Gloucestershire Health & Care NHS Foundation Trust

We found that 2gether NHS Foundation Trust was performing at a level which led to a judgement of good because:

We rated two of the 10 core services that we inspected as ‘outstanding’ overall and seven ‘good’ overall.

• 2gether NHS trust has much to be proud of. The majority of patients and carers were positive about their experiences of receiving care and treatment. Staff were caring, enthusiastic and committed to delivering high quality care and treating patients and carers with dignity and respect. Across the majority of services patients had good access to emotional support and clear evidence that staff considered patient’s diverse and cultural needs.

• The trust was well-led with an experienced, skilled and committed board, including an inspirational, astute and dedicated executive leadership team, insightful and supportive non executives and a dedicated board of governors who provided a robust level of challenge. There were many skilled and enthusiastic leaders and staff throughout the organisation who were working hard to manage the day to day delivery of care, whilst striving to improve the quality of services and provide evidence based and innovative approaches to care and treatment to ensure services would be sustainable and fit for the future. Staff morale was very good across the trust and staff spoke highly of the leadership of the organisation.

• Two of the trust services received an overall rating of ‘outstanding. The crisis and health based place of safety service and acute inpatient services for adult of working age. Both of these services were able to demonstrate excellent practice and innovation which went above the standards expected.

• The crisis and health based place of safety services received a rating of ‘outstanding’ for the key questions, ‘are services caring’ and ‘are services responsive’ and a rating of ‘good’ for all other key questions; giving an overall ‘outstanding’ rating. There was a strong person centred culture within the teams where staff supported patients with wider needs including physical health, emotional wellbeing and social needs. The heath-based place of safety was well managed and was purpose built to provide a safe and effective service. The crisis teams saw patients quickly and patients had thorough, up-to-date risk assessments and care plans, which looked at both their physical and mental health needs.

• The acute in patient services received an ‘outstanding’ rating for the key questions, ‘are services safe’ and ‘are services well-led’ and a rating of ‘good’ for all other key questions; giving an overall ‘outstanding’ rating. There was an underlying philosophy of providing care in partnership with patients and tailoring interventions to meet patient’s individual needs. There was excellent relational security on all wards and an open door policy which allowed patients to come and go as they wished but clear and positive management of patients who were detained under the Mental Health Act. Traditional seclusion was not used, instead staff worked with patients to effectively manage challenging behaviour and interactions were considered and supportive. The environment supported the delivery of high quality care and there was a culture of continuous improvement.

• We found that there were some aspects of care and treatment in some services that needed improvements to be made to ensure patients were kept safe. However, the vast majority of services were delivering effective care and treatment. Staff fully supported patients with their wider needs including physical health, emotional wellbeing and social needs, treating them with kindness and respect while involving them in their care and treatment. Across all services the staff were good at recognising when patients and carers needed safeguarding and the trust encouraged staff to report incidents; incident reporting in all services was good. There was a widespread culture of learning from incidents and there was shared learning across services, through regular ‘briefing notes’ and bulletins.

• Bed management practices were good and we saw effective systems in place for access and discharge across all adult inpatient areas. The trust had only recorded five delayed discharges in the last six months and these were reasons outside of its control. We heard of plans which commissioners had in relation to the new provision of children’s inpatient beds (known as tier 4), as there are non-available within the trusts catchment area.

• The trust had a programme to reduce the use of restrictive interventions on wards which was in the early stages of development. The aim was to work towards eliminating the use of these approaches as reflected in the “positive & safe” national programme. The trust had adopted two nationally recognised models of behavioural management; positive behaviour management (PBM; for learning disability & older adult services in Gloucester) and preventing and managing violence and aggression (PMVA; for working aged adult and older people’s services in Herefordshire). Both these models advocated the least restrictive intervention being used.

• Staff across the trust had good access to mandatory training, there was good induction programmes for all staff, as well as opportunities for continuous professional development. In the majority of services 80% (or above – up to 100% in some services) of staff had completed mandatory training. The trust declared that 48% of staff had received training about the Mental Health Act (MHA). The trust provided MHA training but this was not mandatory. However, it was incorporated into the matrix of ‘professionally required’ training and recommended for clinical staff working at bands five and above. All new health care assistants participated in training for the Care Certificate, a national induction standard for healthcare assistants. The trust planned to ensure that all HCA had access to this training.

