Oxleas NHS Foundation Trust

We rated acute wards for adults of working age and psychiatric intensive care units as inadequate because:

• Wards were admitting new patients before being able to discharge existing patients. This meant that patients were frequently moved to make maximum use of beds. However, we heard of three occurrences where patients had to sleep on sofas or mattresses for one night because of the lack of beds.

• Ligature audits concentrated on areas where observations where not taking place and did not include the whole ward, communal areas were left out. There had been five suicides linked to the core service, the latest of which was in May 2016. Staff awareness of environmental risks was not consistent across the core service.

• The trust had mixed gender wards. At times, the same sex accommodation rules were breached by having male patients in female only corridors.

• Medication cards were physically in poor condition and there was inconsistent recording and reviewing of people’s medicines. Patient allergies were not documented on the medication cards therefore staff were not aware of any medication that should not be given to patients.

• Not all patients received copies of their care plans.

• The trust did not implement local risk registers that highlighted risks pertinent to individual wards.

However;

• The ward environments were clean, bright and the décor and furniture were well maintained.

• Patients received comprehensive assessments during the admission process and received information on the service.

• Physical health examinations were carried out within a 24-hour period and checks were ongoing during the patient’s admission in hospital.

• Psychological interventions were available for patients as part of a group session; one to one sessions were also available.

• Patients were given opportunities to provide feedback on the services they received, such as through tablets and patient experience groups.

• Staff were kind, caring and polite.

We rated forensic inpatient services as requires improvement overall because:

• Only two staff were allocated to work on Birchwood. Staff told us one member of staff would often work alone on the ward if the other member of staff was facilitating patient leaves. The service implemented a lone working policy and staff used this. Sanctioning lone working on a secure inpatient ward risked the safety of staff.

• All wards had potential ligature risks in communal patient areas, including areas where patients had unsupervised access such as an unlocked laundry room on Heath. Trust policy did not require staff to assess for ligatures in all areas of the ward environment.

• The service had a banned item list, which included plastic bags. However, there were plastic bags in all areas of the wards, including areas where patients had unsupervised access such as bathrooms and laundry rooms. Plastic bags posed a risk to patients and staff.

• The seclusion room on Heath did not meet the guidance set down by the Mental Health Act Code of Practice (2015). There were a number of instances when staff did not routinely advise patients of their rights under section 132 of the Mental Health Act and some patients did not have robust capacity assessments in place to confirm they were able to understand and consent to their treatment. Staff did not routinely complete training and updates on the Mental Health Act Code of Practice (2015).

• It was difficult for staff to demonstrate links between when they carried out the ward based ligature audit and when the work to remove or modify risks had taken place. Although, the trust was able to evidence how actions arising from ligature audits were logged, managed and actioned.

However:

• Staff managed risk well and patients told us that the service felt safe. Staff undertook thorough risk assessments for each patient. They were trained in safeguarding adults and safeguarding children procedures. They reported concerns to the local authority when they needed to.

• Staff knew how to report incidents and managers investigated them; and then shared lessons learnt with staff. The service had safe systems to manage medication. There was an on going recruitment programme to fill vacancies and managers had succeeded in recruiting to all nursing vacancies at the time of the inspection.

• The wards provided comfortable, safe, modern and suitable facilities for patients. There were secure door entry systems to prevent unwanted visitors and to manage the security level of the environment.

• Staff provided high quality treatment and care. Different professionals worked well together to assess and plan for the needs of patients. Patients had up-to-date risk assessments and care plans. These focused on treatment plans, recovery and rehabilitation. Staff used specialist tools to assess the needs of patients. Staff routinely supported patients to deal with their physical health needs and developed service-wide initiatives to strengthen this, such as the Food Strategy and the Wellbeing Strategy. Patients could access smoking cessation and drug awareness support.

• To aid their recovery, patients had access to a wide range of specialist psychology and occupational therapy led therapies. These included art therapy, judo, relaxation, anger management, family therapy and a sex offender’s treatment programme. The service provided patients with access to a wide range of sports activities such as basketball, hockey, swimming and a gym. Patients also had access to fun activities, which included shopping trips, B-B-Qs, trips to the seaside, and trips to local places of interest.

