Rotherham Doncaster and South Humber NHS Foundation Trust

Updated 21 February 2020

Not used

Updated 21 February 2020

Our rating of the trust went down. We rated it as requires improvement because:

• We rated safe, effective, and well led as requires improvement, and caring and responsive as good. We rated three of the trust’s 10 mental health core services and one of the five community health core services as requires improvement overall. We considered the current ratings of the nine services not inspected this time.
• We rated well-led for the trust overall as requires improvement.
• The overall ratings for the community health services for adults went down to requires improvement. The overall ratings for the acute mental health services and adults of working age and the psychiatric intensive care unit, the community mental health services for adults of working age and the long stay/rehabilitation service remained the same as at the last inspection as requires improvement. The forensic/low secure services remained good but the rating went down to requires improvement in the safe key question. The rating of the community mental health services for children and young people also remained good with an improved rating in the well led key question but the rating in the effective key questions going down from good to requires improvement.
• Despite the structures, systems and processes in place to sight the board on quality and safety, there were issues identified with the management of some risks and performance in the core services we inspected. Our findings from the other key questions demonstrated that governance processes did not always operate effectively at service level.
• Systems and processes were not effective in ensuring that staff were maintaining accurate, complete and contemporaneous records. Issues were identified with staff accessing information on the system and the consistency in recording information on the patient electronic system, even though the trust had begun implementing this over 18 months ago.
• Systems and processes were not effective in ensuring there were sufficient staff in the acute mental health services and psychiatric intensive care unit, that caseloads were within the recommended number in the community mental health services for adults of working age, and that all staff received the required mandatory training and clinical supervision as is necessary to enable them to carry out the duties they were employed to perform.
• Systems and processes were not established and operating effectively in all services for assessing, monitoring and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk; the ligature risk assessments in place did not identify or mitigate all the ligature risks in the inpatient core services at the time of the inspection.
• Clinical and local audits were not always completed or effective to provide assurance, including in relation to the application of the Mental Capacity Act and recording in the electronic care records. Managers did not always take the action as required in response to these audits and the performance dashboards in place to support them in completing their role.
• Whilst data quality was improving, it remained an area of concern for the trust; further improvement was required to underpin the decisions of the organisation, including the ability to horizon scan and forecast areas of concern.
• Complaints were not always completed, investigated and responded to in a timely way and not all contact with the complainants is documented. We informed the trust and they were acting to address this.

However:

• The trust had an experienced leadership team with the skills, abilities, and commitment to provide high-quality services. They understood the issues, priorities and challenges the service faced and managed them. There was a growing multidisciplinary approach to clinical leadership demonstratable through the appointment of allied health professions chief officer.
• Staff felt valued, supported and listened to and overall felt positive and proud about working for the trust in the services we visited. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution
• Senior leaders made sure they visited all parts of the trust and fed back to the board to discuss challenges staff and the services faced. The trust’s board of governors was proactive and provided constructive challenge to the trust’s senior leadership team.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively. The trust was actively engaged in collaborative work with external partners working within the health and social care system.
• The trust welcomed and proactively sought external scrutiny of its services and its internal processes. The trust had commissioned an external provider to work with them on a programme of board development. The trust was also working with NHS Improvement to implement two key programmes; leadership and culture.
• The trust was committed to improving services and innovating, with services involved in quality improvement processes. The trust was actively involved in research and continued to grow, broaden and engage with the wider workforce as well as stakeholders.

Updated 21 February 2020

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

• We identified issues with the safety, effectiveness and leadership of the service.
• Our inspection findings showed that leaders did not always operate effective governance processes throughout the service to identify, monitor and improve the quality and safety of the service.
• We found that staff did not ensure that patient records were accurate, complete and contemporaneous. Staff did not always report incidents that they should, and managers did not ensure that staff received regular supervision.
• Staff had provided care and treatment to a patient who they deemed had lacked mental capacity to consent to this and had not completed a mental capacity assessment.
• Staff did not always complete and update patient risk assessments regularly.
• Staff could not recall receiving information on lessons learnt from incidents.

