Surrey and Borders Partnership NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this newly registered service, however the rating for this key question remains the same as when we last inspected the locations that sit within this assessment service group in January 2020. This key question has been rated good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed 24 sets of care plans during this assessment. Staff completed a comprehensive mental health assessment of the patient in a timely manner at, or soon after, admission.

15 patients out of the 17 we spoke with told us that they felt involved in the planning of their care, it was reviewed at regular multidisciplinary team meetings and had received copies of their care plans. Two patients said that they had no involvement with their care plans and said that staff did not listen to them. We saw evidence of Risk Reduction Plans which were specific care plans to target individualised patient needs. For example, one patient had a specific risk plan for suicidal ideation and absconding, while another had a plan addressing sexual disinhibition. One patient’s risk plan included a Positive Behaviour Support plan. During handovers, the risks of all patients were discussed.
 

Staff told us that they assessed patient needs by ensuring that care plans were regularly reviewed and by holding weekly multi-disciplinary team meetings when patient care was discussed. Care plans were personalised, holistic and recovery-oriented.

Ward managers described how people's needs relating to protected characteristics were assessed to ensure appropriate support was provided. We saw care plans that showed that dieticians were involved in supporting patients care. Four ward managers and 10 members of nursing staff said that people's physical healthcare needs were assessed on admission and regularly reviewed. We saw good evidence of robust physical healthcare monitoring happening across the wards with regular physical health monitoring using a recognised tool.

There was a range of processes in place to assess patient needs. These included risk assessments, care plans and observation records. We reviewed 17 sets of clinical notes across the wards and reviewed 17 risk assessments as part of this. Of those reviewed, most had been regularly reviewed and updated after incidents. We found that care plans on the wards contained, clear, accurate up to date information including physical healthcare monitoring and good monitoring for patients prescribed clozapine.

Diabetes blood monitoring checks were being carried out as per the care plans for three patients. We also observed there was low use of urgent medication when required, and post-injection urgent medication monitoring was well documented as per the patient’s care plan and trust policy.

All patients told us that they received nursing care, treatment and support that was in line with good practice standards. From reviewing care plans we could see that the interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence. These included medication and psychological therapies.

Patients across the wards said there was occupational therapy support available but it was not regular and they felt that there was not enough ward based activity to keep them engaged. The trust therapies team told us they were acutely aware of this and had taken steps to recruit to the posts and activity staff were due to start in the weeks following the inspection. Patients said their care was reviewed and progressed at regular multidisciplinary ward rounds.

There were systems were in place for monitoring people's physical health during their admission and we observed good evidence of this in relation to diabetes and wound care when required. The ward teams included or had access to a range of specialists required to meet the needs of patients in the wards. As well as doctors and nurses, there were occupational therapists, clinical psychologists, pharmacists, speech and language therapists, and dieticians.

Multi-disciplinary team meetings took place weekly and patients were invited to attend these. A range of disciplines attended including the psychiatrist, named nurse, occupational therapist and psychologist.

Due to the high levels of temporary staff that were being used across all four wards we were very keen to see how ward teams were ensuring that all temporary staff were trained to the same level as regular ward staff. We were pleased to see on all wards that ward managers had a record of all temporary staff that were working on the ward which included evidence of their training and evidence of a specific ward-based induction to each environment.

Ward managers provided staff with supervision meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development and appraisals of their work performance. The percentage of staff that received regular supervision was 69% in March moving to 86% in April as the hospital had identified supervision as an area of improvement. The percentage of staff that had had an appraisal in March was 86% moving to 88% in April showing an upward trend. Supervision and appraisal rates had been an issue that was picked up as part of each ward’s improvement plan and we could see that all ward managers had been set targets and were working towards their improvement targets.

Care plans were stored electronically and were accessible to all staff. Staff said that there was patient representation at the senior leadership meetings and that patients could make suggestions about the services at the ward community meetings which would then be taken to the senior leadership meetings.

