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Provider: Birmingham and Solihull Mental Health NHS Foundation Trust Requires improvement

Read our previous full service inspection reports for Birmingham and Solihull Mental Health NHS Foundation Trust, published on 9 September 2014.

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 August 2017

Following the inspection in March 2017, we have changed the overall rating for Birmingham and Solihull Mental Health NHS Trust from Good to Requires Improvement because:

  • Feedback from staff and evidence from the most recent NHS staff survey suggested a disjoint between the board and staff at service level. Staff groups in several areas reported feeling under-valued and as being unheard concerning key decisions and service re-design.
  • The trust had taken a blanket approach to searches and ordering of food from take away restaurants. The decisions made at board level in relation to the restrictions did not take account of individual risk assessment or patient choice.
  • The oversight and safety of medicines management was compromised as the trust did not have a medicines safety officer in post. The trust policy concerning rapid tranquilisation was also out of date and did not reflect updated guidance from the national institute of health and care excellence.
  • Staff knowledge, understanding and application of the Mental Capacity Act was poor in those community services that cared for children and young people and in the wards for older people with mental health problems.
  • We found that the trust processes for assuring their contractual obligations concerning equality and diversity lacked robustness. In some teams, the provision of information for Non-English speakers was insufficient and in contravention with the Equality Act 2010.
  • The Board Assurance Framework did not focus on strategic risks and instead was an extension of the corporate risk register. This meant that the board were unable to provide robust evidence of an understanding of the trusts corporate risks.

However:

  • Staff, throughout the organisation, were caring, compassionate, kind and treated patients with dignity and respect. Feedback from patients and carers was positive and highlighted the staff as a caring group.
  • Staffing levels across the trust were generally safe and sufficient to provide good care.
  • The trust was involved in several vanguards and new models of care partnerships with external partners. Overall, external bodies were positive about the trust and its role in addressing the challenges faced by the local health economy.
  • Trust services were responsive to the needs of the patient group; this was evident in the inpatient and community services that we visited.

Inspection areas

Safe

Requires improvement

Updated 1 August 2017

We rated Birmingham and Solihull Mental Health NHS Trust as requires improvement for safe because:

  • There was a high use of prone restraint in the trust; out of 1229 restraint between December 2015-November 2016; 580 of which were carried out in the prone position.

  • The trust had implemented blanket restrictions with regards to ordering of food from takeaways and also in relation to searches. Staff stated that the policies were difficult to apply and did not promote an individualised approach to patient choice or risk.
  • The trust did not have a medicine safety officer in post. This was contrary to guidance from NHS England requiring trusts to appoint one. There was limited pharmacy involvement in inpatient settings, which meant that visits to wards by the pharmacy team was cancelled due to low pharmacy staffing levels.

  • The trust rapid tranquilisation policy was based on outdated NICE guidance: NG25 2005. This guidance had been superseded by NICE guidance NG10, published in May 2015.

However:

  • The trust had implemented a system of environmental and ligature risk assessments that identified and provided mitigation to protect people at risk of self-injurious behaviour.

  • Staffing levels across the trust were safe in the majority of services. The trust had been proactive in the 12 months prior to the inspection in embarking upon a focussed recruitment drive for key staffing areas such as registered nurses and healthcare support workers.

  • Mandatory training levels were high across the trust with an average of 94% of staff compliance.

  • Staff understood their responsibilities under the duty of candour.

Effective

Requires improvement

Updated 1 August 2017

We rated Birmingham and Solihull Mental Health NHS Trust as Requires Improvement for effective because:

  • Staff within the specialist community mental health teams for children and young people displayed limited knowledge, understanding or application of Gillick competence.
  • Staff on the wards for older people with mental health problems also displayed a poor understanding of the mental capacity act in relation to recording of decisions and how the act applied to administering covert medication.
  • Care plans were not always personalised and showed little evidence of patient involvement.

However:

  • The trust had implemented the ‘WHAT’ tool that was used for an interactive and informative handover on most wards.

  • We found evidence of a multi-disciplinary approach to patient care delivery, which included external professionals such as local authorities, the GP, third sector and voluntary agencies.

  • Staff were involved in a range of clinical audits to monitor the effectiveness of the services provided. These included audits of infection control and prevention, health and safety and physical health.

