All inspections: Dudley Integrated Health and Care NHS Trust

Our rating of this service went down. We rated it as requires improvement because:

There were environmental risks on some wards. Staff did not always mitigate them, document them and were not always aware of them.
Care plans across all wards were not always of a good quality. There were some gaps in recording of physical health observations taken soon after admission. However, staff did record patients’ physical health needs in their care plans.
There were omissions in the recording or obtaining of patients’ physical health observations soon after admission.
There were blanket restrictions in place on all wards, namely the use of plastic crockery for all patients.
Ward-based audits were not effective. They did not prompt staff to check some important things, which meant they did not identify errors and issues.

However

Wards had enough nurses and doctors. They managed medicines safely and followed good practice with respect to safeguarding.
Managers ensured staff received training, supervision and appraisal. Ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff felt well supported by managers and involved in changes within the service and trust.

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

We rated safe, effective, caring, responsive and well-led as good. We rated five of the trust’s six services as good and one as requires improvement. In rating the trust, we took into account the current ratings of the five services not inspected this time.

We rated well-led for the trust overall as good because:

Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.
Senior leaders understood the challenges to quality and sustainability the trust faced, with workforce, and service delivery, as key challenges. They were able to explain clearly the actions they had taken and the plans they had in place to further address those challenges.
Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The trust was committed to improving services by learning from when things go well and when they went wrong, promoting training, research and innovation and enabled learning across the trust.
Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution.
Our findings from the other key questions demonstrated that governance processes mostly operated effectively at ward level and that performance and risk were managed well.
Ward teams had access to the information they needed to provide safe and effective care and used that information to good effect.
Staff engaged actively in local and national quality improvement activities.

However,

In the Acute wards for adults of working age and psychiatric intensive care units we found that audits did not always operate effectively because issues identified on inspection had not been identified through audits.

The environments we checked in both services were clean, well presented and consideration had been given to their specific uses.
Staffing levels were good across all services we inspected. There were low levels of vacancies and the trust had estimated staff numbers in line with caseloads. There was adequate staffing to ensure that there was cover for sickness at short notice and agency use was limited.
There was always a risk assessment undertaken at initial triage. Appropriate crisis plans had been created where required. Staff were able to respond quickly to deterioration in patients’ health. Patients waiting for treatment were contacted regularly to ensure that risk had not increased. Staff knew what to report and how to report it. Staff received feedback from investigation into incidents at staff meetings and via the intranet. Staff meetings occurred regularly and there was evidence of changes to working practices as a result of feedback at these meetings. Comprehensive assessments were undertaken as soon as possible after referral to the service.
Care records we checked contained up to date information that was personalised and recovery focussed. Staff followed best practice guidelines as set out by the national institute of health and care excellence in a range of areas of service delivery. The service had developed sub teams that were providing specific services. ICAMHS, Tier 2, Flash/Lighthouse and EI were small teams that worked independently but as part of the wider service. There was a full range of mental health professionals available including psychiatrists, psychologists and social workers. Staff were experienced and qualified for their roles.
We observed staff interacting with patients and found them to be exceptionally caring and understanding. They had extremely good knowledge of patient’s needs, likes and dislikes and could engage them. They had also developed strong links top families and carers and could offer them support guidance and advice. Patients and carers, we spoke with were extremely complimentary about the staff, management and service. There was evidence of active involvement from patients and carers where appropriate. Patients thoughts, feelings, history and culture were always considered and every effort was taken to ensure that patients maintained the maximum level independence possible. There was access to a range of support services both within the trust and the local community to support patients and carers. The trust had set target times for referral to triage and assessment to treatment times depending on the type of referral. All of these targets were being met. Staff took active steps to make contact with patients who were not engaging with the service and those who had not attended appointments. There was a full range of rooms available for appointments. Thought had been given to how these rooms were set out. They were all clean tidy and well presented. There was plenty of information in waiting areas and on line that informed patients and carers about a range of local services and support. Patients and carers, we spoke to all knew how to make a complaint and felt that they could do so without fear of retribution. Staff knew how to handle complaints correctly and there was evidence that they had been given feedback linked to investigations of complaints.
Senior leaders within the trust were visible and approachable within the service. Senior team leaders in the service were well respected and staff felt that they listened to them. There was a clear strategy linked to improvements within the service. The trust had a well-defined set of visions and values and staff we interviewed knew and agreed with them. Staff we spoke to felt supported, well respected and proud of the work that they did. They were happy working for the trust and would recommend it for others. There was a clear governance framework that enabled discussion and the transfer of information between management and staff. There was evidence of change and continuous review of working practice. There was evidence that staff had forged close links with teams from around the trust and externally and could work well with them to meet the needs of the patient group.

