All inspections: Herefordshire and Worcestershire Health and Care NHS Trust

We carried out this unannounced inspection of Herefordshire and Worcestershire Health and Care NHS Trust, of the mental health and community health services provided by this trust because since our previous inspection Worcestershire Health and Care NHS Trust, had taken on responsibility for providing mental health service to Herefordshire from Gloucestershire Health and Care Foundation Trust in April 2020.

We carried out this inspection because 2 services that had previously been inspected had been rated inadequate overall. This included acute wards for adults of working age which had been rated as inadequate in July 2022, and community-based mental health services for adults of working age had been rated inadequate in January 2020. We also inspected 2 services which had not been inspected since 2018, both which were previously rated as good. We also carried out this inspection because of concerns we had received about sexual safety of patients at Hillcrest ward.

We also inspected the well-led key question for the trust overall.

At this inspection, we visited 3 mental health services and 1 community health service. We also inspected the well-led question at provider level for the trust overall.

The trust provides the following services:

Acute wards for adults of working age and psychiatric intensive care units
Long stay or rehabilitation mental health wards for working age adults
Wards for older people with mental health problems
Mental health crisis services and health-based places of safety
Community-based mental health services for adults of working age
Specialist community mental health services for children and young people
Community-based mental health services for older people
Community mental health services for people with a learning disability or autism
Community health services for adults
Community health services for children, young people and families
Community Health inpatient services
Community end of life care
Community dental services.

We inspected all key lines of enquiry in all domains (safe, effective, caring, responsive and well-led) in the 4 services inspected. These services were:

Acute wards for adults of working age and psychiatric intensive care units
Community-based mental health services for adults of working age
Mental health crisis services and health-based places of safety
Community health services for adults

We also assessed if the organisation is well-led and looked at areas of governance, culture, leadership capability and improvement. Our inspection approach allows us to make a judgement on how the trust’s senior leadership leads the organisation, and the provider level well-led rating is separate from the ratings of the services we inspected.

In rating the trust overall, we took into account the current ratings of the 10 services which were not inspected this time and therefore bought forward the most recent ratings.

At this inspection, the key questions were rated overall, as requires improvement for safe, and effective, good for caring and responsive and requires improvement for well-led.

The trust-wide well led rating is not aggregated with all the service ratings. The trust-wide well led rating went down. We rated the overall trust-wide well-led as requires improvement.

At this inspection, we rated all 3 of the mental health services we inspected as requires improvement overall. This was an improvement in rating for 2 services since the last inspection. The rating for 1 of the mental health services inspected went down to requires improvement. The rating for the community health service we inspected went down and was rated requires improvement.

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

We found environmental risks at 2 of the services inspected. In acute wards for adults of working age, where accommodation was mixed sex, staff did not sufficiently monitor and observe single sex spaces. This resulted in sexual safety incidents. Two services did not ensure ligature risk assessments were up to date and identified risks were not effectively mitigated.
Two services we inspected had not ensured that patient risk assessments were completed, reviewed, or updated. Not all services had mitigated risks to patients in relation to sexual safety in acute wards for adults of working age. In mental health crisis services, the safety of young people when admitted to a health-based place of safety was not always well managed.
Safety was not a sufficient priority in all services. Staff did not manage sexual safety incidents well. Not all services escalated or reported sexual safety incidents. In acute wards for adults of working age, staff did not take action that was reasonably practicable to report, respond to or mitigate sexual safety risks.
The systems and processes used to manage risks in the trust were not effectively managed. There was a lack of collaborative oversight, escalation or challenge. The trust board was not always sighted on all risks that could affect the delivery of strategy and provision of high-quality care.
Across the trust, not all environments in services we inspected had been well maintained, clean or were fit for purpose. In mental health crisis services, the health-based place of safety in Worcestershire did not meet the standards on the use of Section 136 of the Mental Health Act 1983 (England and Wales July 2011 Royal College of Psychiatry CR159) and the guiding principles of the Code of Practice.
Staff compliance with mandatory training fell below expected standards in 3 of the 4 services we inspected. This included training in basic life support, fire safety training and Mental Health Act training. Systems and processes to monitor training compliance were not effective in these services.
Some services did not receive regular supervision or appraisals. In 2 services the service did not provide data on supervision compliance, and in a third service, compliance was as low as 20%. One service inspected had appraisal compliance at 66%. Systems and processes to monitor supervision and appraisal compliance were not effective in these services.
Psychology waiting times prevented patients receiving interventions in a timely manner in community-based mental health services for adults of working age in Worcestershire. The number of patients on the waiting list had steadily increased each month, from 57 in March 2022 to 161 in February 2023.
We had concerns about staffing in 2 services. In Neighbourhood mental health teams, the service did not have enough staff and some teams had patients who were waiting to be allocated to a caseworker. Vacancy rates were between 17% and 61% across both Herefordshire and Worcestershire. In the Worcestershire health-based place of safety, there were not always appropriate staff available to assess a young person outside working hours. This meant young people had to then stay overnight.
In services we inspected, some systems and processes did not effectively provide managers with oversight or assurance of how services were delivered. Managers did not always have systems to be able to assess, monitor and review the quality of the service. For example, locking of doors, reporting of incidents, adherence to trust policies and procedures training and supervision and appraisal compliance.
Whilst members of the board had the skills, knowledge and experience required, we were not assured that they worked in a cohesive and collaborative way to address areas of risk or concern. Leaders at all levels were not always visible.
Systems of accountability for some areas of governance were not always clear, and not all senior leaders discharged their responsibility of active challenge to decisions and actions robustly. Learning from incidents, and previous inspections had not been shared across the trust or acted on swiftly enough to bring about improved, safe care.
There was evidence of a closed culture within the trust with minimal actions at board level and in services to address equality, diversity and inclusion issues felt by staff. There was a lack of urgency to implement culture change initiatives across the organisation.
We found a lack of evidence to support patient involvement in service development, redesign, and improvement. Whilst the trust published this was in place, there were few examples to show where this occurred.

However:

The trust had a clear vision with values which were understood by all staff. All staff spoken with during our inspection knew the trust values and were able to relate them to their work within the team. Staff knew and understood the provider’s vision and how it applied to the work of their team.
Three services had decreasing rates of bank and agency nurses and support workers. Managers limited their use of bank and agency staff and requested staff familiar with the service. They made sure all bank and agency staff had a full induction and understood the service before starting their shift.
In 2 services we inspected, staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
We were assured that trust safeguarding systems and processes were well managed and risks were mitigated. Staff in the trust were up to date with safeguarding training and knew how to recognise abuse and when to report it.
Across services, medicines management was managed well. Physical healthcare was managed effectively, and staff encouraged patients to live healthier lives.
We saw how staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. They had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
The trust had been impacted by a national cyber security issue which had affected access to the patient recording system. Action taken around the failure of the electronic care record system appeared both positive and proactive. Whilst difficult and time consuming, this was well managed. Staff had been unable to update patient records on this system for several months. Staff told us they could still access the system to view historical records but could not add updates. The trust had developed an interim patient recording system. Staff told us that they had access to both systems and that managers had kept them updated about the system issues.
Staff knew their responsibilities under the Mental Health Act and Mental Capacity Act. The trust had effective and embedded systems and processes for management of duties under the Mental Health Act.
The trust was well positioned within the ICB to influence the health and social care system. We have heard how key Board members advocate and action the agenda with stakeholders. Service managers engaged actively with other local health and social care providers to ensure that an integrated health and care system was commissioned and provided to meet the needs of the local population.
The trust had a clear focus and agenda within the research team with a positive plan to become self-sufficient. Quality improvement was actively encouraged from small local ideas to larger, more complex service improvements. The trust had an agenda to continue to develop their quality improvement approach.
The trust had led on new integrated models of care to improve how people accessed and came into contact with services across Herefordshire and Worcestershire.

How we carried out the inspection

During the inspection, our inspection teams carried out the following activities across 5 wards and 7 community-based mental health service and community health services and 2 health-based places of safety:

spoke with 65 patients and 18 family members or carers of patients
accompanied staff on 2 visits to patients in the community
viewed clinic rooms and reviewed 70 medication charts
spoke with 134 members of staff including senior leaders and managers, consultants, doctors, registered nurses, healthcare assistants, ward clerks, independent mental health advocates, occupational therapists, and physiotherapists
reviewed staff rosters
reviewed 63 sets of patient care records
undertook 14 incident reviews where we looked at information relating to incidents across all 5 wards we visited
observed shift handover meetings, a ward round, a reflective practice group and an occupational therapy patient session
reviewed CCTV footage and the digital images log
observed a Mental Capacity Act training session
attended 14 community visits to observe care and treatment
reviewed a range of policies, procedures and other documents related to the running of the service.

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

What people who use the service say

Community-based mental health services for adults of working age

We spoke with 15 patients who were pleased overall with the service they had received. Most patients told us that staff were kind, respectful and polite and had involved them in decisions about their care and treatment. Patients told us that staff gave them information and advice about medicines and healthy lifestyles. However, 5 patients told us that they had not been given a copy of their care plan.

We spoke with 3 carers, who told us that staff were responsive and caring. However, 2 carers told us they had not been as involved as they would have liked and that they had not been given information on how to access a carers assessment.

