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Provider: Black Country Partnership NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 January 2019

Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating

Our rating of the trust went down. We rated it as requires improvement because:

  • Not all trust properties were clean, well-furnished and fit for the purposes of modern mental health care services. Not all staff always followed infection control procedures. Staff at Pond Lane had poor working conditions. They worked in an untidy, unclean environment with no ambient temperature control.
  • Staff were not consistent in following best practice in the use of restrictive practices. Staff on Dale Ward carried out blanket searches which were not in line with the trust policy. Patients on the psychiatric intensive care unit were only able to smoke at set times.
  • Staff did not manage medicines consistently well in two services. They did not store or keep them at the correct temperatures.
  • Staff in some services did not follow good practice in the development and use of care plans. They did not review care plans regularly and some care plans in wards for people with learning disabilities or autism, did not pay sufficient regard to the monitor of physical healthcare needs of patients relating to diet and weight gain.
  • Not all staff across services received regular managerial and clinical supervision or had an identified clinical supervision supervisor.
  • We found issues of staff knowledge in the Mental Capacity Act and Gillick Competence in some services. Staff working with children and young people in the Early Intervention Service did not have a clear understanding of Gillick Competence or understand where and why this would be applied.
  • In parts of the trust, clinical staff had to use three different electronic recording systems – together with keeping paper notes. This meant that notes were cumbersome and difficult to navigate for people who do not work regularly in the service. However, staff we spoke with were always able to find the information we requested. The trust had plans to implement an electronic patient records system.
  • We did not find evidence of a robust recruitment process for all executive directors. When the planned TCT merger ended the trust found itself without a substantive leadership team and with support from NHSI interim appointments were made from amongst senior managers within the trust.
  • The governance systems from ward to board were not sufficiently strong to have identified and rectified a number of risks. These included environmental risk assessments which were not always location specific, actions on the risk register that had not been taken and the problems with information governance. We concluded that this was a legacy of the aborted merger. During the period when work was under way to createTransforming Care Together, governance was led by the acquiring trust. When plans to merge ended, this left Black Country Partnership Foundation NHS Trust without a substantive governance lead to direct and develop new systems. The trust had since taken action to strengthen their governance structure by making a senior appointment to lead governance and improve its systems.
  • The trust used root cause analysis approach to review serious untoward incidents and mortality lacked consistent challenge at the executive level before reports were signed off. The trust had action plans in place to address this issue.
  • The role of Freedom to Speak Up Guardian was held by a trust board member and that could lead to a conflict of interest for the post holder. This had been reviewed and new plans were in place to seek an external solution.

However:

  • We concluded that the trust board was re-establishing its control of performance following the aborted merger. The trust board operated collaboratively, that meant executives and non-executive directors shared responsibility and liability for decision-making. Apart from the lapses we identified on this inspection, the board had a reasonable understanding of performance, which appropriately covered and combined people’s views with information on quality, operations, and finances.
  • The trust board were visible across the trust. We observed meetings chaired by the chief executive and heard from staff that they knew who the leaders of the trust were.
  • The trust’s vision and values pre-dated the previous plans to merge. The trust planned to refresh them with staff engagement. Staff had an understanding of the vision and values in relation to local services.
  • The trust had an equality strategy in place which they were refreshing in collaboration with patients and staff for collaborative ownership and effectiveness.
  • The trust communicated well with patients, carers, staff and stakeholders. The majority of staff groups felt they knew what was happening in the organisation. Families and carers described a varied experience of communication with staff in the trust but were praising of the support they received from the carers team.
  • The trust strived to improve quality and innovation, for example, the epilepsy improvement group to ensure that all inpatients with epilepsy had a care plan to manage the condition with standard documentation across all learning disability units.
  • The trust were proactive in attempts to employ people across many of the core services but recruitment of staff remained a challenge.
  • The trust recognised its staff in a number of ways, through a simple thank you to formal awards.
  • There was a culture of learning and research across the trust.

