All inspections: Black Country Healthcare NHS Foundation Trust

Black Country Healthcare NHS Foundation Trust was formerly called Black Country Partnership NHS Foundation Trust. It changed its name in April 2020 when it acquired the mental health services previously run by Dudley and Walsall Mental Health Partnership NHS Trust, which is now Dudley Integrated Health and Care NHS Trust.

Since the merger we have completed one inspection in November 2021. This consisted of how well led the trust was and three mental health services: acute wards for adults of working age and psychiatric intensive care units, mental health crisis services and health-based places of safety and wards for older people with mental health problems. We rated the trust overall and all three mental health services as good. In rating the trust in November 2021, we took into account previous ratings for services not inspected.

Following the inspection in November 2021 we told the trust that it must take action to bring services into line with two legal requirements. This action related to this core service was:

Wards for adults of working age and psychiatric intensive care units

The trust must ensure that all ligatures in the acute wards are removed or mitigated effectively to protect patients from self-harm. (Regulation 12) (1)(d)

We told the trust action it should take to improve:

Wards for adults of working age and psychiatric intensive units: The trust should ensure that all patients are involved in their treatment and care and receive a copy of their care plan.

The trust should consider updating the seclusion room at Macarthur Centre to make the environment more comfortable for patients in seclusion.

At this inspection we inspected one core service: Acute wards for adults of working age and psychiatric intensive care units. We inspected this service following reports of safeguarding incidents to the local authority and police which were being investigated at time of inspection.

In November 2021 we rated this core service as Good overall, requires improvement for safe and Good for effective, caring, responsive and well led.

What people who use the service say

Patients said staff were good and had supported them.

Patients told us they could make drinks and snacks when they wanted to although the kitchen on Ambleside ward was locked. Patients said that when they complained about the lack of variety of food this had improved.

Some patients did not have a copy of their care plan and one patient didn’t know they should have one. Other patients said they were not involved in their care plan. Some patients told us they did not have one to one time with their named nurse.

Patients on Dale ward at Penn hospital and patients at Bushey Fields hospital said there were a lot of activities going on. However, on other wards patients said they were bored and there was nothing to do. Patients at Hallam Street hospital said they did not often get to the resource centre for activities so did not have a chance to meet patients from other wards.

Patients told us that staff were kind, caring and interested in them, they said staff knocked on their door before entering and treated them with respect.

One patient’s relative said staff keep them updated on their family member. Another said that staff treated them and their relative with respect.

We rated this service as requires improvement at this inspection because:

The environment had not fully been adapted to ensure patients safety. However, the trust had undertaken significant work to assess ligature risks, undertake incident surveillance and provided funding to the wards where environmental risk was highest. Staff reduced the risks of blind spots by observing patients closely.

Patients said they did not always have one to one time with nurses, and leave was often cancelled. Doctors could not always attend the ward at night but were available by telephone. However, the wards had enough nurses and doctors to ensure patents were safe.

Staff did not always manage medicines safely and did not show they followed guidance from pharmacists.

The trust had not trained all staff in immediate life support.

Staff did not always develop holistic, recovery-oriented care plans informed by a comprehensive assessment.

Staff were not always able to provide a range of treatments suitable to the needs of the patients in line with national guidance about best practice. This was because there were vacancies for occupational therapists and psychologists on some wards. The ward teams did not always include or have access to the full range of specialists required to meet the needs of patients.

On Friar ward the staff did not always work well together as a multidisciplinary team or with community teams and external providers who would have a role in providing aftercare. Staff across the wards were not aware of the role of the newly formed Complex Care team within the trust.

The service did not always have a bed available locally to a person who would benefit from admission and patients were not always discharged promptly once their condition warranted this.

The governance processes did not always ensure that ward procedures ran smoothly.

However:

Staff assessed and managed risk well and minimised the use of restrictive practices.

The ward environments were clean.

Staff followed good practice with respect to safeguarding.

The trust had reduced the staff turnover rates across the wards.

Managers ensured that staff received supervision and appraisal.

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.

Staff engaged in clinical audit to evaluate the quality of care they provided.

Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

Black Country Healthcare NHS Foundation Trust was formerly called Black Country Partnership NHS Foundation Trust. It changed its name in April 2020 when it acquired the mental health services previously run by Dudley and Walsall Mental Health Partnership NHS Trust, which is now Dudley Integrated Health and Care NHS Trust.