Mental health crisis services and health-based places of safety

We spoke with 11 patients and 3 carers. Feedback from patients, family and carers was positive. They described staff as kind and supportive. They told us staff communicated well with them and they received effective and high-quality care and treatment.

Staff made sure patients understood their care and treatment. Patients said staff supported them with their immediate mental health crisis and their recovery by referring them to longer term interventions such as psychological therapies.

Staff involved patients in decisions about the service. Patients could give feedback on the service and their treatment and staff supported them to do this.

Patients told us they felt listened to and staff responded quickly to their views and wishes. Patients were particularly positive about being able to talk directly to consultants and with staff day and night. Patients described the service as life changing.

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

We spoke with 15 patients and 4 carers. Overall, the 15 patients that we spoke with were positive about the service and complimentary of the staff. We received some comments relating to agency staff. Some patients felt that they did not engage with them as well as substantive staff and felt that they were more difficult to work with.

We spoke with 4 patients on Mortimer ward. They told us temporary staff were kind and caring and responsive to their needs. Patients were complementary about the meals provided and said there was lots of choice. Patients told us they heard the loud building work noises during the week due to ongoing building work but had become used to the level of noise and frequency.

One patient said regular staff were very good and they felt comfortable to speak with them. They enjoyed planned walks to Churchill gardens with the occupational therapist and said walking helped them to feel better. They liked regular sessions with the Art therapist on Fridays. Another patient said they enjoyed chatting with staff and felt safe to a certain degree. There were regular staff at night who met their needs.

However, patients did not always feel safe in relation to sexual safety. One patient told us male and female patients usually walked around single sex spaces. Another patient told us about a sexual safety incident they reported to the police as they did not feel staff had taken their concerns seriously.

Community health services for adults

We spoke with 27 patients and 8 carers in this service. Feedback from patients, family and carers was overwhelmingly positive. They described staff as caring, friendly, and supportive. They told us they felt involved in their care and reported good communication from staff. Patients all felt they received effective and high-quality care and treatment.

Patients told us they felt staff listened to them and were responsive to their views and wishes. They said staff gave them advice on their care and treatment in an accessible and clear manner. This included explaining the nature, purpose, and side effects of medicines.

Patients spoke positively about occupational therapy. They said they were provided with appropriate specialist equipment and that staff made sure they were explained how to use it.

Patients, carers and family said they observed good communication with teams within the wider trust and also external teams. For example, they felt that staff regularly liaised with GP practices and were jointly aware of care and treatment decisions.

Despite some staffing issues, particularly within the therapy teams, patients, carers and family mostly fed back that appointments were rarely cancelled or delayed.

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.

We plan our next inspections based on everything we know about services, including whether they appear to be getting better or worse. Each report explains the reason for the inspection.

This report describes our judgement of the quality of care provided by this trust. We based it on a combination of what we found when we inspected and other information available to us. It included information given to us from people who use the service, the public and other organisations.

This report is a summary of our inspection findings. Herefordshire and Worcestershire Health and Care NHS Trust is the main provider of community and specialist primary care services across Worcestershire, and mental health and learning disability services across Herefordshire and Worcestershire. Services are integrated with a variety of partners, and work closely with commissioners, voluntary organisations and communities to deliver services.

Hill Crest is a 25 bed mixed gender ward for adults of working age based in Redditch. The ward provides a 24 hour service offering intensive input for patients who experience acute mental health difficulties. It provides care to people age between 18 and 65 who may be detained under the Mental Health Act and have a home address within the catchment area.

We decided to carry out an unannounced inspection of Hill Crest in response to information of concern we had received about it.

How we carried out the inspection

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

To fully understand the experience of people who use services, we always ask the following 5 questions of every service and provider:

Is it safe?
Is it effective?
Is it caring?
Is it responsive to people’s needs?
Is it well led?

Before the inspection visit, we reviewed information that we held about this service.

During the inspection visit, the inspection team:

Carried out structured observations of how staff were caring for patients.
Attended multidisciplinary meetings on the wards.
Spoke with the ward manager.
Spoke with staff members including registered nurses and health care assistants.
Spoke with patients.
Looked at the quality of the environment on the ward.
Reviewed patients’ care and treatment records.
Reviewed documents related to the running of the service.

Overall summary:

We re-rated this core service following this inspection. The overall rating went down and was limited to inadequate for the safe and well led key questions, due to breaches of regulations.

Due to the serious nature of the concerns we had after the inspection, we served a draft Warning Notice on the trust, requiring them to make significant improvements. This was because we were concerned about the trust not ensuring care and treatment was provided in a safe way for service users, that the premises were not clean, properly maintained or suitable for the purposes for which they were being used and that the trust did not ensure systems and processes were established or operated effectively to assess, monitor and improve the quality and safety of the services. The trust responded to the findings from the Warning Notice and implemented an action plan to address the concerns we raised.

We rated this service as inadequate because:

The trust did not effectively ensure the ward was cleaned and well maintained. During the inspection visit we found areas of the ward that were visibly dirty, including the main food preparation area.
The trust did not ensure that risk assessments were created and reviewed in a timely way. This included one set of patient notes which had no admission risk assessments or care plans completed, no record of multi-disciplinary team discussions and, specific risks identified in the historic patient record, which had not considered potential risks to other patients on the ward or of self-harm.
The trust did not ensure substantive staffing levels were adequate to manage the risk on the ward. The ward was carrying high levels of qualified nurse and health care assistant vacancies which had resulted in the constant and extended use of bank and agency staff on the ward.
The trust did not ensure that the environment was well-maintained and fit for purpose. We found ward areas in a state of disrepair including exposed electrical wire hanging from light fittings and repairs from the removal of ligature points partially completed with exposed metal cap off and fittings not plastered over.
The trust did not assess, monitor and improve the quality and safety of the services they provided. We found that incident forms were not fully completed or reviewed, and risks were not fully considered. This included incidents of sexual safety being rated as ‘low harm’, a lack of external oversight and review and follow up actions that were not always appropriate in keeping patients safe.
We were made aware of a serious incident which involved a patient attempting to throw boiling water and sugar at a member of staff. Two boilers that the ward used remained accessible to patients for 3 days after the incident until the fuse was removed. On the day of our inspection 2 boilers were still in use and producing boiling water indicating that lessons had not been learnt and no actions taken to mitigate any future risk.
We found equipment without in date check stickers attached including fire extinguishers. We also found fire exits blocked by equipment during our inspection visit. Due to safety concerns we addressed the issue with fire extinguishers whilst on site and they were removed the same day.

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

There were sufficient trained, skilled and experienced staff to meet patient needs. Staff had a wide range of clinical and professional skills and worked together well for the benefit of patients and were sufficiently resourced and skilled to be able to respond to changing circumstances in a patient’s well-being.
The service had a good safety record, with few incidents. Good clear care records were maintained, supporting staff to be informed and inform relevant agencies about patient need and vulnerabilities.
The service worked effectively with other teams and agencies and were able to support and signpost patients and carers to relevant outside support.
Staff morale was good and staff were very positive about colleagues, team support, and managers, and resilient enough to work effectively in the faces of challenges presented by a recently reconfigured service.

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

The service had enough staff to care for children, young people and families and keep them safe. Staff had training in key skills, understood how to protect children, young people and families from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to children and young people, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided good care, treatment, advice and support. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children, young people and families, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
Staff treated children, young people and families with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children, young people, families and carers.
The service planned care to meet the needs of local people, took account of children and young people’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of children, young people and families receiving care. Staff were clear about their roles and accountabilities. The service engaged well with children, young people, their families and the community to plan and manage services and all staff were committed to improving services continually.

However:

It was not clear if there were cleaning records to document when cleaning had occurred at all locations. Cleaning records we observed were not always up-to-date and did not always demonstrate that all clinical areas were cleaned regularly.
Not all equipment was serviced and calibrated in line with trust policy.
Safeguarding adults level 3 training module compliance rates were low. Some staff that were required to complete the module had not completed it.
Safeguarding supervision timeframes were not consistent across the workforce and timeframes stated in the policy were not in line with NHS England National Health Visiting Service Specification 2014/2015.

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

Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff managed infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

Primrose ward did not have a dedicated area for preparing medication including controlled drugs. Staff completed this task in an area open to patients and visitors. This meant staff could be easily distracted from completing this which could lead to errors.
The visitors viewing area in the mortuary was not fit for purpose. It was not designed to make visitors as comfortable as possible at a very difficult and distressing time for them. Staff did what they could to mitigate this but were not able to change the way the room was set out or the equipment used
The lack of an end of life care strategy for the trust meant that there was an overall lack of audits and evaluation for end of life care. This affected the governance of the service at a more senior level. However, the trust participated in the national audit of at the end of life, which is a NHS benchmarking audit, and Primrose hospice used a metrics tool to measure quality.
Staffing levels on Primrose Ward meant that at times staff did not feel able to take breaks as they needed to focus on patient care and keep them safe.

Our rating of this service improved. We rated it as outstanding 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 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.
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 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.
Staff treated patients with compassion and kindness and respected their privacy and dignity. They were passionate about working with the patient group and supported them to manage their care and treatment in ways in which they would understand. Staff were highly motivated to develop and adapt treatments that met patients individual needs. Staff had excellent knowledge of their patients, which meant they understood their individual needs. They actively involved patients and families in their care decisions from the start of their treatment.
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 longer than expected targets to start treatment. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
The service was extremely well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly and effectively.
Staff were innovative and were proactive. There were several examples of innovations taking place across the service with a view to enhancing the experience of care patient’s received.

