Oxford Health NHS Foundation Trust

Updated 13 December 2019

Not used

Updated 13 December 2019

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

• Since the last inspection in 2018 the trust has continued to make improvements despite facing some challenging funding issues. An independent report on the level of funding for mental health services in Oxfordshire (commissioned by Oxfordshire CCG, NHSE/I and OHFT) determined that there was a significant funding shortfall in mental health services. A further review carried out by Oxfordshire CCG highlighted a £12m shortfall in mental health funding but also a £10m shortfall in funding for community services. The shortage of funding has required an additional level of dedication and capability from the trust leaders and all the staff to maintain the capacity and quality of the services whilst managing scarce resources.
• During this inspection we inspected six core services and carried out a well led review.
• In rating the trust, we have taken into account the previous ratings of the ten mental health and community health core services not inspected this time. Following this inspection 14 core services were rated as good overall, one was rated requires improvement and one was rated outstanding.
• We found that the trust was led by a highly skilled and experienced senior team, including the chair and non executive directors. There was a strong patient focussed, learning culture within the trust and staff showed caring, compassionate attitudes, were passionate and proud to work for the trust and were involved in the development and improvements within the trust.
• The trust had made the majority of the improvements we said that it should make following our last inspection.
• Across the trust the majority of the environments were safe, clean, well equipped, well maintained and fit for purpose.
• In community services waiting lists were managed well, the number of patients on the caseload was not too high to prevent staff from giving each patient the time they needed and anyone needing to be seen urgently was seen in a timely manner.
• In the wards for people with a learning disability staff had received training in positive behaviour support, patients had individualised behaviour support plans and staff were supporting patients who had challenging behaviours appropriately.
• Generally, staff completed comprehensive risk assessments and managed risks well. Physical and mental health needs were assessed and monitored, and care plans were holistic and recovery orientated. Staff followed good practice with respect to safeguarding.
• Patient safety incidents were managed well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons with their teams and the wider organisation.
• Staff provided a range of care and treatment interventions suitable for the patient groups and these were consistent with national guidance on best practice.
• Staff across all the services we inspected were kind, compassionate, respectful and supportive respected the privacy and dignity of patients. Feedback from people using services and their relatives and carers was highly positive. People who used services were appropriately involved in making decisions about their care. Staff ensured that the emotional and spiritual needs of people who used services were addressed, along with their mental and physical healthcare needs.
• The majority of services had access to the full range of specialists required to meet the needs of patients under their care. There was enough staff with a range of skills needed to provide high quality care. 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. The teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
• Staff planned and managed discharge well. Inpatient services, including wards for people with a learning disability and forensic secure wards, liaised well with services that would provide aftercare and were assertive in managing the discharge care pathway. As a result, people who used services did not have excessive lengths of stay and discharge was rarely delayed for other than a clinical reason.
• The trust had strong governance systems supported by good quality performance information. This meant that at all levels of the organisation staff and members of the board had access to useful information that enabled them to gain assurance and make improvements where needed. This enabled the trust to achieve a balance between assurance and improvement work.
• The trust had positive and collaborative relationships with external partners and was actively engaged with the local health economy in shaping services to meet the needs of the local population.
• The trust continued to build on their innovation as a Global Digital Exemplar, sharing learning and supporting other trusts to make improvements in technology. There was good practice and innovation around IT that was patient focussed such as access to records and ‘I want great care’ and the Blue Ice app.
• The trust had a strong focus on research and had strategic research links both to the University of Oxford and Oxford Brookes University. The trust ran one of only two mental health biomedical research centres in England.

However:

• The seclusion rooms at both Evenlode ward (wards for people with learning disability and autism) and Watling ward (forensic inpatients) did not always offer privacy for patients. Staff on Evenlode were not secluding patients for the shortest possible amount of time. Records showed that patients who were settled were not removed from seclusion promptly so not protecting their human rights. Documentation was not always completed at the correct time.
• Patients on Evenlode did not have access to a speech and language therapist; there had been no provision for 18 months.
• In forensic services the quality of physical healthcare provided to patients was inconsistent between wards and the quality of pre-prepared meals on wards at the Oxford clinic was poor.
• In forensic services there was a lack of parity of access to entertainment between wards. Patients on male wards had access to satellite television and a range of activities, whereas patients on the two female wards had been made to choose between having satellite TV and some activities that incurred a cost (for example, baking).
• Ligature risk assessments were carried out but not always acted upon in Marlborough House inpatient ward.
• In specialist community mental health services for children and young people the increase in demand and capacity issues had created increased wait times for non-urgent referrals.
• Some staff said they found it hard to access supervision.
• The was a lack of robust board level oversight of the Mental Health Act.

Updated 15 January 2016

Overall rating for this core service Good O

Overall, we rated this core service as ‘‘good’’. We found that community services for adults at Oxford Health NHS Foundation Trust were, ‘’good’’ for effective, caring, responsive and well-led services but ‘’required improvement’’ to be safe.