• Staff ensured patients were fully engaged with their treatment programmes and patients were involved in developing their care plans. The service routinely sought patient and staff feedback. They made changes to the way they did things based on this feedback. There was a strong culture of involving patients in the running of the service and patient’s views were taken seriously.

• The service invested in, and was responsive to the needs of, its staff. As a result, staff morale was good. Managers listened to staff and provided them with additional resources when they asked for them. Managers routinely held supervision and annual performance reviews with staff and these were up-to-date. Staff had mandatory training, which managers monitored to ensure compliance. Managers supported staff to develop their skills and career by funding external and specialist courses.

• The service was well led at a local level and managers had good systems in place so they could audit the quality of care. However, senior managers in the trust did not demonstrate that they had sufficient oversight of some audits to determine if they were effective. Ward managers were accessible to their staff. They demonstrated the skills and experience needed to improve the service for patients. Managers and staff were continually looking for ways to improve clinical outcomes for their patients. They encouraged staff to undertake project and research work.

• The service was part of the Royal College of Psychiatrists’ Quality Network for Forensic Mental Health Services and carried out both self and peer reviews with the network.

We rated Oxleas Healthcare NHS Foundation Trust's long stay and rehabilitation wards as good because:

• Cleanliness was good across all wards. Infection audits showed good levels of controls across the rehabilitation and long stay wards.

• Staff used evidence-based tools and assessments to measure needs and risk. Clinicians took part in audits to monitor and improve the quality of care. Staff had access to additional training for their role to improve clinical effectiveness.

• Staffing levels across most of the wards was good except Somerset Villa that operated with lower number. The number of nursing staff each shift on Somerset Villa meant that staff could not do restraints and on nights, there could be one nurse on the ward at any time.

• Staff treated patients and carers with dignity and respect. Staff were enthusiastic, positive and had understood the needs of patients and how to meet them. All patients and carers we spoke with were positive about the care and treatment they had received.

• Staff felt well supported and supervised, staff appraisal rates were good. Mandatory training rates met trust requirements.

• Wards were committed to quality improvement and innovation.

We rated Oxleas NHS Foundation Trust as good for older peoples’ mental health wards because:

• All the wards were well resourced in terms of staff, environments, and activities. The staff teams were consultant psychiatrist led and came from a range of appropriate disciplines. Each environment had older people in mind and were suitably adapted with the right resources. The activities on offer were varied, age appropriate and were rehabilitative in approach.
• Holbrook ward had been purpose built as a dementia specific ward to meet the specific needs of the patient group. For example, there were bespoke rooms, furniture and even smells to provoke pleasant memories.
• Oaktree Lodge offered and provided comfort, spiritual and religious support and activities to people with long-term conditions and some who were at the end of life.
• Staff appraisal, mandatory training and supervision rates were high and there was a commitment from the trust in continuing professional development, career progression and specialist training for their staff.
• Staff used evidence-based tools to assess, monitor, and manage individual patient needs and risks. Assessment and planning was thorough and considered the patient’s physical and mental health. Family, carers and other professionals were involved in the patients’ treatment.
• Staff used outcome measures to assess treatment effectiveness.
• All patients and carers we spoke with were positive about the service’s care and treatment, and patients said they felt well supported. The service had a carers’ support group.
• Staff had a commitment to quality improvement and innovation. Clinicians took part in audits to improve the quality of care. We saw learning from complaints, concerns and incidents and there was a culture of making service improvements as a result of that learning.

However:

• None of the wards had clear lines of vision. The layout of the wards meant that there were blind spots.
• On Scadbury ward we saw that some fire extinguishers were kept in locked cupboards and all staff did not have keys. A more accessible one was kept in the nurses’ station. The trust have provided us with subsequent evidence that this was approved by their fire safety officer and the London fire service.