Inspection areas

Safe

Requires improvement

Updated 9 January 2019

  • Not all wards were clean, well-furnished and fit for purpose. In particular, the acute wards at Hallam Street Hospital were dirty and poorly maintained. A clinic room was littered, dirty and the ward environments were unclean. Staff at Pond Lane had poor working conditions. They worked in an untidy, unclean environment with no ambient temperature control.
  • Risk assessments of the physical environments in which patients received care did not cover all areas, including patient areas. Furnishings in consultation rooms where staff met with patients at Edward Street and Pond Lane were not of a good standard. Consultation rooms were dark, cluttered and uninviting.
  • Staff training compliance rates for fire safety and information governance were below 75%.
  • The use of restrictive interventions did not consistently follow best practice. Staff on Dale Ward carried out blanket searches which were not in line with the trust policy. Patients on the psychiatric intensive care unit were only able to smoke at set times.
  • Staff had not followed the medicines management policy regarding action to take when temperatures go above or below guidelines in two services. Staff were unsure of what actions to take when temperatures were out of range. Staff at Pond Lane did not take appropriate action when medicine storage temperatures exceeded specified ranges.   
  • Staff within the Early Intervention Service team had not received regular management supervision in line with the trust policy.
  • Staff did not always follow infection control procedures. For example, on Friar ward they had left wet bedding left in a patient shower cubicle for several hours. The shower cubicle was locked and not accessible to patients.

  • We found examples where security of confidential information was not maintained. At two sites we visited, Edward Street and Pond Lane, staff had positioned computers in a way that would allow unauthorised people to view computer screens that might contain personal patient information. Staff rectified this when we raised it as an issue on inspection. We found that one patient care plan had been shredded as one member of staff thought this was procedure. The trust investigated this following inspection, after which we were assured that it was an isolated incident and not systemic practice.

However:

  • Every ward for adults of working age had an up to date ligature risk assessment in place, which included photos of all risks to easily identify them. The document contained individual plans telling how to manage risks.
  • The wards complied with guidance on mixed-sex accommodation and had areas specifically for male and female patients.
  • The environments in child and adolescent mental health services at the Gem Centre and Lodge Road were comfortable and inviting for young people using the service. All rooms at the Lodge Road were identically themed to support with consistency for young people who might struggle with changes to environments. Environmental risk assessments were in place at the Gem centre and included consideration of patient areas.
  • Most of the trust’s services 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. Wards for adults of working age had adequate staffing to meet the needs of patients. Staff in the wards for people with learning disability completed mandatory training and had access to specialist training if required. The trust had implemented the safe wards programme.
  • Staff completed person centred physical intervention protocols for all patients who were restrained or had a history of restraint. These aimed to reduce the need for future restraint.
  • Learning disability wards had low usage of rapid tranquilisation and only used restraint on patients as a last resort. We saw staff using de-escalation techniques on the wards. Each patient had a positive behaviour support plan which detailed trigger points and explained how to support them if they became distressed.
  • Staff received feedback from investigations at handovers and monthly meetings. We found evidence of changes to working practice as a result of this feedback.
  • There was a system in place to provide staff with a debrief after serious incidents. This was provided by psychologists attached to each team

Effective

Requires improvement

Updated 9 January 2019

  • Not all patients had an up-to-date care plan. Of the 36 patient records reviewed in the Community Mental Health services for people with learning disabilities or autism, 60% of the records did not have a collaborative, personalised or holistic care plan detailing their treatment aims or recovery goals. We found three records within Early Intervention Service and one record in Child and Adolescent Mental Health Services did not contain an up-to-date care plan. Staff had not removed old copies of care plans and reports from patient files at Penrose House which made the files cumbersome and difficult to navigate.
  • Some patients did not receive a range of treatments based on best practice to support their physical health and encouraged them to live healthier lives. Staff at Daisy Bank had not adequately monitored physical healthcare needs of patients relating to diet and significant weight gain. (The trust completed their plans to close Daisy Bank in September 2018 as part of the national Transforming Care Programme).
  • Staff working with children and young people in the Early Intervention Service did not have a clear understanding of Gillick Competence or understand where and why this would be applied.
  • Not all staff received regular managerial and clinical supervision or had an identified clinical supervision supervisor. Staff within the Early Intervention Service and staff at Penrose were not receiving regular management supervision.
  • Mental Health Act audits were completed but did not show evidence of lessons learnt or actions that had been taken. This had not affected patient care but could do so in the future without improvements.
  • In 31 records reviewed in the acute wards doctors had undertaken a routine mental capacity assessment. These assessments were not specific and were being applied to patients for which it would have been reasonable to assume capacity.