Oxford Health NHS Foundation Trust is the main provider of community health services for adults in Oxfordshire. Services are provided to patients in their homes and at a number of clinics held at community hospitals, health and wellbeing centres and GP surgeries. Care and treatment are provided under the regulated activates: treatment of disease disorder or injury and diagnostic and screening procedures.

Our key findings were:

• There were periods of understaffing across a number of community services. This impacted on patients receiving timely access to safe care and treatment.
• Pressure ulcers were the most frequently reported serious incident. Investigations into these incidents highlighted understaffing as one of the causes. A plan was in progress to reduce avoidable pressure ulcers.
• Patient records did not all contain risk assessments, or these had not been reviewed in line with trust policy, to ensure clinical risks were appropriately managed.

• There were systems and processes in place to keep patients safe, such as infection control, medicines management and servicing of equipment provided to patients. Learning from risks, incidents, near misses was shared with staff.

• Safeguarding protocols were in place and staff were familiar with these.
• Community services for adults used guidance from the National Institute for Health and Care Excellence (NICE). Services monitored and reported on patient outcomes to ensure they were providing an effective service to patients.
• There was well established multidisciplinary team working across almost all the community services we visited. There was an effective system in place for referral, transfer and discharge of patients.
• Staff had completed statutory and mandatory training and described good access to professional development opportunities.
• Not all patients had a malnutrition risk assessment completed at their first visit, in accordance with the trust nutrition and hydration policy.
• Patients received compassionate care that respected their privacy and dignity. Patients told us they felt involved in decision making about their care. We found staff were caring and understanding. Without exception, patients we spoke with praised staff for their empathy, kindness and caring approach.
• Services were planned and delivered to meet the needs of the local population. Services were supportive, adapted to meet the needs of people in vulnerable circumstances and made arrangements to meet the diverse needs of local people, such as through access to translation services.
• Waiting times for most outpatient services were outside the trust target of first appointment within 12 weeks of referral. Actions plans were in place to respond to these issues. Delayed transfers of care were an ongoing concern for the trust. Work was taking place with multiple providers to continue to address this.
• Elements of the trust’s vision and strategic forward plan had been implemented in community services, through the implementation of integrated locality teams. Staff were adjusting to this new model of working, but could see the long-term benefits for patients.
• There were effective arrangements in place, to monitor quality and safety. Staff felt supported by their immediate managers. The culture within community services was caring and supportive. However, staff felt senior management did not always listen to or respond to concerns or suggestions for improvement to services.

Updated 15 January 2016

Overall rating for this core service Outstanding O

Overall community health services for children and young people were found to be outstanding. We found that services were safe, effective, caring, responsive and well-led.

Our key findings were:

• We judged the safety of community health services for children and young people as good.Staff knew how to report incidents using the on-line reporting system and were encouraged to report incidents. Most staff said they received feedback following incidents and learning was shared with them.
• Staff adhered to infection prevention and control procedures and staff had completed the appropriate training. However, no infection control audits had been undertaken in the children and young people’s services. Where equipment needed servicing a plan was in place to manage this.
• The majority of staff were up to date with mandatory training. However, there was a lack of safeguarding supervision recorded onto the learning and development portal by staff. The safeguarding children team record supervision and hold records of attendance locally. Staff we spoke with were knowledgeable about the trust safeguarding process. Staff highlighted the value of the trust safeguarding consultation line which provided easy access to immediate advice from a senior children safeguarding nurse.
• We observed the majority of records were complete and up to date. Although some staff had difficulty accessing electronic records. However, a new electronic record system to overcome access issues was due to be implemented in October 2015.
• We judged the effectiveness of the children and young people’s service as outstanding. Treatment by all staff was delivered in accordance with best practice and recognised national guidelines.
• Staff were encouraged to achieve high performance in the delivery of services. This was monitored through audits and measuring outcomes for children and young people.
• Staff skills and competence were assessed and staff were supported to obtain new skills and share best practice. Staff received clinical supervision and induction programmes were in place for all staff.
• Children, young people and their parents understood what was happening to them and were involved in decisions about treatment and care. We observed good multi-disciplinary and multi-agency working and young people were supported when moving between services.
• Staff understood consent issues such as Gillick competencies and we observed good communication between staff, young people and their parents around consent to specific procedures and sharing information.
• We have judged the care given to children, young people and their families as outstanding. Parents, carers, children and young people were treated with compassion and respect.
• Feedback from children, young people and parents was very positive and they were happy with the care provided by the staff. We observed numerous positive interactions between staff, children and families.
• Parents were empowered to be involved in the care of their children. All parents we spoke with felt they had enough information about their child’s condition and treatment plan. They praised the kind, professional and understanding nature of staff.
• We have judged the responsiveness of the children and young people’s service as good. Services were designed to meet the individual needs of children and young people and were delivered in flexible locations to suit parents and children. For example, the development of the sexual health service by school health nurses in secondary schools.
• We observed staff respecting and valuing the individual rights and diversity of the children, young people and families they cared for. Specialist services were in place for looked after children. Parents told us they were aware of how to raise concerns or make a complaint.
• We have judged the leadership of the children and young people’s service as good.
• Good local leadership was provided throughout the various teams and staff were very positive about the support they received from their team leads and managers.
• Clear management and governance structures were in place through meetings to monitor performance and service risks.
• All staff were positive about working for the trust and took pride in their work.
• The directorate was committed to engaging with young people to obtain feedback and encourage participation of young people in its services. A range of approaches were used to work with young people and parents/ carers and this included the ‘Article 12 group’ which had been operating for six years. It had 35 young people as members. They met regularly and had contributed to the development of the children and young person’s website.

