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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.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 April 2019

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

  • The trust had made insufficient improvements since our last comprehensive inspection in March 2017. This is reflected in the ratings of the core services that we inspected at this most recent inspection. The ratings for two of these five core services have changed from good to requires improvement. This means that four of the trust’s nine core services are now rated as requires improvement overall. We have also once again rated the safe and effective key questions as requires improvement for the trust overall.
  • There were continued concerns raised by some staff from diverse backgrounds about the support they received and whether they were listened to. This was shown in the staff survey results from 2017.
  • Many of the wards that we visited during this inspection had a shortage of permanent nursing staff. They relied heavily on agency and bank staff. This had an impact on the quality of patient care; including the adequacy of risk assessments of patients.
  • Staff consistently told us about a lack of consultation when the trust implemented a new model of working on acute mental health wards. The model integrated occupational therapists into the nursing teams on these wards. As a result, both disciplines could not carry out their basic duties. For example, occupational therapists had less time to carry out therapeutic activities with patients and there were delays in patients receiving medicines from nurses. This had an impact on the morale of staff.
  • Managers did not ensure staff received appropriate professional support and supervision to carry out their duties effectively. Staff had difficulty accessing clinical supervision and there were problems in how managerial supervision was recorded.
  • Some wards did not have fixed nurse call buttons in patients' bedrooms. Staff did not mitigate the risk this posed by assessing whether individual patients, who might be at risk or otherwise be vulnerable, should be provided with a portable alarm to request assistance if needed.

  • Care plans were not always personalised, holistic or updated.
  • Feedback from carers was not always positive regarding staff engagement and a response from concerns.
  • Patients could not always access a mental health bed in a timely manner when in crisis. There were blocks in the wider health and social care system in accessing mental health assessments for patients in crisis.
  • There continued to be problems with medicines management across the trust. Staff did not always follow best practice when storing, dispensing, and recording medication. Staff did not regularly review the effects of medications on each patient’s physical health following the use of rapid tranquilisation.

However:

  • The trust had improved the board assurance framework and risk register. It was now robust and clear. The trust leadership team had improved its cohesion. A plan for quality improvement to improve patient care and safety had started but required further work to embed across the trust. The trust leadership team had the necessary skills and experience to provide innovation and change. The trust had a good understanding of the wider health and social care economy, and were active in shaping local transformation plans.
  • The trust had improved the way it searched patients across services. There was improved individual risk assessments of patients and staff rather than a blanket restriction for search. The trust has also removed blanket restrictions relating to takeaway food providers
  • The trust had improved staff knowledge and application of the Mental Capacity Act across its services. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Managers made sure that staff could explain patients’ rights to them.
  • Staff treated patients with compassion and kindness. They almost always respected patients’ privacy and dignity, and supported their individual needs.

Inspection areas

Safe

Requires improvement

Updated 5 April 2019

Our rating of safe stayed the same. We took into account the previous ratings of services not inspected at this time. We rated it as requires improvement because:

  • There were insufficient permanent registered nursing staff to meet the needs of patients. There was high use of bank and agency staff. We found that patients had to wait for treatment and activities. There was variation in the frequency and quality of risk assessments across the service.
  • Medicines management across trust services remained a problem. Staff did not always follow best practice when storing, dispensing, and recording medication. There were many recorded errors in practice. Staff did not carry out physical health checks consistently after administering rapid tranquilisation. Staff did not always record a discussion of the side effects of valproic acid/valproate with female patients to whom it had been prescribed.
  • Not all staff felt safe across its services. Staff did not always have access to an alarm system or personal alarms to alert others in the case of an emergency.
  • The Building Note relating to acute mental health wards states that 'Service user to staff system call points should be provided in spaces where a service user or attendee may be left alone temporarily, for example within service user bedrooms, en-suite WCs, disabled WCs and therapy or education areas'. Some wards did not have fixed nurse call buttons in patients' bedrooms. Staff did not mitigate the risk this posed by assessing whether individual patients, who might be at risk or otherwise be vulnerable, should be provided with a portable alarm to request assistance if needed.

However:

  • The board, senior leaders and clinical staff had a shared understanding of the main risks to the trust.
  • Since the previous inspection in March 2017, the trust had reviewed it policy and processes when searching patients. The trust had introduced systems that meant blanket restrictions in searching individual patients did not occur.
  • Although figures for prone restraint were similar to the previous inspection in 2017, they were lower than comparable trusts. The use of restrictive interventions, such as restraint, was well managed and reviewed across trust services. Staff participated in the trust restrictive interventions reduction programme. Staff recognised incidents and knew when to report them.
  • Staff understood how to protect patients from abuse and the trust worked well with external organisations when Reporting safeguard incidents.
  • Wards and the team bases for community services were clean, well equipped, furnished and well maintained. There were environmental risk assessments in place and patients were kept safe. Staff followed infection control practice evident across all services.