• Staffing levels were generally good across all inpatient and community teams. Where bank and agency staff was used, the wards and community teams tried to use the same staff for continuity of care and often trust staff would work bank shifts. The highest proportion of staff vacancies was across the inpatient learning disability services. The trust was managing these vacancies within a plan agreed with commissioners in order to minimise the potential impact on staff redundancies from the ongoing reconfiguration of the service. We observed excellent multidisciplinary working across the trust.

• The trust had its own occupational health service called “working well” and was led by a consultant occupational health physician. The service aimed to improve the health and wellbeing of staff, both within the trust and for external public and private sector organisations.

• The trust had a clear vision; to “make life better” for the patients in its care and the carers who supported them. It had established this through a consultation process and aimed to achieve this through delivering high-quality care which would have been suitable for “their own family members”. Staff we met across all services and at all levels showed a high awareness of the trust’s vision, priorities and commitments.

• We found that the trust had developed a detailed governance system to support it to achieve its vision. The process for monitoring risk was robust and the board were sighted on both the corporate and operational risks facing the organisation. These were presented in board meetings via a comprehensive risk register. Local services also maintained local, operational risk registers which fed into the strategic risk register.

• The structure of committees and meetings, which provided the board with assurance, were well established and effective. Most had non-executive director oversight. This ensured an objectivity and appropriate challenge. The trust achieved ‘ward to board’ assurance through a number of mechanisms. The trust governance committee oversaw all aspects of quality (patient safety; outcomes and experience) for the organisation. This included; safeguarding; infection control; patient safety and serious incidents; safer staffing levels for inpatient units; complaints and user experience; locality risk register monitoring and triangulation of information. This committee gave assurance to the board and provided notification on exceptions/ areas of concern. The trust had the right policies in place to support staff in their work.

• The board actively engaged with service users. We observed that board meetings started with a patient experience presentation, undertaken by someone who had first-hand experiences of using the trusts services. Each quarter the board received a service experience report which identified the experience of patients and carers, provided examples of the learning that has been achieved, emergent themes from clinical services, complaints, concerns, comments and compliments and survey information.

• The trust had a strong track record of working in partnership with the independent sector using an integrated model to provide services in Gloucestershire. However, with the recent decision by Herefordshire council to remove social workers from the trust we had concerns about how well the system would operate in the future. We received many positive comments about the trust from clinical commissioning groups, local authorities and health watch groups. They told us the trust was proactive in its local relationships and provided an open and transparent dialogue. However, some third party organisations, representing specific patient groups, were less complimentary about the trust performance and how it engaged with them.

• We found the trust had effective systems in place for financial reporting. These along with key performance indicators for all teams ensured the trust management team were aware of the organisation’s performance throughout the year. The trust planned to report deficit of £0.5m for 2015/16. It intended to return to breakeven in 2016/17, but this statement was based upon the full delivery of next year’s cost improvement plan. This would be the first time the trust had forecast a deficit in 31 consecutive quarters of reporting a financial surplus.

• The friends and family test showed that an average of 75% of staff said they would be likely or extremely likely to recommend the trust as a place to receive care or treatment; 60% of staff said they would be likely or extremely likely to recommend the trust as a place to work and 85% of patient respondents were likely or extremely likely to recommend the trust services.

• The trust was committed to developing its services and had developed a number of excellent and innovative areas of practice including:

• The trust had established a recovery college. The college had been developed and co-delivered with service users. The recovery college provided courses and educational workshops that taught patients to become experts in their own recovery and self-care. The courses that were offered had been co-produced with patients

• There was a programme of Experts by Experience who were involved in a wide variety of trust activity including: recruitment of trust staff; research; committee activity; development and scrutiny activity etc.

• The Gloucestershire Young Carers organisation delivered an integrated project to support young carers of adults with mental illness

• The trust participated in the ‘national viewpoint’ study last year. The trust had been selected as one of two sites in the UK to pilot a survey about mental health stigma with Time to Change

• The trust participated in a number of Royal College of Psychiatrists’ quality improvement programmes or alternative accreditation schemes. Acute wards for adults of working age had an 'excellent' accreditation rating from the accreditation for inpatient mental health services programme.

• Throughout the inspection the trust was very receptive to any comments that we made and we saw immediate action taken when we raised a concern. For example, it rectified a concern immediately about the environment at Lexham Lodge, a temporary facility used by the managing memory team in Gloucestershire whilst their facilities were being rebuilt. It made provision for patients to be seen at home if they could not attend another facility and stopped using Lexham Lodge to see patients altogether. The trust also made the decision to make Mental Health Act and Mental Capacity Act training mandatory for all clinical and appropriate other staff.