Updated 30 August 2018

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

• The service did not always follow relevant national guidelines around storing medicines.

• While there was a system in place to assess and monitor patient risk there were instances where assessments and related care plans were not reviewed in a timely way.

• The sharing of information between staff and others was uncoordinated meaning people did not always have access to the information they required.  
• People were at risk of not receiving effective care or treatment due to lack of pain assessment and personalised care planning.
• Staff understanding of their roles and responsibilities under the Mental Capacity Act 2005 was variable. Staff did not always effectively support patients who lacked the capacity to make decisions about their care.
• The governance and culture did not always support the delivery of high-quality person-centred care. There was not a clear defined strategy for the service.

However:

• Staff were supported in their development.
• Staffing levels were generally at safe levels.
• Incidents were well managed including investigations and the sharing of learning.
• Information about people’s care and treatment was collected and used to improve the service.
• People were supported, treated with dignity and respect and involved in their care.
• People’s needs were met through the way the service was organised and delivered.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Updated 15 January 2016

Overall rating for this core service Good O

The end of life care service is delivered along with other general care services, in community hospitals and patients’ own homes.

Overall, we rated this core service as ‘‘good’’. We found community end of life care service at Oxford Health NHS Foundation Trust were, “good’’ for safe, caring, responsive and well-led services but “required improvement’’ to be effective. This was because improvements to awareness and education had not yet had an impact on patients’.

Our key findings were:

• Services for end of life care were safe and there was a good culture of reporting and learning from incidents.
• Staff did not have a consistent knowledge of the requirements of the duty of candour.
• There were systems in place for escalating concerns about potential safeguarding concerns.
• The community hospitals were clean and well maintained. Equipment was clean and fit for purpose.
• The trust used a single model of syringe driver for end of life care medicines and staff had received appropriate training on the use of these. The administration of medicines by syringe driver was monitored, but the same documentation to record this was not used across the areas we visited.
• Staff participation in mandatory training was below the trusts target.
• The trust had recently introduced a new end of life care plan to replace the Liverpool Care Pathway, that had stopped being used in England in 2013.
• There were sufficient staff to provide high quality care in community hospitals; however this was mainly due to a reduction in the numbers of available beds.
• Patients at end of life had risk assessments completed where indicated.
• The trust could not demonstrate that end of life care was delivered consistently against the ‘five priorities of the dying person’.
• There was a combination of paper and electronic records that made getting key information difficult for staff.
• Information about a patient’s preferred place of care was not always communicated. Outcome data about patient’s preferred place of care and actual place of death was not routinely collected.
• Decisions about resuscitation were not always discussed with the patient or relatives. Do not attempt cardio-pulmonary resuscitation forms were not always fully or correctly completed.
• We found there to be an inconsistent use of pain assessment tools with end of life care patients.
• Staff demonstrated a good understanding of the Mental Capacity Act.
• There was evidence of effective multidisciplinary working that put the patient at the centre of their care. This led to some good examples of joined up working that gave the patient a seamless journey.
• We saw some excellent examples of staff providing care that maintained respect and dignity for the individual. There was also good care for the relatives of dying patients, and sensitivity to their needs.
• Care was delivered with compassion, and staff prioritised the needs of patients at end of life.
• Patients and relatives were given the emotional support they required, and felt that they were involved in the planning of their care. Staff gave patients the time they needed so their visits did not seem rushed, even when the service was under pressure.
• The trust had identified that staff found it difficult to have conversations about their preferences for their care at end of life. Training to address this need had been organised.
• The trust were in the process of implementing the requirements of the ‘one chance to get it right’ document for the delivery of evidence based end of life care. They were meeting with their commissioners and other partners to plan end of life care services to meet the needs of local people.
• Community hospitals provided appropriate facilities for end of life care. There was provision for people with communication difficulties, this included an interpreter service.
• The environments in community hospitals were designed to be suitable for patients living with dementia. Vulnerable patients were identified and effective multidisciplinary working ensured their needs were met.
• Matrons who led end of life care in community services were highly accessible to community nurses, patients and GPs. They worked across boundaries to coordinate end of life care for patients.
• Although the trust did not have a strategy for end of life care, strategic work was being undertaken to improve services. Leaders of end of life services were aware of areas or risk and where they needed to improve services.
• We found evidence to demonstrate that end of life care was an improvement goal for the trust. There was a commitment among staff and local leaders to make end of life care better for patients.
• Staff were aware that they needed further education and training particularly around advance decisions and care planning. We found that staff were engaged in making improvements to both their own knowledge and the services they provided.
• The trust sought and acted on feedback received from patients and relatives.

