safer staffing levels set by the trust. This adversely impacted on activities, escorted leave and potentially patient and staff safety. We also found some patients were waiting a long time for a service, this was especially so in specialist community mental health services for children and young people and psychology therapy services. The waiting lists were also not being appropriately managed which could lead to escalation in patient risk not being recognised.

• Risk assessment and management were inconsistent across the trust. Staff did not always assess patient risk in line with the trust’s policy. Staff did not always update the assessment in a timely manner when patient condition and presentation changed and risks were identified. Staff did not always share information regarding risk with other parts of the service. There were also environmental risks in some inpatient areas that had not been adequately managed by the trust.

• Physical health monitoring across the services was inconsistent. This was especially so where physical health monitoring was necessary in relation to specific medication and its use in long stay and rehabilitation and acute and psychiatric intensive care wards.

• Mental Health Act (MHA) and Mental Capacity Act (MCA) training was not mandatory for the trust staff and there was no overall board knowledge or overview of what training was being delivered or to which staff. Training was arranged and delivered locally and we found some areas where staff knowledge of the legislation in practice was very good. Unfortunately, we also found some areas where the staff knowledge of legislation in practice was very poor.

• Alongside the training for the MHA, we found that the trust had not implemented the changes to the 2015 MHA code of practice in the organisation. There were policies and procedures that had not been updated to meet the requirement of the 2015 code and the changes had not been actioned in practice. This meant that there was no assurance that patients and their carer’s rights were protected.

• Whilst there was overview of staff appraisal in the trust there was no overview of managerial or clinical supervision for staff. We saw examples of supervision at a local level on an individual and group basis. However, this was not consistent across the trust and there were areas where supervision was not being held for a considerable period.

• The trust’s electronic recording system, RIO, had been recently upgraded and different services across the trust were at various levels of implementation. Most services were finding it difficult to use the system effectively with areas needing to find their own solutions to the problems they were encountering. The difficulties were due to the system being slow to load and use information, a mixture of paper based and electronic records at various levels of development and different groups and disciplines or staff using different systems. Whilst some areas had developed their own solutions to problems with health records the inconsistency across the trust left risks to patient care and service delivery.

• There was a lack of assurance that the governance structures in place were effective across the organisation. Senior staff presented information to the board through governance meetings. We found that policies and procedures agreed at the board were not always consistent at a local level. Practice such as medication management, management of environmental risks across services and wards, monitoring and management of waiting lists, data quality to inform performance and the use of electronic and paper based health records were all found to be inconsistent. Some of the practice we saw in these areas was effective and staff had worked hard to provide a good service. However, there was potential for the board not to be aware of the quality of practice delivered by frontline staff due to the governance structure. This was especially evident in Enfield Down, one of the long stay rehabilitation wards, where the governance system had not identified failings in the service.

• The board approved the fit and proper person’s policy on 31 March 2015; this details the trust’s responsibilities and states that the trust will ensure that it has procedures in place to assess an individual against the fit and proper person’s requirements for all the new directors, prior to their appointment. Three of the new non-executive directors had not had Disclosure and Barring Service checks in line with the fit and proper person requirement, which came into force for NHS bodies on the 1 October 2014. This meant the trust was not complying with its policy or this requirement.

However:

• Consistently across the service, we found good communication between staff and patients and staff treating patients with kindness, dignity, compassion and respect. This was supported by comments from patients who were positive about the care and treatment they received from services. There were also good examples of patient and carer involvement in their care.

• Staff uptake of mandatory training was above the trust standard of 80% in the majority of inpatient areas.

• We saw examples of good practice across the organisation and areas where staff had developed aspects of their service. There was proactive management across the trust, often in a challenging environment. We saw some areas of notable practice across areas of the trust, which are detailed within the report. These include; navigation / tele health service; adult epilepsy service; commitment to working collaboratively; ADHD service and prison in-reach; production of easy read cook books; community eating disorder pathway; falls audit and change to practice.

• The trust had a clear structure and governance in place for the reporting of safeguarding incidents from the ward to the board via a number of different groups. Staff followed the incident reporting, complaints and safeguarding procedures, across the services, including duty of candour. Staff described instances where they had received feedback following learning from incidents and we observed evidence of lessons learnt from board to ward in the almost all services. There were named safeguarding nurses and mandatory safeguarding training. Staff were able to explain their responsibilities and local referral procedures for safeguarding.

• The trust had a clear strategy, which established its long-term vision and strategic goals, underpinned by the values of the organisation. The trust had worked closely with its stakeholders to develop these values. The values were embedded in the business delivery units and reflected in the staff behaviours we observed during our inspection. The introduction of the trio of managers, comprising a general manager, a clinical lead and a practice governance coach, in the service lines in each business delivery unit had improved the service delivery, the staff understanding of the transformation programme, and staff morale.