Sussex Partnership NHS Foundation Trust

Updated 27 October 2023

Updated 27 October 2023

Chalkhill delivers a Tier 4 Child and Adolescent Mental Health Service (CAMHS). Chalkhill is run by Sussex Partnership NHS Foundation Trust and is a 16-bedded mixed gender inpatient unit where young people are admitted if they require assessment and treatment for acute mental health needs. Chalkhill is a sole Mental Health facility in the grounds of a general acute hospital, exclusively for 12–17-year-old young people. They offer assessment and treatment of a wide range of mental health difficulties and needs, as well as support for eating disorders and disordered eating.

Chalkhill was last inspected in December 2016 and was rated as Good overall with Outstanding in Caring.

We carried out this unannounced focused inspection because we received information of concern regarding the safety and wellbeing of the young people, high levels of incidents leading to harm, staff training and competence, low staffing numbers, ineffective observations of young people and poor leadership and support. Before the inspection the trust along with the commissioners of the service had identified some safety concerns and had an action plan in place to address. However, the action plan had not been fully implemented and some of these areas remained a concern during this inspection.

We inspected safe and well-led. Following this inspection, the ratings for safe and well-led went down from good to requires improvement. This meant that the overall rating for the service also went down from good to requires improvement.

Following this inspection, we served the trust with a Warning Notice, because we found that significant improvement was needed to ensure that there was effective oversight of processes and practices, staff competence and support and risk assessing the health, safety and welfare of young people. The Warning Notice required the provider to make improvements to meet the legal requirements set out in the Health and Social Care Act by 11 August 2023. In response to the warning notice, an updated action plan was provided, which set out the actions they had taken to immediately address the safety concerns and the actions they planned to take to mitigate remaining risks.

Prior to the inspection, the trust had capped the occupancy levels at 12 beds. This was to ensure a safe patient to staff ratio during the recruitment of clinical staff. Following our inspection and feedback, the trust paused any new admissions and worked to safely discharge some of the young people where appropriate. Post inspection, the trust continued to provide us with information about the detailed actions being taken that allowed us to monitor the service. The trust had regular engagement with us as part of that monitoring process.

Our rating of services went down. We rated them as requires improvement. Our key findings were:

• The ward was not always safe, clean or well-maintained. Staff did not always assess and manage risk well. The environmental security checks and the documentation used to support this did not always capture risks or enable appropriate mitigation to be put in place. Repairs to the ward were not carried out in a timely manner which added to the clinical pressures on the service.
• Staff were not always able to keep young people safe from avoidable harm. There were high levels of repeated incidents which caused harm and potential harm to young people where injury was sustained. Staff did not always identify and report all incidents or near misses of incidents. Incidents were not always reviewed and investigated by competent staff. Incidents were not consistently monitored, and action was not always taken to remedy the situation, to prevent further occurrences and to make sure improvements were made as a result.

• Staff did not always manage risk well. Although staff completed daily environmental checks of the service environment, they did not always identify, remove or reduce risks that were evident on the ward.
• Staff did not always assess and manage risks to young people and themselves. Risk assessments did not always identify or address all a young person’s needs.
• Staff did not always develop care plans that appropriately reflected young people’s assessed needs. Care plans were not always personalised, holistic and recovery oriented. Staff did not always use the information in the care plans when delivering care to young people.
• There was not enough staff deployed with the skills, expertise and experience to meet the needs of the young people. There was a reliance on agency and bank staff, especially at night. There was no assessment of staff competence and some of the staff did not know how to safely support the young people. Staff told us they were not receiving regular supervision and did not feel supported by the service management to carry out their role.
• Staff from the different disciplines did not always work together effectively and this resulted in gaps in the young people’s care.
• There were indicators of a closed culture at the service. The trust did not ensure practice at the service was open and transparent. Staff and young people told us they did not always feel safe or supported to raise concerns. Staff reported exceptionally low morale.
• Staff did not always follow the trust’s policy and procedures on the use of enhanced support when observing young people assessed as being at higher risk of harm to themselves and others.
• Blanket restrictions were evident on the ward which restricted the young people’s movement around the service.
• Feedback from young people and relatives and carers was negative. Young people did not always feel safe on the ward.
• The governance processes did not always operate effectively. Risks were not always managed well, with oversight, monitoring and learning from incidents being poor. The trust processes for reporting and reviewing incidents was not effective. Despite the trust already having an action plan in place, the trust did not have adequate assurance mechanisms in place. They had not identified that young people were not always receiving safe care and had not acted to make improvements in a timely manner.