This service had not previously been inspected or rated. We rated it as good because:

The service had comprehensive systems to help them manage risk to patients and staff. There were processes for the reporting and shared learning when significant events occurred within the service. Incidents were reported, acted on and learning was shared across the service.
Staff were qualified and competent to carry out their roles. They were encouraged to complete mandatory training, and this was actively monitored. There were clear lines and support for staff to be further developed into extended duty roles by completing postgraduate courses.
Staff followed infection control procedures which mostly reflected published guidance.
Staff provided treatment, advice and care in line with nationally recognised guidance. There was an effective skill mix at the service to assist with the ever-increasing complexity of patient.
Staff worked together as a team and with other healthcare professionals in the best interest of patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental health issues and those who lacked the capacity to make decisions about their care.
The service had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
Staff treated patients with compassion. We observed staff treating patients with dignity and respect. We observed clinicians working collaboratively to ensure one patients specific needs were met.
The service took into account patients’ individual needs. Clinics had been adapted to ensure they were accessible for all patients. Staff visited a local day centre where they provided a contact session once month to offer basic oral health screening including soft tissue examination to “hard to reach patients” such as those experiencing homelessness.
The dental health educator actively provided preventative advice, support and training within the local community to support vulnerable groups in various settings. They had delivered several Dental Health Education sessions at a local school under special measures, attended several school readiness events to support parents and families with children who were about to start school and had worked collaboratively with the learning disabilities team and hospital wards to train staff to complete oral health care assessments and to assist people to carry out basic daily oral hygiene procedures.
The service dealt with complaints positively and efficiently.
The service asked patients for feedback about the services they provided. Results of patient feedback were analysed and displayed throughout the clinics for patients to read.

However:

The clinical waste bin at the Dental Anxiety Management Service in Malvern was not locked and was accessible to the public. This was locked during the inspection.
Weekly protein residue tests were not completed on instruments when using the ultrasonic baths at any of the dental services we inspected.
There was no receptionist at the Dental Anxiety Management Service in Malvern and therefore this role was covered by the dental nurses when they were available. This meant that patients were not always greeted at the reception desk if the nurses were in surgery. But this was a small service and a sign and bell was in place to attract the attention of staff.
Paediatric patient wait times from being assigned to the community dental service to receiving treatment under general anaesthesia averaged 25 weeks. A working group had been developed to improve efficiency and reduce the wait times. Although the overall wait was beyond the control of the trust.

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

The service did not have enough staff, who knew the patients to keep them safe from avoidable harm. Staff did not always assess and manage risks to patients and themselves well and did not always keep detailed records of patients’ care and treatment.
Staff did not consistently assess the mental health needs of all patients. Care plans were not always present nor were they always personalised, holistic and recovery-oriented. Assessment and monitoring of patients’ physical health was inconsistent.
Staff did not consistently involve patients in care planning and risk assessment or actively sought their feedback on the quality of care provided.
Patients had to wait longer than they should be expected to because of a shortage of care coordinators and psychologists, which in turn increased the waiting time to see a psychiatrist.
Not all staff in the south Community Assessment and Recovery Service (CARS) felt respected, supported and valued and they reported a culture of bullying and harassment. Not all staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

However:

All clinical premises where patients received care were safe, clean, well equipped, well furnished, well maintained and fit for purpose. The service managed patient safety incidents well.
Staff provided a range of treatment and care for patients based on national guidance and best practice. Staff from different disciplines worked together as a team to benefit patients.
Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
Patients were encouraged to develop and maintain relationships with people that mattered to 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. 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.
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 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.
The service was easy to access and staff and managers managed waiting lists and caseloads well. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly and those who did not require urgent care did not wait too long to receive help.
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 stayed the same. We rated it as good because:

We rated safe, effective, caring, responsive and well-led as good. We took into account the current ratings of the services not inspected this time.

We found that mental health and community health services overall provided by the trust were good, with safe, effective, caring and responsive as good, and the trust was well led. Although senior leaders knew these services well, we were not assured they were receiving all the necessary detail from operational managers about the services provided.

The trust had made the necessary improvements we asked it to make at the previous inspection in 2018. This included the way it reviewed and learnt from deaths, staff had better access to training and supervision, and there was better understanding and adherence to the Mental Capacity Act.

Following a review of services in 2017 provided to children and adolescents mental health services, the service had made significant improvement and we rated them as outstanding overall, with caring and well-led rated as outstanding, and safe, effective and responsive as good.

Eleven out of the 14 core services provided by the Trust were rated as good overall and three further core services were rated as outstanding overall.

Staff across the majority of services treated patients and carers with kindness and respect. Staff regularly told us they were proud to work for the trust. We rated three out of the core services the trust provided as outstanding in caring.

The trust had an experienced leadership team with the skills, abilities, and commitment to provide high-quality services. The trust had set a clear vision and values that were at the heart of the work within the organisation and this was shared by the vast majority of staff we spoke with.

The trust strategy was linked to the vision and values and also aligned with the sustainability and transformation plan for Herefordshire and Worcestershire. The trust had good relationships with external partners such as commissioners and were keen to develop these further.

There were structures in place to oversee risk. Managers had processes in place to review incidents and investigate properly. Patients and staff knew how to complain and the trust shared any learning from incidents and complaints.

Staff and patient groups knew who many of the senior leaders were. They were visible in trust clinical services and staff regularly commented that they understood services well, including risk.

The trust was committed to innovation and quality improvement to improve patient care. This has led to a number of improvements in digital technology to improve staff working in a more agile way and younger people having good access to timely support with their mental health. We found that quality improvement was not carried out by staff generally undertaking front line work with patients however the trust had started to engage with staff to develop quality improvement champions.

The trust were working to improve equality and diversity across the trust and staff groups including disability, LGBT+ and black, Asian and minority ethnic were promoted. The trust did have further work to improve staff survey results from staff from a black and minority ethnic background when supporting career development and though the grievance process.

However;

Patients of working age with mental health problems in the South of Worcestershire were not kept safe as there were not enough staff to see and monitor them regularly. Many patients were left without a care co-ordinator after staff left or were on long term leave. These patients were kept on a holding list that wasn’t adequately monitored. Risk assessments, and care and crisis plans in the South community assessment and recovery service were poor. Staff did not always assess and meet the physical health needs of patients. Not all patients had their rights under the Mental Healh Act updated and staff did not always record capacity to consent to treatment in care records. The trust was slow to address the concerns raised by staff in this service that resulted in staff leaving, taking stress related sick leave and/or whistleblowing about bullying and harassment from managers. Fridge temperature checks in clinic rooms were not always completed. Although senior leaders in the trust had good oversight of their services, we were not assured they were receiving all the necessary detail from operational managers about the service provided.

Staff in the end of life services did not always safely administer medication as the building did not allow them to. We found there was no end of life strategy in place to support service delivery. The viewing area in the mortuary did not provide dignity and privacy

We found concerns in dental services related to infection control practice.

Staff regularly reported there was unreliability of IT systems in some of the services across the trust. They tended to be in old buildings, but the trust was aware and addressing those concerns.

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 stayed the same. We rated it as good because:

We rated safe, effective, caring, responsive and well-led as good. Our rating for the trust took into account the previous ratings of services not inspected this time.
The trust operated collaboratively as a board, that meant executives and non-executive directors shared responsibility and liability for decision-making.
There was a holistic understanding of performance, which sufficiently covered and integrated people’s views with information on quality, operations and finances.
The trust board were very visible across all services of the trust. We were told of many examples of how the board visited and supported clinical services.
The trust understood the challenges to quality and sustainability, and identified the actions required to address them. This was aligned to the wider health and social care economy of Worcestershire. There was good leadership at trust board and sustainability and transformation partnership level.
The trust had refreshed their vision and values for the trust. The strategy and priorities of the trust was aligned to the vision and values, and reflected their part in local sustainability and transformation plans. Staff had an understanding of the vision and values in relation to local services.
Overall, the trust was a good place to work in. Staff often told us it was the best organisation they had worked in. The trust was recognised as a disability confident employer and had been named in the top 100 employers of apprentices.
Governance systems from ward to board provided good performance management information to make decisions.
The trust communicated well with patients, carers, staff and stakeholders. The majority of groups felt included in decisions about service re-design and development. The youth board was a good example of patient involvement and demonstrated that the trust listened to their views and acted on their suggestions.
There were robust 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 digital exemplar programme.
Recruitment of staff was a challenge to the trust but they were proactive in attempts to employ people across many of their services.
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.

However:

In a partnership arrangement with another trust outside of Worcestershire, governance arrangements were complex. However, the trust had learnt lessons and had served notice of the partnership.
The policy and procedures for learning from deaths should be reviewed and updated to reflect the gaps we identified.
Ward managers in one trust core service could not always identify how many staff had received training, supervision or appraisal.
We identified good medicines management across most of the trust however, we saw errors in administration of medication on the acute mental health treatment ward.
Although we saw good adherence to, and understanding of the Mental Capacity Act across the trust, there was evidence that decision specific mental capacity assessments were not always fulfilled when staff completed DNACPR forms in community health inpatient services.

