Gloucestershire Health & Care NHS Foundation Trust

Updated 1 March 2024

We carried out this unannounced inspection of the mental health and community health services provided by this trust as part of our continual checks on the safety and quality of healthcare services. We announced some of the core services at short notice due to the nature of the services. As part of the inspection we also looked at whether the trust overall was well-led.

The 2gether NHS Foundation Trust and Gloucestershire Care Services NHS Trust came together to form Gloucestershire Health & Care NHS Foundation Trust in October 2019. The Trust continues to provide the mental health services it ran before the two trusts came together. It also provides the community-based physical health services previously run by the acquired trust. The ratings of services previously acquired by another trust do not carry over to the new trust. Ratings for the community health services from previous inspections are shown on our website page for the former Gloucestershire Care Services NHS Trust (cqc.org.uk/provider/R1J).

Gloucestershire Health and Care NHS Foundation Trust provides community, physical health, mental health and social care to the population of Gloucestershire. They employ over 5000 colleagues working in the community and at just under 200 sites across over 100 different clinical services and support services. The Trust provide services to a population of approximately 637,070 people widely spread across a geographical area of some 1,024 square miles.

Gloucestershire Health and Care are a Foundation Trust, which means they are not directed by the government but are accountable to the local community through their members and governors who live and work in Gloucestershire and beyond.

The Trust is registered for the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983
• Diagnostic and screening procedures
• Family planning
• Personal care
• Surgical procedures
• Termination of pregnancies
• Treatment of disease, disorder or injury.

Services inspected:

We inspected the following two mental health core services and five community health core services:

Acute wards for adults of working age and psychiatric intensive care units (PICUs).

• This core service had not been inspected since 2016 and was previously rated as outstanding.
• Gloucestershire Health and Care NHS Foundation Trust provide specialist assessment and treatment for adults of working age on four acute admission wards and one PICU ward in Wotton Lawn hospital.

Wards for people with a learning disability or autism.

• This core service was last inspected in 2018 and was previously rated as requires improvement.
• Berkeley House is a service for people with learning disabilities and autistic people who may be informal or detained under the Mental Health Act 1983. Accommodation is arranged into seven individual flats. At the time of the inspection one person was under 18 and four were aged over 18.
• We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
• The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.
• Right support: The provider was developing a model of care that ensured people’s stay was not prolonged to enable them to live successfully in the community with support and prevent admission to hospital.
• Right care: People’s care was individualised, planned and delivered in a manner that met their needs. People’s care promoted their dignity, privacy and human rights.
• Right culture: Staff were supporting people with their transition to live successfully in the community. They were respectful to the people they supported.

Community health services for adults.

• This core service had not been inspected since the two trusts came together. At the last inspection in 2018 with the previous trust this service was rated as good overall.
• The adult community services provided community-based care and treatment for people with various needs. The integrated community teams (ICTs) worked with specialist services to meet independent care and treatment needs for people within Gloucestershire.
• ICTs included registered nurses and healthcare assistants to deliver district nursing across the county.
• Specialist teams included the diabetes team, tissue viability service, complex leg wound service, lymphoedema service, telecare, wheelchair services, physiotherapy, occupational therapy, reablement, rapid response team, podiatry, home first, bone health service, musculoskeletal physiotherapy and cardiac rehabilitation teams.

Community health services for children and young people.

• This core service had not been inspected since the two trusts came together. At the last inspection in 2015 with the previous trust this service was rated as good overall.
• Services provided include school nursing, health visiting, public health nursing, children’s community nursing, a complex care team, a children in care team, occupational therapy, physiotherapy, speech and language therapy, and school aged immunisations.
• Teams provided care and treatment from community-based clinics, hospitals, children’s centres, schools, and in children and young people’s homes.

Community health inpatient services.

• This core service had not been inspected since the two trusts came together. At the last inspection in 2015 with the previous trust this service was rated as good overall. A focused inspection of the safe domain was carried out in 2018 and rated as requires improvement.
• The trust has seven community hospitals with inpatient wards, located at Cirencester Hospital, Dilke Memorial Hospital, Lydney and District Hospital, North Cotswolds Hospital, Stroud General Hospital, Tewkesbury Community Hospital and Vale Community Hospital.

Community end of life care.