We rated wards for people with Learning Disability and Autism as good because:

• The ward was visibly clean and tidy. Whilst the ward was mixed gender, men and women were admitted to separate self-contained flats. The ward had a good track record of safety with no serious incidents in the last six months. Staff reported incidents appropriately.
• The ward was well staffed with a full time modern matron on the ward as well as a ward manager. Any bank staff used were regular and familiar with the ward and patients. Staff were up-to-date with mandatory training and had received an annual appraisal. All staff received training in positive behavioural support which met the needs of the specialist patient group.
• All patients had a good quality care plan that was personalised to their individual needs. Staff carried out care and treatment reviews regularly. The physical health care needs of patients were assessed and monitored appropriately. All patients had access to music and art therapy on the ward.
• Clinical staff took part in a range of clinical audits including prescribing observatory for mental health, to monitor the effectiveness of the service provided. Staff carried out general audits on the wards, including audits of completion of patient observations.
• The ward had an effective multidisciplinary team (MDT), comprising of speech and language therapists, clinical psychologists, therapists and a consultant nurse, all based part time.
• Feedback from people who had used services and their carers was mainly very positive.
• There was a full range of equipment on the ward to support patient needs. Therapy sessions were held in rooms specifically allocated to this with essential equipment. The ward had a well-equipped sensory room.
• Staff morale was high. Staff told us that they felt supported and safe on the ward.
• Staff had created and implemented easy-read personal profiles for each patient, which contained a wide variety of physical health information about them and their needs and preferences. Patients could take this with them to every health appointment and after discharge.

However:

• Two fire extinguishers were found stored under the desk of the reception office at the front of the ward. This meant that if they were needed they could not be adequately accessed if there was a fire at the other end of the ward. Another two fire extinguishers were found in a locked food storage cupboard on the main corridor. This would have impacted on patient safety if there was a fire on the ward. The trust has provided us with subsequent evidence that this was approved by their fire safety officer and the London fire service.
• The communal areas on the ward did not have a ligature risk assessment. The risk was mitigated as the unit operated high patient to staff ratios and service users were never left unsupervised in communal areas.
• Patients’ bedrooms were not personalised. The bedrooms were not very homely and did not appear to have any colour. Staff attributed this to the fact that some of the current patient cohort did not like pictures or things hanging on the walls.

We rated mental health crisis services and health-based places of safety as requires improvement because:

• The environment of the health-based places of safety and day treatment teams had several ligature anchor points, which posed a high risk to patients. The Bromley and Bexley day treatment team facilities had not completed environmental risk assessments including a ligature assessment in areas where patients would be unsupervised. The service was not aware of the risks, which meant that the risks were not adequately mitigated.

• The risk assessments completed by the home treatment and day treatment teams demonstrated inconsistencies in how staff documented and managed risks. Care records lacked evidence that patients had person-centred, detailed crisis plans. There was a lack of evidence that physical healthcare monitoring was regularly taking place. The home treatment teams did not always demonstrate that staff carried out an initial physical health screening or full assessment.

• Staff did not routinely carrying out checks of personal panic alarms, clinical equipment and infection control. One team did not have access to emergency life support equipment including emergency drugs, which meant that staff was unable to attend to patients in an emergency.

• Bromley HTT and Greenwich day treatment teams had not ensured that all staff had completed all mandatory training courses. Twenty-five percent of staff in Bromley HTT had not completed basic life support training. Thirty-three percent of staff had not all completed breakaway training and 50% of staff had not completed food safety training in the Greenwich day treatment team.

• Staffing levels varied across the three boroughs. Staff in some teams found it difficult to manage the increasing acuity of the caseload. Staff told us that on occasions joint visits were unable to take place, as there had not been enough staff. Patients were provided with transport in order for them to attend the team base to be seen.

• Bexley day treatment team had minimal psychology input and was unable to provide specialist psychology support to their patients. After the inspection, the trust advised us that an additional two days per week of psychology input would be provided to the day treatment team starting from October 2016.

• Trust systems and processes were insufficient in ensuring that the health-based places of safety-protected patient’s safety, privacy and dignity.The entrance doors to the Greenwich place of safety were clear glass and meant passers-by were able see in to the place of safety.One of the places of safety did not provide a comfortable environment for patients, as there was no bed or shower facility available.

• The trust did not provide staff with specific Mental Health Act (MHA) training in accordance with the new MHA code of practice. Staff lacked knowledge in the application of the MHA and were unable to support patients that remained under the MHA in the community

• Patients did not have access to information, which related to their rights as a patient and independent mental health advocacy. The information was not clearly displayed in waiting areas and in the health-based places of safety.

