Black Country Healthcare NHS Foundation Trust

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

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

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the effectiveness of people’s care, treatment and support was inconsistent.

Although care was generally delivered in line with evidence-based practice and staff demonstrated appropriate knowledge and skills, care plans and risk assessments were often generic, lacked sufficient personalisation and did not always reflect patients’ current needs. Some patients did not have condition-specific care plans to guide staff in managing significant physical health needs. However, we also saw examples of well-developed, personalised care plans and good compliance with Mental Health Act and Mental Capacity Act requirements.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. People’s mental, physical and wellbeing needs were assessed using structured processes, and assessments were reviewed regularly to ensure care and treatment remained responsive to changing needs and circumstances.

Staff assessed patients before admission to identify their clinical, risk and disability-related needs and ensure they were admitted to the most appropriate ward. Following admission, staff completed structured assessments of patients' mental and physical health needs. Assessments were undertaken by appropriately qualified professionals, including registered nurses, medical staff and occupational therapists. Patients were reviewed by a consultant psychiatrist shortly after admission, and occupational therapists screened patients within 12 to 72 hours to identify any additional support needs and inform personalised care planning. Where further needs were identified, staff sought input from relevant specialists.

We reviewed 17 patient care records across the services. Records generally demonstrated that patients had received appropriate admission assessments, regular reviews and ongoing multidisciplinary input. Most records evidenced compliance with the Mental Health Act and Mental Capacity Act and showed patients' care and treatment had been reviewed regularly.

Patients' needs, risks and treatment plans were reviewed through multidisciplinary team meetings to ensure care remained responsive to changing circumstances. Staff described how information from assessments was used to identify additional support needs and coordinate input from relevant professionals.

The evidence showed a good standard. Care and treatment were informed by evidence-based practice and relevant clinical guidance. Patients had access to multidisciplinary and recovery-focused support to meet their mental and physical health needs, although staffing pressures sometimes reduced access to therapeutic activities and occupational therapy programmes.

Four of the five sites visited were acute inpatient wards providing specialist assessment, care and treatment for people experiencing acute mental health difficulties. Care was delivered by multidisciplinary teams that included psychiatrists, doctors, nurses, healthcare support workers, psychologists and occupational therapists. The MacArthur Centre provided Psychiatric Intensive Care Unit (PICU) services for adult men requiring intensive assessment and treatment due to the level of risk associated with their mental health needs.

The primary aims of admission were to stabilise patients' mental health, maintain safety, promote recovery and prepare people for discharge. Staff supported patients to understand their mental health, develop self-management strategies and, where appropriate, build confidence in managing their own medicines.

Patients had access to a range of therapeutic, psychological and recovery-focused interventions. Occupational therapy programmes included life skills, cooking, employment support and welfare rights advice, helping patients develop practical skills to support independence and successful discharge. Patients also had access to specialist substance misuse support through an external service that regularly attended the wards.

Staff monitored patients' physical health using recognised assessment tools, including the Malnutrition Universal Screening Tool (MUST) and Waterlow assessments, to identify risks and ensure appropriate interventions were provided. Care and treatment were delivered through multidisciplinary working and reflected the principles of relevant NICE guidance for the treatment and management of severe mental illness, including the provision of pharmacological, psychological and recovery-focused interventions.

Although staff consistently told us that staffing pressures reduced patients' access to regular occupational therapy programmes and therapeutic activities, staff demonstrated the knowledge and skills required to deliver care and treatment that was informed by current evidence-based practice and tailored to patients' individual needs.

The evidence showed some shortfalls. Multidisciplinary teams generally worked well together to support people. However, delays involving some external agencies and difficulties accessing medical input at times did not always support coordinated care and timely discharge planning.

During the 3 multidisciplinary team (MDT) meetings we observed during the inspection, there was effective collaborative discussion between team members. Staff demonstrated a good understanding of patients' needs, and discussions about care, support, and risk management were thorough and meaningful.

Many staff we spoke with commented positively on how well the MDT worked together to share information and provide a high standard of care to patients.

However, some staff said there was room for improvement in joint working with local authorities and social care services. Staff told us that it could be difficult for patients to be allocated a social worker in a timely way. They also described delays to some patients' discharges while waiting for care packages or suitable housing arrangements to be put in place.

Some staff reported difficulties contacting ward doctors at times. They told us this could affect aspects of patient care, such as the timely completion of routine admission assessments. Staff said that when these issues arose, they escalated their concerns to the clinical director.

The evidence showed some shortfalls. The service did not always support people to manage their health and wellbeing effectively or maximise opportunities to improve their physical health and reduce future care needs.

Staff told us they promoted health and wellbeing through health education, support for the trust's smoke-free approach, encouraging access to leave and activities, and discouraging the consumption of some items, such as energy drinks. Staff said they sought to support healthier lifestyles while respecting patients' individual preferences and choices.

Staff described a range of resources and interventions intended to support patients' physical health, including access to gyms, occupational therapy-led activities, healthy meal options and support from physical healthcare staff. Staff also told us they developed care plans for patients with specific physical health needs, including diabetes. The hospitals provided nicotine replacement therapy and electronic cigarettes where required to support patients to reduce or stop smoking.

However, patients gave mixed feedback about opportunities to participate in physical activity. One patient told us staff regularly supported patients to leave the ward to smoke but did not provide the same level of support to access the gym or other exercise opportunities. Other patients reported they were unable to use the gym because there were insufficient numbers of trained staff available to supervise sessions. Leaders recognised this issue and told us they planned to increase access by providing Level 2 Gym Instructor training for ward staff.

Staff described ongoing challenges in implementing the trust's smoke-free policy. They told us restrictions on smoking could lead to patient distress, unauthorised leave from wards and an increase in incidents. During the inspection, we observed patients and staff smoking in areas where smoking was not permitted, including hospital car parks, demonstrating that the policy was not always consistently followed.

The evidence showed some shortfalls. The service monitored safety and performance through audits, governance processes and quality improvement activity. However, there was limited evidence of a consistent approach to measuring patient outcomes or evaluating the effectiveness of care and treatment.

The trust monitored a range of quality and safety information, including incidents, restrictive interventions, staffing and clinical documentation. This information was reviewed through governance meetings, audits and quality improvement processes to identify areas for improvement.

However, we found limited evidence that the service routinely used recognised outcome measures to assess the effectiveness of care and treatment or monitor patients' progress. While the trust could demonstrate how it monitored safety and performance, it was not always clear how patient outcomes were measured or how improvements in care were evaluated.

The evidence showed some shortfalls. The service did not consistently demonstrate that consent processes had been followed appropriately or that patients' involvement in decision-making had been clearly documented. Best interests decisions were not always recorded where patients lacked capacity to make specific decisions.

We reviewed patient records and found several examples of decision-specific mental capacity assessments that had been completed and documented appropriately. However, where patients had been assessed as lacking capacity to make a specific decision, best interests decisions were not always recorded.

Several patients told us they felt involved in decisions about their care and treatment. They said staff discussed their needs, sought their views and obtained consent before making decisions about treatment or sharing information.

Documentation relating to consent was inconsistent. Some records clearly evidenced discussions with patients and demonstrated that informed consent had been sought and obtained. However, other records did not provide sufficient evidence that these discussions had taken place or that consent had been obtained. We also found examples of generic statements about consent, decision-making and care plan co-production that were not supported by records demonstrating how patients had been involved in decisions about their care and treatment.