Caring

Good

Updated 1 August 2017

We rated Birmingham and Solihull Mental Health NHS Trust as good for caring because:

  • The trust’s overall score for privacy, dignity and wellbeing in the patient led assessments of the care environment (PLACE) 2016 was 93.9%, which was around 4.2% higher than the England average of 89.7%. All sites scored above the national average.

  • We saw that staff interacted with patients in a positive, friendly and respectful manner and most patients we spoke to were positive in their views of staff.

  • Most wards had information and systems to orientate patients at the time of their admission.

  • Wards had regular community meetings. Staff kept minutes of these meeting and displayed these on wards.

  • The trust had developed the ‘See Me’ project for service users that involved them in forums and meetings across the trust.

Responsive

Good

Updated 1 August 2017

We rated Birmingham and Solihull Mental Health NHS Trust as Good for responsive because:

  • Most teams were responsive to the needs of patients who required access to services during periods of crisis or for routine appointments. Staff were proactive in reaching out to patients who did not attend for appointments.

  • The trust’s approach to managing and investigating complaints was effective and confidential involving a patient experience team, patient advice and liaison service (PALS) team. The organisation disseminated lessons learned from complaints through a process that included the circulation of a newsletter to all staff and through team meeting discussions.

However:

  • Some patients had long length of stays in forensic and long stay rehabilitation mental health wards. The high lengths of stay were attributed to a group of patients who had a bed for life and some patients who were subject to Ministry of Justice approval before discharge

  • In some services, information for patients who did not speak English as a first language was also displayed in English. This meant that Non-English speakers might suffer a delay in accessing treatment or support.

  • Between December 2015 and November 2016, 164 patients were placed out of area. Post inspection the Trust provided figure which showed that the range of out of area placements between October 2016 and February 2017 was between two and six, showing a good improvement

  • We found that over 300 patients experience delayed transfer of care.

Well-led

Requires improvement

Updated 1 August 2017

We rated Birmingham and Solihull Mental Health NHS Trust as Requires Improvement for well led because:

  • The trust had not implemented the Equality Delivery System (EDS2). A senior staff member was unaware that implementation of EDS2 was a contractual requirement. Equality analyses were not completed for all major decisions or policies.

  • The Board Assurance Framework did not focus on strategic risks and instead was an extension of the corporate risk register.

  • Staff groups in several areas reported feeling under-valued and as being unheard with regards to key decisions and service re-design.
  • The Allied Health Professional (AHP) group lacked identified leadership.
  • In seven of the nine services that we inspected we rated the safe key question as required improvement.

However;

  • Staff received mandatory training and the trust had an overall compliance rate of 94%. This meant that staff were given the training they needed to carry out their roles.

  • Processes for assuring that directors were ‘fit and proper’ were clear and consistent. We reviewed four director files and found all checks and declarations had been completed.

  • Services were well led at local level and staffing was sufficient to provide patients with good care and treatment.
  • The trust was a key partner externally in several of the local vanguards and new models of care. Feedback from local partners in health, local authority and oversight groups was positive.
Checks on specific services

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 1 August 2017

We rated the Long stay rehabilitation mental health wards as good because:

  • We found the units to be clean, spacious and comfortable with good quality furnishings and décor throughout, including well-maintained gardens.
  • Staff interactions with patients were appropriate and demonstrated a good understanding of individual patient needs.
  • Patients had the choice of a wide range of therapeutic interventions and activities to aid rehabilitation.
  • Carers were involved in the care of their relatives. We saw resources for carers and information on carers groups. Each unit had a carers champion /lead.

However;

  • Medicines management practices were inconsistent and potentially put patients at risk. We found discrepancies relating to the storage, prescribing and administration of medicines.

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

Updated 15 November 2018

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

Staff were concerned that twice in August 2018, two patients had been admitted above the agreed patient numbers. This had led to two patients sleeping in the seclusion room after  they no longer needed seclusion. There were no other beds available. This could compromise a patients’ dignity and privacy.

Staff expressed concerns about staffing levels and low staff morale. They said that it sometimes impacted upon patient leave being rearranged and their ability to take breaks. We found that the day time staff fill rate was consistently below 100% in the two months prior to inspection. Managers told us they tried to fill the gaps in the staffing  rota when they could, but these staff were not always available.