Ratings of services previously run by a trust acquired by another do not carry over to the new trust. This report includes ratings for the three mental health services of the newly formed trust that we inspected this time, and for mental health and community health services run by this trust under its previous name.

We have not taken into account previous ratings for mental health services formerly run by the Dudley and Walsall trust. Information about those services is available on our website pages for that trust under its new name (cqc.org.uk/ provider/RYK/reports).

Our normal practice following an acquisition would be to inspect all services run by the enlarged trust. However, our usual inspection work has been curtailed by the COVID-19 pandemic, so we inspected only those services where we had cause for concern.

We inspected the overall management of the trust and three mental health services:

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

• Mental health crisis services and health-based places of safety

• Wards for older people with mental health problems

We rated the trust overall and all three mental health services as good. In rating the trust we took into account previous ratings for services not inspected this time. We rated the trust as good because:

The trust was formed in April 2020 at the start of the Covid 19 pandemic and during the implementation of the lockdown measures initiated by the Government. We noted how much time the board had invested in creating the new organisation during the Covid-19 pandemic.
The trust board was diverse. Non-executive directors represented different communities and the executive directors presented an effective mix of members from diverse backgrounds and with a wide range of skills and experience. A number of the non-executive directors had a NHS or local authority background which supported good discussions at trust board. The trust was highlighted by a national healthcare journal for having the highest share of black, Asian and minority ethnic very senior managers.
The clinical strategy identified key priority areas of focus which were linked to the trust’s vision.
Governance processes had been implemented and operated effectively across the organisation to ensure that performance and risk were managed well. There were clear responsibilities, roles and systems of accountability to support good governance and management. There was a positive and open culture across the trust. Staff told us they felt happy and enjoyed their work. There was good staff morale in services. Staff felt respected, supported, and valued and we heard how well the trust supported staff during the COVID-19 pandemic. Leaders modelled positive behaviours, and development of staff was encouraged. There was an extensive wellbeing offer available to staff, including the wellbeing hub offering mental health support, flexible working, and aids on keeping well.
There had been good engagement with external stakeholders. The trust had key roles in the development of the local health and social care system working and collaborated with care providers to improve mental health services. The trust engaged with local people who used services in the design of new buildings.
The trust had developed a triumvirate management structure across its divisions that was supporting the development and focus on local services. Whilst their structure was new there was good work in developing local governance around quality and safety. A triumvirate approach brings together three managers, including operational, clinical, and managerial, to support change to local areas.
The trust had made firm commitments to equality and inclusions. The Cultural Ambassadors programme collected equality data that fed into the trusts plans for equality and inclusions. The staff networks for black and ethnic minorities, disability, and LGBTQ+ were actively supported and had been awarded the Disability Confident Award.
Infection prevention and control (IPC) was well managed and monitored. Services were responsive and dealt with frequent changes in IPC requirements during the pandemic.
Staff completed and regularly updated environmental risk assessments of all wards areas and removed or reduced the majority of the risks they identified, an exception being in the wards for older people with mental health problems. Staff followed procedures to minimise risks where they could not easily observe patients.
Patient involvement in planning care was now in place and the voice of the patient in changes to services had been considered.
Patients we spoke to in mental health wards for adults said that staff treated them with respect and dignity. Key workers and occupational therapists were highly praised. Relatives were similar in praise to staff in older people’s wards and thought their family received good care. Relatives and carers understood the need for tighter restrictions during the pandemic. However, the need for improvements were highlighted in the following areas; to be provided with more information about medication and treatment, communication between wards and carers could be improved, and access to care and support slowed the process of discharge.
There was a good working relationship between the Mental Health Act (MHA) administration team and the wards, community teams and the executive team. This had continued during the pandemic. The MHA team provided regular reports to the executive team to provide assurance that the MHA was appropriately applied within the trust.
Services treated concerns and complaints seriously, investigated them and learned lessons from the results. Managers shared the outcome of complaints with their ward teams.
The trust board, heads of departments and senior leaders had access to the information they needed to manage risk, issues and performance across the trust. Staff had easy access to clinical information and were maintaining good quality clinical records.