Effective

Requires improvement

Updated 5 April 2019

Our rating of effective stayed the same. We took into account the previous ratings of services not inspected at this time. We rated it as requires improvement because:

  • Care plans across the trust were not always personalised, holistic or involved the patient. This is what we also found at the previous inspection in March 2017. They did not always meet the needs of the patient and were not always reviewed or updated in line with trust guidance.
  • Staff did not have access to regular managerial and clinical supervision. The recording and reporting system for management and supervision and clinical supervision required improvement. Appraisal rates in some services did not meet the trust target. This meant that staff did not have the necessary time to reflect on their practice and career development.
  • Following the introduction of a new model of working in mental health acute wards, staff raised concerns about the integration of occupational therapists into the ward staffing complement. This meant that occupational therapists had reduced capacity to effectively carry out their roles including undertaking activities with patients.
  • Section 62 Mental Health Act paperwork was not always reviewed and referrals for a second opinion appointed doctor were not always completed on time.

However:

  • Staff across the trust had improved their knowledge and skills in the Mental Capacity Act and Gillick competence since the previous inspection in March 2017. Most services were compliant with the Mental Health Act and the Code of Practice. Patients’ were read their rights when detained and were regularly updated.
  • Physical health monitoring for patients with mental health problems was co-ordinated well across the trust. Patients were regularly reviewed by multidisciplinary teams and they were supported to live healthier lives. Care and treatment interventions were aligned to national best practice and guidance, and staff participated in regular audit.
  • Staff had access to induction and training that supported their roles. Compliance across the trust was above 75% and regularly achieved the trust target of 90%.

Caring

Good

Updated 5 April 2019

Our rating of caring stayed the same. We took into account the previous ratings of services not inspected at this time. We rated it as good because:

  • Staff treated patients with compassion and kindness. Staff were caring and passionate about their roles. They respected patients and worked hard to ensure patients’ needs came first. Staff ensured that patients had easy access to independent advocates.
  • Staff across most services involved patients in care planning and risk assessments but this was not always reflected in the electronic healthcare records.
  • The trust had embedded the ‘See Me’ programme and had improved patient involvement in planning trust services.

However:

  • Staff had not ensured the confidentiality of confidential information in one older people’s mental health ward.

Responsive

Good

Updated 5 April 2019

Our rating of responsive stayed the same. We took into account the previous ratings of services not inspected at this time. We rated it as good because:

  • The design, layout, and furnishings of the wards and most services supported patients’ treatment, privacy and dignity. Patients had their own rooms where they could keep personal belongings safe. There were quiet areas for privacy and where patients could be independent of staff when risk allowed.
  • Staff supported patients with activities outside the service, such as work, education and family relationships. This included access to the recovery college that was valued by patients. The service was accessible to all who needed it and took account of patients’ individual needs. Staff helped patients with communication, advocacy and cultural support. The trust worked positively with ethnically diverse communities.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

However:

  • When there was high demand for crisis services and beds in acute mental health awards, the trust could not always meet the needs of patients. There were delays in mental health assessments for people in the emergency departments at local acute hospitals and in health-based places of safety because of a lack of access to approved mental health professionals. Some patients in the PDU were on occasion waiting over 24 hours for treatment. Bed occupancy rates in adult mental health wards were regularly over 100% and patients did not always have a bed to return to following leave. There was not always a bed available when patients required a psychiatric intensive care bed.

Well-led

Requires improvement

Updated 5 April 2019

Our comprehensive inspections of NHS trusts have shown a strong link between the quality of overall management of a trust and the quality of its services. For that reason, we look at the quality of leadership at every level. We also look at how well a trust manages the governance of its services – in other words, how well leaders continually improve the quality of services and safeguard high standards of care by creating an environment for excellence in clinical care to flourish.

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

  • The trust had made insufficient improvements since our last comprehensive inspection in March 2017. This is reflected in the ratings of the core services that we inspected at this most recent inspection. The ratings for two of these five core services have changed from good to requires improvement. We have also once again rated safe and effective as requires improvement for the trust overall.
  • There were local governance issues in some core services linked to the quality of care plans, medicines management and risk assessments.
  • There was a shortage of staff across key clinical services and a reliance on bank and agency staff. There were not effective systems in place for staff to receive supervision and for managers to collect the information. This impacted on the morale of staff.
  • We heard from staff about bullying and discrimination within parts of the organisation. This appeared to be a cultural problem that had existed for a number of years. We recognised that the trust was working hard to address these issues but further work was required.