• There was an inconsistent approach in the use of outcome measures. Home treatment teams were using specific measures and the day treatment teams were not. This did not ensure that teams were able to review their clinical effectiveness. However, the trust planned to roll out a new tool that was being piloted by the Bromley HTT.

• The teams were not ensuring that the systems and procedures that were in place were working effectively. The processes in place to ensure that patients were receiving safe care and treatment, which also protected their privacy and dignity, needed to improve.

However:

• The trust had plans to review and refurbish the health-based places of safety, although there were no set dates for completion. The trust had responded to and rectified the privacy and dignity issue at the place of safety in Greenwich after the inspection.

• Staff within the home treatment teams, day treatment teams and health-based places of safety demonstrated good practice in responding to people in crises. Staff were professional, caring and supportive. Teams routinely reflected on incidents and looked at how practice could be improved and lessons learnt.

• The health-based places of safety were adequately staffed.

We rated Oxleas NHS Foundation Trust as good for older peoples’ mental health community- based services because:

High standards of risk assessment and risk management were consistent across all of the services. Potential patient risks were reviewed regularly and patients had individualised crisis plans. In all of the services, there was an ongoing focus on patient safety.

Staff went above and beyond what was expected of them. All grades of staff were accessible, and went beyond service limitations to meet the needs of patients and carers.

The care home project worked with care home staff to effectively support their residents. The memory service also provided an early identification service for residents with suspected dementia.

Following referral, patients waited under six weeks until they were assessed by memory services. Six weeks is the target time for all memory services to achieve by 2020.

The advanced dementia service co-ordinated and provided palliative care to patients with dementia. Staff in the service supported and advocated for patients and carers, including decisions concerning where the patient wished to die.

Complaints were viewed as a learning opportunity. Incidents and complaints were thoroughly investigated. Learning from incidents and complaints was communicated to all services. There was an open and transparent culture.

The strategic direction of the directorate focussed on effective partnership working. Co-operation and collaboration with partners was seen as key to providing a holistic, high quality service to patients and carers.

The senior management team promoted a culture of high standards and continuous improvement. This culture was reflected in each of the services. Standards of care were consistently high across all of the services.

We rated the community based mental health services for adults of working age as good because:

• The services had effective systems for managing risk. Staff reviewed risks to patients at meetings that were held several times a week. Patients had risk assessments and clear risk management plans in place.
• Most teams had few vacancies. Staff and patients had access to a psychiatrist when they needed one. Managers monitored and adjusted the caseloads of staff so that they could provide safe care and treatment to patients. Teams were piloting a case load weighting tool aimed at ensuring staff caseloads were balanced.
• Complaints and serious incidents were investigated. The lessons learned were identified and shared with staff in the community teams. Staff made improvements in systems and care to help reduce the chances of the same type of incident or complaint happening again.
• Teams worked effectively with other trust services such as home treatment teams, child and adolescent mental health teams and employment advisors. Staff worked in partnership with local voluntary sector organisations to provide social inclusion programmes which supported patients’ recovery. The teams were establishing good working relationships with local GPs.
• Most staff were up to date with mandatory training, received an annual performance appraisal and had regular clinical and managerial supervision.
• Staff provided care and treatment that was evidence based and in accordance with national guidance. Managers in the early intervention service had been proactive in making sure that staff had the skills to deliver family interventions. Psychologists and psychotherapists were integrated into the teams, which helped improve patient access to therapies.
• Staff provided caring and compassionate care to patients and carers. They understood the needs of individual patients. Patients were positive about the care and treatment they received.
• Clear systems of governance supported the teams to learn from incidents and complaints and make improvements in care and treatment. Managers had instant access to key performance information, which helped them monitor and improve the effectiveness of the service, as well as ensuring staff training, supervision and appraisal were up to date.