We did not find that the procedures for personal alarms was robust. Staff told us permanent staff took their alarms home with them and any spares on the ward were distributed to bank and agency staff. If staff forgot to bring their alarms to work, there would be less available to bank/ agency staff and visitors. Staff were not aware that there were spare alarms kept on reception at the Oleaster Unit.

However,

On this focussed inspection we found that the staff were open and transparent. They were caring towards the patients and wanted to support them as best they could.

Staff completed incident forms to raise concerns about patients numbers and staffing levels. We saw that managers had kept in touch with the ward during periods where patient numbers were above agreed amount.

We saw that staff kept up to date care records. Patients had up to date risk assessment and management plans in place assessments.

The ward had a barber’s chair and one of the ward staff had sourced the chair, specialist shaving, and hair dressing equipment themselves. The ward was planning to convert the unused bathroom on the ward into a mini-barbers shop.

Child and adolescent mental health wards

Good

Updated 1 August 2017

We rated Birmingham and Solihull Mental Health NHS Foundation trust’s child and adolescent mental health wards as good because:

  • Young people received care and support according to their individual needs. Staff formed strong relationships with young people and their families, who all told us staff treated them with respect, kindness and compassion. Young people, families and staff worked in true partnership when planning care and setting individual goals.

  • Staff were encouraged to be innovative and improve the service. Recent quality improvement work to reduce incidents of violence and aggression had started to lead to a reduction in use of restraint and rapid tranquilisation.

  • Young people were involved within the service at different levels. From running activities to reflecting with staff on how the day had gone. They could contribute to improving the environment, be part of governance groups and help with the recruitment of staff.

  • Care records were of a high quality and included the voice of the patient and families/ carers where appropriate. Risk assessments and management plans were thorough and updated as needed.

  • Effective governance processes were in place. Staff reported incidents and learnt lessons. Staff took time to reflect on clinical practice and looked at how they could improve outcomes for patients.

However:

  • The trust policy for rapid tranquilisation did not incorporate the latest National Institute of Clinical Excellence (NICE) guidelines published in May 2015 and we found young patients had been prescribed medicine outside of the current guidelines.
  • The seclusion room on Larimar Ward had no clock.
  • Patients on Atlantic and Pacific did not always have access to the seclusion room. In the last six months, staff had used the room to seclude an adult patient, three times.

  • Patients on Larimar Ward had no access to a multi-faith room and access to outside space was limited.

  • Larimar Ward is next to adult wards. Commissioning arrangements placed restrictions on the rights of an informal patient to leave the ward. Informal patients were unable to leave the ward without a staff escort.

  • We found some section 17 Mental Health Act forms to be incorrectly completed.

Community-based mental health services for adults of working age

Good

Updated 2 August 2017

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

  • All locations where patients were seen and treated had access to emergency equipment.

  • All buildings were clean and well maintained.

  • There was adequate hand washing facilities and we observed staff following infection control practices.

  • Patients and carers were happy with the way that staff worked and the services that were offered to them.

  • Patients felt that their needs were met and that the services belonged to their community.

  • Staff felt supported by senior managers and told us that they were able to share their concerns with the chief executive officer for the trust.

Community-based mental health services for older people

Good

Updated 1 August 2017

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

  • Staff routinely completed and updated patient risk assessments. They developed and recorded crisis plans with patients. This meant there were plans in place to reduce risks if patients were in crisis. Staff had a good understanding of safeguarding and the procedures to keep people safe from abuse. The service carried out regular environmental risk assessments to monitor and improve the safety of buildings.

  • The service had clear policies to support staff when they worked alone. Staff were aware of the lone working policy and the procedures to follow if they needed support when working alone. Staff knew how to report incidents and felt able to report concerns.

  • Staff knew their patients well. They kept records of patient care and treatment up-to-date, including any changes in circumstances. Staff routinely carried out mental capacity assessments when necessary and supported patients to manage their physical health needs.

  • The service worked well with other teams and agencies to enable patients to move between services as their needs changed. Staff communicated promptly and effectively with patients’ GPs and other relevant agencies.