However,

  • Most staff provided care and treatment based on national guidance and pathways were in line with National Institute for Health and Care Excellence. Staff followed guidelines for a range of issues including best practice in administration of medication, psychological, family and behavioural therapies and interventions in mental health conditions.
  • Staff provided a range of care and treatment interventions suitable for the patient group. Patients had access to clinical psychologists and occupational therapists. Staff in the Promoting Access to Main Stream Health Services team were proactive in ensuring that patients’ physical healthcare needs were being met. The trust had trained some staff to deliver solution focused training to new staff. This meant staff could offer a consistent therapeutic approach to patients.
  • Staff were skilled, experienced and qualified in their area of work. Staff we spoke with demonstrated they had the right skills and knowledge to meet the needs of the patient group. They were up to date with mandatory training. Penrose House and The Larches had access to a wide range of health professionals to support patients. These included speech and language therapists, occupational therapists and psychologists who provided a range of therapies to suit the needs of each patient.
  • Staff understood safeguarding and appropriately reported issues. Staff had received training in safeguarding for both adults and children. They knew who to contact at the trust for advice.
  • Staff monitored physical health needs appropriately and routinely liaised with children and young people GP to ensure physical health needs were met. Ward staff developed good relationships with staff in community teams.
  • Staff engaged in clinical audits and findings were discussed at quality meetings attended by service leads. Good practice was routinely shared and actions from audits were fed back to teams through team meetings and addressed in supervision. Staff participated in benchmarking and quality improvement initiatives.

Caring

Good

Updated 9 January 2019

  • Staff demonstrated a sensitive, caring and compassionate attitude in their work with young people. They acted in a respectful and discreet manner and were responsive to people who needed emotional support and advice. We found that staff treated patients with care and compassion and permanent staff knew individual patients and their needs well.
  • Staff supported patients to participate in planning their care. They used easy read information with words and pictures to support patients to understand the care they received. Patients were assessed for a communication passport to be developed on admission to the ward. Staff encouraged family and carers to be involved as much as possible and with the consent of the patients. Apart from protected mealtimes families and carers could visit when the wanted to.
  • Staff took person-centred approach in their responses to people using the service. They demonstrated understanding of individual children and young people’s personal, cultural, social and religious needs. Staff used a range of methods suitable across age groups and abilities to find effective ways to communicate with young people about their care.
  • Most patients had access to regular community meetings on their wards. Wards had “you said we did” noticeboards. Carers were involved in patient care, ward meetings and activities where appropriate. Staff routinely enabled families and carers to give feedback on the service they received and made changes and improvements to the service based on their feedback. Most patients and their relatives gave positive feedback about the wards.
  • Hallam Street Hospital had an expert by experience service development volunteer role. This meant patients had the opportunity to work alongside staff on time specific projects to support the development of services and review documents; policies and procedures that affected the experience of patients at Hallam Street Hospital.
  • Patients had good access to independent advocacy. Staff ensured patients were referred and made information available to patients on the wards. Staff directed patients to other services and supported them to access those services.

However:

  • Staff did not routinely provide carers with information about how to access a carer’s assessment.

Responsive

Good

Updated 9 January 2019

  • The trust had set target times from referral to triage and then to admission for crisis services. All services we inspected were compliant with these targets. The crisis and liaison teams were able to respond very quickly to urgent referrals, usually within one hour. Staff within Child and Adolescent Mental Health Services achieved their target of 18 weeks for referral to assessment. Crisis, Home Treatment and Early Intervention Service met their targets for responding to referrals, there were no young people waiting to access treatment within these teams.
  • Staff actively engaged with people who did not attend appointments, found it difficult or were reluctant to engage with the service. They offered flexibility when offering appoints were dynamic and compassionate in their approach to engaging children and young people.
  • There were a range of rooms and facilities available across services. These included clinics attached to both health-based places of safety that were fully equipped to deliver care. Equipment was easily available and where required was checked in line with national guidance.
  • All services we checked had a range of information available to patients. Information provided was in a form accessible to the patient group for example in easy-read form for people with learning disability.
  • Patients knew how to make a complaint and stated that they would feel able to follow the process if required. Staff were well equipped to handle complaints appropriately and within trust policy.
  • Staff knew how to access interpreters for patients who required this service.
  • The trust was part of the West Midland MERIT vanguard, this was a group of neighbouring trusts working together to enable patients access to local beds and reduced the need for patients to travel significant distances for a bed. Most patients had their own bedrooms although some were expected to sleep in bed bays or dormitories.
  • Patients had access to a wide range of activities to support recovery in most services.

However:

  • There were delayed discharges at Penrose House and Daisy Bank. These occurred due to a lack of suitable accommodation being available for patients with complex needs. (The trust completed their plans to close Daisy Bank in September 2018 following inspection).
  • Some patients referred to speech and language or physiotherapy were waiting longer than expected to receive an assessment.
  • The liaison team had lost their allocated interview rooms in the hospital where they were based. This meant that they were conducting assessments and interviews in rooms that were unsuitable.