Updated 13 December 2019

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

• Staff treated patients with compassion, kindness and respect. They understood patients’ specific needs and helped them make decisions about their care and treatment.
• Services were delivered to meet the needs of local people, and staff worked well with others in the wider health and care system to plan patients’ individual care.
• There was effective leadership and senior managers developed the service vision and strategy, with engagement with partners in health and social care. The governance arrangements supported improvements in service quality. Leaders and staff understood the key risks and risks were managed and escalated appropriately.
• The services were delivered based on national guidance and evidence-based practice. Staff carried out audits to ensure they followed best practice.
• Staff reported and learnt from incidents.
• Services were delivered in accessible premises and planned to provide convenient care, close to people’s homes. Equipment was safety checked and was in good condition. Medicines were well-organised, stored safely and at the right temperature, and staff protected people from infections by keeping the environment and equipment clean.

• Staff completed and updated risk assessments for each patient and kept clear records.

• The services sought patient feedback and had systems to manage and respond to complaints.
• Safeguarding training targets had been met. All staff had received an appraisal within the last year. The majority of staff had completed mandatory training required by the trust although a small number of staff had not completed training in key clinical skills.
• There was a positive and caring working culture. Staff respected the patients, their colleagues and managers. They responded kindly if patients were afraid or distressed. Staff understood the need for some patients to have privacy or a quiet space.
• Clinical leaders were respected by staff. They were knowledgeable about quality issues and priorities, understood what the challenges were and took action to address them.

However

• The service had a number of permanent staff vacancies. Leaders had identified this as a key risk and were continuing to recruit additional staff and offered in-house training to attract new staff from a range of clinical backgrounds.
• At Henley and Witney staff had difficulty observing patients due to the layout of the waiting areas. There was a risk that staff might not observe patients who deteriorated and needed prioritised care.

• Staff told us they found it difficult to access supervision.

Updated 13 December 2019

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the young people and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of young people on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
• Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. They actively involved young people and families and carers in care decisions.
• Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However;

• In Marlborough House the ligature risk assessment did not always include actions staff should take to ensure areas with ligature risks were safe. They were not updated to include work that had already been completed.
• In Marlborough House staff members did not always ensure that any changes to young people’s care plans were updated quickly to ensure staff members work consistently with the young people.
• In Marlborough House young people’s physical health assessments were kept in the clinical notes. They were not easily assessible to staff because they were not kept with the information in the young person’s care plan.

Updated 13 December 2019

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

• The service provided safe care. Clinical premises where young people were seen were safe and clean. The provider made improvement following the requirement from the last inspection in 2015 to address the number of young people on the caseload of the teams, and of individual members of staff. At this inspection, staff said their caseload was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that young people who required urgent care were seen promptly. Staff followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the young people. 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 young people. 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 young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. They actively involved young people and families and carers in care decisions.
• The service was easy to access. Staff assessed and treated young people who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
• The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

• Although the service made significant improvements following our last inspection in 2015 to address the variable quality of risk assessments. In the care records we reviewed we found there were still a small number of risk assessment that had not been regularly reviewed and staff were not always using any rating scale to ascertain the severity of these risk to young people.

• The increase in referrals and capacity issues had created increased wait times for non-urgent referrals. The trust had a single point of access in Oxfordshire and Buckinghamshire which screened and triaged all referrals so that each could be passed to the most appropriate service or team to provide care and treatment. All children and young people referred to be seen urgently were seen within one week. All others received care and treatment within the national target of 18 weeks. However, commissioners of the service had set a target of seeing 75% of referrals within 12 weeks, some teams, for example, South East Oxfordshire and North Oxfordshire and Melksham were not meeting this target. The trust was well aware of the issues, had contracted with a private provider to outsource the assessment of children and young people deemed to be at lower risk and had a waiting time mitigation plan in place and was actively managing the waiting list.

• Documentation of children and young people`s views in care plans were variable across the hubs and appeared dependent on the practitioner who wrote the care plan.

• Supervision were not always recorded in line with the trust`s policy.

Updated 30 August 2018

We rated the service as good overall because:

• The service maintained safe staffing levels across all the teams we inspected and both staff turnover and sickness were low.
• Caseloads were manageable and both patients and carers commented positively on the availability of staff when they needed them.
• Incidents were well reported and monitored and routinely discussed in multidisciplinary team meetings, with learning shared with the rest of the team.
• The trust embraced the Transforming Care 2015 agenda.
• Staff were highly skilled, qualified and experienced.
• Care plans were well recorded and were available in accessible formats for people with different communication needs.
• Patients and carers were actively involved in the care provided and praised the staff for their understanding and supportive approach.
• Staff worked hard to ensure that patients gained access to the right care at the right time, through effective management of external waiting lists and tracking cases through the service.
• Staff ensured accessibility for the service by travelling to patients’ homes and day services for appointments.
• Feedback from patients and carers had informed significant service developments.
• All staff and patients we spoke with described a positive experience of the transition of the service from the previous provider. Carers described the process as seamless and staff universally said they felt welcomed and supported and optimistic about the future of the service.
• The service promoted a culture in which people with a learning disability were respected and valued as individuals and in which learning disability was not treated as an illness. A clear vision for the future of the service was understood by staff and had been shared with patients and carers.