However:

  • In the months preceding this inspection, the trust had improved collective leadership and the board and senior leaders were confident about plans to improve the quality of care. The trust was working with a number of organisations and stakeholders to improve services. They had learnt from other organisations to develop a culture of quality improvement and we saw signs of achievement.
  • The board and senior leadership team had set a clear vision and values that were at the heart of all the work within the organisation. Clinical managers we spoke to shared the same values and the majority thought that the trust was well-led. Senior leaders were visible and well connected with services. They had a shared understanding with clinical staff of the risks the trust face.
  • The trust had improved the skills and knowledge of staff in the Mental Capacity Act since the previous inspection in March 2017. Safeguarding structures and processes are clearly defined and were working effectively.
  • The trust was working positively with a range of partners in the wider health and social care economy. This ranged from influencing local sustainability and transformation plans, working with three NHS trusts locally as part of an innovative MERIT Vanguard, and within an accountable care organisation with one other NHS trust and independent healthcare charity to commission and deliver secure care services.
  • The trust had developed and was working positively with patient and carer groups. The ‘See Me’ service user involvement scheme was valued by patients and carers. The trust ran a number of groups and courses for patients and carers in local communities, often reflecting the diverse communities it served, that included the recovery college and mindfulness awareness.
  • The trust was committed to improve services by promoting research, innovation and training. There was strong links with universities that underpinned collaborative working around workforce and clinical practice. Staff were encouraged to work on ideas to improve practice and leadership courses were available for staff to attend.
  • The trust collected, analysed, managed and used information well to support its activities, using secure electronic systems with security safeguards. The trust treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Checks on specific services

Community-based mental health services for adults of working age

Good

Updated 21 January 2021

Mental health crisis services and health-based places of safety

Requires improvement

Updated 21 January 2021

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

Requires improvement

Updated 21 January 2021

Reference: Specialist eating disorder services not found

Good

Updated 9 September 2014

The specialist eating disorders services provided by Birmingham and Solihull NHS Foundation Trust are based at The Barberry. The services include an inpatient ward, Cilantro, which has 10 inpatient beds. There is also a day service adjacent to Cilantro ward where day patients attend between 8am and 4pm, Monday to Friday. The service also includes an outpatient service.

We found that this service was safe. The trust had identified potential risks to the service and had processes to ensure that these were avoided where possible. Incidents were reported and there were governance systems in place to make sure learning from incidents was used both in the service and across the trust.

The service used a number of specialist outcome measures to make sure that its effectiveness was assessed. There was a strong governance structure in the department was strong and used learning from incidents, complaints and internal audits. Staff had a good understanding of best practice and were aware of the evidence base of their work. Although the teams worked well across different disciplines, there were sometimes difficulties in working with other professionals outside the service.

We found that this service met the needs of the people who used them. People told us that they were treated with kindness and empathy by staff, who were well-trained and aware of their needs. People who used the service told us that staff treated them with respect and consideration.

Staff and patients raised concerns about the length of waits for outpatient therapy, which were long. There was a risk that this could impact on patient outcomes. The service understood the needs of different communities and was able to adapt. We also saw that staff worked closely with family members and were open to feedback from people who used the service.

Staff we spoke with felt that the service was well-led. They were able to deliver a good service and felt that they were supported by the trust at board level. Senior management in the trust were visible and staff told us that they felt able to raise concerns.

Reference: not found

Requires improvement

Updated 21 January 2021

Inspection report


Reference: Neuropsychiatry Services not found

Updated 9 September 2014

Neuropsychiatry services provided by Birmingham and Solihull NHS Foundation Trust were based at the Barberry Centre. This service provided care and treatment for people with people who had a variety of conditions, including sleep disorders, chronic fatigue syndrome, Huntington’s disease, and somatisation disorders.

We found that these specialist services delivered within the West Midlands area were valued by people who used the service. The staff were knowledgeable and had specialist skills that enabled them to deliver safe and effective care.

Staff were supported in their roles and had access to specialist training as well as mandatory training. This meant that staff were able to deliver care and treatment in the areas they worked in to a high clinical standard.

People who used the service told us that they had had good experiences of the service and that staff treated them with kindness and respect.

The department had a strong base in current research practice and staff were enthusiastic. The service was responsive to the needs of the people once they were referred. However we found a long waiting list for this service.

While some staff felt slightly detached from the trust, due to the differences in the nature of the service they delivered, all staff told us that they felt supported by their managers and felt that the senior leadership in the trust had an interest in their work.