However:

In two of the core services inspected, the environment had not been well maintained. These were across mental health wards for adults of working age and for older people. Maintenance teams had not undertaken repairs in a timely way. However, all areas used by patients were clean. Some patients continued to share bedroom spaces in dormitories. However the trust had clear and timely plans to eliminate dormitories.
There were not always sufficient alarms for staff working in the wards for older people. This meant staff could not get help quickly if there was an emergency.
The seclusion room at the Macarthur Centre psychiatric intensive care unit was poorly furnished and the toilet and washing facilities needed updating. It did not meet the requirement of the Code of Practice
Patients on the acute wards for adults of working age did not have sufficient access to psychology services.

How we carried out the inspection

During the inspection, our inspection teams carried out the following activities across 11 wards in the three core services inspected:

• reviewed 49 care records

• reviewed 44 medication records

• interviewed 52 staff and 10 managers

• interviewed 14 patients

• spoke with 13 family members or carers of patients

• checked 14 clinic rooms

• attended 7 meetings

During our well-led inspection, we spoke with 50 senior leaders of the organisation and looked at a range of policies, procedures and other governance documents relating to the running of the trust.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Patients we talked to that used the wards for adults of working age told us that they were cared for in a dignified and caring manner. They told us that staff treated them with respect and tried to include them in their care where possible. Patients spoke highly of their key workers and occupational therapists on the wards. Some patients told us that they were not given enough information about their medication or treatment, and some patients were not given a copy of their care plan.

Relatives and carers of people who had used the wards for older adult felt that their loved one was receiving good care from the hospital. They said that nurses should have more help and that they earned every penny.

Most of the carers we spoke to stated that communication was a particular problem between the ward and relatives and carers. Access to follow on care and support appeared to slow down patient’s discharge.

Relatives and carers said although Covid restrictions on the wards felt quite tight it appeared to have prevented Covid in the hospitals.

Due to concerns about the pandemic and possibility of cross infection inspectors were not able to accompany staff on community visits and therefore were unable to speak to patients who were been looked after by the crisis teams.

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services

We received a number of notifications relating to the acute inpatient mental health services for adults. These related to the quality of care, staff attitudes and engagement with patients.

Due to the nature of the notifications we decided to visit two locations within the service. These were Hallam Street Hospital and Bushey Fields Hospital. Whilst there we visited 5 wards. The wards we visited were Abbey, Friar and Charlemont wards at Hallam Street Hospital and Wrekin and Clee wards at Bushey Fields Hospital

We did not rate this service at this inspection. The previous rating of requires improvement remains

Staff had completed and regularly updated risk assessments of all wards areas. however the trust had not removed or reduced any risks they identified. The trust used regular bank and agency staff to fill shortfalls in staffing. Staff had not completed risk assessments for each patient on admission / arrival, using a recognised tool. When staff had completed a risk assessment, they had not always reviewed this regularly, including after any incident. Risk assessments were not always completed in the electronic record. Patient notes were not comprehensive. All full time staff could access information easily but bank and agency staff were unable to access the electronic patient record. Staff had not always completed a comprehensive mental health assessment of each patient on admission or soon after. We found examples where mental health risk assessments had been used from previous admissions. Patients had not had their physical health assessed soon after admission and regularly reviewed during their time on the ward. Staff had not always developed comprehensive care plans for each patient that met their mental and physical health needs. Care plans were not always personalised, holistic and recovery-orientated. Staff had not always explained to each patient their rights under the Mental Health Act in a way that they could understand. Informal patients had had restrictions applied to them preventing them from leaving the wards unsupervised. Staff did not always support patients to understand and manage their own care treatment or condition. Patients said there was a difference in the support that they received from the day staff and the night staff. Patients said that night staff were not as caring as day staff and did not offer the same level of support. Staff did not always understand and respect the individual needs of each patient. Staff did not always involve patients or give them access to their care planning and risk assessments. Some staff told us that they were less sure of the organisations visions and values since the trust merged twelve months ago. Governance processes did not always operate effectively at team level and performance and risk were not always managed well. The introduction of the electronic recording system had been problematic. Staff did not collect or analyze data about outcomes and performance in all areas.

We had significant concerns about the care and safety of people using the service and wrote to trust under section 31 Health and Care Act 2014. We asked the trust to provide an action plan detailing how they had addressed each of the concerns identified or how they planned to address immediately. The trust responded with a robust action plan detailing action they had and were taking to deal with all of the concerns we had identified.

How we carried out the inspection

During the inspection we undertook five ward tours and clinic checks, we also looked at communal dining and therapy areas.