• This core service had not been inspected since the two trusts came together. At the last inspection in 2015 with the previous trust this service was rated as good overall.
• End of life and palliative care is provided 24 hours a day and seven days a week across community services including community hospitals and community-based services.
• The children’s community nursing team supports children and young people with end of life, palliative care and complex needs. Where required, they are able to draw upon support from the district nurses who also care for adult patients.
• The trust has developed specific expertise to support end of life care through their:

Integrated care teams, and specifically district nursing colleagues. 

Community rapid response teams. 

Specialist palliative care occupational therapy. 

Expertise within community hospitals inpatient services. 

Children's community services. 

• The trust works collaboratively with the palliative care team based at the local NHS acute trust and with local hospices.

Sexual health.

• This core service had not been inspected since the two trusts came together. At the last inspection in 2018 with the previous trust this service was rated as good overall.
• The trust provided a comprehensive sexual health service across the county. This included an integrated sexual health service, HIV treatment and psychosexual medicine. The trust also provided a pregnancy advisory service and Sexual Assault Referral Centre (SARC), but these services were not included as part of this inspection.
• Services were delivered from two main bases, Hope House and Milsom Street Centre. Staff delivered services at other locations within the community but many of these had been closed during the Covid-19 pandemic.

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

Services we did not inspect

We did not inspect the community dental service at this time. The service was rated as good during the previous inspection when services were provided by Gloucestershire Care Services NHS Trust. We do not currently have any concerns about this service and will continue to monitor in collaboration with our primary medical services team.

Overall rating

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

We rated effective, caring, responsive and well led as good, safe as requires improvement.

We rated seven of the trust’s services as good and none as requires improvement. In rating the trust, we took into account the current ratings of the ten services not inspected this time.

The trust had a high quality, compassionate leadership team with the skills, abilities, and commitment to lead the provision of safe, high-quality services. They recognised the training needs of managers and staff at all levels, including themselves, and worked to provide development opportunities for the future of the organisation. Senior leaders visited parts of the trust and fed back to the board to discuss challenges staff and the services faced.

The board and senior leadership team had a clear vision and set of values that were at the heart of all the work within the organisation. They worked hard to make sure staff at all levels understood them in relation to their daily roles. Staff understood the vision and values, and how to apply them in their work. Staff were clear about their roles and accountabilities. The trust had a clear strategy document in place, and this was directly linked to the vision and values of the trust.

The trust board had a good oversight of the challenges facing the services and wider health economy. They were an influential partner in the developing Gloucestershire Integrated Care System and understood the importance of addressing health inequalities in the system. Services planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. We saw evidence of positive feedback from patients and carers across all the sites we visited. People could access the service when they needed it and did not have to wait too long for treatment.

The trust board and all working in the trusts’ services had a clear patient centred focus. They made sure to include and communicate effectively with patients, staff, the public, and local organisations. The trust leaders had worked hard to improve the culture throughout the organisation, and to support staff, both through the pandemic and beyond, in the recovery phase. Staff felt respected, supported and valued and were focused on the needs of patients receiving care.

There had been some positive developments through the pandemic, including the trust response to managing the infection, prevention and control agenda, and supporting the wider system. The approach taken by the trust had been welcomed by partner organisations and highly praised. The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. We saw evidence of a commitment to quality improvement and innovation in the services we inspected. Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. Leaders promoted and supported continuous improvement and staff were accountable for delivering change.

The trust had a clear structure for overseeing performance, quality and risk. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Services controlled infection risk well. Staff assessed risks to patients and acted on them. Services managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve services.

Services provided good care and treatment based on national guidance and evidence-based practice. Managers made sure staff were competent. Staff worked well together for the benefit of patients, protected their rights, advised them on how to lead healthier lives, supported them to make decisions about their care, and gave them access to good information.

Staff treated people with compassion and kindness, respected their privacy and dignity and understood people’s individual needs. Services were inclusive, took account of patients’ preferences and their individual needs. People had their communication needs met and information was shared in a way that could be understood.

The trust benefitted from having good quality leadership, and effective governance processes helped the services to keep people safe, protect their human rights and provide good care, support and treatment.

However:

While there was a clear strategy document in place, work still needed to be done to embed this in practice. Not all staff felt the trust was truly integrated following the merger. Much of the work to integrate the trust had taken place through the pandemic so face to face contact had been somewhat limited and there was still work to be done to engage some staff fully. This included issues with the IT systems. The trust was aware of these and was working on a simplicity project to address these issues. The information systems within teams were not all integrated, meaning relevant information could be held in separate systems and difficult to find. While outcomes data, quality improvement opportunities and evidence-based policies and procedures were reviewed within the clinical governance framework, we were not assured how this information was shared with staff.