However:

• Although the trust provided guidance to staff on issues of patient confidentiality it was not clear that all staff followed the guidance and understood the boundaries. There was a risk that staff were not always maintaining confidentiality and could compromise patients’ privacy, particularly when leaving telephone messages.
• Waiting times for assessment had improved since the introduction of the re-designed model of care for working age adults in the community. However, the primary care plus teams were inconsistent in terms of how promptly they were able to assess urgent and routine or non-urgent referrals. For example, some teams had assessed over 80% of urgent referrals on the same day and 100% within two weeks. Whereas another team had assessed no urgent patients on the same day and 68% within two weeks in the same time period.
• Staff did not routinely attend training in the Mental Health Act, this was not mandatory. Some staff said they had limited understanding of the Act and associated code of practice.

We rated Oxleas NHS Foundation Trust community mental health service for people with learning disabilities or autism as good because:

Staff worked in innovative and creative ways to provide people, their families and carers with support, care and treatment that made a positive difference to people’s lives. Staff assessed in detail the personal needs of individuals and provided them with care and treatment plans that were holistic and addressed their needs. As well as a wide range of psychosocial and psychological interventions the service also provided innovative support to people living with anxiety and depression.

People who use servcies, their families and carers consistently told us that the standard of care they received was very high and that it had made a positive difference to the lives of all those who used the service.

The service empowered people to contribute to the development of services giving them the opportunity to formally review staff practices, materials, premises and to actively participate in the recruitment of staff to ensure the service met people’s needs.

Systems were in place to ensure that staff continuously delivered services according to best practice and staff liaised and worked with external agencies to share knowledge of best practice methods and ideas.

We observed that staff treated people with care and respect in every aspect of their work and demonstrated patience and concern about all aspects of their mental and physical health.

Staff ensured that they continuously obtained the feedback of people, their families and carers, providing numerous opportunities for them to give their comments and concerns.

The service was well led with a clear commitment from senior management to ensure that staff were well supported, their ideas encouraged and opportunities provided for their professional development. As a consequence staff morale was high and staff were committed to mutually supporting each other to maintain high standards of care.

Overall rating for this core service

Overall, this core service was rated as ‘Good. This was because:

• Systems used to identify patients at risk of deterioration were used effectively.
• Patients received their medicines safely when they were prescribed.
• Facilities were well maintained in a clean and hygienic condition and staff employed recognised infection control practices.
• Adequate numbers of suitably qualified and experienced staff met patients’ needs, and kept them safe and patients received adequate medical supervision.
• Robust systems for assessing and mitigating risks were embedded. When incidents did occur, there were well understood systems for reporting and investigating these, and changes were made to practice in light of the lessons learnt.
• Patients received care that followed latest published guidance and best practice and outcomes were in line with national averages.
• Patients received adequate pain relief.
• Patients were supported to eat and drink suitable food in sufficient quantities. However feedback from patients about the quality of food was mixed.
• Staff received adequate training to safely undertake their role, and their performance was supervised and appraised.
• Patients received care from a multidisciplinary team who worked cohesively to deliver care that met their needs.
• Patients were positive about their experience. They were treated with compassion and their privacy and dignity were respected.
• The service was well placed to meet the diverse needs of patients and was committed to providing care as close to home as possible.
• Admissions to the service were well managed to minimise risks to patients. Discharge from the service was well planned to ensure the needs of patients would continue to be met. Delayed discharges were usually beyond the control of the hospitals.
• Staff shared a vision and philosophy of care within the service, with a strong rehabilitative ethos. Senior leaders were visible and staff were supported by their immediate managers to provide high quality services.

We saw some good practice, including:

• Compliance with national infection control guidance.
• A strong ethos of promoting independence and rehabilitation.
• The implementation of a system called pressure ulcer prevention strategy (Pups) to reduce pressure ulcers.
• Multidisciplinary team working between nursing, therapy and social care staff.

We rated the service as good because:

• Patients told us they generally felt safe in the service. Staff effectively mitigated individual clinical risks.
• Staff were positive about working for the trust. Mandatory training rates were high; staff felt supported and accessed regular supervision. The teams consisted of enthusiastic people with patient care as their priority. Services included a range of staff able to deliver psychological therapies recommended by NICE.
• Parents, carers and young people felt services were welcoming, clean and comfortable and gave very positive feedback about how staff treated them. The trust employed a participation worker who supported engagement with young people and families to support their involvement in service development.
• Staff regularly assessed and discussed elevated risks. This meant that young people and parents/carers had crisis plans in place if needed.
• Service waiting times were within the trust maximum target of 13 weeks. Services could offer rapid response in an emergency between 9am and 5pm. Bromley CAMHS was a pilot site for an out-of-hours service and was able to offer an emergency response between 9am and 9pm on weekdays and 8am and 10pm on weekends.
• Services had developed several helpful resources, such as a physical healthcare clinic and a self-help and referral website called ‘headscape’. This was created with the input of young people and provided information about mental health issues and self-help.