However:

• Since our last inspection, the number of serious incidents had reduced, and the service had made improvements in staffing to ensure the service had enough staff who received the training required.
• The service provided care and treatment mostly based on national guidance and evidence-based practice.
• Staff treated patients with compassion and kindness. They provided emotional support to patients and their carers and involved them in understanding their conditions and in decision making.
• The service planned care to meet the needs of local people. It was inclusive and responsive in providing care to people when they needed it.
• Staff felt respected, supported and valued. Leaders were visible and approachable, and the service engaged with patients, the public and local organisations to plan and manage services.

Updated 19 January 2016

The trust had appropriate risk reporting structures in place. The trust investigated and reported incidents in line with an appropriate policy. We saw evidence of the service sharing learning incidents with staff. There were safeguarding systems in place to ensure children and young people were protected from harm. Staff were knowledgeable and experienced in the safeguarding of children and young people, and in responding to patient risk. Staffing levels and caseloads were broadly appropriate for the service being delivered and were in line with commissioned levels. Where shortages in staff were identified this was raised with the local commissioning service to request additional resources.

Staff received mandatory training, although it was not clear whether all staff were up-to-date with their mandatory training. This was due to a discrepancy between data provided by the trust and local data shown to us by managers. There was a broad awareness of the principles of duty of candour and an appropriate policy was in place. Only management level staff had received full training on this at the time of our inspection.

Staff practiced evidenced based care and treatment. The service used technology and telemedicine to keep in touch with potential service users, including those in hard to reach groups. There was good evidence of multi-disciplinary working within the trust and with local networks. Staff were aware of the principles of consent, and we observed them practicing it during their work. There were also clear and easily accessible referral routes into services. We heard good examples of transition planning for children moving between the health visiting and school nursing service.

The trust was not meeting some targets set by NHS England for this year and its Commissioning for Quality and Innovation (CQUIN) target for breastfeeding. However, the service had identified these issues and mitigating action was being taken to address them. There were variable levels of staff appraisal rates throughout the service. It was not clear whether all staff were up-to-date with their appraisals. This was due to a discrepancy between data provided by the trust and local data shown to us by managers.

We spoke with children, young people and families, and observed care taking place. We found evidence that staff practiced compassionate care and provided emotional support to children, families and other professionals. People who used the services told us they felt involved and understood the care and advice offered to them.

The trust planned and delivered services that met people’s needs and were responsive to the changing needs of the local population. It also used innovation in care to meet the needs of local population and hard to reach groups. This included ensuring additional resource was available when the service noted low breastfeeding uptake. This took into account equality and diversity needs and the needs of people in vulnerable circumstances. There was full access to translation and interpretation services, and links with new migrants to the area and the local lesbian, gay, bisexual and transgender (LGBT) community.

Services were easily accessible and children and young people could access services in a variety of ways, in a manner and at a time to suit them. We saw examples of learning from complaints. This included the use of action plans to inform improvements.

There was a clear vision within the service that focused on innovation and placed the patient at the heart of services. Leadership was not a top down process and staff of all levels showed leadership within services. There was a system in place for the local and corporate management and leadership of the children, families and young people’s service. There were systems in place for linking governance, risk management and quality measurement at service level and at board level. We saw examples of how this information was also cascaded to staff.

There was a positive and responsive leadership supported by an open culture. Leaders supported and empowered staff to drive improvements and to develop. There was extensive evidence of engagement with both the public and staff, and we saw clear examples of staff and public feedback and interaction used to drive and improve services. There were many examples of innovation aimed at increasing access to services and educating children, young people, and their families. There were systems in place to ensure improvement and sustainability. We saw good examples of evaluations of projects taking place to ensure that the service understood and could learn from its successes and failures.