However:

• All staff spoke positively and, in a kind, caring and respectful manner about the young people. Our observations of interactions between most staff and young people also reflected this.
• The mandatory training programme was comprehensive and met the needs of young people and staff.
• Staff completed risk assessments for each patient on admission, using a recognised tool.
• Young people eligible to take leave were able to take this with the support from staff.
• There had been successful discharges where young people had been supported to move on from the service.
• There had been recent positive changes to the management of the service.
• The service had access to a range of specialists including nurses, occupational therapists, physical health nurses, psychologists and social worker.

What people who use the service say

Young people told us they did not always feel safe on the ward. They told us staff were varied in their approach, and whilst there were certain staff they described positively, they also spoke about staff who they felt did not know them well and did not listen or help them when needed.

What carers and relatives of people who use the service say:

Relatives told us they did not feel their young person was safe or well looked after at all times at the service. They told us about communication concerns, specifically when incidents and investigations happened and not being informed or kept updated. They felt they had to always phone and request information repeatedly as key workers were not always keeping them up to date with their young persons care and their lives whilst they were at the service. They felt there was a lot of agency staff who did not know the young people and their needs well. One relative did say they were invited to multidisciplinary team meetings to discuss their young person’s care and they felt the service was welcoming when they attended.

Updated 23 January 2018

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

• One domain was rated as outstanding (Caring) and four domains were rated as good (Safe, Effective, Responsive and Well-Led).
• The service had addressed and managed the concerns raised at the last inspection.
• Clinician’s caseloads were continually monitored and managed. Risk to patients on waiting lists was well managed and mitigated.
• All patients entering the service had thorough risk assessments and management plans in place. There were excellent safeguarding policies, procedures and lead practitioners in the service.
• Supervision was happening regularly in line with trust policy. On inspection, we saw that supervision completion rates were much higher than data submitted and had significantly improved since the last inspection.
• The service appropriately monitored and managed patients physical health needs. We witnessed excellent working relationships with partner agencies to arrange for further physical health testing when required. Multidisciplinary and interagency working across the service was excellent. We saw the service engaging with many partner agencies to benefit their patients.
• The service delivered a range of evidence-based specific treatment pathways and therapeutic interventions for patients.
• We observed many positive and engaging interactions between staff and patients and staff demonstrated a caring attitude towards patients. Patient and carer feedback on staff attitudes was excellent. Patients and carers felt involved with the delivery of their care and felt that their voice was heard.
• The service provided an advice consult experience (ACE) for patients and carers to join and become involved in service projects and give feedback on staff recruitment panels.
• The service delivered a variety of additional campaigns, workshops, events and support groups to equip patients and carers with skills and tools to deal with their mental health in the community, reduce stigma and encourage social interaction.
• Sites were within target times for assessment, except for the Hampshire locations where we saw clear and effective plans in place to reduce the waiting times. The service was on average within national target times for referral to treatment.
• The service was managing the risk of their waiting lists well and were constantly engaging with patients, parents and carers to assess any changes in circumstances and risk. There was a consistent and effective approach across the service to dealing with crisis and emergency situations.
• There was clear leadership direction from senior members of staff within the service with sufficient leadership training and opportunities for all staff. Staff were extremely proud to work in the service and for the trust and morale was generally high amongst all staff.
• The service undertook a variety of staff wellbeing activities and days to support staff wellbeing and contribute towards the services recruitment and retention plan.
• Local management and systems of supervision and appraisals was appropriate and monitored regularly at all locations. There were regular audits in place to monitor for regularity and quality of supervision by senior leadership.
• Innovation within the service was excellent. The service had a culture of driving positive change from the bottom.
• Front-line staff had the confidence, support and encouragement to suggest and try new ideas.

However:

• There were no alarm systems in place for Chichester and not all therapy rooms had alarms in Eastleigh. Staff did not carry personal alarms at either of these sites.
• Not all patient risk assessments were updated within six months, as per trust policy. We found this in 13% of the care records we reviewed.
• As at December 2017 the core service was just below the trust’s target for mandatory training (at 84% compared to the target of 85%) and five mandatory training courses were below 75% completion. The service submitted an action plan to us which showed how they planned to ensure all staff completed mandatory training by March 2018.
• Some sites did not have enough therapy rooms. This impacted on the delivery of care at one location where appointments were either not being made, shortened or cancelled at the last minute.