Well-led

Good

Updated 9 January 2019

  • Although we identified some lapses in governance and the overall trust rating had moved from Requires Improvement to Good, we concluded that the trust board’s ability to focus on day to day governance had been hampered because of flux around the proposed merger but we saw evidence that they were picking up the reins again, which demonstrated good leadership.
  • The trust board operated collaboratively, that meant executives and non-executive directors shared responsibility and liability for making decisions.
  • There was a rounded understanding of performance, which suitably covered and combined people’s views with information on quality, operational services and finances.
  • The trust board were very visible across all services of the trust. Many staff told us that they knew and saw the executive team visiting services. The chief executive held regular meetings across the trust for staff to come and share their experiences working within their services.
  • The trust understood the challenges to quality and sustainability, and identified the actions required to address them. This aligned to the wider health and social care economy of the Black Country. There was good leadership at trust board and its input into the sustainability and transformation partnership level.
  • The trust had retained its vision and values for the organisation. The strategy and priorities of the trust aligned to its vision and values. Staff had an understanding of the vision and values in relation to local services.
  • Staff told us they could influence change within the organisation. Staff had been consulted on changes to the structure of wards for people with learning disabilities and had the opportunity to contribute to strategy and design. Staff felt able to report concerns and incidents and knew how to do this.
  • Staff we spoke to felt respected and listened to by their managers and senior managers within the trust. They stated that they felt a sense of pride in their role and the trust in general. The trust recognised staff and volunteers’ staff in a number of ways, through a simple thank you to annual achievement awards.
  • The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems. Managers had access to systems to support them with their role, including access to data and dashboards showing service and staff performance information.
  • The trust had an equality strategy in place which they were refreshing in collaboration with patients and staff for collaborative ownership and effectiveness.
  • Staff, patients, and their families had access to up to date information about the trust. The trust communicated well with patients, carers, staff and stakeholders. The majority of staff groups felt they knew what was happening in the organisation. Families and carers described a varied experience of communication with staff in the trust but were praising of the support they received from the carers team.
  • There were arrangements in place to identify, record and manage risks. Patients mental and physical health was assessed, and care and treatment planned.
  • The trust worked hard to improve quality and innovation, for example, the epilepsy improvement programme to ensure that all patients with epilepsy had a comprehensive plan for the management of the condition.
  • Recruitment of staff was a challenge to the trust but they were proactive in attempts to employ people across many of their services.

However:

  • We did not find evidence of a robust recruitment process for all executive directors. When the planned TCT merger ended, the trust found itself without a substantive leadership team and with support from NHS Improvement, interim appointments were made from amongst senior managers within the trust.
  • Governance systems from ward to board provided performance management information to make decisions needed further strengthening. Including environmental risk assessments, risk register actions and information governance. During the TCT process, governance was led by the acquiring trust. When plans to merge ended, it left the Black Country Partnership Foundation NHS Trust without a substantive governance lead to direct and develop new systems. The trust had acted to strengthen their governance structure by making a senior appointment to lead governance and improve its systems.
  • Actions identified on the risk register were not complete despite being signed as complete. Not all risks identified were on the risk register and some risks did not identify staff who were responsible and accountable for the actions identified. Environmental changes to Edward Street identified following an incident in February 2017 were not complete at the time of inspection in July 2018.
  • There were three electronic recording systems being used alongside a system of paper notes. This also included different sets of notes for different disciplines within the team. This meant that notes were cumbersome and difficult to navigate for people who did not work regularly in the service. However, staff we spoke with were always able to find the information we requested. The trust had plans to implement an electronic patient records system.
  • The trust used a root cause analysis approach to review serious untoward incidents. The review of mortality lacked consistent challenge at an executive level before reports were signed off. The trust had action plans in place to address these issues.
  • We found a lack of maintenance and cleanliness at Hallam Street Hospital and Pond Lane. We raised our concerns with the trust and they took action to improve. The chief executive informed us of improvements they had made and that their recent Patient Led Assessment of the Environment (PLACE) had given Hallam Street 100% for cleanliness and over 99% trust wide.
  • The role of Freedom to Speak Up Guardian role was carried out by a member of the trust board and could lead to a conflict of interest for the post holder. This had been reviewed and new plans were in place to seek an external solution.