However,

• There were some area of care and treatment that clearly needed improvement. We received a number of negative comments from patients and carers. Some patients and carers expressed some serious concerns about the care, treatment and services they had received from the trust. They made it clear that they felt the trust needed to make improvements in some areas and take more appropriate action to deal with their complaints and concerns..

• Overall, we rated the trust as ‘requires improvement’ for the key question ‘are services safe’? We found pockets of poor practice and poor services that needed improvement in wards for older people, rehabilitation wards, wards for people with learning disabilities and community services for older people and those for adults of working age. None of these were generic in nature or widespread across the trust.

• Whilst we welcomed the trusts approach to not using seclusion, we were concerned that staff within the learning disability wards were using a form of it but not recording it as such appropriately. The trust had been working with Gloucestershire clinical commissioning group and Gloucestershire county council to agree and develop a new model of care for patients with learning disabilities for some considerable time. Whilst there was a commitment by all to provide high quality services close to home for patients with complex needs and some redevelopment work has started at Hollybrook there had been several setbacks with the plans to develop a community supported living facility. In addition, there was no clear discharge process for patients and those with discharge plans had no timeframe for discharge.
• On one older person’s ward (Jenny Lind); standards for privacy and dignity on mixed sex wards were not always met. There were no en-suite washing facilities or separate sleeping and washing areas for males and females but we saw plans the trust had for refurbishing the rooms to provide en-suite facilities.
• On rehabilitation wards policies and procedures were not always followed in ensuring incidents were reported and the facilities at Oak House needed significant improvement.
• In community services for older people staff working at the memory assessment services had caseloads of over 300 patients per full time worker, resulting in 11% of annual reviews being missed. There was a long wait of up to six months for access to psychological therapy in Herefordshire. Sickness levels were high in Herefordshire with one team at 9%; there was a lack of clinical supervision for staff and a lack of managerial supervision for staff in Gloucestershire.
• In community services for adults of working age sound proofing in the team base for Herefordshire meant that patient confidentiality could be compromised as conversation could be clearly heard outside of rooms used to see patients and cleaning arrangements needed attention to ensure all areas were clean and suitable for patients.
• In a number of services across the trust we had some concerns that staff did not always record all relevant information in electronic patient records (RiO). This included staff not recording risk assessments, risk alerts and medication reviews in care plans. Care plans were not always comprehensive and it was not always clear whether patients had been involved in developing their care plans. Crisis plans, outcome scales and consent to care documentation was missing from patient records some information was either not located in the correct sections or was missing altogether. Staff in community services experienced particular difficulties around the completion of records on RiO, travelling long distances to see patients, the inability to input information in ‘real time’ and having to go back to bases to input information impacted on their ability to maintain robust and contemporaneous records. However, the trust had developed a number of programmes of work to help address/improve this. The director of quality was leading work to ensure the trust met its milestones for delivering improvements.
• 2gether NHS Foundation Trust provided caring, effective and responsive services to the people it serves. In the main services were safe although some improvements were needed in some services. It was a well-led organisation and we are confident that the trust will continue to ensure it delivers high quality, contemporary and innovative services and will ensure improvements are made in all the areas that we have identified as needing improvement. We will be working with the trust to agree and action plan to assist it in making improvements were needed.

We rated specialist mental health services for children and young people as good because:

• There was good interagency partnership working with Action for Children, youth offending and substance misuse teams, children’s services and paediatricians. Staff worked in a way, which was open and transparent and gave examples of when they had contacted children and young people and parents to discuss issues sensitively. All teams showed innovative practice and examples of this included a project with the military, the development of a reunification team and the functional family therapy team.

• Children and young people had access to a wide skill mix across all services .The skill mix in all teams included occupational therapists, nurses, nurse prescribers, art therapists, psychiatrists, psychologists, cognitive behavioural therapists and dialectical behavioural therapists giving children and young people access to a wide holistic service. Medical cover was good within the teams and there was access to a psychiatrist during the day and out of hours.

• All services had clear criteria for assessing referrals and signposted those that did not meet this. Missed appointments and reasons for cancellation explored and addressed where possible.

• Safeguarding processes were in place. All staff received training and were able to speak with confidence about making referrals. Service managers provided representation on safeguarding boards and gave regular updates in team meetings.