However;

The service used an electronic recording system for patients care records but medical staff continued to record information on paper notes. This meant that it was difficult to navigate the care plans and finding the correct information was sometimes difficult. We found that all information was correct and there was a correlation between paper and electronic notes.
There was a lack of parity across the services at Dudley and Walsall. Each service had a different upper age limit for patients. In Walsall stated the cut off age to receive care was at the end of the educational year on the patients 17th year and Dudley stated that it would be the end of the educational year on their 16th year. The limits were set as part of a commissioning contract but were being reviewed.

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

• The trust had made all the necessary improvements since the previous inspection in November 2016. We rated safe, effective, caring, responsive, and well led as good. We saw an improvement in the overall rating for acute wards for adults of working age and PICU from requires improvement to good.

• We rated all five of the trust’s seven core services we inspected as good. In rating the trust, we took into account the previous ratings of the core services not inspected this time.

• The trust ensured that risk assessments were completed and updated regularly. Staff updated risk assessments for each patient to understand how to best support them. Staff had good access to patient records and stored them safely. Staff knew how to keep patients safe and reported incidents, including abuse, when necessary. Staff learnt lessons from incidents.

• Care planning was individualised and regularly updated. A range of care and treatment interventions was delivered in line with guidance from the National Institute for Health and Care Excellence.

• The majority of staff had good knowledge of the Mental Health Act, the Mental Capacity Act and the Deprivation of Liberty Safeguards. Staff were up to date with training in the Mental Health Act and Mental Capacity Act.

• Staff were kind, compassionate and respectful and protected the privacy and dignity of people using services. Patients and those close to them were involved in decisions about their care, treatment.

• Services were planned to address the needs of local people and the trust had a good understanding of the needs of patients in their community. Staff ensured that service users and carers received the help they needed through good communication, advocacy and appropriate cultural support.

• There was a robust complaints process that supported patients and carers to complain and raise concerns. The trust provided information to patients and their families to better understand services available to them.

• There was good leadership across the trust from the board to front line managers with the right skills to undertake their roles. The board had good understanding of performance, which appropriately covered and combined their views with information on quality, operations and finances.

However:

• The acute wards for adults of working age had high numbers of vacancies for qualified staff.

• Medical staff in the CAMHS did not use the electronic records system that the rest of the team used, instead they kept paper records.

• Staff working in the wards for adults of working age did not receive regular supervision.

• Wards at Bloxwich hospital had multiple occupancy rooms. The ward environments there also offered less space for patients and activities. However, the trust was planning to address the issue through the commissioning of a new building. This intent would need to be fulfilled to address these limitations.

Our rating of this service stayed the same. We rated it as good because:

Staff were supervised and appraised and had access to regular team meetings. We reviewed the supervision records for each team and saw that staff were receiving supervision every four weeks in line with the trust policy. There were effective governance processes throughout the service. Managers had systems in place to monitor staff compliance with mandatory training, supervision, appraisals, and the performance of the service.
Staff completed comprehensive assessments of patients’ needs at the start of the treatment, including their mental health, physical health and social care needs. Staff completed risk assessments of each patient at initial assessment. We reviewed 14 care records. These showed that staff completed thorough and detailed risk assessments and that they updated them regularly.
Patients were actively involved in the planning of their care. We saw evidence in patients care plans, where they had given their views. Families and carers had appropriate involvement in patients care. Care records showed that, where appropriate, families and carers were invited to attend care programme approach reviews where they were able to share their opinions on patients care treatment.
Patients were able to access psychological therapies recommended by the National Institute for Health and Care Excellence. The psychology team were able to offer cognitive behaviour therapy, dialectic behaviour therapy, steps programme, and mindfulness. However, patients needing to see a psychologist could wait between six months and one year.
Managers had the skills knowledge and authority to perform their roles. We saw that managers were available to staff and regularly attended multidisciplinary meetings, patient meetings and were available to support staff when required
Services had systems in place to share lessons learned from incidents and complaints. Senior managers met twice a month to discuss incidents across the trust. The service had systems in place to manage information. The trust used electronic systems to collect data from the service. The trust had electronic systems to recording incidents, risks, and patient information.

However:

All five centres had presented problems with the environment, space or access. Two centres were not well maintained and another two had limited space to deliver care and treatment. Staff told us that it was often difficult to book rooms to see patients, especially on days when the doctors had a clinic.
Systems did not allow staff ready access to Mental Health Act and Mental Capacity Act paperwork. Mental Health Act administrators kept all Mental Health Act paperwork off site and there was not a system in place to store these electronically to allow staff access.