We rated safe, effective, caring, responsive and well led as good.
The service, and the staff working for it, exuded a positive atmosphere. The service had undergone a major re-organisation in 2017 and staff and managers acknowledged this had been an enormous challenge. Even though some staff still expressed reservations about the effectiveness of the change, all staff we spoke with were positive about working for the service.
Patients and carers were positive about the service, particularly praising the sensitive, helpful, patient-focused approach of staff. The service engaged with patients and carers, communicating openly, giving information and ensuring they were able to give feedback and were listened to.
There were sufficient numbers of staff to support patients safely. Staff had manageable caseloads and were able to respond promptly to any changing needs of patients. Care and treatment records were kept up to date and informed and reflected good practice.
The service worked effectively with other agencies and supported patients in engaging with the wider community, and in increasing their own well-being by supporting healthy living choices and initiatives
The service learnt from incidents and complaints and used these as part of making improvements in safety and effectiveness.
There was a wide range of health professionals to meet needs, with a wide range of experience and skills. The service had addressed a shortage of psychiatrists and psychologists by recent recruitment.
Multi-disciplinary team meetings worked effectively with all health professionals working together in the best interests of individual patients. Professionals from other agencies were also effectively involved.
The service monitored the physical health of patients, paying particular attention to any effects from medicines used to treat their mental health.
Management offered good support to staff at all levels. New staff were properly inducted and staff received appropriate supervision and appraisals. Managers supported staff through the re-organisation of the service and offered support to staff who whose performance was affected by the challenges of adapting to the changes
The service had a clear operational policy, so all that staff were clear on their role, and the aims of the service. All staff comments and work reflected the fact that the service was patient focused and recovery focused.

However:

There was still a waiting list for psychology assessments, for both screening and full assessments in some areas. This had been reduced and the service was confident that the appointment of new permanent psychologists would help reduce this further.

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

We rated safe, caring, responsive and well-led as good and effective as requires improvement.
Staff identified and appropriately managed environmental risks. The wards had access to emergency and medical equipment that was regularly checked and well maintained. The level of cleanliness in all three wards was of exceptionally high standard.
The wards had enough staff that were experienced and qualified, and had the right skills and knowledge to provide safe patient care. Staff reported incidents appropriately and shared lessons learnt from the investigations. The wards had regular and effective multidisciplinary team meetings and worked well with other external organisations.
All patients had up-to-date, comprehensive risk, physical health and mental health assessments that informed risk management and care plans. Staff regularly reviewed and updated care plans that were personalised, holistic and recovery orientated.
Staff followed good practice in medicines management and monitored and reviewed the effectiveness of the medicines prescribed in line with the national guidance. Patients had good access to physical healthcare, including access to specialists, and their nutritional and hydration needs were met.
Staff treated patients with kindness, dignity and respect. Staff understood the needs of individual patients and involved them and their relatives in their care and treatment. Staff enabled patients and families to give feedback about the service.
The service had plans to escalate discharges and avoid unnecessary delays. Patients had access to information about their care and treatment and could be provided in an accessible format or different languages. Staff knew how to protect patients who raised concerns from discrimination and harassment.
The service had robust governance processes to manage quality and safety. The managers had the skills, knowledge and experience to perform their roles and supported and valued staff to contribute to the strategy of the trust.

However:

In our last inspection in January 2015, we asked the trust that this service should ensure that managers give regular formal supervision to staff. When we inspected this time we found staff were still not receiving regular supervision.
Athelon ward was an old design building with a mixture of single beds and small bed-bays which meant that privacy and dignity for patients in the bed-bays could be compromised.
Staff did not give patients copies of their care plans and not all patients could make a call in private.

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

We rated safe, effective, caring, responsive and well-led as good.
The service kept people safe from avoidable harm by ensuring sufficient staff with the right training, supervision, knowledge and skills. Risk assessments were thorough and staff planned patient care around their needs. Staff had good awareness of safeguarding issues, incidents were reported, and lessons learnt cascaded to staff.
Staff used best practice and national guidance to complete comprehensive assessments of their patients, and communicated their needs within the multidisciplinary team, the wider trust and with their external partners to ensure patients received effective and consistent care and treatment.
Patients told us staff treated them respectfully and they were involved in their own care. They felt they were listened to and both patients and carers were provided with relevant information and support to manage their condition.
The teams responded to patients quickly and managed their caseload effectively to ensure they could provide care when the patient required it. Teams were meeting their targets and dealt with complaints effectively.
There were good governance arrangements in place and experienced managers and staff monitored the quality of the service they provided through the use of audits, patient feedback, incidents and complaints and key performance indicators. Staff were positive about the trust and had developed innovative ideas with their teams.

However:

The trust lone working policy was inconsistently applied across the home treatment teams, which meant staff could be at risk if colleagues did not know of their whereabouts.
Staff in the home treatment teams did not monitor the temperature of the rooms where medicines were stored. This meant that staff could not be sure that medicines had remained within optimum temperature ranges and their efficacy had not been compromised. However the trust rectified this immediately when we informed them.
Patient involvement in care planning was variable across the home treatment teams, and not all patients had received a copy of their care plan, however the service had recently implemented a ‘getting well’ plan to improve this.

We rated effective, caring, responsive and well led as good and safe as requires improvement.
Risks had been identified and were mitigated through the purchase of specialist equipment and working practices. Ward areas and bedrooms were clean and well presented.
There was plenty of staff for patients to have one to one time with their named nurses. Staff were qualified and experienced to undertake their roles. Records were complete, contained all the information required to deliver care and were stored securely.
Care was provided in line with national guidance including that set out by the National Institute of Health and Care Excellence. Patients had access to a range of treatment options and nationally recognised tools were used to monitor their effectiveness.
Staff received an adequate induction and mandatory training annually.
We observed staff offering support and care to the patients on the wards. Patients stated that they felt well cared for and that they would recommend the service. Staff understood the needs of the individual patients and treated them with respect. Carers and family members were encouraged to engage in the recovery process.
Patients we spoke to stated that they knew how to use the complaints process and that they would feel comfortable to do so if required. Advocacy services were in place to support patients who felt they needed to raise concerns or make formal complaints.
Information gathered as a result of investigations into complaints or incidents had been fed back to staff and there was evidence that this information had informed change.

However:

Staff did not always adhere to health and safety protocols. We saw that a number of fire doors had been propped open on Holt Ward.
There were practices in place around the administration of medication on Hillcrest that could have caused errors.
Patients on Holt Ward did not have access to their own bedrooms and toilets were locked off. This required that patients found a member of staff to unlock the door before they could access them. Some observation practice could have compromised patient dignity.

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

We rated caring, responsive and well-led as outstanding, and safe and effective as good.
Since the last inspection, the wards had acted on our feedback and there had been significant improvement in the quality of patient care. The wards had comprehensive ligature risk assessments and action plans in place. The self-administration of medicines policy was being followed. The wards completed clinical audits and regularly monitored the quality and effectiveness of the wards.
All staff had received training on the Mental Health Act and the Code of Practice and systems were in place to monitor and check all MHA documentation adhered to the requirements of the MHA. All staff had received training in the effective use of the Mental Capacity Act and Deprivation of Liberty Safeguards.
Safety was managed well on the wards; systems in place to monitor safe and the quality of the wards. The wards met safe staffing levels to keep patients safe. All patients had comprehensive risk assessments and management plans in place, which were reviewed and updated regularly. Staff raised safeguarding concerns and reported incidents. The fire alarm system at Keith Winter House was audible throughout the building.

All patients had care plans, which were recovery focussed, personalised, holistic and updated regularly. Rating scales and outcome tools were used to measure and monitor a patient’s progress in treatment. Staff had the skills and competencies to deliver effective care and received regular supervision and annual appraisals.
Staff treated patients with dignity and respect, were kind and compassionate and support the patient to understand and manage their care and treatment. Staff had built a very good rapport with patients, supported the patients to achieve their goals and ensured all their needs were met.
Patients were encouraged and supported to develop skills to prepare them to live independently in the community. Each patient had discharge plans in place that involved other agencies and providers, who engaged with the patients to achieve the plan. Patients engaged with a range of activities on the wards and in the community to build on the skills needed to live independently and had access to volunteering schemes, education and employment.
Managers demonstrated strong leadership of the wards. The staff respected the managers, felt supported and were given the opportunities for career and professional development. The wards developed a culture of openness and staff were encouraged to raise concerns, and were fully involved in developing and delivering improvements to practice.

Our rating of this service stayed the same. We rated it as good because:
We rated well-led as outstanding, safe, caring and responsive as good, and effective as requires improvement.
The service kept people safe by ensuring sufficient staff with the right training, supervision, knowledge and skills were in place. Risk assessments to patients were thorough and staff planned care accordingly. Staff followed infection control procedures and wards were clean. Medicines management was effective. Incidents were investigated and managers ensured that staff learning was in place.
Staff used best practice and national guidance to complete comprehensive assessments of their patients. Staff were suitably skilled and worked well within multidisciplinary teams. Patients physical health and hydration needs were appropriately met. Measures were in place to effectively monitor treatment outcomes.
Patients’ told us staff treated them respectfully and they were involved in their own care. Staff provided emotional support to patients.
The trust planned and provided services in a way that met the needs of local people and were delivered where possible in a way to ensure flexibility, choice and continuity of care. The service took account of patients’ individual needs. Waiting times for treatment and arrangements to admit, treat and discharge patients were in line with good practice. The service treated concerns and complaints seriously and lessons learnt were shared with all staff.
Quality improvement initiatives were evident across this core service. This has led to improvements in the quality of care and the leadership managers offered to therapy staff. Staff reflected the vision and values of the trust, and there was a positive culture of support and involvement for patients, carers and staff. The trust had effective systems for identifying risks and planned to eliminate or reduce them. The trust was committed to improving services by learning from when things go well and when they do go wrong, promoting training, research and innovation.