The end of life community teams did not all monitor the effectiveness of their service by completing end of life audits.

While there were systems and processes to safely prescribe, administer, record and store medicines in the acute and PICU (psychiatric intensive care unit) wards for adults of working age, staff did not follow national guidance for the physical monitoring of patients after the administration of rapid tranquilisation. The service also did not have processes to manage the risk and wellbeing of patients who may be prescribed antipsychotic medicines over the BNF maximum recommended dose.

The acute and PICU wards did not have personal emergency evacuation plans for patients who may need assistance to evacuate a building or reach a place of safety in the event of an emergency.

How we carried out the inspection

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

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

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

Before the inspection visit, we reviewed information that we held about the services and asked a number of other organisations for information.

During the acute wards for adults of working age and psychiatric intensive care unit inspection, the inspection team:

• visited four acute wards and one psychiatric intensive care unit. We looked at the quality of the ward environment and observed how staff were caring for patients
• visited three clinic rooms and reviewed 16 medicine charts
• interviewed five managers and the matron for the service
• spoke with eight patients and nine carers or relative of patients
• spoke with 17 staff including a consultant, two doctors, three psychologists, a physical health nurse, nurses, health care assistants and therapists which included, physiotherapists and occupational therapists
• reviewed 15 care and treatment records
• observed a medical ward round, a multidisciplinary team meeting and a bed management meeting
• observed a patient’s community meeting
• visited the therapy centre within the service.

During the wards for people with a learning disability or autism inspection, the inspection team:

• visited Berkeley House
• spoke with the ward manager and two deputy managers
• checked the clinic room
• spoke with one person and three relatives
• spoke with three staff including nursing staff and support workers
• spoke with the clinical director and transformation lead
• spoke to an independent support worker
• reviewed four care records and four treatment records
• reviewed a number of meetings minutes and looked at a range of policies and procedures related to the running of the service.

During the community health services for adults inspection, the inspection team:

• spoke with 35 members of staff including, but not limited to: service managers, the operations manager for urgent care and speciality services, community nurse leads, community managers, physiotherapists, band 5, 6 and 7 registered nurses, nurse prescribers, occupational therapists, the patient flow staff team and triage nurses
• reviewed 13 care and treatment records
• reviewed incident reports
• observed two patient podiatry appointments, one bone clinic patient appointment and a wheelchair assessment team patient appointment
• reviewed team meeting and governance meeting minutes
• attended a senior leadership network meeting
• looked at a range of policies, procedures and other documents related to the running of the service.

During the community health services for children, young people and families inspection, the inspection team:

• spoke with 46 members of staff including: service directors, heads of service, occupational therapists, physiotherapists, speech and language therapists, children’s community nurses, children’s support workers, school nurses, health visitors, and children’s nursery nurses
• spoke with 11 children, young people or families
• reviewed 23 care and treatment records
• attended and observed ten sessions facilitated by staff, including team meetings, handovers, health assessments, clinics and home visits
• toured the environment of three premises where care was provided
• looked at a range of policies, procedures and other documents related to the running of the service.

During the community inpatients inspection, the inspection team:

• visited all four wards at four community hospital sites, looked at the quality of the ward environment and observed how staff were caring for patients
• spoke with 18 patients who were using the service
• spoke with three carers or family members of patients using the service
• spoke with the managers for each ward
• interviewed 14 staff including consultants, staff nurses, healthcare assistants, occupational therapists, physiotherapists, pharmacists, hotel services staff and social workers
• reviewed 28 care records of patients
• attended two multidisciplinary team meetings and a ward handover
• carried out a specific check of medication management and administration records on all wards
• looked at policies, procedures and other documents relating to the running of the service.

During the community end of life inspection, the inspection team:  

• visited Cirencester, Tewkesbury and George Moore hospitals
• visited integrated community nursing teams in Cheltenham and Tewkesbury, the rapid response teams, the out of hours’ nurses team at Edward Jenner Unit and staff at the children’s community nursing team in Cheltenham
• spoke with the end of life lead, the deputy director of nursing, other members of the senior management team, clinical leads, matrons, managers, hospital and district nursing staff, domestic staff, administrative staff and call handlers
• spoke with 10 patients, nine carers and 10 staff
• reviewed 16 care records and six prescription charts
• observed three home visits and two team meetings.