Consent to treatment forms were not attached to patient’s medication charts.

Our rating of this service improved. We rated it as good because:

The ward environments were clean and tidy. The acute wards were in the process of refurbishment to improve the environment, patient experience and promote well-being and recovery.
Staff assessed and managed risk through robust risk management plans, they followed best practice in de-escalating and managing challenging behaviour. Risk assessments were regularly updated as required.
Patients were supported with their physical health needs. Staff monitored patient’s physical health and when required arranged specialist care from professionals for patients.
The trust had good reporting systems in place. All staff were aware of how to report incidents and knew what incident should be reported. Staff understood how to protect patients from abuse or exploitation. They worked in collaboration with other agencies to support patients.
Staff were kind, caring and supportive towards patients and understood patient needs. Patients and carers were involved with care planning and invited to attend and contribute to ward reviews.
Patients and carers could provide feedback on the service through, the trust internet site, completion of feedback forms and carers groups. Patients had weekly community meetings whilst on the ward. When discharged there were opportunities to attend the public board meetings to provide feedback through an initiative called “Patient stories”.
Staff were involved with the trust action plans to improve services. This included the refurbishment of the wards, audits such as the application of the Mental Health Act, Capacity assessments, infection control and staffing.
Leaders were visible to all staff and patients. They were approachable and created a unified approach with all staff.

However;

Not all patients had access to a nurse call systems apart from Ambleside ward. The trust was piloting a new alarm system at another service. Once this was completed the new system would be used across acute services if found appropriate.
Staff alarm systems were different across both sites. Staff felt alarms were more robust at Dorothy Pattison hospital as at Bushey Fields personal attack alarms were used. Staff felt in isolated parts of the ward it would not be heard which put them at risk.
Although clinic rooms were locked and access was through key card. The trust used wooden storage cabinets to store controlled drugs. This did not follow the Misuse of drugs (Safe custody) regulations 1973.
There were a number of vacancies within the acute wards for qualified staff that could impact the quality of care patients received.
On Langdale ward four patients shared bedrooms. There were two patients in one room. Staff asked patients on admission if they objected to sharing. Although they did not object, patients felt their privacy and dignity was compromised by having to share.
Not all patients received information on medication they had been prescribed. Staff did not consistently record consent to treatment within the prescription charts and patient records.
Staff supervision was compromised on one ward due to staffing shortages. Other wards stated they had experienced difficulties with providing consistent supervision. Recording of supervision was not always completed. There were gaps in the supervision matrix on three of the acute wards.

Our rating of this service has stayed the same; we have rated it as good because:

The service had enough nursing and medical staff, who knew the patients and received basic training to keep people safe from avoidable harm. There was a low turnover of staff and no bank or agency staff had been used to ensure a high standard of care and consistency within the teams. Staff said that they liked their jobs and enjoyed working for the trust and supported each other across the teams.
Staff completed and updated risk assessments for each patient and used these to understand and manage risks individually. Patients had crisis plans and knew who to contact in the case of an emergency. All patients had a comprehensive, up to date care plan and risk assessments were reviewed regularly support was also offered for their carers and families.

There was evidence that staff followed the national institute for care and excellence guidelines when prescribing medication. Interventions also covered support for employment, housing and benefits. All patients had had their physical healthcare needs considered and offered treatment and support for these if required.
We observed comprehensive, thorough and effective multi-disciplinary team meetings and handovers between teams. The trust had a Mental Health Act administrator who ensured that the Act was followed and offered support to staff.
We observed staff being respectful, sensitive, kind and compassionate when supporting patients and their families and carers. Patients said they were able to give feedback on the service they received and felt supported.
Patients were seen as soon as possible and within set times and were offered flexible appointments to ensure that they were able to access the service.
Staff knew and agreed with the trust’s values and were consulted about what they should be. Staff said they felt able to raise concerns without fear of victimisation and felt supported by the managers.

However;

Staff did not receive adequate support from management though appraisal and supervision. We found non-medical staff were not all in receipt of an annual appraisal or regular supervision. This limited their ability to develop and reflect on their clinical practice.
The service provided mandatory training in key skills to all staff but had not made sure everyone completed it.

Our rating of this service stayed the same. We rated it as good because:

All wards were safe, clean well equipped, well furnished and well maintained. The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff kept detailed records of patients’ care and treatment secure. Staff completed and updated risk assessments for each patient and used these to understand and manage risks individually. Staff recognised and managed incidents well and reported them appropriately.
Staff worked collaboratively with patients to formulate care and treatment plans that addressed their individual needs. Staff had appraisals, supervision and were encouraged and supported to access opportunities to update and further develop their skills.
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and Mental Capacity Act 2005.

Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Patients had their own bedrooms where they could keep personal belongings safely. At Bloxwich hospital there is dormitory accommodation. The design, layout, and furnishings of the ward/service supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as community groups, attending religious venues or maintaining family relationships. The service managed concerns and complaints well and learned lessons from the results.

Ward managers and clinical leads were knowledgeable and passionate about their service and provided visible leadership on wards. Staff were passionate about their work, working for the trust and with their patients.

We have changed the rating for Safe from requires improvement to good because;

At the time of the last inspection in February 2016, the clinic rooms did not have any alarms in at either base. Since then, the trust had been unable to install room alarms but had provided each staff member with a personal alarm. This helped ensure that staff and patients’ safety was maintained.
During the last inspection, we saw not all of the patient’s records contained up to date risk assessments. We found there had been significant improvements and all of the records we looked at during this inspection, contained a fully completed and up to date risk assessment.
We told the trust during the last inspection they should continue to reduce the waiting lists. The trust has since agreed a target with the commissioners to reduce the waiting lists by 40 cases by March 2017.
We told the trust in February 2016 they should ensure cleaning records of toys should be maintained. During this inspection, we saw cleaning records showing that toys were cleaned regularly.
We found at the last inspection staff were not aware of the trusts lone working policy and did not adhere to local protocols. All of the staff we spoke with during this inspection were aware of the trust’s lone working policy and could explain how they adhered to local protocols.

This meant that the service had met Regulations 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014; Safe care and treatment and Regulation 15 of the Health and Social Care Act (Regulated Activities) Regulations 2010; Safety and suitability of premises.

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

In both teams, the duty worker system enabled a same day response to urgent referrals and any crisis calls from existing service users, their carers or other professionals. Making use of the detailed crisis plans prepared by case managers, the duty worker was able to prepare an individualised response to a particular service user’s immediate needs.

In our previous inspection in February 2016, we had found all of the service users’ records that we checked had completed risk assessments in place and there was clear evidence of review and update. The trust had conducted an internal case note audit in May 2016 that had identified incomplete risk assessments in a majority of the 40 records examined. Managers had put in place a plan to improve this shortfall. We found, on this inspection, that initial risk assessments were present for all service users. Staff had completed more detailed risk assessments in 75% of the care notes we reviewed. Where appropriate crisis management plans had also been.

Managers at Walsall had acted promptly to ensure the safety of service users during a period of high levels of sickness. They used bank staff and experienced staff from other areas of the trust to monitor caseloads and maintain the duty worker system.

We found both teams had regular meetings in which staff could discuss incidents and lessons learnt from their own team, the older adult service and other areas of the trust.

Service users and carers told us that they felt safe in the care of the teams and confident that staff would respond promptly to any urgent concerns they might have.

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

Following our last inspection in February 2016, we rated the wards for older people with mental health problems as good overall and in the safe domain. During our most recent focussed inspection of the safe domain, we have found no evidence to suggest that the rating should change from good.
The service made robust use of risk assessments and observation to ensure that patients and staff were safe at all times. Staff clearly documented individual risks in patients care records and we saw that these were regularly reviewed.
Staffing levels were sufficient to maintain the safety of patients and ensured that staff could appropriately manage any challenging behaviour.
The ward environments were clean and well maintained. Staff were diligent in maintaining the cleanliness of the wards and we saw examples of cleaning schedules and environmental risk assessment.

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

During the most recent inspection, we found that the trust had not addressed all of the issues that caused us to rate acute wards for adults of working age as requires improvement after the inspection in February 2016. Improvements were made in other areas but there were some areas that were not fully addressed and there were changes in other areas that were good in the last inspection to requires improvement.

We found that the governance systems in this core service were not effective and robust enough to identify and address all the gaps in the quality of service provided. Staff were not up to date with mandatory training at 65% and the trust did not sufficiently monitor mandatory training for staff.

Although there was a clinical audit process in place, it had not identified or been used effectively to monitor and address gaps in the quality of the service. The systems did not effectively identify or address shortfalls in the care delivered in relation to physical healthcare, rapid tranquillisation, care plans, risk assessments, Mental Capacity Act or emergency equipment checks.