  • Staff treated patients with kindness, dignity and respect. They routinely involved patients and carers in developing their assessments and care plans. The service was responsive to the needs of patients, carers and care homes. Patients told us they could get appointments when they needed them and doctors were accessible to both staff and patients. They said they could contact their allocated worker if they needed to speak with them. Patients were very positive about the service they received. The trust employed a team to gather feedback from patients and carers and used the information to make improvements to the service.

  • Staff had access to regular supervision and there were some opportunities for them to develop their skills and career. They were up-to-date with their mandatory training. Staff had a working knowledge of the Mental Health Act and the Mental Capacity Act.

  • Local leaders were visible and accessible to staff. Senior managers sometimes visited the teams.

  • Managers carried out regular audits, including audits of patient records. The service recorded referral and discharge data. They used dashboards to inform staff and managers if they were meeting their key performance indicator targets. This meant they could tell how long people waited to be seen by the teams and if staff carried out reviews in a timely manner.

However:

  • The service did not have a consistent process to audit safe and secure handling of medicines within the community teams. The trust pharmacy team carried out audits at each site in early 2017 but prior to this, there were gaps of over three years in some teams. There was no effective monitoring of clinic room temperatures in three teams and the clinic rooms in two teams were dusty and cluttered. Staff in most teams told us they believed their caseloads were too high and many told us they felt they needed to work at home, in their own time, to perform essential activities such as updating care plans and risk assessments.

  • Caseloads were high and some staff worked unpaid hours to complete essential case recording.

  • In some areas of the service, staff told us there were long waiting times for patients to access psychological therapies. The trust told us the longest waiting time was four weeks.

  • Most carers and patients did not know how to make a complaint about the service. Despite this, they told us they were sure they could find out how make a complaint if they needed to and were confident they would be listened to.

  • Consulting rooms where staff saw patients at the East Hub were very poorly soundproofed which meant conversations could be easily overheard. Consulting rooms at the North Hub had glass panels, which meant people using the corridor, could easily look in.

  • Some staff felt senior managers did not listen to the feedback they provided about organisational change and they had not received a response when they had used the trust formal feedback process called “Dear John”. Three staff said they did not have confidence in the whistleblowing process or in the Dear John process.

  • A number of staff felt unsettled about the organisational changes taking place within the trust and this led to a degree of low morale within most teams.

Forensic inpatient/secure wards

Good

Updated 1 August 2017

We rated Forensic inpatient/secure as Good because:

  • Staff could observe all areas of the wards at Ardenleigh, Reaside and The Tamarind Centre and at Hillis Lodge. They used risk assessments and observations to mitigate the potential risks to patients. Wards had adequate levels of staffing to meet the needs of patients and used bank and agency staff who were familiar with wards and patients where possible.

  • Wards had a full range of mental health disciplines and staff had the skills necessary to carry out their roles. Training levels in the Mental Capacity Act and Mental Health Act were high and staff felt confident to use this legislation to support patients.

  • Staff demonstrated that they understood the individual needs of patients who said they were respectful and friendly. Staff provided activities that met the needs of patients and supported them to develop skills for independent living.

  • Staff felt motivated and well supported to do their jobs. Managers listened to their concerns and responded to these. Staff had opportunities for professional development.

  • At Ardenleigh, patients needing seclusion had to be taken through a children and adolescents ward to use a seclusion room. This could affect the safety, dignity and privacy of the patients.

  • At Ardenleigh, the womens service had accessed seclusion facilities via the adolescent ward.

  • Staff used different tools for risk assessment and care planning which meant that at times the quality of these was inconsistent which could affect the care of patients.

  • There was no standard approach to recording capacity in the records and whether patients had been read their rights under the Mental Health Act.

  • Audits and governance structures were not sufficient to ensure quality of documentation and medication and clinical equipment errors were identified.

  • Fridge and clinic room temperatures had not always been recorded and some equipment such as needles were out of date on some wards. Some wards had excessive stock of medication did not record the date this was opened.

Mental health crisis services and health-based places of safety

Requires improvement

Updated 1 August 2017

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

  • Night time staffing of the crisis resolution home treatment team and RAID teams often fell below planned staffing levels.
  • Medicines management practice was not robust across all teams. We found that there were gaps in medicines reconciliation, transportation in community teams and documenting of patients’ allergy status.
  • We found that staff at the health based place of safety did not consistently monitor the quality and completeness of monitoring forms completed by staff.
  • We found that patients and staff did not always have access to alarm points, and alarm systems at trust locations had not been effectively checked to ensure they worked.