During the sexual health services inspection, the inspection team: 

• visited Hope House and Milsom Street Centre and looked at the quality of the environment
• spoke with 12 staff including clinical leads, service managers, senior nurses, health advisors, nurses, health care assistants and receptionists.
• spoke with four patients who were using the service
• reviewed records relating to 13 patients’ care and treatment
• observed how people were being cared for
• observed a multi-disciplinary team meeting reviewing patients’ care
• looked at a range of policies, procedures and other documents relating to the running of the service.

What people who use the service say

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

Most patients said staff treated them well, listened and treated them with respect. They said nurses looked after them and there were enough people to help if they needed anything. However, some patients said they found it difficult to interact with staff due to the high turnover.

Carers and family members said staff were “really helpful” and provided a level of care which was “thoughtful and considerate.” However, most said that communication with the hospital could be improved.

Wards for people with a learning disability or autism:

We are improving how we hear people’s experience and views on services when they have limited verbal communication. We have trained some CQC team members to use a symbol based communication tool. We checked that this was a suitable communication method and that people were happy to use it with us. We did this by reading their care and communication plans and speaking to staff or relatives and the person themselves. In this report, we used this communication tool with one person to tell us their experience.

We used one person’s preferred method of communication to seek feedback. When one person was shown the bedroom card they said “safe”. This person smiled when holding the staff card and gave a “yes” response when holding the call for help card. This indicated the person felt safe and received appropriate care and treatment from staff.

Three relatives praised the staff for the kind and compassionate care shown to their family members. They told us they were involved in the care planning process and felt confident to approach the staff with concerns.

Community health services for adults:

Feedback from patients from March 2022 from the friends and family test (FFT) returned as being 100% positive.

Comments from patients and carers included comments stating satisfaction with the kindness and re-assuring care provided by staff. Patients also stated they felt staff gave them time and did not rush their appointments. Feedback we viewed from a family member stated that their mother was very happy with the care they had received and if they were happy then he was happy.

There were thank you cards pinned up all around office spaces we visited. The common theme of thank you messages included appreciation for kindness and compassion from staff.

Community inpatients:

The patients we spoke with said that staff were friendly, respectful and provided them with individual treatment to meet their needs. Patients found the service easy to access and did not have to wait a long time to receive the support they needed.

Community end of life care:

Patients and carers told us:

“Nurses have made the experience as good as it could be. They are so attentive, supportive, knowledgeable and caring.”  

“Nurses are fantastic. I always get a response quickly with a positive outcome. I have complete confidence in the (district) nursing team. They just know what to do.”  

“The nurses explain what they are doing at every stage and why it might be of benefit but ultimately they leave the decision up to me.”  

“I can't fault them, they are very caring.”  

“The nurses are amazing. You can see it in their faces that they just want the best for us.” 

“They give us plenty of time to make decisions. They offer an amazing service.”  

“They give excellent care to my (relative) and our family. Staff are so kind and respectful. We are always involved if there is a change to my (relative's) medication and decision making.”  

“Nurses are very approachable - I know I can ask them anything.”  

“The treatment has been absolutely outstanding. We are gobsmacked at how good the care is.” “They keep us informed and have given us leaflets about what to expect. The nurses talk frankly but do it kindly and at a level we can understand.”  

“Nothing is too much for this (nursing) team. The staff are wonderful and clever.”  

Sexual health services:

Overall patients were very positive about the service. 

People said staff were friendly, respectful and provided them with individual treatment to meet their needs.  

Patients had found the service easy to access and did not have to wait a long time to receive the support they needed. 

We also reviewed recent results from the Friends and Family Test (FFT) used by many NHS services to gather service user feedback.  Ninety five percent of all patients felt they had been treated with dignity and respect and had been involved in decisions about their care and treatment. 

Updated 18 August 2022

Updated 18 August 2022

Updated 18 August 2022

Updated 18 August 2022

Updated 17 March 2022

Updated 18 August 2022

Updated 1 June 2018

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

• Services were safe. There were effective policies and procedures in place to ensure the safety of children, young people, families, carers and staff. Staff had the skills, knowledge and training required to perform their role and they managed identified risks. Staffing levels were good across all teams.
• Staff kept comprehensive and up to date care records for children and young people. Information was recorded from the point of referral and frequently updated. There was evidence of joint working between children and young people and staff.
• The service offered a range of treatment and care options in line with national guidance. Each team base had a range of rooms and equipment to deliver care and treatment. Teams included a range of professionals such as nurses, psychologists, social workers, occupational therapists and psychiatrists.
• Staff treated children and young people with respect, dignity and as partners in their care.
• There were effective governance systems in place to support the delivery of good quality care.