Updated 28 June 2018

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

• The leadership, governance, and culture promoted the delivery of high quality person-centred care. Staff had the skills they needed to carry out their role effectively and in line with best practice. Managers were visible and there was a strength and resilience across ward teams to deliver high quality care to patients.
• Since the previous CQC inspection, managers had taken appropriate action to mitigate and manage the risk to patients by assessing and monitoring venous thromboembolism (VTE).
• Staff told us they were proud to work for the trust and promoted a patient-centred culture.
• Patients, families, and carers felt staff communicated with them effectively and made them feel safe. Staff involved and informed them about care and treatment, promoted the values of dignity and respect, and were kind and compassionate.
• Services were organised to meet the needs of people. Managers and healthcare professionals worked collaboratively with partner organisations and other agencies to ensure services provided flexibility, and continuity of care.
• Staff were competent and had the skills they needed to carry out their roles effectively. The majority of staff had completed mandatory and statutory training and managers had good oversight of the process.

However:

• Although medicines were securely stored and handled safely, we found evidence of prescribing and transcribing errors in the medicines administration charts we looked at. For example, we found incorrect spelling of medicines and use of non-approved abbreviations. Medicines also accounted for 23% of all incidents reported between 1 October 2016 and 30 September 2016. Errors included incorrect dosage and incorrect prescription.
• Compliance level for safeguarding adults level two and level three was variable across the three wards and below the trust target.

Updated 19 January 2016

We rated the end of life care services at Rotherham Doncaster and South Humber NHS Foundation Trust hospital as good for safe, effective, caring, responsive and well led.

There were sufficient staff for the number of patients at the hospice. Community nursing had challenging caseloads and often had to prioritise their work. Bank staff were used to backfill sickness and absence. Staff were aware of incident reporting and there was evidence that lessons had been learnt and improvements have been implemented to maintain safety. The hospice and the day care centre were visibly clean, tidy and staff worked bare below the elbow to reduce the spread of infection.

We found staff attendance of mandatory training was slightly less than the trust expected level of 90%. This has been identified by the management and action is being taken to improve it. There was sufficient equipment to deliver care in a safe manner. The hospice had a bariatric bed. Two bedrooms had been designed to support patients with dementia.

There was good evidence that staff were aware of the most up to date guidance, such as the five priorities of care. They explained that the guidance ensured that people and their families are at the centre of decisions about their treatment and care.

We saw patients were regularly assessed and appropriate pain relief was administered in a timely manner by staff at the hospice and in the community. If a patient was not receiving adequate nutrition or hydration by mouth, even with support, the doctor considered other forms of clinically assisted nutrition or hydration, such as intravenous fluids, to meet the patient’s needs. The managers were working collaboratively with the service commissioners to improve the monitoring of the services to demonstrate progress.

Patients and family members told us that staff understood their needs, treated them with respect and maintained their dignity and privacy. We observed several examples where staff treated the whole family with care and compassion. This was especially the case when young parents with children required palliative and EoLC. Patient’s records showed that when patients experienced physical pain, discomfort or emotional distress staff had responded compassionately and appropriately.

At meetings, staff addressed each patient’s holistic wellbeing by discussing physical, psychological, social and spiritual needs. This meant that that they were able to understand the needs of the individuals and involve them and their family members in the plan of care. Patients and relatives were empowered and supported by staff to manage their own health, care and wellbeing to maximise their independence. The hospice worked closely with different religious groups and had twenty-four hour access to support groups for different religious needs.

There were arrangements in place to ensure patients and their families were able to access the appropriate care without delay. People who used the service knew how to make a complaint or raise concerns. Patients and relatives told us that staff encouraged them to make constructive comments and they felt that staff listened to them.

Patients were admitted to the hospice between 8.30am and 4pm between Monday to Friday. This meant some patients who were eligible for admission were delayed or were admitted to other NHS wards. However, there was on call out of hours cover for patients.