However:

We could not find evidence that decision specific mental capacity assessments were always fulfilled when staff completed do not attempt cardio-pulmonary resuscitation (DNACPR) forms.

Our rating of this service stayed the same. We rated it as good because:
We rated safe, effective, caring, responsive and well led as good.
Patients were protected from avoidable harm and abuse, systems were in place to investigate incidents and concerns and staff received suitable training in safety systems. Risk assessments were completed and care plans implemented to keep patients safe and promote wellbeing.
Care and treatment were planned and delivered in line with evidence based guidance and standards, and systems were in place to ensure trust policies reflected the latest guidance.
Patients were happy with the care they received and were very complimentary about the staff who cared for them. We observed care being delivered in a kind and caring way, by staff who demonstrated compassion and experience.
We observed robust multidisciplinary working to provide co-ordinated patient care.
Most patients were seen for an initial assessment in a timely manner once they had been referred.
The needs of patients were taken into account when planning and delivering services. Staff were flexible to meet the needs of patients.
Patients were given information about how to make a complaint or raise a concern. There were systems in place to evaluate and investigate complaints.
Staff were aware of the organisation’s values and strategy.
There were robust governance and risk management systems in place.
Staff were innovative and worked with external organisations to examine where local improvements could be made.
Despite the work pressures staff were compassionate, sensitive and kind to people who use the service.
Senior managers provided good leadership and were visible and accessible to both people who use the service and staff.

However:

The service had challenges in recruiting sufficient specialist staff which meant that the service, in particular specialist community nursing, was understaffed at times which had an impact on caseloads. However, we saw no evidence that patient care was compromised.

Staff could not hear emergency alarms, which delayed their response. Medicines were not always stored within optimal temperature ranges in the clinic room.
Caseloads for care coordinators had increased and delays in discharging people who did not require their service prevented staff from providing a fully effective early intervention service.
Information technology problems prevented staff from completing their mandatory training, therefore, training compliance was lower than the expected national targets.
Risk assessments had not always been updated to reflect the patient’s risks. Patients reported they had not been routinely offered a copy of their care plan.
Staff within the early intervention team reported they did not receive information following incidents or other changes in Forward Thinking Birmingham. They did not feel integrated within the HUB. Staff worked effectively and enjoyed working within the early intervention team although morale was low.

However,

Staff received regular supervision and an annual appraisal identified staff learning needs.
People who use the service reported polite, courteous and knowledgeable staff, who provided a good standard of care to enable them to recover from their illness.
Staff were responsive to patients when in a crisis, and were meeting national referral and treatment time targets.

Team meetings and management supervision did not always take place; this could affect the level of support and information that staff received. The ward manager did not keep a record of staff compliance with clinical supervision and staff attendance did not appear to be consistent from the information we were given; it was unclear that staff were receiving enough support in their clinical practice.
The quality of care plans varied and not all were sufficiently detailed or up-to-date. Four of the five patients we spoke with did not have a copy of their care plan.At a ward handover meeting, we observed that staff did not share important information about a patient’s risk. This could have affected risk levels on the ward.
There was no structured activity programme on the ward and patients told us there was not enough to do. The ward manager said that there was a programme of structured activity being planned.
Patients’ possessions were not always locked away. Staff told us lockers where they kept patients’ valuables did not always lock effectively and we saw an open locker with a patient's property in.
We saw that record keeping was not always effective; seven of 16 observation charts that we looked at contained omissions where staff had not signed to say that they had completed patient observations. Staff recorded fridge temperatures where medication was stored, but had not identified that low temperatures recorded might affect the way medication worked.

However:

Staff managed the risk to patients on the ward effectively. They carried out detailed risk assessments and risk management plans for patients. Staff completed environmental risk assessments and the ward was fitted with anti-ligature furniture and fittings. A ligature risk is anything that patients could use to attach a cord, rope or other material with the aim of strangling or hanging. Staff reported incidents and there was learning from these.

Patients were involved in their care and decisions about their treatment through regular ward round review appointments and multidisciplinary team meetings. Patients told us that there were always staff on the ward to support them and that staff were responsive to their needs. Patients could feed back about their experience of the ward and ask questions at weekly community meetings.

Patients said that staff were kind and respectful. Staff demonstrated that they understood patients’ needs and rights. Staff ensured that they informed patients of their rights regularly during their stay. Patients had access to an independent mental health act advocate (IMHA) who visited the ward each week.

The ward had a range of rooms that were used for treatment and care. There were separate male and female ward areas; this met the Department of Health directions on mixed sex accommodation. Patients could personalise their rooms and could see their visitors in a private room.

Staff knew the most senior managers in the organisation and all staff said they had supportive managers. Staff completed mandatory training and other training that was specific to their role. Staff told us that they enjoyed their job and said that they worked in a supportive team.

Staff effectively managed risk; environmental risk assessments were carried out and staff worked to reduce environmental risks identified. Staff used recognised risk assessment tools and all were up to date. Staff developed individual risk management plans for patients. Staff regularly reported incidents and there was evidence that changes had been made in response to learning from incidents.
Staff were visibly caring and empathic towards patients and carers. This was demonstrated in care plans, care records and in the interactions between staff and patients’ we observed. The peer support worker held a weekly community meeting, working closely with patients and could support them when communicating to staff their needs and wishes.

Patient’s care plans were up to date, personalised and holistic. Patients were involved in treatment decisions at multidisciplinary meetings. The effectiveness of treatment and care was clearly monitored using audit processes and outcome tools, and in multidisciplinary meetings.

There was effective multidisciplinary team working where the team members communicated with each other and made shared decisions. Discharge was carefully planned with community teams and there was a robust system for monitoring activity and progress in relation to discharge.
There were established governance systems; Staff described good working relationships with their managers and staff were supportive of each other. Staff said that managers listened to them and they felt valued.

However

Staff did not monitor and record the clinic room temperature, therefore they could not be assured medicines were kept within agreed temperature ranges to protect their efficacy. However, following the inspection, the ward had put processes in place to ensure staff were monitoring and recording the clinic room temperatures.

Two patients told us that they did not have a copy of their care plan. We could not be certain that care plans were being given to patients, as this was not consistently recorded in the care records that we reviewed.
Staff did not consistently record the reason when patients did not receive prescribed medication in the medicine chart.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We rated Worcestershire Health and Care Trust to be performing at a level that led to a judgement of good.

We found that the trust had reviewed and acted on feedback from the CQC comprehensive inspection of January 2015. This meant that four core services that were rated as requires improvement in January 2015 were now providing good care and treatment to patients and young people.

The trust had commenced and embedded a number of initiatives county wide to support direct care delivery.

The trust had reviewed the re-design of acute wards and community buildings, and future provision of mental health services, with patient groups, trust staff and commissioners.

We saw the trust involved patients and stakeholders to improve services; an example was young people had re-designed a community service for children and young people in Worcester. Patients on wards could see the difference they made with a 'you said, we did' board.

The recovery star was embedded in acute wards. It is an outcome tool that measures change and supports patient recovery.

A new electronic patient records system had been introduced meaning information was held securely. A single point of access across Worcestershire had been developed meaning patients were triaged and assessed more quickly. Staffing levels had increased in acute wards and across community services.

The living experience of patients admitted to wards had improved, for example, trust staff knew how to change the temperature of the wards and there was sufficient seating in the Harvington ward dining room.

We saw a peer support system was introduced to support patients in wards. Peer supporters have lived experience of mental health. We found peer support workers running therapy groups and they formed part of a patients recovery.

The trust engaged young people through a youth trust board meaning that stigma about mental health would be reduced. A website had been developed to promote wellbeing and support for young people.

We did find however, that some buildings presented a risk to patients who may wish to harm themselves.

During this focussed inspection, we found that patients, relatives, staff and senior managers engaged openly to the inspection team.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

We gave community-based mental health services for adults of working age an overall rating of good because they had made improvements since the last comprehensive inspection in January 2015. Some of these improvements include:

the trust extended the single point of access (SPA) system across Worcestershire. This meant that GPs could refer directly to a single team and ensured consistency. The SPA team risk assess and prioritise appointments for patients. Urgent cases would be dealt with by the crisis teams and non urgent referrals would be referred to community mental health teams. Overall, the management of referrals had improved in Worcestershire, leading to a consistent approach across community teams
patients had access to, and were referred to specialised mental health services when clinically appropriate, for example, eating disorder services
the trust had introduced protocols to clarify roles and responsibilities for duty workers. This made it clear to staff who undertook this role and it is now embedded in community teams. The duty worker is a point of contact and support for patients and external agencies who ring community teams. The role also helps cover for staff who may be absent through sickness, training or leave
staff had developed a good understanding of lone working in trust buildings and working in the community. The trust had increased the number of staff who had accessed de-escalation and conflict resolution training.

the trust had introduced a single operating procedure (SOP) to support and monitor waiting times for referral. Waiting times are reviewed at trust and local level
the trust implemented an electronic care records system county wide. This had improved access for staff to patient information, including out of hours. Storage of information had improved with most notes transferred to the electronic system
the Redditch community team integrated medical notes into multidisciplinary care records for patients. this improved access to patient information to staff
the trust responded to low staffing levels in the Droitwich team by reviewing service provision county wide. This led to the Droitwich team merging with another community service to support staffing levels
the trust had implemented training for staff in the Mental Capacity Act (MCA). This has improved staff knowledge of the MCA and its application in practice
although we did not inspect the well-led domain, we saw evidence of greater engagement with staff about service re-design

Although there was improved monitoring of waiting times to see a psychologist, 41% of patients had to wait over 18 weeks.