Not all risk assessments were present or up-to-date, they were not detailed enough to capture all risks and did not clearly show how staff should manage the risks identified.
Care plans lacked detail and not all were up-to-date, person-centred or recovery-focused.
During the most recent inspection, we found gaps in checks of emergency equipment and medicines on Ambleside, Clent and Kinver wards and errors with medicines management practice. Staff did not always follow the trust’s rapid tranquillisation policy after they administered rapid tranquillisation. They did not always carry out the required physical health observations and complete the monitoring forms.
We also found that staff did not always carry out physical health monitoring for all patients in line with the trust policy and national guidance.
Staff did not fully adhere to the principles of the Mental Capacity Act. They did not always assess capacity to consent on a decision-specific basis or record sufficient details for decisions made by them or patients.

However:

The trust had reviewed all blanket restrictions in line with their least restrictive practice policy and made improvements.
The trust had made improvements to supervision practice and the acute wards had an average staff supervision rate of 86% by 31 October 2016. Records showed that ward managers provided regular and good quality supervision to staff.
Staff explained to patients their rights on admission, at regular intervals thereafter and recorded this in patients’ notes.
Informal patients were aware of their right to leave the ward. There were clear signs displayed to explain these rights at the exit doors on each ward.

Following the inspection in November 2016, we have changed the overall rating for Dudley and Walsall Mental Health Partnership NHS Trust from requires improvement to good because:

The trust had made improvements to the documentation of long-term segregation and the management of blanket restrictions on the adult acute wards. The trust had revised all blanket restrictions and new protocols were now in place. Long-term segregation occurs when a patient is not allowed to mix freely with other patients on the ward on a long-term basis due to reduce the risk they pose to others. Blanket restrictions are rules or restrictions placed on all patients within a ward with no individual assessment considered.
Since our inspection in February 2016, the trust had reduced the specialist community services for children and young people’s waiting lists. We found that although waiting lists existed, teams had made significant reductions.
The staff throughout the trust displayed a dedicated and caring attitude towards people who used the services. We saw several examples of staff being respectful and inclusive. Feedback from patients, carers and families also reflected this.

The core services we inspected were responsive to the needs of the people who used them. The trust demonstrated listening and learning from complaints. Patients we spoke with knew how to raise concerns and complaints, and said staff gave them feedback.

We also carried out a ‘well led’ review and found the leadership across the trust at a senior management level had continued to develop a new positive culture of leadership. We found in most of the services we visited that staff morale was good and staff reported managers supporting them to carry out their roles effectively.

However:

Although some teams had made improvements regarding care plans and risk assessments, we found that the consistency and quality of documentation across the services we inspected had not improved significantly. We found examples of missing, incomplete, out-of-date risk assessments and care plans that were not recovery orientated.
In some teams, the management of medicines and emergency equipment was not always safe. We found that staff did not always regularly check and seal emergency equipment using a tamper proof seal.
In the older people’s community services, not all of the recommendations made in previous inspection reports had been put in place. We found that managers had not provided an introduction to physical health education to unqualified staff, or personal safety training to all staff in teams. They had not updated their lone working policy before planned extended working hours in the Walsall team.

Although the trust had made a degree of improvement with regard to the monitoring of mandatory training, we found some teams’ compliance remained below the trust target. The adult acute wards Mental Health Act training remained below trust target and staff did not fully follow the principles of the Mental Capacity Act.

Although staffing had generally improved in areas where this had previously been a concern, occupational therapists and psychologists remained concerned that they lacked the capacity to effectively function in their roles and in multidisciplinary teams.

We rated mental health crisis services and health based places of safety as good overall because:

During this most recent inspection, we found that the services had addressed most of the issues that had caused us to rate mental health crisis and health-based places of safety as requires improvement following the February 2016 inspection.

Secure, lockable rucksacks were now in use in the crisis teams, which meant staff could safely transport medication to patients’ homes. The teams were monitoring and recording when controlled medications were dispensed to patients, which meant staff were now following the trust policy.

Managers had made a number of changes to the procedures that staff should follow when responding to crisis calls. Staff responded to calls in a more timely manner and effective systems were in place to monitor calls received and the response time. This had ensured that there was a consistent approach to staff response to crisis calls across the services.

Staff were receiving supervision more regularly and the trust had implemented a standard form, which ensured there was consistent approach to supervision for all staff across the trust and had systems in place to monitor compliance.

However:

Despite the joint agency paperwork used in the health-based places of safety being updated, the majority of records we reviewed were incomplete or missing. This meant the trust could not monitor how long a person had been in the place of safety and whether they received their rights under the Mental Health Act.

There was a lack of effective audits or processes in place to monitor the quality of the recorded information in the health-based places of safety.

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 Dudley & Walsall Mental Health Partnership NHS Trust was performing at a level, which led to a judgement of Requires Improvement.