Updated 23 December 2016

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

• The trust maintained safe staffing levels across teams. Turnover, sickness and vacancy rates were low in the teams we inspected. The trust managed vacancies pragmatically when they arose by discussing the needs of each team and varying staff skills accordingly. Staff in all teams were highly skilled, qualified and enthusiastic about their work. Staff accessed specialist training to improve their skills. Staff morale was high and all staff reported feeling supported by their team, local management and trust management.

• Staff completed thorough risk assessments and reviewed risk appropriately. Risk assessments covered all areas. Staff reported manageable caseload numbers across all teams we inspected. Staff raised safeguarding alerts to the local authority competently and knew what to report.

• Multidisciplinary and interagency working was excellent. We saw initiatives to improve working with mental health teams, dementia teams, social care and child and adolescent teams. We saw interagency working to promote the Transforming Care Agenda 2015. This aims to improve services for people with a learning disability and a mental health problem or behaviour that challenges. Staff promoted joint working agreements with relevant teams to prevent admission to hospital for people using the service. Staff provided high quality training packages to other teams and providers to raise awareness of learning disability issues and to improve care in these areas.

• The service worked effectively with people who found it hard to engage. They provided bespoke packages of care to enable people to live in the community who may otherwise be in hospital.

• Staff treated people using the service with respect and sensitivity. Staff really cared about the people they worked with. People using the service and their carers spoke positively about staff and the service they provided. The trust employed therapy assistants to ensure all staff and providers worked effectively with people with learning disabilities. All locations were accessible for people with physical disabilities and all locations provided easy read signage. Information, reports and care plans were all available in easily accessible formats.

• The trust was committed to research and evidence based practice. Staff were proactive at trying out new initiatives and being involved in research and development.

However:

• Staff did not complete crisis plans routinely. These plans inform people using the service and their carers who to contact or what measures to take in a crisis.

• Staff reported incidents but did not always learn lessons from the investigations of these incidents. This meant services missed opportunities for improvement.

• The trust recently introduced the electronic database, care notes. However, the trust had not implemented standard operating procedures. As a result, different teams and staff from different disciplines recorded information in different formats and in different sections. This meant it was not easy to find information in the notes as individuals recorded things differently.

• Teams did not use outcome measures to monitor effectiveness and progress of interventions.

• The teams did not routinely ask people using the service to complete satisfaction surveys. This meant that the teams missed opportunities to improve services in response to feedback.

Updated 23 December 2016

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

• Staff were providing a safe service. Staff were aware of the risks for individual people who used the service, medication was managed well and staff had a good understanding of safeguarding. Staff were able to see people who used the service in a timely manner and prioritised people who needed urgent support.

• Practice reflected current guidance and there was good access to a wide range of interventions. There was good use of outcome measures to monitor if services were effective. Audits that were specific to the service were carried out to provide assurances of robust care with improvements made where needed.

• Staff were consistently caring and showed warmth, kindness and respect to people who used services and their carers. They provided practical and emotional support. Staff went the extra mile to care for people in a person centred way and involve carers and people who use the service in their care. Groups and accessible information was provided for people and carers. The needs of carers were assessed and support groups were provided.

• Staff morale was good. They were well supported with access to training and other opportunities to reflect and learn. There were opportunities for leadership training and career progression.

• The teams worked well with GPs, the local authorities and other local services and groups.

• People who used the service, carers, staff and external stakeholders were encouraged to give feedback through a range of mechanisms and these were used to make improvements.