There was advocacy information available to patients on all the wards and there was a clear referral pathway for patients to be supported with mental health advocacy. Advocates met with patients monthly. Advocates could be involved in independent seclusion reviews and they said that senior staff were responsive to concerns and complaints raised by patients.

Staff meetings were being held monthly as per trust policy. Staff discussed incidents, security/ligature risks, and the dates of forthcoming events. MDT meetings took place weekly and were attended by all disciplines. There was a comprehensive discussion of patient’s risks and needs and clear evidence of a recovery focused approach including steps towards discharge clearly articulated. The MDT showed good partnership working with community teams.

Staff used technology to support patient care. At the time of inspection, this included video calls with relatives during meetings about patient care.

Staff took part in clinical audits, benchmarking and quality improvement initiatives. The service conducted monthly audits of medication, patients’ records, observations and engagement (including a review of CCTV). Managers used results from audits to make improvements. For example, when the service scored below 85% in an audit, the audit was repeated until sufficient improvements had been made.

There were a variety of processes in place to support staff teams and services working together. All staff attended their ward handovers at the beginning of each shift. The member of staff allocated to security then completed a checklist to ensure that all risk items and areas of the ward including ligature risks, were safe and patients accounted for prior to the other staff leaving. In the main staff handover, information was shared using a recognised handover tool. This tool identified patient activities, mental state, medication issues, any leave taken and any discharge planning progress. There were morning community meetings which supported patient involvement and included discussion around activities and ward maintenance issues.

Patients told us that they were well supported in relation to their discharge including partnership working between ward staff, community mental health teams and social care providers. We reviewed 24 sets of care records and found that 15 patients had discharge plans in place from early into their admission. The other 9 patients had very recently been admitted to the ward and so these plans had not yet been developed.

The service worked in partnership with other wards, community services and the local safeguarding teams. The trust shared learning with other services through the provider collaborative and brought in learning from other organisations. Ward teams had effective working relationships with external teams and organisations. For example, the wards had regular contact with the independent advocacy service. Managers also worked closely with bed managers in NHS trust’s that placed patients at the service. Managers also worked closely with the Trust's bed flow team. Members of the bed flow team were invited to multidisciplinary team meetings every two weeks to discuss the progress of, and plans for, their patients.

The hospital supported people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

Staff identified patients’ physical health needs and recorded them in their care plans. Staff conducted checks of each patient’s pulse, temperature, weight, height and blood pressure each day or week as required. Staff wrote up detailed progress notes for each shift covering patients’ compliance with medication, food and fluid intake, personal hygiene and sleep.

Staff made sure patients had access to physical health care, including specialists as required. Patients were seen promptly by a doctor when they felt unwell.

Staff continuously monitored patients’ health, their mental state and well-being. At twice daily handover meetings, staff noted details of patients’ sleep, food and fluid intake, personal hygiene, compliance with medication, and engagement in activities. Any changes in a patient’s presentation were discussed at the daily multidisciplinary team meetings.Staff used recognised rating scales to assess and record the severity of patients’ conditions and care and treatment outcomes. For example, doctors used the Global Assessment of Progress to measure patients progress and outcomes. The Glasgow Antipsychotic Side-Effects Scale (GASS) was used to measure any adverse effects of medicines.

Staff assessed each patient’s capacity to consent to admission and treatment on admission. Capacity was monitored and recorded at multidisciplinary team meetings. Records showed that these assessments covered the four elements of capacity.

If a patient was detained under the Mental Health Act 1983, the arrangements for their detention and treatment were consistent with the requirements of the Act and accompanying code of practice. Staff supported patients to understand how the Mental Health Act applied to their situation and that patients understood their right to appeal.

When staff felt a patient may have lacked capacity to make a decision, staff provided support. For example, if a patient was thought to lack capacity to consent to treatment, staff explained why the treatment was important, how they would benefit from it and described any possible side-effects.

Staff engaged with patients’ families to understand each patient’s history and interests.