However:

• Staff did not carry out regular environmental ligature risk assessments. There were several areas where ligature risks were present. For example, in bathrooms where staff were unable to fully mitigate risks.
• There were several vacancies across teams so there was pressure to meet the demands on the service. A large number of vacant posts had been recruited to and staff were waiting to start. In the interim, agency staff filled a large amount of the vacant posts.
• Leaflets that were available, for example about the complaints procedure, were only available in English. Information about advocacy services was not displayed clearly across all services.
• The trust had designated a CAMHS inpatient bed on an adult acute ward for use when an inpatient CAMHS bed was not available. There was a protocol on the use of this bed, which was a shared responsibility between this team and the acute ward concerned; however, we found several examples where CAMHS and other trust staff had not followed procedures appropriately. CAMHS staff had not worked together with other trust staff to ensure that the environment on this ward was appropriate and safe for a young person.
• We found evidence that feedback and learning from incidents was effective within a borough, but not as effective across services in the three different boroughs.

We judged that Community Adult Services were good. This was because:

• We found that there were arrangements to ensure that patients were safe, and there were systems to report, investigate and learn from safety incidents.
• We found that care and treatment was based on current guidance and best practice.
• Patients told us that they were treated with kindness and empathy and that their dignity was upheld.
• Services were arranged to respond to patients’ individual needs and could be accessed when they were required.
• We found that services were well-led; with a positive learning culture which staff were engaged in and identified with.
• Governance systems were in place to monitor safety and service quality and there was an emphasis on on-going quality improvement.
• Staff felt supported by their line managers who encouraged staff to innovate and develop their practice.

Overall we rated community end of life care services at Oxleas NHS Foundation Trust good.

This was because:

• We found staff provided focused care for dying and deceased patients and their relatives.

• Do not attempt cardio-pulmonary resuscitation (DNACPR) forms were generally completed in accordance with national guidance.

• Community health services had policies, guidelines and training in place to ensure that all staff delivered suitable care and treatment for a patient in the last year of their life.

• Community health services provided end of life care training for staff which was mandatory for community nursing staff.

• Community health services fulfilled the World Health Organisation definition of end of life care and met the National Institute of Health and Care Excellence’s (NICE) guidance.

Overall services for children, young people and families were rated as ‘Requires Improvement’. We found community health services for children, young people and families were ‘Requires Improvement’ for safe and well led. We found community health services for children, young people and families were ‘Good’ for effective, caring and responsive.

Our key findings were:

• There were ongoing incidents related to the electronic system, communication issues and record problems. These were being periodically reviewed but had not been resolved.
• There were inconsistent methods of recording messages, which meant the trust could not be assured messages had been responded to in a timely manner. Lapses in communication had been identified as a risk when working with vulnerable families.
• There was no caseload weighting tool to ensure health visitors could deliver an equitable service across the trust. Some caseloads were very high, above the upper limits as set by professional organisations.
• Allocation meetings where staff allocated work were not recorded consistently. This meant there was no process to review staff allocation. There was no robust system regarding allocation of families and their level of need with the capacity of the staff to meet the need.
• Some premises were not suitably equipped for families to ensure their safety and infection prevention and control measures were not consistently in place.
• Data was not robust in relation to health visiting performance and the trust could not be assured it was able to deliver health visiting services to meet people’s needs.

• School nursing for 2014/15 achieved 100% uptake in the reception year National Child Measurement Programme and 99.9% in year 6. A new healthy weight programme had been introduced for those children classed as overweight to meet the high rate of obesity.
• The trust delivered care in line with current evidence-based guidance, standards, best practice and legislation. There was good engagement with other providers and across disciplines, we saw some excellent examples of multidisciplinary working.