We visited the living well team and found them to be the hub for outreach engagement. They had a membership of multicultural staff and had links with diverse groups of people within the serving population. Independent interpreters were used to help patients and families to help staff meet patient’s needs. The facilities at the hospice were focused on Christian worship and staff acknowledged there was work to be done around providing multicultural facilities for people.

The community staff said their strategy was to lead the way with compassionate care, to be a workforce that reflects the community, and to ensure they provided good quality care. The ultimate vision was for staff to work in partnership with all services, take ownership and be proud of care delivered.

There was a good supportive culture within staff in EoLC and palliative care teams. We also witnessed management ensuring measures were in place to protect the safety of staff who worked alone and as part of dispersed teams working in the community.

Staff were encouraged to bring their ideas forward and action those where appropriate.

There were clear lines of accountability including clear responsibility for escalating and cascading information between senior management team and the clinicians and frontline staff. Staff made comments that feedback from surveys and investigatory outcomes was delayed in reaching them.

Updated 21 February 2020

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

• The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff ensured that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff delivered holistic, recovery-oriented care informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed decisions relating to these well.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was easy to access except where patients required specialist assessment for autism and attention deficit hyperactivity disorder . Staff assessed and treated patients who required urgent care promptly. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.

However:

• Not all staff had completed their mandatory training and not all staff had access to clinical supervision.
• Staff did not provide a physical copy of the care plan to patients and/or carers.
• The service had very long waiting times for patients who required assessment for autism and attention deficit hyperactivity disorder.
• The care plan audits we looked at did not identify that staff recorded information consistently in the care record.
• The service did not always respond to complaints within the timescales set out by the trust.

Updated 12 January 2017

We rated community mental health services for adults with a learning disability or autism as good overall, because:

• There had been improvements since our last inspection. The trust had upgraded the safety and security of the buildings occupied by community teams for learning disability. Staff had carried out and recorded service user risk assessments. Staff caseloads were reduced at the Ironstone Centre because staffing levels had been increased. This meant safer care was being delivered.

• Decision specific capacity assessments were recorded in service user care records where appropriate. Managers told us new Mental Health Act training had been introduced and most of their staff had attended.

• Staff reported that morale was better although reorganisation at Doncaster was causing staff some concerns.

• Following our inspection in September 2015, we rated the services as 'good' for Caring, and Responsive. Since that inspection, we have received no information that would cause us to re-inspect those key questions or change the ratings.

Updated 19 January 2016

We rated Rotherham Doncaster and South Humber NHS Foundation Trust as good because:

• The skill mix within the service was sufficient to ensure good quality care and treatment. This led to flexibility across the teams allowing staff to cover essential visits and clinics in the event of unexpected illness or holiday leave.
• Patient risk assessments were updated when new risks were identified and during patient reviews. Staff documented daily any increased risks if a patient’s mental health deteriorated. The care records we reviewed all had up-to-date risk management plans. This meant staff could make changes to the care they gave their patients keeping them safe.
• Multidisciplinary teams managed the referral process, assessments, on-going treatment and care by discussing the best treatment and pathway options for each individual. This meant patients received care and treatment that suited their individual needs.
• Patients gave positive feedback and felt personally involved in the development of their care plans. Staff delivered care to patients and their carers in a compassionate and respectful manner. Support groups for carers were available and staff arranged for respite care when appropriate. Carers consistently told us that staff actively supported them and valued this service.
• Patients took part in national initiatives to raise awareness of the needs of people with young onset dementia. The day care facility attached to the young onset dementia service allowed patients to organise their own activities and therapies. It supported people to live active lives in their community and maintain their day-to-day skills, friendships, hobbies and interests. The memory services either had accreditation or were in the process of achieving accreditation with the Royal College of Psychiatrists’ memory service national accreditation programme. The young onset dementia service in Doncaster was carrying out research in partnership with Sheffield Hallam University. Rotherham memory service was researching a cognitive stimulation therapy project. Staff from North Lincolnshire set up a choir for service users and carers. They were finalists at the recent Alzheimer’s Society dementia friendly awards for best dementia friendly involvement initiative.