We spoke with nine patients and five carers to discuss their experiences.

We interviewed two service managers, a discharge coordinator, four ward managers, a modern matron, seven qualified nurses, seven health care assistants, two doctors, one occupational therapist, two student nurses, a house keeper and a ward administrator.

We attended one ward review. We also reviewed 9 sets of patients notes, incident forms from across all five wards, ligature risk assessments from both locations, audit paperwork and assorted policy documents.

The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding. Though the service received a large number of referrals, the number of patients waiting for an appointment for longer than trust set-targets of 18 weeks was low.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the 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. Care plans and sessions had been developed specifically to engage individuals. Thought had been given to patients’ interests and past experience to develop sessions and identify placements where they could use their skills. Patients told us that this reduced anxiety and made them feel like they were fully involved and, in some cases, having a positive influence at their placements.
The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude patients who would have benefitted from care.
The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

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

The service provided safe care. Clinical premises where patients were seen were now safe and clean. Previous problems with storage of medicines had been solved. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff now developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit and benchmarking to evaluate the quality of care they provided. Staff at Sandwell CAMHS participated in a multi-agency thematic inspection to audit how well local agencies worked together in an area to protect children.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. Patients and carers we spoke with said they actively involved them in care decisions.
The service was easy to access. Staff assessed and treated patients who required urgent care promptly. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
The service was now well led and had put effective governance processes in place to ensure that procedures relating to the work of the service ran smoothly.

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

Acute wards at Hallam Street were based over two levels, they had blind spots and ligature risks. Ligature risk assessments were complete for each ward and identified each risk with mitigation. Staff completed enhanced observations to manage risks but said the environments were challenging when trying to support acutely unwell patients.
Supervision rates were low for two of the wards between 20% and 50%. The trust recording systems for clinical supervision were not reliable. Managers told us there were delays with the system updating information they provided around supervision and training.
staff used restrictive and controlling behaviours towards informal patients wanting to go off the wards for short periods.
There was inconsistent leadership support for staff on two wards due to ward manager vacancies and changes within management.
Staff did not always record fridge and room temperatures, or act to manage temperatures that had exceeded or were not within the recommended temperature range. We found gaps in the cleaning records on two wards where staff had not recorded dates when the clinic rooms were cleaned.

However,

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

We rated it as good because:

The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was sufficient for staff to give each patient the time they needed. Staff managed referrals to the service well and ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers if appropriate. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
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 as appropriate.
The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait long to start treatment. The criteria for referral to the service did not exclude people who would have benefitted from care.
The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

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

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.

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.

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.

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.

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.

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.

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.

We found that the service provided good care and support to patients. Where there had been errors or areas of poor practice these had been addressed and action plans put in place to ensure these would not happen again.
All staff had received Managing Actual and Potential Physical Aggression training and understood the need to use de-escalation techniques with patients. Restraint was used as a last resort to ensure patients and staff did not come to harm. Staff had guidance on how to use this through the patient’s person centred physical intervention plans, which were detailed, and person centred.
Staffing levels were good and managers could adjust this to meet the needs of patients. This meant the unit used bank and agency staff when patients needed additional observations or support. Where possible this involved using people who had previous knowledge of the unit.
Staff ensured each patient had individualised care plans, which reflected the patients likes, dislikes and preferred activities. Patients had a structured programme of daily activities both on the ward and in the community.
Staff felt well supported by managers who had a visible presence on the unit. Managers knew patients and had a good understanding of their individual needs.

However:
There had been issues where staff did not engage with patients in a positive way and used strategies to manage patient behaviour, which was not good practice. The trust acted quickly to stop this and prevent it happening again in the future

We rated wards for people with a learning disability and autism as good because:

During this most recent inspection, we found that the services had addressed the issues that had caused us to rate wards for people with a learning disability and autism as requires improvement under the safe domain following the November 2015 inspection.
We saw many improvements to the services since our inspection in November 2015. On all of the wards we looked at ligature points were risk assessed and where identified were adequately mitigated. Staff were made aware of both the ligature risk assessment and the mitigation plan for each ward.
Emergency bags and ligature cutters were easily accessible to all staff.

However

Safe food storage was not practiced on all of the wards that we inspected.

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.

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.

We rated the service as good overall because:

The caseloads of health visitors was 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.