• Feedback from children and young people and families was extremely positive about the teams and the way they responded to individuals.

However:

• Staff did not always record that care plans were person centred, reviewed the risk assessments, put crisis plans in place or recorded physical healthcare consistently.
• There were no tier 4 inpatient beds available and children and young people had to be placed out of county often a great distance from home. In order to address this the trust had introduced the tier 3.5 service which was being further developed.
• Hereford clinic rooms were dull and not appropriately decorated or set up for use by children and young people.

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.

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.

We rated older people’s inpatient services as good because:

• All the wards were clean and safe.
• Staff were visible on the wards, there were sufficient staff on the wards of the right grades and experience with appropriate skills, training and competencies to care for patients appropriately.
• Patients were protected from the risk of unsafe medication practices.
• Each patient had a comprehensive, individually tailored, risk assessment.
• The service had robust arrangements in place to ensure that staff learn from incidents, or when things go wrong.
• Care plans were person-centred, holistic, recovery orientated with detailed intervention plans.
• Staff applied recommended best practice and guidance to ensuring that patients received care which was high quality and effective, including pharmacological and psychological interventions recommended by the national institute for health and care excellence.
• Patients, family and carers were included in the decisions about their care and were listened to by the professionals involved.

• There were no delays in admission to the older age adult’s wards and no out of area placements attributed to a bed not being available.
• Patients had a comprehensive discharge plan in place and there were no delays in discharge that can be attributed to the trust.
• The service had a limited number of complaints in the past year and staff were supported to learn from the complaints received.
• Staff were clear about the organisation’s visions and values and worked with a clear philosophy on ensuring each patient received the highest standards of care possible and there were governance arrangements in place.

• The service had accreditation for its inpatient mental health services awarded for their work and commitment to elderly care by the Royal College of Psychiatrists, and electro convulsive therapy, which is a procedure where a brief application of electric stimulus is used to produce a generalized seizure.

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.

We rated wards for people with learning disabilities or autism as requires improvement because:

• the trust had been working with Gloucestershire clinical commissioning group and Gloucestershire county council to agree and develop a new model of care for patients with learning disabilities for some considerable time. Whilst there was a commitment by all to provide high quality services close to home for patients with complex needs and some redevelopment work has started at Hollybrook there had been several setbacks with the plans to develop a community supported living facility     
• there was no clear discharge process for patients and those with discharge plans had no timeframe for discharge
• at Hollybrook all patients had been in service since 2012 and one had been there for 17 years
• there were no effective processes in place for patients to input into their care or the development of the service. The were no plans to address this and no plans to involve patients in planning the new service
• we were concerned there may had been episodes of seclusion that were not recognised or recorded as such by staff. Staff had not always followed the trust policy on seclusion
• the unit was not using outcome measure tools to assess and monitor patient progress
• staff continued to use china cups on a ward even though the patient were not allowed to use these and had to use plastic cups
• staff at Westridge wore a uniform that consisted of a blue tunic and blue trousers, which resembled a theatre uniform. Staff told us that at least one patient’s family felt the uniform was inappropriate. There were no plans to review the style of uniform worn
• patients did not receive a copy of their care plan and patient's views were not recorded in their care plan. In Hollybrook staff felt patients would not understand their care plan and no attempts had been made to address this issue
• the reasons why patients might lack capacity was not reviewed regularly
• the trust’s covert medication policy was not always followed
• the patient satisfaction tool in place was not accessible by patients with poor literacy skills. most patients were unable to use the complaints procedure. There were no plans to address this
• at Hollybrook staff had not had formal supervision although reported that informal supervision took place and that they felt supported

However:

• as part of the new model of care the trust had developed a learning disabilities intensive support team to support patients that would normally be admitted to hospital to be cared at home. This had resulted in fewer admissions to the inpatient units
• the units were clean and tidy and furnishing was in a good state of repair
• prone restraint (when a patient is held lying face down on the floor) was never used on Hollybrook and only used in Westridge when a patient had taken themselves to the floor, face down and was then only used for the shortest time necessary
• staff were trained in proactive behaviour management techniques. Behaviour management plans were individualised and based on the analysis of incidents. Staff could explain the types of behaviours patients displayed and a range of interventions used
• all patients had risk assessments on admission and a care plan for any identified risk
• care plans were in place and were reviewed regularly and records were kept securely
• staff received safeguarding training and could advise us on how to respond to a safeguarding issue
• a number of items were restricted on both sites this included alcohol, knifes and other dangerous items which was appropriate to the services, additional restricted items were based on the individual patients need
• physical health was assessed on admission and necessary on going health monitoring was in place
• we saw patients being treated in a compassionate way and treated with dignity and respect 
• communication aids were used that were personalised and met patients’ needs. For example, a DVD had been developed to advise patient about admission to Hollybrook
• family contact was encouraged and patient could use a variety of methods to remain in contact
• patients could personalise their room
• the service considered patient compatibility when considering admissions