However:

• There were no independent advocacy services for children and young people. Staff did not always understand the importance of an independent advocate and felt that they were able to advocate for children and young people.
• We had concerns about confidentiality in both the Linden centre and Park House as therapy rooms were not soundproofed.
• The physical health of children and young people using the service in Gloucestershire was not always recorded.

Updated 27 January 2016

We rated community mental health services for people with learning disabilities and autism as good because:

• Access to clinics and other facilities was good with ramps and disabled toilets available in clinic settings.
• Staff were meeting the four week waiting time from referral to assessment. People who used the service were involved in care planning. Staff understood the individual needs of people who used services and knew how to support and involve them in their care. Risk assessments were routinely carried out but these were not always recorded on the electronic recording system. Care pathway planning and implementation was being developed and there was a good understanding of national and professional guidelines so staff were implementing best practice.
• There were adequate staffing levels to meet the assessment needs of people who used services.
• Staff were experienced and had the necessary qualifications and skills to carry out their role. There were opportunities and support to attend external courses. Informal and formal supervision was undertaken and staff felt supported operationally and clinically. There was an adequate monitoring system in place for training, supervision and appraisal in all teams.
• Teams reported that service level leadership and management structures were good and they felt supported and listened to. Staff morale was very good and teams were enthusiastic and well-motivated. There was effective multidisciplinary and inter-agency working.
• An incident reporting process was in place and staff were aware of how to report incidents. Systems were in place to share learning from incidents. Staff were able to identify abuse and safeguarding concerns and follow the correct procedures for their service. The patients and carers we spoke to all felt that they would be able to make a complaint if they needed to and felt that this would be listened to. A variety of easy read leaflets and documents was available to help patients who used services understand treatment options and information about the service.
• Patients, carers and service providers spoke highly of the teams and told us that staff were inclusive, caring, responsive and they felt listened to.

However:

• There were waiting times to access some treatments
• Clinical audit was not embedded within the service
• There was lack of a clear vision and strategy to continue to develop and improve the service.

Updated 1 June 2018

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

• Staff vacancy rates were low across the teams. Managers monitored and managed the effects of sickness absence well in most teams.
• Caseloads were manageable within the teams. Patient records contained current, relevant and comprehensive holistic information. All patients had care plans in place.
• Staff completed risk assessments on admission. Staff assessed the physical health health of patients regularly and took action to address any physical health problems.
• There were three serious incidents reported in the previous 12 months. Staff used effective reporting systems and learned from incidents.
• All the environments we visited were comfortable, clean and welcoming. Environments had disabled access and toilets. Conversations could not be heard from outside interview rooms and staff were aware of issues around privacy and dignity during confidential interviews.
• Staff understood their responsibility around safeguarding adults and children. Staff attended mandatory training and knew how to raise a concern.
• Clinic rooms were well equipped and maintained. Staff made sure equipment was checked regularly.
• Staff were focussed on the health and wellbeing of patients. Staff involved carers in assessment and treatment and offered support and advice on issues and services. Patients, families and carers told us they were happy with the care received.
• Staff received supervision and appraisals. Teams discussed clinical and managerial issues in weekly multidisciplinary meetings. Managers identified learning needs of staff and provided opportunity to develop.
• There was evidence of strong leadership across the teams, particularly in the services our previous inspection identified as requiring improvement. Managers were visible and supportive, and motivated their teams to create a positive culture. Managers challenged underperforming members of staff.
• Staff morale was generally good. Staff were positive about the leadership in the trust. Staff were also aware of the senior management team, and told us that senior managers were visible and accessible.

However:

• Staff sickness levels in the Tewkesbury service had an impact on patient visits. Visits were often cancelled and staff needed to telephone instead at these times.
• All patients had care plans in place, but they varied in quality and patients did not always have a copy of their care plan. Staff did not always document if they did offer a copy.
• Staff highlighted the complaints procedure to patients and families. However staff did not always manage informal complaints transparently. We could not establish how teams decided if a complaint should be handled formally or informally.
• Although all patients had robust initial risk assessments, records demonstrated they were not always updated regularly.
• Some staff did not carry personal alarms at all times.