We rated the safety of services as requires improvement; partly as we consistently found the recording and review of individual patient risk to be of a poor standard. We also found that team bases were not always safe as some lacked alarm systems; which compromises the safety of both staff and visitors.

The quality and effectiveness of care planning was inconsistent. We found that care plans were not always holistic, person centred or recovery focused. We also found issues with the application of the Mental Health Act in relation to blanket restrictions and staffs’ understanding of the rights of informal patients who wished to leave the acute wards.

Staff were consistently caring and treated patients with kindness, dignity & respect. The Trust was very proactively working on patient and carer engagement and had introduced several initiatives such as experts by experience, youth forums and involved those who used services in the recruitment of staff.

We found the trust services to be responsive to the needs of the people who used services. Overall, access to services was achieved in a timely manner and the trust had improved delays when discharging patients. In most services, patients had access to a range of activities and therapies.

We found the trust to be well led. We were particularly impressed with the interim chief executive. Staff and patients spoke very highly of the changes that he has introduced since coming into post 6 months prior to the inspection. We did however conclude that governance processes were not always robust or fully embedded throughout the trust.

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

Patients and carers we spoke to consistently praised the service that they received. Everyone we spoke to knew the names of the staff that worked with them and stated that they felt that staff made an effort to treat them as individuals
Appraisal and supervision levels among staff were very high and staff satisfaction was good. Rates of staff retention were extremely high across the service. All staff we interviewed spoke about their commitment to the service and job satisfaction.
Staff were working to national guidance and were able to demonstrate best practice. They were able to link working practice to relevant guidance from national bodies such as the national institute for care excellence (NICE). Staff were able to state which parts of guidance documents related to different aspects of their roles. Knowledge of guidance was very good.
Staff set aside a portion of appointment times to engage patients socially. They had developed exceptionally good knowledge of the people they cared for and were able to engage them on a number of levels. This meant that staff had developed indivudulised approaches to working with their patients. They had also developed effective relationships with carers.
The senior executive team is well known and respected within the service. They engaged staff and patients and took time to develop close and effective working relationships. All staff we spoke to felt that the senior executive team understood the service and would listen to staff.

However:

Staff did not receive personal safety or mental health act training as part of their mandatory training calendar.
The safe call at Beeches hospital did not work which presented a risk to patients that use the service.
There was no policy or protocol update as a result of the introduction of agile working. This was a system of working whereby staff were provided with a lap top and were able to enter information into notes externally from the office. This meant that staff did not have to return to their base in order to complete paperwork. This meant that staff did not have good knowledge of the risks that this new working practice may pose.
The Oasis patient recording system was difficult to navigate and does not communicate with other patient recording systems used across the trust.

We rated Dudley and Walsall Mental Health Partnership NHS Trust as Good because:

Staffing levels were adequate and vacancy rates were low across the services.
There were effective safeguarding processes in place. All staff received training in child and adult safeguarding, levels one to three.
All staff had received training in child specific management and prevention of aggression and violence.
Patients had access to a wide range of professionals who had additional training in specific psychological therapies, for example, cognitive behaviour therapy, cognitive analytical therapy, eye movement desensitisation reprocessing, family therapy and psychotherapy.
Staff completed a wide range of clinical audit. For example, caseload audit, deliberate self-harm audit and the national prescribing observatory for mental health.
Staff were sensitive to the needs of patients and showed good knowledge of the issues they faced.
Physical health care needs were monitored on a regular basis.

However

Although child and adolescent mental health services (CAMHS) had introduced initiatives to reduce waiting times and provide a more responsive service, there were still long waiting times for specialist partnership working.
There were no safety alarms in place at any of the sites across the core services.
There was no access to a CAMHS psychiatrist outside of normal working hours.
Risk assessments were not always fully completed, detailed or up to date.
CAMHS staff used different systems to record care plans and update risk information. This could lead to errors in patient care.
Confidentiality was compromised at the Dudley service base due to the poor sound proofing in the interview rooms.

We rated Dudley and Walsall mental health partnership as requires improvement because:

controlled drugs were not being appropriately recorded by staff
trust policies were not followed when transporting medication
access to resuscitation equipment was limited for the CRHT services
management supervision was not occurring on a consistent basis care plans did not consistently include the views of the patient,
joint risk assessments at the place of safety were not consistently recorded
patients were not always being informed of their rights under the mental health act
some information at the place of safety was recorded on out of date forms that did not incorporate the new code of practice
the trust operational policy on the use of the place of safety had not been updated since 2011

However:

environments were safe and clean
there were three exits from the place of safety in line with the royal college of psychiatry guidelines
we saw evidence of good multi-disciplinary team working
there were minimal delays for patients who were waiting for mental health act assessments
staff included patients in the discussion of their care
appointment times were flexible to meet the needs of the patients
there were robust systems in place for reporting, recording and learning from incidents

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

Patients, carers and staff told us of positive experiences of care. Staff were caring, respectful and compassionate towards patients, carers and colleagues. Patients and carers said they felt involved in their care.
Buildings inspected were clean and they were accessible to patient, carers and staff.
Clinic rooms in each building were equipped to assess and treat patients.
There was a range of informative leaflets for patients and families.