We gave specialist community mental health services for children and young people an overall rating of good because they had made improvements since the last comprehensive inspection in January 2015. Some of these improvements include:

Staff vacancy rates had reduced and recruitment to posts continued. Administration roles had been filled to support CAMHS delivery of care. Staff shortages had been taken off the trust risk register.
The service had moved towards an electronic patient records system and records were kept securely.
A single point of access to CAMHS was embedded across the county, meaning that referrals were triaged quickly and young people in crisis were responded to appropriately.
Waiting times for assessment were within trust and commissioner targets. CAMHS monitored waiting times through a spread sheet and multi-disciplinary team meetings.
Risk assessments were of good quality and person centred, although three new referrals to the Wyre Forest team in November 2015 did not have a risk assessment. Staff were using accredited risk assessment tools.
Young people were allocated a care coordinator who supported clinical and risk issues prior to accessing psychological therapies.
Staff were flexible to meet the needs of young people, for example, they had a choice of appointment times and staff held therapeutic groups in different trust buildings to suit local need.
Access to, and recording of supervision was more consistent across services.
Staff received training on the Mental Health Act and the Code of Practice. Staff demonstrated an understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff had a good understanding of how to identify and report safeguarding concerns.
Staff had access to, and most staff attended, de-escalation, safety & disengagement, and conflict resolution training.
Staff continued to use the nationally recognised 'Choice and Partnership Approach'.
The trust had engaged young people to join a youth trust board and they were engaged with service re-design.
Services at Worcester south had undergone redesign and redecoration.
Regular team meetings were held and staff supported each other.
Staff told us, and we saw from the staff survey that, they were motivated at work and had good support from immediate managers.
Although young people who required specialist inpatient treatment were admitted outside of Worcestershire, the trust liaised with NHS England to facilitate appropriate admission and provided contact to support discharge.

Waiting times to access specialist psychological treatment was reduced, however, some young people were waiting over 25 weeks.

The trust had made significant improvements to its long stay/rehabilitation mental health wards for working age adults since the last comprehensive inspection in January 2015. We have now rated the core service overall as Good because:

A ‘Self-Administration of Medicines Policy’ which was followed and medicines were stored safely with the wellbeing of patients in mind.
Clinical audits were carried out regularly to monitor the effectiveness of the service.
All staff received supervision and it was taking place regularly.
Staff received training on the Mental Health Act and the Code of Practice.
Staff demonstrated an understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff had a good understanding of how to identify and report safeguarding concerns.
There was a clear system for recording, reporting, and learning lessons from incidents.
The unit had a well-equipped physical examination room and access to an emergency bag.
There was good collaborative working within the multi-disciplinary teams and good partnership working with external agencies to support the recovery of patients.
Staff and patients worked well together and treated each other with dignity and respect.
Patients were involved in their care planning and reviews and met regularly to discuss any issues.
Patients had daily meetings and used these meetings to discuss collaboratively any concerns. They were respectful and were supported by staff to make changes to improve any issues raised.
Patients had a varied programme of activities and we saw a culture of recovery at the unit.
Staff clearly worked well together to achieve their objectives and saw how these fit within the organisation’s vision, values, and objectives.
The Trust had governance processes in place to manage quality of service.
There was good leadership and managers were accessible to support staff. Staff felt supported by their managers.

However:

there were still concerns relating to the overall safety of patients and staff. For example, ligature risks and the alarm system required improvement to ensure the safety and wellbeing of all.

We gave an overall rating for acute wards for working age adults and the psychiatric intensive care unit (PICU) of Good because:

The trust had systems in place to manage the risks identified within the ward through the use of risk assessments and increased levels of observations. They had put up additional mirrors in the ward to improve visibility around the ward. The trust had reviewed long term solutions to the ward redesign to reduce the risk to patients. This review formed part of service redesign across Worcestershire that included plans for public consultation, but was on-going. However, potential ligature points, identified in January 2014, remained in place with no timetable of works available to support plans made to remove them.
Staffing levels had increased and the managers had direct access to NHS professionals when they needed additional staff.
The ward used the recovery star model and actively engaged patients in the discussion about their care needs.
The trust was introducing a single electronic patients record to replace the multiple paper records previously used.
There was positive and caring interaction with patients.
Patients' dining experience was positive. Patients' had access to a dining room where there was sufficient seating for all to eat.
There was clear leadership and staff involvement in the ward developments.

We did not rate this core service. The inspection team did not collect sufficient information to ensure, with a high degree of confidence, the rating applied is robust. However, we have outlined our findings below.

The staff we interviewed were able to demonstrate that they had an understanding of the Mental Capacity Act 2005 (MCA) and also the Deprivation of Liberty Safeguards (DoLS).

We saw that there were policies and procedures in relation to the MCA and DoLS to ensure that people who could not make decisions for themselves were protected.

We saw from the records we looked at that where people lacked the capacity to make decisions a best interest meetings were held.

Care records covered a range of needs and had been regularly reviewed to ensure staff had up to date information. There were also detailed assessments about the person's health that included specific care plans.

When required other health professionals had been involved to help ensure that people’s complex needs could be met.

All of the people we spoke with were positive about the care provided and how the services were managed.

Systems were in place to monitor and review people’s experiences and complaints which ensured improvements were made where necessary.

Staff were trained and experienced and showed high levels of motivation and commitment.

We saw that staff were warm, friendly and supportive in the way that they spoke with and cared for the people using the service.

All staff were able to tell us about people’s needs, and were positive about how the service was managed.

The carers and relatives we spoke with were very happy with the service provided and all felt that people were provided with safe and effective care.

When people’s needs changed all of the teams inspected were able to demonstrate that they responded and where necessary worked with other professionals to ensure that needs were met.

We rated the community mental health services for children and adolescents as ‘requires improvement’ because:

Staffing vacancies and sickness meant there were long waiting times to receive treatment.
Staff vacancies had affected the completion of administration tasks.
Risks were found regarding safety and security in some teams.
Records were not always held securely and were not easily accessible to frontline staff.
Record of mental capacity and consent to treatment assessments were not always clearly documented.
Young people accessing crisis services did not always have an assessment carried out by appropriately skilled staff.
If required, young people could not be admitted to an in-patient facility locally and were placed out of area.
Carers and young people were not always aware of the trusts complaints procedure.
Recording staff supervision and arrangements were not consistent across teams.
Staff did not feel that the trust were responding effectively to their concerns regarding low staffing levels.
Several staff expressed low morale and lack of communication from senior managers regarding the actions by the trust to address identified concerns.
Feedback from people using the service, staff and others was not being used to continuously improve and ensure the sustainability of the service.

Staff received training in safeguarding and demonstrated that they knew how to do this effectively in practice.

Staff were using the nationally recognised ‘Choice and Partnership Approach’ (CAPA).

Staff provided a range of therapeutic interventions in line with National Institute of Clinical Excellence (NICE) guidelines.

Regular team meetings took place and the staff told us that they felt supported by colleagues.

We found evidence of the trust providing a service to meet young people’s diverse needs, including an identified learning disability pathway.

Young people and carers reported they were treated with dignity and respect and gave positive feedback about staff.

Staff showed an understanding of the individual needs of young people.

The LD CAMHS service review showed parents and carers were highly satisfied with the service they received.

We rated community services for people with mental health problems as good because:

Teams were committed and effective in treating older people with mental health problems. Where integration of mental and physical health aspects of the service had been combined, services were particularly effective, as people’s holistic needs could be more readily seen and managed. People using the service showed high levels of satisfaction. Staff showed high levels of motivation, and were well supported and trained.

The mental health team at Warndon clinic in Worcester, by contrast to other teams, showed low morale, telling us they were working in an unsuitable environment without sufficient support. Warndon clinic itself appeared overcrowded and cramped.

Where medications were stored, proper records were not always kept of this medication to ensure it was safely kept and used.

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

Wards provided safe environments where patients felt secure.

Patients’ needs were assessed and monitored individually. There was good physical health care, good therapeutic treatment and activities. Wards were dementia friendly where required and risks were well-managed.

Staff showed a good awareness of patients’ rights.

Patients were full of praise for staff and the care and support they offered. Patients and their carers were kept informed and involved in treatment and care. Patients indicated they were in a safe, secure environment that was helping them.

The service enabled people to be treated and discharged within clear timescales and responded to patient need promptly and effectively. Patients benefited from the care, support and treatment provided during their stay.