Updated 27 January 2016

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

• The heath-based place of safety was well managed and was purpose built to provide a safe and effective service. Systems and procedures were in place which supported staff to keep themselves and patients safe from harm.
• Patients were seen quickly and there were no waiting lists. Patients had thorough, up-to-date risk assessments and care plans, which looked at both their physical and mental health needs. Care plans were holistic, person-centred and recovery focused. Care plans were effective in supporting patients through their mental health crisis. Carers were identified and supported in their role.
• Staff supported patients to take positive risks as part of their recovery. Patients could access shorter-term, psychological therapies as part of their crisis resolution and patients waited no longer than around four weeks for this. Staff referred patients to other teams for longer-term psychological interventions. Patients were supported to work toward a safe discharge from the team and were referred to other services for longer term help to manage their longer term goals and mental health.
• Staff worked well together to provide a safe and effective crisis service to their patients. They shared important information with each other quickly and effectively. Handover and multidisciplinary meetings were well managed and were effective in managing patient risk and progress. The teams had good multidisciplinary, cross service and interagency joint working arrangements.
• The service had developed strong links with community groups who could offer additional support to their patients. Staff worked well with the police and ambulance service to deliver an effective and responsive 136 service to patients. Where issues were identified these were proactively dealt with.
• Staff listened to their patients. The trust had an effective and embedded system for collecting patient feedback. The service was making changes based upon feedback from patients, carers and stakeholders. Patients were extremely positive about the service they received and the staff who supported them.

Updated 1 March 2024

Gloucestershire Health and Care NHS Foundation Trust provides community, physical health, mental health, and social care to the population of Gloucestershire.

Gloucestershire Health and Care is a Foundation Trust, which means they are not directed by the government but are accountable to the local community through their members and governors who live and work in Gloucestershire and beyond.

During this inspection on 10 and 11 October 2023, we visited Berkeley House, a stand-alone unit for people with a learning disability located in a residential housing estate on the edge of the town of Stroud.

During this focused inspection we inspected the safe, caring and well led domains as well as parts of effective and responsive due to having received concerns raised by the Trust around the care and safety provided to patients at Berkeley House.

We rated this service as inadequate because:

• People’s care and support was not provided in a safe, clean, well equipped, well-furnished, and well-maintained environment. The service did not always meet people’s sensory and physical needs.
• The service failed to review and monitor significant restrictive practices and consider how they could be reduced. However, staff had commenced the HOPES (harness, opportunities, protective enhance system) training to support their knowledge in restrictive practices.
• People who used the service were not supported to be independent and have control over their own lives. The service was unaware how significant restrictions on people’s human rights and freedom may impact on their wellbeing.
• There was best interest decision documentation regarding the use of CCTV in all service users’ records, but staff did not always follow the provider’s policy regarding its usage. The monitor recording the CCTV was visible to visitors. This did not protect the person’s privacy, dignity, and risk of abuse.
• The service did not have the service of a psychologist for over 2 years. The Trust however had psychology input which was provided from the Community Learning Disability Team on a regular basis by referral.
• While people were given choices, the care records identified a lack of activities taking place which meant people were not partaking in their planned care and were not being supported to achieve their goals. The behavioural analysis plan for each person was not reviewed and updated.
• There were systems and processes to safely prescribe, administer, record and store medicines. Staff members did not always adhere to them during the inspection. Health care assistants were administering medicines which were not in line with the Trust’s guidance. The electronic administration records identified numerous gaps in the administration of medicines. There was no managerial oversite to manage concordance. Some patients were prescribed “as required” medicines with no oversight to the reasonings why or whether this was effective.
• Staff did not always receive regular supervision.
• The weekly multidisciplinary team meetings did not always work well. Staff did not always work well together to provide the planned care required for each person.
• People did not have clear plans in place to support them to return home or move to a community setting. Following the inspection, the Trust informed us all patients had received a discharge plan.
• There was not a recognised model of care and treatment for people with a learning disability or autistic people. Monthly quality assurance data were completed and analysed but the management team did not always pick up issues on compliance which meant they were not aware of how the service was performing.
• Outcomes data and quality improvement opportunities and evidence-based policies and procedures were reviewed within the clinical governance framework. However, staff spoken with said they did not know how well the service was performing because information was not disseminated and shared with them.
• The service failed to analyse incidents comprehensively to consider triggers, themes, and trends and how incidences of distressed behaviour, and restrictive practices could be reduced. Records seen did not identify key themes and trends to mitigate the risk or reoccurrences of distressed behaviour or to reduce restricted practices imposed.