However:

• Whilst staff had a very good working knowledge of the Mental Capacity Act, teams were not recording capacity assessments consistently.
• Some patients experienced a lengthy wait for nursing assessments and speech and language therapy assessments despite caseloads being low.
• Outcome measures were not used to track patients’ progress.
• Whilst referrals and discharges from the main teams were well managed, pathways between professionals were not always clear and could involve long wait times.
• Governance systems to manage pathways and care coordination responsibilities were not always clear and in some cases resulted in duplication of work between the intensive support and community teams.

Updated 13 December 2019

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

• The service provided safe care. Clinical premises where patients were seen were safe and clean. 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 their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude people who would have benefitted from care.
• The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

• Staff had not consistently assessed and recorded capacity clearly for patients who might have impaired mental capacity.

Updated 30 August 2018

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

• The places of safety were well maintained, discreet, quiet and secure.
• The trust provided a safe and patient-focused place for assessment, by ensuring appropriate facilities, such as safe furniture that should not cause injury, courtesy packs for patients and televisions and game consoles.
• Patients were able to keep their mobile phones and electronic devices after an individual risk assessment was completed by staff.
• The monthly problems in practice meetings were well attended by the police and the trust. These meetings ensured there was an appropriate setting to discuss problems and to improve and maintain their relationship.
• The trust had a clear and comprehensive standard operational procedure, which had been reviewed in December 2017, and a new form in order to extend the period of detention in the place of safety following the change in the law.

However:

• There were concerns that the ambulance services were not more engaged in the problems in practice meetings. In recent months the attendance at meetings had improved.
• The Interagency Joint Working Protocol for the Management of Mental Health in the Thames Valley Area had not been updated with the recent change of the law.

Updated 13 December 2019

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well and managed medicines safely. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of patients with a learning disability (and/or autism) and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• Managers ensured that staff received training, regular supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward, who would have a role in providing aftercare.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed, other than for a clinical reason.
• The service worked to a recognised model of mental health rehabilitation. It was well-led and the governance processes ensured that ward procedures ran smoothly.

However:

• Staff did not follow good practice guidance when secluding patients. They did not complete a seclusion care plan at the correct time and seclusion records did not demonstrate that patients had been only been secluded for the shortest possible amount of time. The seclusion room did not always offer the patient privacy.
• There was no speech and language therapist for the ward and staff had not been able to access one for 18 months.
• The trust did not keep staff up to date with changes to the Mental Health Act and the Mental Capacity Act. Agency staff did not always follow care plans.
• Patients reported that staff disturbed them at night by not closing doors quietly.

Updated 13 December 2019

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed individualised, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. In general, ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
• 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 planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• The quality of physical healthcare provided to patients was inconsistent between wards. Staff teams from different wards had developed local processes which were largely dependent on nursing staff to deliver.
• The location of the seclusion room on Watling ward was adjacent to the central communal area of the ward so other patients could potentially see into the room and could hear when the occupant was distressed. The CCTV screen for the Kestrel ward seclusion room was located in a high position and so was visible to other patients using the intensive care area of the ward at that time.
• Patients were not happy with the Halal options on the menu of pre-prepared meals offered on some wards, such as Kennet.

Updated 24 August 2016

We rated long stay/rehabilitation mental health wards for working age adults as good because:

• Staff were well qualified and experienced. Mandatory training rates were high, appraisals were at 100% and staff supervision happened regularly.

• Safeguarding procedures and policies were thorough and all staff knew how and what to report.

• Mental capacity was discussed as appropriate and Mental Capacity Act processes were followed. Staff gave examples of when the Mental Capacity Act may be used.

• Team meetings happened regularly and had a variety of formats including business meetings, health and wellbeing meetings and reflective practice. Staff were well supported.

• The full range of mental health disciplines provided input into the ward. Multi disciplinary working was robust.

• There was a comprehensive and well structured activity programme suitable for a rehabilitation ward. The ward had a full range of activity rooms and accessible outside space available for use.

• Patients were treated with respect. Staff were interested and engaged with patients. There was a happy atmosphere on the ward.

• Patients were encouraged to participate in the running of the ward. Community and planning meetings happened daily and patients were involved in the development of the new activity programme.

• All blanket restrictions noted at the last inspection had been lifted. Any restrictions still in place were for health and safety reasons.

• The policy of using short term leave beds for inpatients from other wards had ceased. This was a trust directive.

• The ward offered an inreach service to patients on the waiting list to help them prepare for admission. An outreach service was also offered to those patients on long term leave and ready for discharge to ensure continuity of care.