Staff interacted with patients in a responsive and respectful manner at all times and showed a good understanding of individual needs. Staff showed high levels of motivation and morale. They all felt part of a positive team and felt well supported and trained.

There was pressure on staffing that further recruitment was expected to relieve.

Patient privacy in New Haven could be improved and the service could do more to ensure patients have more of a say in music being played on the wards.

Having a patient with dementia on a functional ward sometimes required additional staffing and could divert staff away from their roles of supporting patients with functional illnesses. On one ward patients had limited privacy when making calls via the ward phone. These were relatively minor issues in wards where a positive and treatment-focused atmosphere prevailed and was much praised by users of the service.

We gave an overall rating for acute wards for adults of working age and the psychiatric intensive care unit (PICU) of requires improvement because:

Assessments had been completed to identify ligature risks on the wards but action had not been taken to reduce all of these in some cases.
Individual care plans for managing the ligature risks did not identify the individual behaviours of the patient that would alert staff to an increased risk of the patient self-harming.
There were blind spots on all wards that meant that staff could not ensure patients’ safety.
In Harvington ward learning from some incidents had not reduced the risks to patient safety.
The current care plan and risk assessment formats did not show staff how to support patients. This had been identified and a new format was to be used.
The number of systems used to record patient’s information meant that some information was not shared and this posed a risk to patient safety.
Staff did not demonstrate a good understanding of the Mental Health Act (MHA) and Mental Capacity Act (MCA). Patient’s capacity to consent to their treatment had not been assessed in some cases.
Staffing levels on Harvington ward did not ensure patients safety.
A blanket restriction had been applied on Harvington ward. This meant that none of the patients could use the canteen area off the ward to eat their meals because of the risk of some patients absconding.
The environment on Harvington ward did not promote patients recovery and ensure they were comfortable during their stay.
There were no clear lines of responsibility across the service to ensure that improvements were made and risks to patients’ safety were reduced.

The overall rating for wards for people with learning disabilities was that these services were good.

The staff we interviewed were able to demonstrate to us that they had an understanding of the Mental Capacity Act 2005 (MCA) and also the Deprivation of Liberty Safeguards (DoLS).

We saw that there were policies and procedures in relation to the MCA and DoLS to ensure that people who could not make decisions for themselves were protected. We saw from the records we looked at that where people lacked the capacity to make decisions about something, that best interest meetings were held.

Care records covered a range of needs and had been regularly reviewed to ensure staff had up to date information. There were also detailed assessments about the person's health that included specific care plans.

We observed that staff were able to support people with dignity and respect in a safe and caring manner. We found that people who needed help to manage their anxiety were effectively supported by staff. We saw that when required other health professionals had been involved to help develop strategies for doing this.

All of the people we spoke with were positive about the care provided and how the services were managed. Systems were in place to monitor and review people’s experiences and complaints which ensured improvements were made where necessary.

Staff were trained and experienced and showed high levels of motivation and commitment. We saw that staff were warm, friendly and supportive in the way that they spoke with and cared for the people using the service.

All staff were able to tell us about people’s needs, and were positive about how the service was managed.

The carers and relatives we spoke with were very happy with the service provided and all felt that people were provided with safe and effective care.

When people’s needs changed all of the locations inspected were able to demonstrate that they responded and where necessary work with other professionals to ensure that needs were met.

People were assessed in a timely manner and risks were reviewed regularly and updated. Information was shared between agencies such as the police, acute trust and local authority. Crisis and care plans were in place and personalised for all patients.

Incidents, complaints and safeguarding were low; However staff were trained and could describe what they would do when these instances arose. Learning from these was discussed in team and business meetings and supervision.

The Health Based Place of Safety (HBPoS) had been effective in reducing the need for police cells to be used. All teams met their targets for managing referrals and assessments.

Care was being delivered by highly skilled staff .Care and treatment was reported by patients and carers unanimously positive. Patients had been involved in some staff interviews and patient groups were being involved in the development of the local crisis concordat.

The local crisis concordat plan was in the early stages of development and information had not been cascaded to the operational teams.

Staff understood their roles and responsibilities and how this linked to the team and trust vision. They said it was a good place to work in, where they were valued and listened to.

We gave an overall rating for the community mental health teams for working age adults and early intervention services of Requires Improvement because:

The staffing establishment in the Droitwich team was on the service’s risk register due to the number of agency staff used. Several agency staff were due to leave and we were informed that the funding to recruit agency staff would cease April 2015. It was not clear what the plans for staffing following this period would be.
The referral system variable across the teams. There was a large amount of inconsistency across teams in respect of waiting times for urgent and non-urgent referrals. There was a risk that people requiring timely access to the team may be missed because the referral system was not always working effectively.
There was no clearly defined role of the ‘duty worker’.
There was a risk that information about people’s care across the community teams could be missed. There were different electronic and paper based systems in use and staff within teams were not always working to the most up to date system. This had been identified as a trust and local level risk.
In the Redditch team the medical staff and medical notes were not based within the same building.
Training in the Mental Capacity Act 2005 (MCA) was not mandatory in the trust. Across the teams an overview of the completion of this training was not monitored for all staff.
There were no agreed waiting times for urgent and non-urgent referrals across teams. This did not promote equity for people waiting to be allocated a named worker and commence the treatment process.
There were long waiting lists and times for psychological interventions.

However, we found that:

Staff were compassionate and supportive and recognised people’s individual needs.

There was strong leadership at a local level across all of the teams that addressed issues of culture within teams where this was identified.

We gave long stay/rehabilitation mental health wards for working age adults an overall rating for of Requires Improvement because:

The ligature risk assessments carried out had identified high and medium level risks on both units. There was no detailed risk management or action plan to address these risks adequately.
A ‘Self-Administration of Medicines Policy’ was not followed. There were no risk assessments to identify the risks posed to individuals and other patients living at the unit to ensure that medicines were stored safely.
Clinical audits were not carried out regularly to monitor the effectiveness of the service.
Staff supervision had not been taking place regularly and consistently.
Staff had not received training on the Mental Health Act and the Code of Practice. There was some inconsistent practice on patients’ capacity to consent to their treatment. There were no audits carried out by the clinical team or MHA administration team to ensure that all MHA forms were correct.
Staff had not received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff did not demonstrate good understanding of MCA and DoLS. Manager and staff were not aware of checks taking place to monitor the MCA.

Staff had a good understanding of how to identify and report safeguarding concerns. There was an effective way of recording incidents, near misses and never events from which staff had learnt. The units had well-equipped physical examination rooms with emergency equipment.

Comprehensive assessments were complete on admission with regular physical health checks and monitoring in place. There were referrals made for specialist intervention when needed. Good collaborative working within the multi-disciplinary teams a number of different professionals internally and externally attended review meetings.

Staff were polite, friendly and willing to help. They treated patients with respect and dignity. Staff demonstrated a good understanding of the individual needs and were able to explain how they were supporting patients with a wide range of needs. Patients were involved in their care planning and reviews and were free to air their views.

All admissions to these units were planned well ahead and patients experienced a stable stay on the same unit during their admission period. Patients had a varied programme of activities which was linked to an individual programme. Staff respected patients’ diversity and human rights. Patients were able to raise complaints when they wanted to and they were listened to and given feedback.

Staff demonstrated a good understanding of their team objectives and how theses fit within the organisation’s vision, values and objectives. The trust had governance processes in place to manage quality and safety. There was good leadership at unit level and managers were accessible to support staff. Staff were kept up to date about developments in the trust and felt supported by their managers.

Overall rating for this core service Good

This was a good service offering compassionate palliative care and treatment for patients in community hospitals, other community care settings or in their own homes.

The staff were passionate about their work and highly motivated to provide the best possible care to meet the needs and preferences of patients and their families.

We spoke with patients and their families and one relative said, ‘‘the care is excellent, I can’t fault it’

The service had improved documentation and processes for advance care planning.

They were working within a number of national programmes such as NHS Improving Quality approach set out in the document ‘One Chance to Get it Right’. The service was also improving the quality of service by implementing high impact actions for improving choices: ‘Where to die when the time comes’.

Staff were highly competent and were able to report incidents and learn from incidents and complaints to improve safety for patients. Staffing levels were good for and consultant advice and support was available out of hours. The community nursing teams offered a service seven days a week. The leadership of the service was committed and innovative and they collaborated well with local independent providers of hospice services.

We gave an overall rating for the community health services for older adults and the minor injury units of Worcestershire Health and Care NHS trust as good because:

The trust provides adult community services to support people in staying healthy, to help them manage their long term conditions, to avoid hospital admission and following discharge from hospital to support them at home.
Services are provided in clinics, outpatient departments and in people’s homes.
The minor injury’s unit (MIU) provides a service for a wide range of minor injuries that do not require attendance at the local acute NHS trust.
The MIU provided treatment or advice to people who presented at this service.
The services had identified the risks at local level. They had action plans and outcomes in place to manage this.
The trust management had ensured that learning from serious incidents was shared with front-line staff. This meant that these staff members had the benefit of the results of investigations into incidents.
Some staff demonstrated a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). When staff assessed the mental capacity of a patient to consent to care and the sharing of information, the assessment was thorough.
Despite the work pressures staff were compassionate, sensitive and kind to people who use the service.
Some service managers provided good leadership and were visible and accessible to both people who use the service and staff.

We judged community health inpatient services to be safe, effective, caring, responsive and well led.