We rated community-based mental health services for older people as requires improvement because:

• Staff working at the memory assessment services had caseloads of over 300 patients per full time worker, resulting in 11% of annual reviews being missed. There was a long wait of up to six months for access to psychological therapy in Herefordshire.
• We found the environment at Lexham Lodge, a temporary facility used by the managing memory team in Gloucestershire whilst their facilities were being rebuilt, was unsafe and unsuitable for older people accessing the building. The trust responded immediately to our concerns and arranged for all patients to be supported inappointments as home visits rather than outpatient appointments at Lexham Lodge.
• Patients told us they did not know how to complain and they had not been given the opportunity to feedback about their services.
• Staff did not record all relevant information in electronic patient records (RiO). This included staff not recording risk alerts and medication reviews in care plans. Some progress notes were detailed. However, most information was either not located in the correct sections or was missing altogether. Crisis plans, health of the nation outcome scales and consent to care documentation was missing from most of the patient records we examined. Staff working in the later life team who were supporting some people with end of life care had not recorded advanced decisions in RiO records.
• Sickness levels were high in Herefordshire with one team at 9%. There was a lack of managerial and clinical supervision in the Herefordshire teams and managers in the community teams in Gloucestershire had only received three managerial supervisions in one year. Staff in Herefordshire told us that the combination of losing three manager posts and the withdrawal of the social services component (social workers, carer assessment workers and their caseloads) from their teams had made them feel stressed at work. Staff felt unsupported and were unsupervised.
• Senior staff felt they were not consulted with or listened to by the senior executive team about changes and developments to their services. Some said there had been a lack of transparency in regards to service development and changes.

However:

• Staff in the community mental health teams had manageable caseloads, averaging 30 patients per full time worker. Wait times for initial assessments were mostly within the four week wait target time and any breaches were well managed. Staff offered patients flexible appointment times and locations. There were short wait times for access to psychological therapies in the later life team in Gloucestershire. Staff told us they reviewed antipsychotic and anti-dementia medication regularly, although they could have documented this more in RiO notes. Patients had good access to advocacy.
• Teams in Gloucestershire were well staffed and any vacancies were well managed. Managers here used long-term bank staff and did not use agency staff. Sickness and turnover rates were low. Teams held regular multidisciplinary meetings and teams in Gloucestershire had developed strong links with other services both internally and externally. Lone working policies were robust and reliable throughout all services.
• Managers shared good learning from incidents and complaints, cascaded to all staff in team meetings and learning events.
• The dementia education team at Sherbourne House worked innovatively to develop community awareness about dementia. Leaflets were displayed in waiting areas for patients to find information about advocacy, their rights and how to access services. Managers in all but the later life team utilised key performance indicators to monitor performance on team performance.
• The staff we spoke to were motivated, passionate, caring and dedicated. They promoted choice and were respectful of their patients. They were very proud of the job they did.
• Patients were complimentary of their staff teams. Patients had good access to advocacy.

We rated acute wards and PICU for adults of working age as good because;

• All wards had a wide range of activities from 9am to 9pm seven days a week. These were tailored to patients’ individual needs and encouraged engagement. We also witnessed staff interacting with patients in a motivated and enthusiastic way.
• There was clear evidence of relational security on all wards and this was observed in the interactions between staff and patients. Staff were able to demonstrate detailed knowledge of the patient group.
• All wards at Wotton Lawn were clean, soft furnishings and décor was in good condition and well-presented and the environment was well lit. Patients had had input into the decoration of the ward areas and patients’ art work was hung on the walls around all common areas of the wards. At Mortimer ward the best use had been made of the environment. It was clean and well-lit and blind spots and ligature risks had been identified and mitigated with control measures in the most cases.
• There was evidence of a programme of continual improvement. ‘Safewards’ was being introduced across all wards. Staff were members of national groups linked to their areas of work. The trust had introduced a nationally recognised certificate in healthcare for all new health care assistants.

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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.