Checks on specific services

Community-based mental health services for older people

Outstanding

Updated 26 April 2016

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

  • Staff had good knowledge of safeguarding. They were trained to level three and identified risks and appropriate referrals were recorded.
  • Each care and treatment record contained detailed risk assessments and risk management plans. These were reviewed regularly.
  • Patients had access to advocacy services and staff knew how to support patients to make sure they had access.
  • Patient information leaflets explaining how to complain were available in all locations. Staff knew how to respond to complaints.
  • Each team followed appropriate national institute for health and care excellence guidelines; these included the use of low-dose antipsychotics in people with dementia and dementia,supporting people with dementia and their carers in health and social care.
  • In order to meet the needs of the local population, the treatment and recovery unit had developed a Punjabi cognitive stimulation group. A further cognitive stimulation group had been developed in partnership with West Bromwich Albion football club.
  • Staff told us they felt their managers were approachable and supportive.

  • There was no occupational therapy or psychotherapy input within community-based mental health services for older people. The treatment and recovery unit and the groves day centre had no psychology input.
  • Patients were not formally involved in the development of services or in staff interviews.

Wards for people with a learning disability or autism

Good

Updated 9 January 2019

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

  • All wards had detailed risk assessments and used these to keep patients safe. Ligature risks were managed well by staff who used detailed plans to manage patients care. Rooms were clean and well maintained and the clinic room was fully equipped to meet the needs of patients.
  • Staff managed medication well. They had good support from the pharmacists and ensured medication was administered in a safe way to patients.
  • Staff used national guidance including that set out by the National Institute for Health and Care Excellence to provide care for patients. Staff ensured care plans had been completed with input from patients and had updated them on a regular basis as patient needs changed.
  • Staff treated patients with compassion and patients we spoke to said that staff looked after them and helped them Staff ensured patients had good access to advocacy. They made referrals or encouraged patients to refer themselves where possible.
  • Patients always had their own bed to return to following a period of leave. Managers kept beds open for patients during the transition phase to new placements to ensure this was a smooth process for patients.
  • Patients had access to an excellent range of easy read materials. We saw these were completed in both pictures and written language depending on the needs of each individual patient. Medication leaflets had a photograph of the medication box and medicines to support patients to understand what they had been prescribed and why.
  • Staff felt supported in their roles. Staff reported that managers and senior staff at a local level were supportive and approachable. Managers used a dashboard to monitor staff performance including mandatory training and supervision.

However:

  • Levels of clinical supervision for staff were low for qualified staff and healthcare assistants at Penrose House and for qualified staff at Daisy Bank due to staff sickness and there was no one available to provide this.
  • Staff stored old copies of care plans and reports in patient files at Penrose House which made the files cumbersome and difficult to navigate.
  • The activity programmes at Penrose House and Daisy Bank were limited and staff needed to ensure these were taking place.
  • The wards did not complete audits of the Mental Capacity Act and actions in the Mental Health Act audits had not been completed. Staff had completed paperwork appropriately and this had not directly impacted on patients but had the potential to do so if not improved.
  • Daisy Bank and Penrose House had delayed discharges at the time of the inspection. These were due to issues outside of their control such as suitable placements not being available for patients with complex needs. We saw that staff did what they could to keep the process moving for patients. As part of the Transforming Care Programme, overseen by NHS England, Daisy Bank closed post-inspection that meant they had no delayed discharges.
  • Daisy Bank had not had permanent leadership over a period of 18 months and this had impacted on morale of the staff and patient care however the trust made the decision to close this ward in September 2018.

Community mental health services with learning disabilities or autism

Good

Updated 9 January 2019

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

  • The service provided safe care. Clinical premises where patients were seen were safe and clean. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • The teams included or had access to the full range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with services outside the organisation. Patients were able to see a psychiatrist in a timely manner and were seen urgently if required.
  • Staff ensured that patients received any necessary assessment of their physical and mental health needs and provided a range of care and treatment interventions suitable for the patient group. Staff in the promoting access to main stream health services team (PAMHS) were proactive in ensuring that patients’ physical healthcare needs were being met and supported patients to live healthier lives.
  • Staff used the Mental Capacity Act appropriately to determine if a patient had the capacity to make a specific decision. Staff gave patients every possible assistance to ensure they had the capacity to consent to treatment before they assumed that the patient lacked the mental capacity to make this decision.
  • Staff attitudes and behaviours when interacting with patients showed that they were respectful and responsive. Staff understood the individual needs of patients, including their personal, cultural, social and religious needs. Staff informed and involved families and carers appropriately and provided them with support when needed.
  • All information provided was in a form accessible to the patient group. Staff provided patients with easy-read documentation to understand their treatment. Staff knew how to access interpreters for patients who required this service.
  • Patient’s received responsive care from the service. The teams followed up with patients who did not attend appointments and supported them to attend in the future. Patients knew how to complain or raise concerns, and staff knew how to handle complaints appropriately.
  • Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the services they managed, were visible in the service and staff found them approachable. Staff knew and understood the trust’s vision and values. Staff felt respected, supported and valued. Staff spoke highly of the service manager. Staff felt positive and proud about working for the trust and their team.
  • The provider had a comprehensive schedule of meetings and reporting systems to ensure good governance of the service. Staff had access to up to date information about the work of the services they used. Staff participated in benchmarking and quality improvement initiatives and had opportunities to participate in research.