• Staff morale was high. Staff reported good working relationships with each other and good management at ward level.

However:

• Staffing levels continued to be a challenge and all staff reported staff shortages. This had improved over recent months and procedures were in place to ensure safe staffing and improve recruitment and retention.

• There was no money management policy on the ward. This could patients at risk of money mismanagement and staff at risk of allegations.

• Care plans did not include the entirety of the work being done with patients. This work was happening but was not reflected in the care plans.

• Some gaps were noted in checking of emergency drugs, the cleaning rota and the safety testing sticker for electrical equipment. This was brought to the attention of management during the inspection who agreed to resolve this.

Updated 30 August 2018

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

• The wards, including the clinic rooms, were clean, had good furnishings and were well maintained. Staff ensured that equipment, including emergency equipment, was also well maintained, checked annually and was clearly monitored. Ward doctors prescribed medicine in a streamlined way and in line with the National Institute for Health and Care Excellence (NICE) guidance. The recording and maintaining of good medicines management was in place across all wards and there was good input from pharmacy colleagues.
• The management of risk both within the environment and to patients was well managed. Staff had completed a risk assessment for each patient at the point of initial assessment and managed patients’ physical and mental health risks in line with trust policy and NICE guidance. Staff were aware of risks, documented and communicated this well. Staff followed good policies and procedures for the use of observation and adjusted observation levels according to individual patient need.
• Care planning was inclusive and included input from a range of disciplines as well as the patient and their carers. Patient welcome packs included a ‘Knowing Me’ questionnaire that asked patients and carers questions around personal likes, dislikes and preferences.
• There was a good skill mix of staff on the ward and mental health nurses had access to a physical health course. All staff received level one dementia training and level two dementia training was being piloted. Ward based psychologists offered therapy in line with NICE guidance that included weekly cognitive stimulation groups, cognitive behavioural therapy and provided formulation training for staff. There was a good range of occupational therapy and access to a full range of rooms and outdoor space.
• There was a good multi-disciplinary approach to care treatment and discharge. There were regular ward rounds on each of the wards that included a wide range of disciplines and had discharge planning as a key focus. The wards contributed to daily inter-county bed management teleconferences with community mental health teams. There was a trust social care lead in place who assisted with planning and discharge.
• Staff demonstrated good awareness of safeguarding issues, how to report an incident and learning from these was shared. However, safeguarding incidents and referrals were not collated on the wards for the purpose of data collection or review.
• Training compliance with the Mental Capacity Act 2005 was at 100% and above the trust target. Staff demonstrated a good understanding of the Act, in particular the five statutory principles, Deprivation of Liberty Safeguards (DoLS) and trust policy around best interest meetings.
• Staff demonstrated respect, patience and compassion for patients and were very aware of any changes to a patient’s presentation. There was a clear emphasis on promoting patient choice and independence and staff sought patient and carer views to inform the care plans. Patients felt safe and well cared for on the wards. There was access to a lesbian, gay, bisexual, and transgender lead for the wards and patients received support to access tools that translated key care information into their first language.
• The wards varied in how dementia friendly they were. Sandford and Cherwell wards were decorated to assist patients with dementia, with the use of colour zoning and good signage that included pictures accompanied by large words. All wards had plans in place, at various stages, to create a sensory garden. Amber ward had minimal signage and colour zoning that would have assisted patients with dementia.
• Ward managers had access to a development programme designed to link leaders, improve communication skills and help them understand trust priorities. Organisational changes were communicated effectively and staff felt supported by their line managers and described feeling valued. They felt positive and proud about working for the provider and their team.
• To address the high number of staff vacancies, senior staff worked with local universities to engage with nursing students at an early stage. We saw examples of other staff, such as housekeepers, that had been encouraged to undertake training as healthcare assistants.
• At the time of our inspection, all three wards had received Accreditation for Inpatient Mental Health Services (AIMS) – OP (Wards for older people). The Royal College of Psychiatrists ‘Essential Standards’ were assessed across the wards and in February 2018 the results were found to be ‘good’ overall.

However:

• Staff vacancies were high overall. Shifts were usually covered by bank or agency staff who knew the wards. The ward managers could adjust staffing levels daily to respond to the wards’ changing needs.
• There were no nurse call buttons in the patient bedrooms on Amber ward except for the assisted bathrooms and two assisted bedrooms. The ward mitigated the risk and the trust planned to install an alarm system for patients on Amber ward in July 2018.
• Trust audits showed a high variance of compliance across the wards for timely assessments of malnutrition and incontinence and the inclusion of incontinence in care plans.
• Not all medicine charts contained patient photographs when the patient had consented. The lack of photographs on medicine charts was contrary to trust policy.
• Mandatory training for staff in this core service fell just below the trust’s target of 90% and this included staff training compliance in the Mental Health Act (1983). However, staff had a good understanding of the Mental Health Act (1983), the Code of Practice (2015) and the guiding principles.
• Compliance with appraisals was below the trust’s target rate of 90%. Staff told us they had had an annual appraisal.
• Despite patients presenting with this diagnosis, there was no specialist training in emotionally unstable personality disorder.
• Staff on Amber ward told us that morale was sometimes low and they attributed this to the ward staffing issues, particularly when they were required to work with agency staff that did not know the patients. Some staff on this ward also reported feeling isolated from the rest of the trust at times. However, the trust had appointed a modern matron to work across both Oxford and Buckinghamshire to ensure consistency and equity.