We found that some aspects of medicine management needed improvement. It was unclear if unwanted controlled drugs were destroyed or returned to the patient on discharge from Pershore Community Hospital.

There was evidence to show that staff recorded and reported incidents and completed risk assessment and risk management plans. Patient risks were assessed and plans were developed to reduce them.

All five community hospitals were clean and well maintained and staff recognised and practiced infection control procedures.

Patients received care that followed the latest published guidance and best practice with outcomes that were generally in line with national averages.

Care was delivered by nurses, support staff and allied health professionals and was overseen by hospital consultants and general practitioners (GPs).

Patients and their relatives were all positive about the care they or their relative received. We saw staff were respectful towards patients and made sure that they were treated with dignity.

Complaints were managed appropriately and lessons learned. The hospitals had local clinical governance meetings and were represented on the trust’s monthly quality meetings.

Staff told us they felt supported to give high quality care by their managers and the trust board. We found that staff were motivated and enjoyed working at the community hospitals.

During the inspection, we spoke with 58 staff, including nurses, occupational therapists, physiotherapists, hotel services staff, admin and clerical support staff, GPs and visiting clinical staff. We also spoke with 32 patients and 8 relatives. We observed interactions between patients and staff and we reviewed 18 sets of care records.

Our judgements were made across all of the hospitals visited, where differences occurred at particular hospitals we have highlighted them in the report.

Overall this core service was rated as good. We found community health services for children, young people and their families were safe, effective, caring, responsive and well led. .

Worcestershire Health and Care NHS Trust delivers community based services to children, young people and their families throughout Worcestershire.

Our key findings were as follows:

Staff were caring, compassionate and respectful.
Arrangements had been put in place to minimise risks to children and young people receiving care.
There were some concerns about the consultation of staff and parents regarding the transfer of children and young people from North Worcestershire to Birmingham Community Healthcare (BCHC).
The services within the children and young people, families (C&YPF) service delivery unit had undergone a period of change which had introduced new ways of working. There were / had been shortfalls in staffing levels. Staffing shortfalls had been identified on the risk register which meant that these risks had been escalated to and monitored at trust board level.
Systems were in place to monitor quality and people’s outcomes.
We observed potential gaps in service provision for example access problems for some parents to child development centres.
Individual management of the different divisions providing services to children, young people and families were generally well led.

We saw some good practice including:

A ‘Young Person’s Board’ had been created and the speech and language therapy services had been redesigned to include a talking walk-in facility.
One staff member from the speech and language therapy team was awarded the ‘Shine a Light’ directorate award for communication services for children.
There were many examples of good collaborative working within the multi-disciplinary team.

However, there were also some areas where the trust needs to make improvements:

There were gaps in record keeping within some of the records we reviewed.
There were shortfalls in the use of evidence based pathways for health visiting service and ‘The Healthy Child Programme (2009)’ had not been delivered in the reception classes of Wyre Forest Special School.
We found that staff clinical supervision and management supervision had not been embedded across the service delivery unit.
We visited the minor injury units (MIUs) throughout Worcestershire and found that there was inconsistent evidence demonstrating that consent had been obtained and recorded.
We saw that improvements were required in relation to the facilities for children and young people within the minor injury units we visited.
We were informed that leadership within the health visiting team was not dynamic or motivational and that there had been a slow response to staff queries. This was especially evident with regard to the proposed changes in health visiting provision.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

During the whole of this inspection, we found that patients, their relatives, staff and senior managers where all willing to engage in an open and frank way.

We rated this provider requires improvement and although we found areas of good practice across most care areas there are some patient safety issues that need to be addressed. At times, the trust did not provide effective care that met the standards of recognised good practice and some teams were not always responsive to the needs of patients and their carers.

Across the mental health services some good standards of patient safety were achieved however, we found unmanaged ligature risks on Harvington ward and in the rehabilitation units. While the service had carried out a ligature risk assessment, they had in some cases, taken no action to address the identified risks. On Keith Winter and Cromwell House there was some confusion about the expectation to address this and the inspection team found an inconsistency of approach to managing ligature risk in this area.

Some teams there had taken an innovative approach to tackling the problems of unsuitable ward environment by using mirrors to enable staff to have improved sight on some ward this was not in place. On Harvington ward there was restricted sight throughout the area to ensure effective patient safety.

In most areas medicines were managed safely however, there were some instances where we found unsafe practice. We found minor concerns across a range of settings including non-adherence to the policy for self-administration and inappropriate or inadequate storage and record keeping.

There was an inconsistent approach to training, ensuring staff understood their responsibilities regarding the Mental Capacity Act (MCA), and in some areas the Mental Health Act (MHA) which was relevant to their role. However, there was high adherence to mandatory training. We found that staff carried out treatment and care in line with recognised evidence based practice.

The care provided by this trust, with the exception of one ward, was of a good standard and we found that the services were well led in most core services with strong senior leadership driving through change and developments. The teams worked to uphold the values and vision of the trust and provide good care for patients.

Across the community health services, we found overall, the services were delivered to a good standard, with the exception of two patient safety concerns at each of the two injuries units where we found an unsuitable mattress, equipment not maintained and inappropriate storage of hazardous products.

We found in the community inpatients wards that arrangements to minimise risks to patients were in place with measures to prevent falls and pressure ulcers. We saw evidence of good practice including the use of safety dashboards; clean clinical areas and good infection prevention and control practice.

In the end of life services, we found a new audit process, delivered by peers, was producing a new energy and motivation about fundamental aspects of nursing care such as infection control, record keeping, risk assessment and medicines management.

We had positive feedback from patient, carers and we saw that interventions were delivered in a sensitive and dignified way. There were some exceptions to this and in Harvington ward, we found that staff were not able to respond to all patients in a timely manner.

Complaints were handled effectively the feedback and learning was shared at local level and via the executive team if necessary. Trust premises were, in the main, accessible for patients. Interpreters were available and staff knew how to access the service if needed. The inspection team noted that information was available to patients and carers in a range of languages.

Across all core services, staff knew how to support people who wanted to make a complaint.

However, access to treatment in some core services was not responsive to patient need. In the CAMHS and community mental health service, we found long wait times to access some treatments.

The trust displayed the vision, values and strategy across the wards and patients areas. The staff told us the senior leadership had high visability and welcomed the patient safety walkbouts carried out by the chair and the chief executive.

Staff morale, in the main, was good and staff told us that they felt it was a good place to work. Mostly, we saw services being well led at local level and staff teams felt supported in their role.

The trust were keen to learn from incidents and feedback and showed a commitment to improving practice by participating in a range of external peer review and service accreditation schemes. The trust were keen to improve their record on staff appraisal and discussed this with the inspection team as a priority action for the coming year.

Overall, the inspection team found the trust had some issues that needed to be addressed but that the leadership and senior team were best placed to make the changes required.

Mental Health Act responsibilities

The governance structure for the monitoring of the Mental Health Act (MHA) was undertaken by the MHA Monitoring Group which was chaired by a non-executive director and attended by further non-executive directors and associate managers. MHA governance is separate from the wider governance arrangements, resulting in a lack of a consistent approach to auditing and monitoring of the MHA. The MHA monitoring group does not have any representation from the quality team but does report into this group. However, this does not allow the rich data available from the independent group of managers to be fed into the quality governance or patient experience. There is an annual MHA report to Trust Board

The MHA administration team clearly demonstrated their roles, systems and processes. The team members could provide a clear outline of their arrangements for assuring the powers and duties of the MHA are completed. The MHA administration team were very clearly focused on documentation for admission, renewal and hearings. Other statutory papers were seen to be outside their scope, including checks on consent to treatment forms and section 17 (leave of absence) forms. These documents therefore did not receive any review or scrutiny beyond the clinical team.

Issues identified on the wards are detailed later in the report.

Mental Capacity Act and Deprivation of Liberty Safeguards

Knowledge and practice of the Mental Capacity Act (MCA) was variable. Some staff where well informed about their legal responsibilities under the MCA which was reflected in practice.

In older people’s services, staff were aware that capacity could fluctuate and that lack of capacity in one area did not mean capacity was restricted in other areas. Patients were involved in their care and we observed on a number of occasions that staff obtained verbal consent before carrying out any interventions.

People were supported to make decisions where appropriate and when they lacked capacity, decisions were made in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. There were records of best interests meetings in some patient files. In some teams, MCA assessments were discussed in multi-disciplinary meetings.

However, some consent to treatment forms were signed by carers when it had been assessed that a patient lacked capacity to consent. This would only be lawful if the carer had lasting power or attorney for personal welfare which was not evident in the notes.

Staff’s knowledge and understanding of the Mental Capacity Act was less evident in some of the inpatient services and rehabilitation team. In some teams staff felt they did not have any responsibility under the MCA and did not know how the legislation applied to their work with patients. It appeared that some staff had a limited understanding that capacity was linked to specific decisions and some records showed that where it was assessed that the patient lacked mental capacity this was for all decisions the patient would make.

The trust informed us that MCA training was covered in safeguarding training and not a mandatory requirement for staff. Records seen demonstrated that in some services training in the MCA and DoLS formed part of the locally agreed training programmes, but in other services it was not monitored. Some staff were not able to tell us who they would contact as the lead person on MCA within the trust

Issues identified on the wards are detailed in the core services report.

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

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