However:

  • Staffing levels could not be increased to accommodate an increase in caseload or acuity of the patient group. This meant that some staff were managing high caseloads. Staff caseloads were not formally reviewed and the service did not use a caseload management tool.
  • More than half of the records reviewed did not contain a holistic, person-centred care plan that demonstrated the patient’s goals, treatment aims or detailed involvement across the multidisciplinary team. Patients were not routinely offered a copy of their care plan.
  • Staff were not fully documenting when a best interests meeting had taken place for a patient who lacked capacity to make a decision.
  • Staff did not routinely inform people using the service how they could access independent advocacy.
  • Some patients referred to speech and language or physiotherapy were waiting longer than expected to receive an assessment.

Wards for older people with mental health problems

Good

Updated 9 January 2019

  • The environments were clean and tidy. The ward layout meant staff did not find a good line of sight and there were ligature risks on all wards, staff mitigated these risks with good observation practice.
  • Risk assessments were completed and updated when risks changed.
  • Staff reported incidents using the trust’s database. Lessons learnt were used to make improvements to services.
  • Multi-disciplinary teams worked for the good of the patient. We saw the involvement of inpatient and community
  • teams as well as other local hospitals working together to provide good care.
  • Patients had access to a range of therapies provided by a range of staff employed by the trust.
  • Staff cared for patients with respect and compassion. Their interactions with patients showed their understanding of the patient group and their needs. Patients and carers gave positive feedback about the staff and the wards. They gave feedback on the service.
  • Staff involved patients in the planning of their care they involved carers and relatives if appropriate to support with care planning.
  • Staff assessed and monitored patients’ physical health throughout their admission. Patients had access to professionals specialising in aspects of physical care such as podiatrist.
  • There was a range of rooms available for patient use for activities and access to a garden at both sites. Patients also used the facilities at the Lighthouse at Edward Street Hospital.
  • Ward managers were always visible on the wards, staff said they were passionate, knowledgeable and supportive of the staff.
  • All managers promoted a positive culture throughout the service, staff felt valued and appreciated by them.

Specialist community mental health services for children and young people

Requires improvement

Updated 9 January 2019

  • There were concerns regarding the environment at Pond Lane and Edward Street. Staff within the Early Intervention Service at Pond Lane worked in an untidy and unclean environment. There were concerns around infection control and medication storage temperatures at Pond Lane.
  • Environmental risk assessments were not completed for all sites. Where actions were identified within completed risk assessments, these were not always completed to ensure office areas were clean, safe and tidy environments to enable staff to carry out their duties safely.
  • Staff did not adhere to their own policy on medicine storage. Medicines were not stored at an appropriate temperature at Pond Lane and staff did not take appropriate action when these exceed specified ranges.
  • Staff within the Early Intervention Service did not have a clear understanding of Gillick competence and understand when and why this would be applied. This could have led to competent young people not being appropriately involved in their care.
  • The service did not ensure actions identified on the risk register were completed. Actions identified where signed as completed when they had not been.

However:

  • Child and Adolescent Mental Health Services and Crisis and Home Treatment teams had suitable premises to see young people. Environments had been decorated with children and young people at the centre. Staff had used their knowledge of young people and feedback from people using the service to create a suitable therapeutic environment.
  • Staff managed medication well. They had good support from the pharmacists and ensured medication was administered in a safe way to young people.
  • Staff provided care and treatment based on national guidance and care pathways were in line with the recommendations of the National Institute for Health and Care Excellence. Staff followed guidelines for a range of issues including best practice in administration of medication, psychological, family and behavioural therapies and interventions in mental health conditions.
  • Staff across the service treated young people with respect, care and compassion. Young people and their families spoke positively about the care and treatment from staff and the service.
  • Staff had good relationships and worked well with each other to achieve good outcomes for young people. Managers and senior staff at a local level were visible, supportive and approachable.