Updated 30 August 2018

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

• Staff effectively managed risks for patients of acute mental health wards and the psychiatric intensive care unit. We observed shift handover sessions and multidisciplinary patient review meetings where staff discussed risk levels in light of recent events. Staff had worked to improve the clarity of the care pathway for patients diagnosed with emotionally unstable personality disorder, following two serious incidents in 2017.

• Staff actively sought to use verbal de-escalation techniques to resolve, and where possible pre-empt, situations where patients were becoming agitated or aggressive. Staff only used physical restraint as a last resort, when verbal de-escalation was unsuccessful. Every ward had a member of staff nominated to lead on work to reduce the use of restrictive interventions.

• Staff completed comprehensive mental and physical health assessments of each patient at the point of admission. Each ward had good access to physical healthcare. The trust operated a smoke-free environment and staff supported patients with smoking cessation groups and nicotine replacement therapy.

• Vaughan Thomas ward was participating in a three-year research project to study the benefits of a specially designed unit to monitor (installed at the junction between wall and ceiling) patient movement and bodily processes whilst in their bedroom. The aim was to develop a system that allowed staff to remotely monitor patient night-time safety without having to disturb the patient whilst asleep.

• All wards in this core service had gained national accreditation for demonstrating that they met a certain standard of best practice in their area. The six acute wards had gained accreditation for inpatient mental health services – working age units (AIMS – WA). Ashurst ward had gained accreditation for inpatient mental health services – psychiatric intensive care units (AIMS – PICU).

• Vaughan Thomas ward had been shortlisted for a national award in the Student Nursing Times Awards for 2018. The ward was one of several nominated for student placement of the year, and was the only mental health ward on the shortlist. The winner was due to be revealed at an upcoming awards ceremony.

• Staff were passionate about their work and motivated to deliver high quality care to patients. Staff told us they felt supported by their ward manager, modern (ward) matron and senior matron and able to raise concerns. We received a great deal of feedback from staff who told us that team morale had significantly improved in the last 12-18 months.

• Patients had access to local advocacy services who visited each ward on a weekly basis and multifaith spiritual support was available to patients who desired it. The provider’s patient advice and liaison service (PALS) held a drop-in surgery on wards ward every week. Staff could access interpreters as needed and could provide information leaflets in over 60 languages, to cater for the needs of all patients and carers.

• Staff treated patients in a caring, respectful and responsive manner. Staff displayed a high level of understanding of the individual needs and abilities of patients. Patients and carers we spoke with told us they were happy with the care provided by staff.

• Staff actively involved patients and carers in aspects of care delivery. Staff sought the input of patients and carers when carrying out risk assessments and formulating care plans. Patients and carers were able to provide feedback on the service during regular meetings.

However:

• Staff vacancy levels within this core service were high. The number of qualified nursing vacancies amounted to 49% of the establishment total as of 30 November 2017. During the 12-month period November 2016 to October 2017, 19% of total hours were filled by bank staff and 25% were filled by agency staff. Staff we spoke with were concerned about the impact of high levels of staff vacancies on the team and the running of the service. They spoke of the extra stress placed on substantive staff when the ward was operating with a high proportion of agency workers.

• Compliance levels for some mandatory training courses were below 75% at the time of our inspection.

• There were several issues with seclusion rooms. The seclusion room on Ashurst ward was quite dirty, with visible blood stains on one of the walls. The intercom unit outside the seclusion rooms on Ruby and Sapphire wards were located too far from the door, which meant that patients inside the seclusion room would be unable to see the member of staff they were talking with. There was no clock visible from the seclusion room on Ruby ward. The patient control of the vision panel in the seclusion room door on Ruby ward was broken so that a secluded patient would be unable to see outside the room.

• Staff were potentially exposed to elevated risk when working on the health-based place of safety attached to some of the wards. During the course of our inspection, an incident occurred in which staff did not have a full, accurate, easily-accessible risk profile for the patient in the health based place of safety.

• At the time of our inspection visit, the overall appraisal rate for non-medical staff within this core service was 58%. The trust’s target rate for appraisal compliance was 90%. The wards with the lowest appraisal rates were Ashurst with 29% and Phoenix with 31%.

Updated 30 August 2018

Oxford Health NHS Foundation Trust provides community based mental health services for adults of working age who require a service, but do not need to be admitted to hospital for treatment. Some adults may be subject to conditions under the Mental Health Act 1983.

We inspect and regulate healthcare service providers in England.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs and well led?

Where we have a legal duty to do so, we rate the quality of services against each key question as outstanding, good, requires improvement or inadequate.