• Staff told us they felt respected and valued. All staff said they enjoyed their jobs and liked working in their team and for the trust.
• Innovation was promoted by the trust.  For example, the use of technology to improve access to health information on sexual health websites for Bexley and Greenwich as well as the electronic application ‘app’ for new parents.

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 Oxleas NHS Foundation Trust as requires improvement overall because:

• Not all services were safe and the trust needed to take action to address areas of improvement. For example, some wards had fixtures and fittings that people at risk of suicide could use as a ligature anchor point; these potential risks had not been adequately assessed and addressed.

• The environments at some community based services did not fully promote the privacy, dignity and recovery of patients using these facilities.

• The governance arrangements in place to take action following serious incidents that required investigation and trust wide learning were limited by the pace of investigations.

• Concerns regarding the trust wide management of medicines were identified.

• At Green Parks and Oxleas House mental health acute admission services, each ward had between 16 and 19 beds. In addition to this, they each had one surge bed. Staff said the surge beds were used daily. Records showed us that patients in those rooms had a length of stay ranging from two days to a week. All staff told us bed pressures were the biggest issue, and that the situation had been intense during the previous 12 months. When the demand for beds was high, patients were moved between areas.

• Across the acute wards, patients were being admitted before discharging existing patients. This meant that patients were frequently moved to make maximum use of beds. However, we heard of three occurrences where patients had to sleep on sofas or mattresses for one night because of the lack of beds. A number of patients had experienced sleeping on sofas and mattresses on the wards waiting for a bed to become available.

• We were informed and saw evidence that that beds for patients on leave would be used for new admissions and patients were being moved between wards and locations to accommodate new admissions. We were told by patients that having to sleep on other wards during their admission this made them anxious.

• Front line staff did not receive ‘refresher training’ on the Mental Health Act and the revised code of practice. Some relevant trust wide policies had not been updated to reflect the revised code of practice.

• The seclusion room on Heath did not meet the guidance set down by the Mental Health Act Code of Practice (2015).

• There were a number of instances when staff did not routinely advise patients of their rights under the Mental Health Act and some patients did not have robust capacity assessments in place to confirm they were able to understand and consent to their treatment.

• The trust did not use a weighting tool to ensure health visitors deliver an equitable service across geographical locations.

• The trust data collection and collation mechanisms were not robust for health visitor service metrics and breastfeeding data at six to eight weeks postnatal.

• The trust did not complete initial health assessments within 20 days.

• The trust did not make arrangements to ensure that all the child health clinics were suitably equipped for families and children to ensure their safety.

However:

•  Staff provided high quality care throughout the trust. We found examples of staff providing a high level of patient centred care and providing positive emotional support to patients who were distressed.
• In community health services we found that there were arrangements to ensure that patients were safe, and that there were systems to report, investigate and learn from safety incidents.
• We saw good multidisciplinary working and generally people’s needs, including physical healthcare needs, were assessed and care and treatment was planned to meet them.
• Services were clean with good infection control practices.
• In community health services, patients received adequate pain relief and were supported to eat and drink suitable food in sufficient quantities.
• The trust was meetings its obligations under the Duty of Candour and the fit and proper persons requirement regulations.
• The trust had robust processes in place to identify and report serious incidents.

• Front line staff received appropriate training, supervision and professional development. Some staff told us they had been given a lot of support to learn new skills or update their skills.

• Complaint information was available for patients and staff had a good knowledge of the complaints process.
• In community health services admissions were well managed to minimise risks to patients. Discharge from the service was well planned to ensure the needs of patients would continue to be met. Delayed discharges were usually beyond the control of the hospitals.
• The trust held bed mental health bed management meetings once a week and two daily telephone conferences. These meetings included managers from the inpatient and crisis teams. The attendees provided up-to-date information on bed status, a review of admissions waiting for beds, accelerated discharges to accommodate new admissions and patients that were in beds outside of the trust area and possible return dates. Any patients moved between wards were recorded on the trust electronic system as an incident.
• The trust had participated in a range of patient outcome audits, research and accreditation schemes. Prompt actions had been taken when concerns were identified by audits.

• The trust has a number of effective initiatives to engage more effectively with users and carers.
• Trust wide leadership was visible and proactive to front line staff.