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

Requires improvement

Updated 9 January 2019

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

  • The ward environments at Hallam Street Hospital were not always clean and staff did not always follow infection control procedures. The wards had numerous blind spots and ligature risks, the wards were over two floors which meant staff used increased patient observation levels. Staff told us they were challenging environments to manage acutely unwell patients.
  • Staff did not always ensure that emergency equipment was in kept order. On two wards we found that the emergency equipment bag was not in order and staff did not document that medical equipment was routinely maintained and cleaned.
  • Staff did always follow safe medicine management procedures. Staff were unsure of the procedures to follow when the temperature of the clinical rooms were above recommended range.
  • One door on the psychiatric intensive care unit was not anti barricade, which meant that patients could barricade themselves in the room. Following an incident this room was no longer used by patients.
  • Staff on Dale Ward carried out searches on all patients; regardless of the level of risk. This blanket approach to searching patients was not in line with trust policy.
  • Staff mandatory training compliance did not always meet the trust target of 85%. Information governance and fire safety training compliance levels were below 75%.
  • Staff did not assess patients’ mental capacity in line with the Mental Capacity Act. We saw evidence that Mental Capacity Act documentation was not completed appropriately and that patients’ assessments were not decision specific.
  • Not all staff had regular clinical supervision and one third of staff on the psychiatric intensive care unit did not have an identified clinical supervisor.

However:

  • The ward environments at Penn Hospital and Macarthur Unit were clean and well maintained.
  • The wards complied with guidance on mixed-sex accommodation and had areas specifically for male and female patients.
  • Staff completed a risk assessment for every patient on admission and updated these as needs changed or incidents occurred. We saw evidence for this in the 31 care and treatment records we reviewed.
  • Patients had appropriate access to physical healthcare. Nursing staff and doctors monitored patients’ physical health throughout admission.
  • Staff attitudes and behaviours showed that they treated patients with dignity and respect.
  • Staff were supported to take care of well-being whilst at work. The trust recognised staff and volunteers’ success within the service through annual achievement awards.

Mental health crisis services and health-based places of safety

Good

Updated 9 January 2019

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

  • There were high levels of experienced staff who had undertaken a complete mandatory training programme. Regular monthly meetings ensured that staff received feedback after serious incidents and were kept up to date about improvements to the service. Care records were up to date and contained holistic and individualised information relating to care.
  • All records we checked contained comprehensive assessments including an assessment of physical health. Staff followed best practice guidance issued by national organisations such as the National Institute for Health and Care Excellence. There was a full range of mental health disciplines available to patients across the service. Staff had good knowledge of the Mental Health Act and Mental Capacity Act and how they were relevant to their service users.
  • We observed care being delivered by staff who were professional and knew their patient’s needs. They were able to tailor care delivery to the specific needs of the individuals and were aware of a wide range of impact factors such as history, culture, gender and individual ability. Where possible patients were involved in the development of their own care. Where appropriate families and carers were also involved.
  • All services we inspected were compliant with targets set by the trust in relation to referral to treatment times. The crisis and liaison services could respond quickly to urgent referrals. Information about this service and local services to support patients was available in a range of languages. Patients we spoke to were aware of how to make a complaint and felt that they would be comfortable to do so if they needed to.
  • Staff understood their roles and how they related to the trusts core values. Managers were visible and well respected. Staff felt well respected and valued by the trust. All staff we interviewed stated that they were proud of the work that they did and felt that the trust supported their development.

However

  • Some of the environments we inspected presented risks. The electronic and paper recording systems were cumbersome and difficult to navigate.
  • There had been some issues with communication with teams outside of the trust.
  • The liaison team had lost its specialist interview rooms at the local hospital where they were based. This meant that they were conducting interviews and assessments in rooms more suited to physical health care delivery.

Community-based mental health services for adults of working age

Good

Updated 17 February 2017

We changed the overall rating for community-based mental health services for adults of working age from requires improvement to good because:

  • At the last inspection, we found that not all services had access to emergency equipment. This had been an issue for the Wolverhampton complex care team north. During this inspection, we found that improvements had been made and all services had access to emergency equipment including defibrillators and oxygen.
  • During the inspection in November 2015, we found that the fridge temperatures in the Wolverhampton complex care team north had not been routinely checked and this could lead to harm to patients. During this inspection we found that the trust had installed fridge-monitoring equipment, which was linked to the mental health hospital, so that temperatures could be monitored at all times.
  • The trust had addressed the issues of waiting times in the single point of referral service and they were now meeting their targets for completing assessment. The other services did still have waiting lists, but these were closely monitored and had already been assessed for risk during the initial assessment. Patients on the list had access to a duty worker should they need to speak to someone for advice.
  • At the last inspection, there were issues with Mental Health Act paperwork and the legal status of patients being recorded on prescription charts. We found that these issues had been resolved with support from the trust's Mental Health Act team.
  • At the previous inspection, we found that these services used a range of systems to record patient information. This was still the case and the trust still need to fully resolve this issue however we found that this was mitigated due to staff communication and the weekly multidisciplinary team meetings that took place which included ward staff, community teams and the crisis team.