Where necessary, we take action against registered service providers and registered managers who fail to comply with legal requirements, and help them to improve their services.

We plan our inspections based on everything we know about services, including whether they appear to be getting better or worse.

At the last comprehensive inspection of this core service in June 2016 we rated the community based mental health services for adults of working age as good for the safe, effective, caring, responsive and well-led key questions which resulted in an overall rating of good. We re-inspected all five domains as part of this inspection.

Our rating of these services stayed the same. We rated them as good because:

• The provider had determined safe staffing levels and the number, profession and grades of staff in post matched the overarching staffing plan. Across all teams well trained and supported agency staff were used to cover any staff vacancies.
• Team managers had regular caseload supervision with practitioners to ensure that caseloads were manageable and shared equally between the team. Part time staff and social workers with responsibility for safeguarding had reduced caseloads to enable them to manage their time effectively.
• We reviewed 22 care records of patients across the three teams. Staff had completed a risk assessment for each at the point of initial assessment. Staff updated risk assessments regularly and after any reported incidents. Staff shared risk appropriately with colleagues and discussed high or particular risks with senior team members in supervision, reflective practice sessions and in multidisciplinary clinical meetings. This ensured risk was clearly communicated between all staff. Crisis management plans were in place and groups were available in the day hospitals which looked specifically at planning to manage safely in a crisis.
• Care plans clearly reflected the individual persons’ needs that staff had identified during the initial assessment. Care plans were personalised, holistic and recovery focused. Staff used a nationally recognised good practice care planning tool called the, ‘recovery star’ to ensure the full involvement of patients. Patients told us they had received a copy of their care plan and had participated in their risk assessment.
• All teams had embedded posts, employed by a community mental health organisation, which specialised in housing and employment. These staff had strong links with local colleges, housing organisations, local employers and enabled patients to acquire living skills to support patients find employment, vocational placements or work based training. These staff could also support patients with their benefits claims to ensure they were claiming appropriate benefits.

• All teams visited had a physical health clinic to ensure those using services had access to physical health screening and regular health checks. Teams were actively promoting healthy lifestyles and provided information on smoking cessation and healthy living. We saw that patients were referred and supported to attend their GP surgery.

• Staff provided a range of care and treatment interventions including psychological therapy, medication and social support. Interventions such as family intervention therapy for those with psychosis were in line with National Institute for Health and Care Excellence guidelines. Treatment offered at the day hospitals included groups on mindfulness, health and wellbeing, anxiety management, mood management and wellness recovery action planning.
• Whilst on inspection we saw that staff participated in wide range of clinical audits to monitor the effectiveness of the services provided. Areas covered included, ensuring good physical healthcare, ensuring adherence to the care programme approach, monitoring the quality of care plans, implementing the ‘true colours’ mood monitoring tool and developing educational, mental health information booklets. Action plans were developed to address any areas identified for improvement. Each team had a dedicated research assistant post.

• Each team had a duty system to respond to any sudden deterioration in the mental health of a person using the service. Staff would be on the daily rota and would know in advance if they had any assessments to complete on that day. The team leaders and duty worker would have a daily morning meeting to discuss any planned assessments or contacts needed that day.
• All three teams were working to a flexible assertive community team model which meant that patients needing increased support and contact would be identified by staff and receive more frequent and intensive contact from the team. When patients needed this enhanced support, they would be placed in the ‘step up’ category, which meant that they received additional sessions with staff and could utilise the on-site day hospital services. Each team maintained a ‘step up’ board which listed patients in this category, so all staff knew who was receiving this additional support.
• Skilled staff were available to assess patients in a timely manner. Each day both the assessment and treatment teams looked at all new referrals. Urgent referrals would be prioritised and processed by the teams, if required on a twice daily basis across all community teams. No team had a waiting list for either assessment or allocation to a treatment team. Each team had daily zoning meetings at which staff reviewed the risk of patients using the service to ensure they were receiving the appropriate amount of contact from the team.
• The community teams were well-led and had clinical lead managers in position. The managers were visible within the service during the day-to-day provision of care and treatment, they were accessible to staff and they were proactive in providing support and leadership. All staff we spoke with, without exception commented positively on this. The leaders of these teams had the skills, knowledge and experience to perform their role to a high standard. They had a very detailed and comprehensive understanding of the services they managed.
• Team leaders had access to their teams’ performance dash boards so could monitor their team’s key performance indicators and key risk issues. Team leaders used the boards daily in handover and clinical meetings.

However:

• There was some confusion with one staff member at both the Elms Centre and the Valley Centre about what emergency equipment was stored on site.

• Two staff at both the Elm centre and the Valley Centre said they were not consistently ringing in at the end of each working day as per the trust lone working policy.

• In four cases, across all teams, the physical health section of the electronic care records system did not always make reference to why a physical health assessment was not carried out.

• The capacity section of the electronic care records did not have entries in 10 out of 22 cases to confirm that capacity was considered. However, this form had been recently introduced and capacity assessments had been recorded in a different section of the care records.