Updated 7 June 2019

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

• We had very significant concerns about the crisis team based at Millview.
• The amount of medical cover varied across services as most of the consultants worked part time. Staff told us that there were sometimes problems because the junior doctors that provided cover were sometimes reluctant to prescribe medicines because they didn’t know the patients.
• There was evidence that the low morale, resistance to change and culture of the crisis team at Mill View Hospital was having a negative impact on the care and treatment that some patients received. Care plans and risk assessments were not kept up to date to ensure patients were receiving the care and treatment they needed.
• The care records reviewed across the four teams varied with respect to their quality and level of detail. The risk assessments and care plans at Meadowfield, Chichester and Langley Green were comprehensive, holistic and recovery orientated. At Mill View, of the six risk assessments reviewed, one had no risk assessment and five contained limited information that did not accurately reflect the current clinical presentation of the patient. In four of the six records reviewed care plans were missing in two of these patients with high risk and complex needs were identified. The remaining two records that had care plans, were not holistic and did not reflect the full range of needs of the patients. Staff did not always act on review of overdue care plans that had been flagged on the whiteboard. An investigation into a serious incident at Mill View in December 2017 had identified the lack of a crisis personalised care plan as a contributory factor. The investigation into the incident recommended that all patients should have an individualised care plan in place by March 2019.
• Staff from the places of safety did not always record the time that the approved mental health professional and section 12 doctor had been requested. This meant that the nurse could not accurately calculate the time from request to completion of assessment.
• Staff told us that there were sometimes delays in accident and emergency due to a place of safety not being available, approved mental health professionals and police said there were sometimes delays in identifying an available place of safety because of the referral process involved a pager, which then delayed a response to initial contact. Staff said that because ambulances did not always meet the trust policy’s agreed response time, an alternative health ambulance company was used to transport patients to the place of safety.

However:

• Staffing numbers were based on caseload and patient needs. Managers used regular bank staff who knew the patients and service well. The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• Staff discussed risks and safeguarding concerns during regular handovers. Staff held meaningful discussions and spoke about patients in a respectful and caring manner. Staff had access to psychiatrists, to ensure all risks from patients on their caseload were safely managed. Staff saw all patients daily for the first three days and then reviewed frequency of visits. We saw evidence that staff saw patients twice a day where risk was considered high.
• There was a range of disciplines in the crisis teams which included doctors, nurses, psychologists, occupational therapists and social workers. All staff we spoke with were appropriately experienced and qualified to meet the needs of patients.
• Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned. The trust sent a bulletin to all staff with information about recent incidents and any learning identified. Staff had access to debrief sessions after serious incidents that were facilitated by senior managers and psychologists.
• We saw effective multi-agency working with a variety of services including the police, ambulance services, approved mental health professionals, rapid response team, street triage and in-patient wards.
• Patients at Langley Green could access the day service for daily group therapy in a range of psycho-social interventions Monday to Friday. Groups offered included mindfulness, managing anxiety and art therapy.
• We observed staff from the mental health telephone service who were supportive, kind and caring in their conversations with callers.
• Patients from the crisis teams spoke positively about the support they had received. They said that staff were responsive, listened and were easy to talk to and they had found the support invaluable. People who had used the places of safety said that staff had treated them with kindness and respect and had done their best to make them feel comfortable.
• The trust had introduced initiatives including a pilot to improve the referral process in Chichester and the introduction of an early discharge nurse to bridge the gap between wards and the crisis teams.
• An urgent care lounge had recently been opened at Langley Green to provide a calm environment for patients waiting to be assessed. The trust planned to open a psychiatric decision unit at Mill View in April 2019 which will cover the whole of the county.
• The managers and team leaders demonstrated the skills, knowledge and experience to perform their roles. All leaders showed a good understanding of the service and could clearly explain how to provide high quality care.
• A lead nurse for quality and compliance had been in post since October 2018. They were responsible for standardising processes and improving services to patients in the places of safety. Staff reported an improvement in clinical practice and cascading information since they had been in post.

Updated 23 December 2016

At our last inspection in January 2015, we found the service required improvement. Since the last inspection the service had improved. This time we rated wards for people with learning disabilities or autism as good because:

• Staff supported patients in a safe ward, which was clean.They identified risks in the ward and developed plans to keep patients safe.

• Staff completed full assessments for patients, which included their individual needs and risks.They used these assessments and worked with patients to develop individualised care plans, which followed professional guidance.

• Staff used safe techniques when restraining patients and reviewed incidents of restraint to see if they could support patients in a less restrictive manner in the future.

• The ward multi-disciplinary team had an appropriate range of professional skills to meet patients’ needs. Staff worked well as a team and felt well supported.

• Staff supported patients in a kind and considerate manner, whilst maintaining their privacy and dignity. We observed staff being very supportive to patients.The feedback we received from patients and their carers was positive. Staff involved people in the care they received.