However:

• People had their communication needs met and information was shared in a way that could be understood.
• People’s risks were assessed regularly, and people’s care and support plans reflected their sensory cognitive and functioning needs.
• Staff ensured that people had regular contact with their families.
• People had access to advocates when required.

Information about the service

The core service was last inspected in April 2022 and was rated as good overall.

Berkeley House is a service for people with learning disabilities and autistic people who may be informal or detained under the Mental Health Act 1983. Accommodation is arranged into 7 individual flats. At the time of the inspection 6 of the flats were in use. One person was under 18 and 5 were aged over 18.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

The service had to demonstrate how they were meeting the underpinning principles of Right support, Right care, Right culture.

Right Support: The provider was developing a model of care that ensured people’s stay was not prolonged to enable them to live successfully in the community with support and prevent admission to hospital.

Right Care: People’s care was individualised, planned, and delivered in a manner that met their needs. People’s care promoted their dignity, privacy, and human rights.

Right Culture: Staff were supporting people with their transition to live successfully in the community. They were respectful to the people they supported.

The Trust is registered for the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983
• Diagnostic and screening procedures
• Treatment of disease, disorder, or injury

Updated 27 January 2016

We rated 2gether NHS Foundation Trust as good because there was evidence of good practice in all five domain areas of safe, effective, caring, responsive and well-led.

Fourteen months before our inspection there had been  a homicide on the ward; a member of staff had been murdered by a patient. We found that the staff on the ward had worked very hard to recover from this incident as a team whilst supporting patients and maintaining a safe environment. The team had supported each other well and it was evident that, whilst the emotional effects of the incident were still felt, the staff team had been able to prioritise patient care. Measures had been put in place to address safety but this had been done in a way which minimised blanket restrictions and continued to support patients towards recovery and independence.

The environment was clean and safe with good staffing levels and use of bank staff familiar with the ward. Seclusion was not used and restraint used rarely. There were very clear procedures for managing risk. Incidents were reported and staff learnt from these.

Staff carried out a thorough assessment of patients' care needs before admission and updated this regularly. It was evident that patients were involved in this process but this was not fully reflected in care plans. There was a high standard of physical healthcare monitoring. We found good multi-disciplinary working with a range of professionals available and an open culture which encouraged all members of staff to contribute.

Interactions between staff and patients were warm and respectful. Patients were positive about their treatment on the ward. Patients were involved in their care and staff supported patients to maintain contact with their families.

Admissions to and discharges from the ward were planned. Beds were never used when a patient was on leave. There was a range of rooms available on the ward included a fully equipped gym which was accessible throughout the day. There was a range of activities available on and off the ward seven days a week. Patients knew how to complain. However, no record was kept of complaints resolved at a local level.

Team morale was good. Staff felt supported by local management and by colleagues within the team. Staff had access to additional as well as mandatory training and told us that they were easily able to access informal supervision. Following the serious incident last year the team had felt supported by the local management and there was a comprehensive action plan in place.

Updated 27 January 2016

We rated 2gether NHS Foundation Trust as good because:

• Clinic rooms were clean and well maintained in the rehabilitation wards, medicines were mostly managed safely.

• Care plans were of high quality, holistic and based on patient identified goals.

• Strong multidisciplinary teams provided high quality interventions and worked effectively. Staff had access to further training to allow them to provide higher quality care to patients.

• The vast majority of patient feedback on the care received was positive. Patients said that staff were always available and that they valued the way staff treated them.

• We observed staff had treated patients with care and respect.It was evident that they had built solid therapeutic relationships based on kindness and respect.

• Patients had free access to outside areas; all of the wards had a range of rooms to provide activities for patients.

• Patients received food in line with their dietary requirements; one ward had an in-house chef which meant that patients could collectively decide what food to eat that day.

• Patient feedback was sought in a variety of ways; staff listened to patient concerns and took action.

• There was strong local leadership and high staff morale.

There were elements within the overall service that could be improved, such as improvement in governance systems to ensure that policies were being followed and the facilities in Oak House.

Updated 15 June 2022

Gloucestershire Health and Care NHS Foundation Trust provide specialist assessment, treatment and care for older people with functional mental health problems and people with dementia. The service has three wards within Charlton Lane Centre; Chestnut, Mulberry and Willow.

We carried out this unannounced inspection of the wards for older people with mental health problems as we had received information that raised some concerns about the safety and quality of the service.