Staff had a good understanding of the risk and treatment needs of patients. Community services were able to respond quickly to urgent referrals.
Staff were clear about their roles and responsibilities for reporting incidents and concerns.
Staff followed safeguarding processes.
Staff supported patients to monitor their physical health, develop confidence in social settings and return to work.
Staff supported patients whose first language was not English and those who had a hearing impairment.
CRS staff monitored and care coordinated patients admitted to hospital outside of Dudley and Walsall.

Staff reflected the values and visions of the trust in their work.
Staff said team managers supported them and they received regular management supervision.

However:

Training levels for staff in the mental health act (MHA) was low.
Some care plans and risk assessments were out-of-date.
Caseloads were high in Walsall community recovery services.

Some staff did not follow lone working protocols.
There was poor uptake of clinical supervision.
Some interview rooms did not have alarms and some staff working areas were not well maintained.

The service did not always update staff and they did not feel engaged in the trust’s organisational restructure.

We rated Dudley and Walsall mental health Partnership Trust as good because:

Patients and relatives were extremely positive about the standard of care and described the care as excellent.
Wards were clean and safe.
De-escalation techniques such as distraction, talking and guiding people to quiet areas were widely used to manage patients in the least restrictive way possible.
Staff undertook robust assessments on admission. Assessments were regularly updated after incidents and as patients’ needs changed.
Assessment of nutrition and hydration took place on admission using the malnutrition universal treatment tool. Ongoing monitoring took place during mealtimes on a daily basis.
Effective and detailed handovers took place three times daily on all wards. The handovers gave the opportunity for staff to check understanding of each patient/carer needs.
There was a range of mental health disciplines on the ward including an activity coordinator, and occupational therapist and pharmacists. The wards had access to psychology.

However:

Ligature cutters were not easily accessible.
There was confusion about the use of the Mental Health Act and the Deprivation of Liberty Safeguards legislation.
There was limited space on Linden and Cedars wards with multi occupancy rooms and male and female bathrooms next to each other.

We rated acute wards for adults of working age as requires improvement because:

Records relating to the use of the long term segregation were not maintained in line with trust policy. There was evidence that clinical documents were missing and there were errors contained within the records that were present. Risk assessments were at times incomplete and did not always contain updated information and there was a lack of profession specific standardised assessment and outcome measures evident in care records at Dorothy Pattinson Hospital.
Blanket restrictions were in place and some wards that we inspected carried out searches of all patients on return from leave. This did not adhere to either the trust's own search policy or the 2015 Mental Health Act code of practice.
Attendance rates at essential and mandatory training were low across most of the wards that we inspected and below targets set by the trust for minimum compliance. We saw that staff attendance at Mental Health Act training was low, two wards had an average attendance figure for staff of below 40%.
There were variations across the five wards of the processes in place to allow informal patients leave from the ward. There was evidence that patients who had informal status under the Mental Health Act had experienced delays in being allowed to leave wards and patients raised these concerns with us during the inspection process.
Daily checks of emergency equipment were not always completed and we found that a defibrillator for emergency use on one ward was not working. Staff informed us they would need to use equipment from a neighbouring ward if an emergency situation occurred.
Clinical supervision rates were variable across the five wards we visited and were not being consistently recorded by managers.
Most staff and patients that we spoke to at Dorothy Pattinson hospital said there were insufficient staff to deliver a quality service and that high rates of bank and agency staff impacted on the consistency of care provided. The five acute wards had an average staff vacancy rate of 14% with the highest being 21%.
Allied health professionals told us they felt there were insufficient resources for them to deliver a service that met patients needs and concerns were raised with inspection staff by patients, carers and stakeholders about the lack of provision of occupational therapy and psychology at Dorothy Pattinson hospital.