• The service had clear systems for reviewing quality information and implementing learning.Staff reported when things went wrong and investigated these incidents to identify how they could improve in the future. Staff had developed and completed improvement action plans following our last inspection, which rated the service requires improvement.During this inspection we found staff had implemented necessary changes and made many improvements.

Updated 7 June 2019

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

• We rated four key questions as good (Safe, Effective, Caring and Well-led) and one key question as outstanding (Responsive).
• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors and ward managers could adjust the staffing levels based upon the acuity on the wards. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Not all patients prescribed high dose antipsychotic medicine had their physical healthcare appropriately monitored. High dose antipsychotic medication is medicine that is prescribed in excess of the upper limits recommended by the British National Formulary
• Fir ward at The Chichester Centre was storing patient bank cards and money in the medicine cupboard temporarily. This was inappropriate and posed a risk to the security of the cards. The service immediately rectified the issue when we highlighted it to them.
• Ash and Hazel wards had items in their clinic rooms that were past their ‘use by’ date. These included oral syringes, urinalysis test strips and disposable tourniquets. This was immediately rectified when highlighted to the service.
• On two wards, staff were not ensuring that medicines were stored at the correct temperature. Fir ward’s fridge temperature was consistently recorded as above eight degrees celsius whilst storing patient medicines. This posed a risk to the efficacy of the medicines. This was immediately rectified when highlighted to the service who moved the medicine into a different medicine fridge. The trust advised us that this was a recording error by staff reading the thermometer temperatures. Additionally, Hazel ward’s clinic room was consistently recorded as above the maximum temperature threshold stated in trust policy. The ward had ordered an air conditioning unit and the pharmacy team reduced the medicine expiry dates in accordance with trust policy in response to the raised temperatures.

Updated 23 December 2016

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We rated long stay/rehabilitation wards for adults of working age as good overall because:

• Clincal risk was well managed with risk assessments reviewed and updated in ward round meetings. Environmental risks were identified and addressed regularly and managers ensured that environmental risk assessments were regularly undertaken. These were shared with staff in monthly meetings. There weresystems in place for sharing information with staff around lessons learned

• the average Patient Led Assessment of the Care Environment score for cleanliness across all services was 93%; with three of the services scoring 100%

• staff on all wards provided patients with a full and comprehensive programme of therapeutic, recovery focussed activities and interventions. Activity plans were patient led and designed around personal needs and choices. All of the services promoted and encouraged positive risk taking within their ethos and actively supported patients towards independence.

• there were enough staff to provide patients with regular 1:1 time and staff informed us that leave was not cancelled because of staffing levels. Patients confirmed that leave was regularly facilitated

• overall compliance with mandatory training for the services was 81%. This was higher than the trust compliance rate of 65% - 75% in all areas of mandatory training

• staff completed comprehensive assessments for all service users in a timely manner. All 30 care records we reviewed were up to date, personalised, holistic and recovery orientated. Records showed that patients had ongoing physical health monitoring, using national early warning scores needs and this was recorded in patient notes.

• we observed positive therapeutic relationships between staff and patients at all wards and we observed strong local leadership across the wards, which staff and patients confirmed.

Updated 7 June 2019

Sussex Partnership NHS Foundation Trust provides wards for older people with mental health conditions who are admitted informally or detained under the Mental Health Act 1983.

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

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

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

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

At the last comprehensive inspection of this core service in October 2017, we rated the wards as good for the five key questions (safe, effective, caring, responsive and well-led). We re-inspected all five key questions during this inspection.

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding
• Staff developed a holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialities required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
• The service managed beds well in most wards and many patients were discharged once their condition warranted this.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Although we concluded that staff actively involved patients in their care, on St Raphael ward the plans did not contain patients’ preferences including their likes and dislikes around their care. Also, there were no accessible or easy read care planning tools available for patients who might need them on most wards including St Raphael, Opal and Brunswick wards.
• Due to high demand for admissions, patients on Heathfield ward did not always have beds available to them when returning from leave.
• Heathfield and St Raphael wards had shared sleeping arrangements where more than one patient had to sleep in the same bedroom. The four dormitories on Heathfield ward had only one sink each.
• The dining room on Grove ward was very enclosed and was not decorated in dementia friendly colours.