However:

  • Patients reported that staff were caring, polite and respectful and we saw this demonstrated in our observations.
  • Staff reported that teams worked well, were supportive and worked hard to deliver patient care.

Specialist community mental health services for children and young people

Good

Updated 8 March 2018

We changed the overall rating of inadequate to good because:

  • On inspection we found that the trust had put systems and processes in place to address the actions we had told them they ‘must’ take to address regulatory breaches we had found on inspection in March 2017. The trust had also taken action to address the ‘shoulds’ we recommended they take to improve the service.

  • Staff completed risk assessments for children and young people. These were recorded in the care records and updated every six months or as needed.

  • Staff routinely established and recorded consent to treatment and documented evidence of considering Gillick competence and capacity where appropriate.

  • Senior management had reviewed policies and procedures relating to the running of the service. These policies had been agreed by the trust and review dates for 2020 had been set.

  • Staff ensured that prescription pads and prescriptions were stored in line with the trust policy.

  • Staff monitored the cleanliness and working order of physical health monitoring equipment and therapeutic toys.

  • Staffing vacancies had reduced and the service had 15 more whole time equivalent staff than on our previous inspection March 2017. Turnover had reduced from 25% to 13%.

  • Staff compliance with mandatory training, supervision and appraisals was good and compliance rates above the trust target level of 90%.

  • Work was in progress to make both sites more child and young person friendly and to increase the level of sound proofing within interview rooms.

However:

  • The mobile phone staff safety application was not fully working or accessible on 50% of staff mobile phones.

  • Staff were using trust templates on the electronic care record system to record care plans. However, we felt that there was further improvement required. Not all care plans were detailed, personalised and holistic. We found evidence of basic care planning in 15 of the 28 care records we reviewed. The majority of these basic care plans were found within the eating disorders team. Care plans did not always record or reflect the voice of the patient, or reflect the quality of care staff were providing.

  •   The service did not undertake regular audits of care records to assure progress in this area.
  • We were not assured that staff reported all incidents on the trust incident recording system or aware of what they should report. We were told of two incidents that should have been reported and had not been reported.

Wards for older people with mental health problems

Good

Updated 1 August 2017

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

  • Staff took time to explain, orientate and re-assure patients as appropriate, supporting them to be safe but also to be as independent as possible. Ward managers were able to adjust staffing levels to take account of the fluctuating needs of patients, so that patients had additional support when they needed it. The service had a low rate of serious incidents. Staff used de-escalation techniques wherever possible as an alternative to restraint or seclusion. Positive comments by patients and visiting relatives reflected the good work by staff.

  • The teams worked together effectively to resolve care and treatment issues. Wards had access to support from a variety of clinicians and other professionals. Psychology support was available to help support staff in understanding and resolving patient behaviours. Medical support was available promptly. Occupational therapists provided activities and assessments to help patients gain or regain skills and enhance their well-being.

  • Care records were up to date, needs assessments and physical health care checks took place promptly after assessment. Monitoring systems were in place to ensure patient well-being.

  • Wards were clean and there was a range of rooms and equipment to support treatment and care.

  • Food was good and highly rated by patients. Patients were able to get snacks and drinks at any time of day or night.

  • Staff morale was good; staff expressed confidence in being able to report anything of concern. Staff were very positive about their teams and the support from immediate managers and sickness and absence rates were below the national average. Effective systems ensured staff received training, supervision and appraisals.

However:

  • The service was administering medication for physical health conditions covertly without appropriate safeguards in place for detained patients. There appeared to be no distinction between the procedure for administering medicines covertly for mental health needs and those for physical health needs.

  • Some mental capacity assessments were only partially completed on Rosemary and Bergamot wards.

  • Cleaning checklists were not always completed on Rosemary ward, indicating that equipment may not have been checked and cleaned as often as it should be.

  • There was a lack of suitable short-term rooms for patients when they presented a risk to themselves or other patients. Many staff felt patients might benefit from having a purpose-made de-escalation room available.

  • Lounge areas on the three Juniper wards were relatively small and were frequently crowded.