The hospital is registered to provide the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983.
• Diagnostic and screening procedures.
• Treatment of disease, disorder or injury

The last comprehensive inspection was in 2018 when the service was delivered by 2gether NHS Foundation Trust prior to the merger with Gloucester Care Services NHS Trust. Following that inspection we rated the service good overall and good for the key questions, ‘are services safe, effective, responsive and well-led and outstanding for the key question, ‘are services caring’.

Following this inspection our rating of this service went down. We rated them as requires improvement because:

• Staff could not always observe patients as there were blind spots on all the wards. Environmental risk assessments did not include reference to these, or the actions taken to mitigate these risks.
• While there were systems and processes in place to prescribe, administer and store medicines these were not always managed safely. The wards did not have processes for the management of transdermal patches. A transdermal patch is a patch that attaches to your skin and contains medication.
• The service did not always have enough staff to care for patients and keep them safe. All wards had vacancies and could not always find bank and agency staff to cover shifts. Agency staff did not have access to the trust’s electronic system to enable them to review clinical information.
• While the wards had dedicated female lounges, these were often used by male patients, visiting family members and used as low stimuli/de-escalation rooms. This did not meet the requirements of the Mental Health Act Code of Practice.
• Most staff had completed Mental Capacity Act (MCA) training. However, staff we spoke with were unclear about their understanding, application and recording of the Act and how this affected their work with patients.

However:

• Staff assessed the risks and needs of patients and acted on them. Staff had training in key skills and understood how to protect patients from abuse. The service managed safety incidents well and learned lessons from them.
• Staff participated in the provider’s restrictive interventions reduction programme and followed national guidance for the physical monitoring of patients after the administration of rapid tranquilisation.
• Staff gave patients enough to eat and drink and pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients.
• Staff generally treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service followed the John’s campaign initiative which advocates for the right of people with dementia to be supported by their carers in hospital.
• Patients had access to the Reminiscence Interactive Therapy Activity (RITA) tool which is a touch screen solution to help patients to recall and share events from their past.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for patients to give feedback. Patients could access the service when they needed it and did not have to wait too long for treatment.
• Leaders supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their role.

How we carried out the inspection

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

During the inspection visit the inspection team:

• Visited three wards. We looked at the quality of the ward environment and observed how staff were caring for patients.
• Visited three clinic rooms and reviewed seven medicine charts.
• Interviewed three ward managers, the matron and the deputy director for mental health and learning disabilities.
• Spoke with four patients and nine carers or relatives of patients.
• Spoke with 19 staff including five doctors, social worker, clinical dementia lead, nurses, health care assistants and therapists which included; physiotherapists, occupational therapists and the speech and language therapist.
• Reviewed 12 care and treatment records.
• Observed two staff handover meetings, a music therapy group and a patient feedback meeting.
• Attended three focus groups with a variety of staff including therapists, nurses and health care assistants.

What people who use the service say

Some patients said staff treated them well and listened and treated them with respect. They said nurses were nice and there were enough people to help if they needed anything. However, other patients said they got the help they needed but sometimes staff gave the impression that they did not really care. All said there was no continuity in staffing, and that some staff were very noisy.

Carers and family members we spoke with said they were “very happy with the care” and “couldn’t have hoped for a nicer place”. However, most said that communication with the hospital could be improved.

Updated 18 August 2022

Updated 27 January 2016

We rated 2gether NHS Foundation Trust community mental health services for adults of working age as good because:

• Staffing levels were safe and caseloads were manageable. There was good access to psychological therapies and to group activities. We observed very good care being delivered and patients gave very positive feedback about their treatment in the service.
• Teams worked well together, met regularly to discuss their work and were supportive of one another. There were opportunities for leadership development and career progression. Managers at all levels were available and supportive.
• The service were referring to National Institute for Health and Care Excellence guidelines to ensure best practice.

However

• There were sound proofing issues in the team base for Herefordshire which could compromise patient confidentiality. Cleaning arrangements did not ensure all areas were being cleaned sufficiently.
• Risk assessments were missing from some patients records. Care coordinators were not completing their own mental capacity assessments and were deferring this task to social workers and doctors. This meant the person assessing the patient’s capacity was not necessarily the person making the decision on behalf of the patient. This was not in line with the procedures of the Mental Capacity Act.
• There was no mandatory training on the Mental Health Act or Mental Capacity Act and some staff felt they needed a better understanding of these areas.
• Some management reports were inaccurate and out of date. This made it difficult for them to ascertain compliance with key performance indicators.