Updated 28 May 2021

We undertook an unannounced, focused inspection of Langley Green Hospital to see if the provider was now meeting the requirements of the warning notice that we served (under section 29a of the Health and Social Care Act 2008). Following our previous inspection in February 2021. The warning notice required the provider to make urgent improvements to ensure that patients who had physical healthcare needs were monitored appropriately and had their needs met to keep them safe.

We also looked at whether the provider had ensured that there was always enough nursing and support staff on all wards, at all times to provide safe, good quality care to patients.

Langley Green is a hospital for people with acute mental health problems. The teams provide assessment and treatment for people across four wards;

• Amber ward, 12 bed psychiatric Intensive Care Unit (PICU),
• Coral ward, 19 bed acute wards for working age adults
• Jade ward, 19 bed acute wards for working age adults and
• Opal ward, 19 bed mixed sex, integrated care for working age adults and older people

We visited all four wards to check whether the provider had made the required improvements to the safety of the service. This inspection was a focussed inspection so therefore did not provide a change to the existing rating.

We did not rate this service at this inspection. The previous rating of requires improvement remains.

We found:

• The service now had enough nursing and support staff to keep patients safe. Since our last inspection, the provider had address staffing levels on all wards and employed agency nurses on a longer-term basis. The trust had also changed the working hours of senior staff to cover 24 hours a day.
• Staff had received training in how to meet the physical health needs of patients and each ward had two physical health champions identified. The physical health team visited the hospital twice a week. Staff reviewed the physical health needs of patients at every handover and at the daily safety huddle.
• Since the last inspection, the provider had reviewed all patients’ physical health needs, to ensure that were met and monitored. Staff had developed care plans for each identified physical health need and included them in the patient’s risk assessment.
• Staff knew how to escalate concerns about physical health. Staff had correctly completed food and fluid charts on Opal ward. Staff on Amber and Opal ward had competed physical health monitoring following rapid tranquilisation correctly.
• Managers had introduced a physical health audit, to ensure that they had oversight of the needs of patients and ensure the needs were being met.

However:

• Staff told us they had enough staff to manage on the wards but still felt that there was not always enough staff on wards if they had to support other wards during incidents.
• Food and fluid charts on Jade ward did not include a target amount and staff had not calculated the total amount of fluid consumed by patients. On Jade ward staff had not calculated the total National Early Warning Score on post rapid tranquilisation charts. We reported this to senior staff during the inspection and they agreed to take immediate action to address these issues.
• Doctors had not reviewed do not attempt cardiopulmonary resuscitation (DNACPR) decisions on admission to the hospital. Staff did not always discuss DNACPR decisions with patients. The provider took immediate action to address this.
• The physical health audit had not identified that staff were not routinely assessing patient’s risk of venous thromboembolism on admission (in line with National Institute for Health and Care Excellence guidelines). The provider has now updated the audit to include to address this.

How we carried out the inspection

During this inspection, we interviewed 17 staff including managers, doctors, nurses and healthcare support workers. We spoke to seven relatives of patients, reviewed nine patient care records, looked at a variety of documentation relating to patient care and other documents relating to the running of the service.

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.

What people who use the service say

We spoke to seven carers and they told us that communication from the hospital could be improved. They told us that it was difficult to get through to the wards on the telephone and staff did not always call them back or call when they were supposed to. Carers told us that when they complained about staff not calling back, staff told them they were busy. Carers told us they were not involved in the care planning for their relative, even when staff had told them they would be, and therefore did not know what care and treatment they were receiving. Most carers told us they did not know what physical health support their loved one was receiving or how staff were supporting their relative with hospital appointments. However, carers felt most staff were friendly and polite and that their relative was safe at the hospital.