However:

• The community mental health teams held caseloads that exceeded Department of Health guidelines.
• Patients’ care plans were not always personalised or holistic and the quality varied across the teams. Some care plans did not consider all aspect of the patient’s wellbeing or support their recovery.

Updated 19 January 2016

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

There was a skilled multi-disciplinary team. Some staff were trained as best interest assessors and some had undertaken training in cognitive stimulation therapy, wellness recovery action planning and motivational interviewing. The advanced nurse consultant was a Queen’s nurse. The title of Queen’s Nurse indicates a commitment to the values of community nursing, high standards of practice, excellent patient-centred care and a continuous process of learning and leadership. Staffing levels and the skill mix within the teams meant the staff on duty were able to meet patients’ needs.

We saw a number of excellent examples of proactive work to improve patients’ experiences. The teams actively promoted advance decision making so that other people could understand how patients would like to be cared for when they were not well.

In Doncaster, there was a carers’ support worker and a wellness action recovery worker. There was an innovative peri-natal mental health service that provided specialist interventions at home to reduce admissions to mother and baby mental health units.

In Rotherham, there was a dedicated service for deaf patients with mental health problems. They worked with children and young people aged 14-18 as well as adults. They supported patients by promoting their deaf identity, to help them live and work as valued members of the deaf and wider communities.

Rotherham and Doncaster operated a new model liaison and diversion service introduced by NHS England. The service supported patients with mental health conditions, substance misuse problems and learning disabilities who were suspected of committing an offence and came into contact with the police. There was also a street triage team working with the police. This team had significantly reduced detentions under section 136 Mental Health Act 1983 (MHA). This year, the street triage team had won the trust’s award for partnership working and the Doncaster district police diversity achievement of the year award.

At Great Oaks, the acute care service, including the mental health crisis service, had planned a “perfect week”. This was a groundbreaking exercise in mental health services. It focused on organisational development and better patient care, safety and experience.

There was a drive to increase participation in research, such as research into decision making around treatment for patients diagnosed with personality disorders and research into early discharge.

The service had significantly reduced waiting times for mental health assessments for patients with learning disabilities and autism, in line with National Institute for Health and Care Excellence (NICE) guidance.

The referral system enabled patients to access help and support directly when they needed it, 24 hours a day, seven days a week. The mental health crisis services focused on helping patients to be in control of their lives and build their resilience so they could stay in the community and avoid admission to hospital wherever possible. The teams had established positive working relationships with other service providers such as the acute admission wards, GPs and community services and groups. The teams worked with the acute wards and community teams to plan patients’ transitions between services in a holistic way. They ensured discharge arrangements were considered from the time patients were admitted, to ensure they stayed in hospital for the shortest possible time.

All but one patient we spoke with told us they had a copy of their care plan and that they had been involved in formulating it. They said staff sought feedback from them about care planning and their views had been included in the care plan. Carers told us that they had been able to ask questions and the staff responded knowledgeably and informatively. The care plans we reviewed and the care we observed showed that patients’ individual, cultural and religious beliefs were taken into account and respected. Patients were supported to maintain their social networks and independence in the community.

In all the teams, we saw the staff were kind, caring and compassionate and supportive of patients. When we spoke with patients, they were positive about the support they had been receiving and the kind and caring attitudes of the staff team.

All the teams were managed well. There was a good governance structure to oversee the operation of the mental health crisis teams. Staff received appraisal and a range of supervision, managers investigated complaints, incidents were reported and investigated, changes were made when they were needed, staff participated in audits and safeguarding and Mental Health Act 1983 procedures were followed.