However:

There was evidence across all acute wards of comprehensive physical health assessments taking place following admission and care plans were in place to monitor this.
Patients had access to beds on the acute wards in their catchment area and there was access for patients to beds on their return from leave in the community. When patients were moved between wards this was justified on clinical grounds and in the interests of the patient. There had been no out of area placements for patients requiring a bed on the acute wards in the six months prior to our inspection.
Most staff we spoke to said they felt there was a positive culture of team working and mutual support.
There was access to training and development programmes for qualified and unqualified staff and we were told that the trust were supportive for staff and encouraged professional development. Staff were able to describe the trust's recently updated values and how they incorporated them into their clinical practice. Ward managers that we spoke with said that the trust's senior management team were visible and accessible if needed.
There was evidence of learning being disseminated and staff debriefs taking place following serious incidents There was also evidence of duty of candour and the involvement of families during investigations by the trust into serious incidents that had occurred.

Bushey Fields Hospital

Core service provided: Three acute admission wards; Two older people's wards; One Health Based Place of Safety

Male/female/mixed: male/female/mixed

Capacity: 99

Dorothy Pattison Hospital

Core service provided: Two acute admission wards; One Longstay/forensic/Secure services ward; One Health Based Place of Safety

Male/female/mixed: male/female/mixed

Capacity: 52

Bloxwich Hospital

Core service provided: Two older people's wards

Male/female/mixed: mixed

Capacity: 40

The trust has three main hospital sites: Bushey Fields Hospital in Dudley, Dorothy Pattison Hospital in Walsall and Bloxwich Hospital in Walsall. There are 191 beds; of which five are extra care area beds for people who require intensive nursing because their mental health problems have caused them to become agitated. The overall level of bed occupancy is lower than the national average (81% compared to the England average of 85%).

The trust also has staff based in about 28 locations across the two boroughs who provide care to people who live in their own homes.

The trust provides core mental health services and additional services such as Substance Misuse and Military Veterans services.

At the time of the inspection, the Board was leading work to change the way in which the trust’s services are organised. These changes had unsettled some staff; some staff that we talked to reported feeling unsupported by the trust and did not feel confident that if they raised concerns that they would be listened to and treated fairly. During the course of the inspection, we received some whistleblowing information from a number of staff across different disciplines and locations. Some staff reported to us that they felt ‘fearful and frightened of the culture within the organisation’ and were reluctant to raise concerns in fear of reprisal. Some staff reported this as ‘bullying’. However other staff reported that they felt very engaged.

The Non-Executive Directors (NED’s) were able to describe to us the information flows and how they challenged what they did not understand. The NED’s had a very robust understanding of all of the issues that the trust was facing and how they were to be tackled but always with an eye on quality.We concluded that the non-executive directors were a strong group who understood their role and exercised their duties effectively.

The trust had a robust approach to learning from incidents and ensured this was embedded in practice across all levels.

Although the trust ensured that all staff undertook mandatory training, it did not always meet the need for specific specialist training. For example, those working in older people’s services had not been trained in dementia care and we concluded that this had an impact on the quality of care received by people using this service.

The trust worked well with other local stakeholders, such as the local authorities and the clinical commissioning groups and we saw evidence of good multi-disciplinary team working; particularly between adult inpatient and community services.

With a few exceptions, we found that the trust’s staff were caring and had a good approach to patient care, and interacted positively and compassionately with people. We also saw examples of the trust’s staff providing good physical healthcare.

Clinical staff recorded risk assessments for all patients but were not so good at developing management plans in line with the assessments.

During our inspection we observed that some patients, on wards for both younger and older adults, were being secluded (nursed in isolation from other patients) without the safeguards and checks set out in the Mental Health Act Code of Practice being followed.

Before our inspection, the trust had identified problems with provision for older people and we agreed that this was the case for both inpatient and community services. Temporary nurses work many shifts on the older people’s wards at Bushey Fields hospital due to unfilled staff vacancies. We observed restrictive practices on both Malvern and Holyrood wards and we concluded that patients’ dignity and privacy were not always respected on Holyrood ward. The latter was due to a combination of an unsafe ward environment and staff practices. We also concluded that there was no clear vision for the future of community mental health services for older people in Dudley and Walsall.

The quality of mental health care provided to children and adolescents was good but was only available during office hours. Young people with a mental health problem could not access specialist help out of hours and there was no intensive home care provision to support children and young people in a crisis. Children and young people were waiting a long time to receive the right service after initially being referred.

We found that application of the Mental Health Act across the services was good. People were lawfully detained and had their rights read to them at the appropriate times. People’s access to independent mental health advocacy (IMHA) varied across the trust as it was not clear that a referral to IMHA had been made when people lacked capacity.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

All Inspections

We rated acute wards for adults of working age as requires improvement because:

However:

Bushey Fields Hospital

Dorothy Pattison Hospital

Bloxwich Hospital