Updated 23 January 2018

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

• There were sufficient numbers of staff in each team. Staff vacancies were low and were covered by appropriate use of bank or agency staff. Team leaders reviewed caseloads regularly with practitioners to ensure these were manageable.
• Staff could access a consultant psychiatrist for routine or urgent appointments.
• We reviewed 51 care records of people using services. Staff had completed a risk assessment for each at the point of initial assessment. Staff updated risk assessments regularly and after each reported incident. Each team had a duty system to respond to changes in risk or deterioration in the health of people using services.
• Staff had completed safeguarding training and demonstrated good awareness of safeguarding issues. Teams within West Sussex and Brighton and Hove had integrated social workers who took the lead role in any safeguarding inquiry. Within East Sussex the social workers were co-located which helped facilitate communication with the local authority.
• All staff knew how to report an incident on the trust reporting system. Staff received feedback and learning from incidents at team meetings and via the trust patient safety matters newsletter. We saw evidence of a change in practice following incidents which resulted in more joined up care for people using services.
• All care records of people using services we reviewed had a comprehensive needs assessment. Assessments were person centred, holistic and recovery focused. Care plans reflected the needs identified in the initial assessment.
• The early intervention service had a physical health champion to ensure staff were meeting the physical health needs of people using the service, and over 90% of all people using the service had received their annual physical health screening.
• Staff monitored the effects of medicine on the physical health of people using services and reviewed this regularly in physical health clinics. This was in line with guidance from the National Institute for Health and Care Excellence.
• The trust had a duty of candour policy to which staff adhered. This ensured that staff were open and transparent with those using services and their families and carers and kept them informed of any incidents that might have affected them. The duty of candour policy clearly set out the steps staff must take when informing others following an incident.
• Teams offered a variety of treatment options to people using services including National Institute for Health and Care Excellence approved interventions such as family therapy for those experiencing psychosis and cognitive behavioural therapy for anxiety and depression. Each team was multidisciplinary and included nurses, doctors, social workers, psychologists and occupational therapists as well as peer support workers.
• Staff received regular supervision in a variety of ways. Staff could access clinical, management and peer supervision as well as reflective practice sessions and support from risk circles. Annual appraisals were completed or booked and staff reported these were meaningful and appropriate to their role.
• All teams had good relationships with other teams within, and external to, the organisation. We saw good evidence of joined up working between crisis services, inpatient services and the community teams. Staff had good links with the local authority and teams in West Sussex and Brighton and Hove had employed social workers.
• People using services reported that staff treated them kindly, with respect and maintained their dignity. Staff worked with people using services to help them understand their condition so that they could manage these themselves more effectively.
• We saw evidence in care records of involvement of the people using services in their care planning. Care records showed that staff discussed care plans with those using services and offered them a copy of their care plan.
• Carers we spoke with told us they were kept informed and up to date with any changes in the care for the person receiving the service. Carers were invited to attend review meetings and care programme approach meetings.
• The trust had a set target time for referral to assessment and referral to treatment times. Each service across the trust was meeting these timescales. Each team had a duty system which could see urgent referrals on the same day, or within five days as appropriate. All routine referrals were seen within 28 days.
• The Glebelands service had developed an integrated service with people using services and non-statutory organisations in the area called the Pathfinder Alliance. This was a co-production between the trust, people using services and the third sector and was only one of three in the country.
• The Ifield Drive service had developed a service to provide mental health support to armed services veterans. The service could take referrals directly from veterans, or from their GP. The service aimed to support veterans transition into civilian life and had specialist practitioners who had an understanding of military culture and what the veterans may have been through.
• Staff provided people using services with information on how to make a complaint as part of the initial information pack. People using services told us they knew the process for how to make a complaint.
• All services had a wide range of rooms to see people using services, including clinic rooms. These were all soundproofed to maintain confidentiality. Each waiting area had a suitable supply of information on local community groups, advocacy and medicine information.
• There were clearly defined roles for team leaders and service managers within each team inspected. Team leaders demonstrated a clear understanding of the service they were providing and how it connected to the wider community service.
• All staff we spoke with said they felt proud to work for the team they did, and all emphasised the strong working relationships in the teams. There was an open culture of honesty amongst the practitioners and all staff felt they could offer constructive challenge to one another.
• The trust was involved in numerous pieces of research for people using services, their carers and staff. Staff were encouraged to be involved in service development and quality improvement work.

However:

• Staff at Linwood did not follow the trust lone working policy. Staff at Linwood made arrangements to buddy up with another practitioner at the start of each day. This meant that no one practitioner had oversight of these arrangements. We raised this with the trust during the inspection who gave us assurances that they would ensure staff at Linwood followed the lone working policy.
• Not all mandatory training was up to date across all teams. We raised this with the trust who provided a plan for when this would be completed.
• Staff did not always record on the electronic system why a care plan may not have been provided to the person using services. Some care plans for people using services were detailed in consultant letters, but this was not always recorded.