Forensic inpatient or secure wards

Good

Updated 17 February 2017

We have rated forensic inpatient/secure ward as good overall because:

  • Following our inspection in November 2015 we rated the service as ‘good’ for Effective, Caring, Responsive and Well led. Since that inspection, we have received no information that would cause us to re-inspect these key questions or change the ratings.

However:

  • Our rating of the safe key question remains requires improvement. This was because following our inspection of this service in November 2015, we asked the trust to ensure that training was provided to increase staff awareness of the Mental Health Act code of practice. During our inspection in October 2016, we found that less than 60% of qualified and unqualified staff had received this training. This was below the NHS national training standards and the trust's training compliance target.

Community health services for children, young people and families

Good

Updated 17 February 2017

We rated the service as good overall because:

The caseloads of health visitors were being monitored and managed well. Action was taken to ensure health visitor’s caseloads were manageable, in line with national guidance. Staffing levels in health visiting had improved since our last inspection. The caseload of the Family Inclusion Team had been reduced by transferring the care of some families to other members of the health visiting team.

The equipment provided for children used at home was being maintained in line with manufacturer’s maintenance requirements.

Improvements had been made to record keeping including the use of tracer cards when notes were transferred to another service.

Staff were ensuring children were safe by notifying the safeguarding team of any concerns using the trust’s incident reporting system.

Assessment and care planning was based on evidence-based guidance

There was a clear approach to monitoring, auditing and benchmarking the quality of children’s’ services and the outcomes for people receiving care and treatment.

Staff had the skills, knowledge and experience to deliver effective care and treatment

Staff worked with other agencies in multi disciplinary teams to ensure the care children received was well co-ordinated.

Staff provided age appropriate care. They took time to interact with children and young people and their families and took account of children’s individual physical, emotional and social needs.

Staff recognised when children and families needed additional support. Staff helped families to understand the treatment provided and enabled them to make decisions around the care they received. Families were involved in planning care and treatment and could access interpreters and other support when required.

The clinical commissioning group (CCG) were developing a strategy to meet the needs of local families. Clinicians and managers from the children and family service were actively working with the CCG to develop services.

The service worked with social services and education providers to meet the needs of Children and Young People in the area, particularly children with complex needs, life-limiting conditions and disabilities.

Children waited longer than the trust’s target of 8 weeks from referral to treatment target but met the national waiting time standards for providing timely access to initial assessment, diagnosis and treatment

Health visiting services were meeting the targets for child development checks

Issues identified at the last inspection which required improvement had been addressed by managers in the trust.

There were good governance arrangements in place which meant incidents, audits, national guidelines and risks were discussed and the appropriate actions were taken.

The performance of the service was managed and action was taken to improve performance

Leaders had the capacity, capability, and experience to lead effectively

However,

The trust was not achieving targets for level 2 and 3 safeguarding training The proportion of staff who had completed the training had fallen since our last inspection from 88.2 % for level 2 and 93.3% for level 3 to 82% and 79% respectively. This meant 34 of eligible staff had not completed level 2 training and 31 staff had not completed level 3.

Children were referred to other teams within the trust but there were no shared records. Each service kept their own information about a child’s needs. Information was held in paper records. An IT system which supported information sharing was not in place and the service could not share information with GPs.

Not all services were accessible at one location for example speech therapy was not provided at the Sunflower Centre where other therapy services and the Children’s Assessment Unit was based.

The pathway for the Family Inclusion Team and the access thresholds was not clear and there was a risk that some families in need might not receive the level of service they required.

The Board did not have a designated executive lead for children. A non executive lead had been identified.

A strategy was being developed with the local Clinical Commissioning group but this was not yet in place.

Senior leaders were not visible to all staff.

The trust used a system of restorative supervision but the role of this form of supervision was not clear within the trust’s supervision policy. Restorative supervision was provided in addition to routine supervision for staff the trust believed needed additional support.