The staff understood their responsibilities relating to the duty of candour. They knew what a notifiable safety incident was and explained what they were expected to do. They were clear that they would explain and apologise to patients and their families in any event.

The staff we spoke with told us that morale was good. Many staff told us they were proud of the job they did and said they felt well supported in their roles. They felt valued and were positive about their jobs. We saw excellent examples of staff suggestions being implemented.

There was excellent commitment to quality improvement across all the teams and they had developed various services to improve care. However, at the time of the inspection we did not see any formal process for the teams to meet with each other. This meant they may miss opportunities for learning and sharing. We found examples of good or excellent practice in all the teams that could have been shared across the service.

Updated 11 May 2017

We rated wards for people with learning disabilities at Bungalow 2 as good because

The ward was clean and tidy. Durable material covered walls and surfaces making them safer for the patient.

Staff were skilled and trained in safeguarding.

Care records were up to date, there were comprehensive care plans in place.

Due to the specific needs of the patient, there had been three independent assessments of the patient. This was to look at their treatment pathway and suggest interventions.

The ward had significant staffing issues following the unavailability of some staff following a safeguarding incident in February of this year. This however had been temporarily resolved and some senior staff had been brought in to ensure support, consistency and oversight of the service.

Government policy and the department of health’s document ‘positive and proactive care’ endorsed positive behaviour support. Key staff had attended training to facilitate this approach and further ‘train the trainer’ training was planned for September 2015.

However

• Incidents of restraint in this area were the highest in the trust between 01 November 2014 and 30 April 2015 272 incidents were recorded. The provider and ward staff were aware of this and were working hard to reduce this amount.

• Whilst staff supervision figures showed a steady rise, they were below the trusts expected target.

Updated 21 February 2020

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

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

Updated 21 February 2020

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

• The service was not consistently providing safe care. Staff did not always reduce the risk within the ward environments. Staff did not assess and manage risk well. Staff had not completed all their mandatory training, did not record seclusion in line with good practice and there were blanket restrictions on Coral Ward.
• The service was not consistently providing effective care. Staff did not always document holistic, recovery-oriented care plans reflecting the comprehensive assessment. Staff did not always discharge their roles and responsibilities under the Mental Capacity Act 2005.
• The service was not consistently well led. Governance processes did not operate effectively at ward level and performance and risk were not consistently well managed. There were gaps in care planning and seclusion records. Environmental checks were not always completed or acted on when an issue had been identified. The correct process had not been followed when a patient transferred to the bungalows at Emerald Lodge, and to identify and report blanket restrictions on Coral Lodge.

However:

• The service worked to a recognised model of mental health rehabilitation. Staff provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• Most ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

Updated 28 June 2018

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

• The wards had systems and processes in place to keep patients and staff safe. Staff recognised safeguarding concerns and escalated these appropriately. They identified patient risks and put plans in place to manage these. Staff followed effective medicines management practices to ensure the proper and safe use of medicines.
• Staff provided compassionate care and treatment to patients. They took the time to interact with the patients and feedback was positive across all wards. They supported patients with dignity and respect and involved them in their care.
• Carers were involved and encouraged to be partners in the care of the patient. Staff involved them in decision-making and supported their needs in addition to the patients.
• Staff carried out a comprehensive assessment to identify a patient’s needs. Care plans reflected the needs and incorporated the patient’s history and preferences. Staff reviewed the plans regularly and involved other specialists when needed.
• Wards included, or had access to a full range of specialists required to meet the need of the patients. Staff were suitably skilled and had the knowledge and experience to deliver effective care, support and treatment.
• All the wards had welcoming premises and the facilities to meet the needs of patients. Bedrooms were all ensuite and patients had a secure place to store their belongings. There were quiet areas on the wards where patients could meet visitors or make phone calls in private.
• Staff mostly enjoyed their roles and felt supported and valued within their immediate teams. Ward managers had the skills, knowledge and experience to support their role and promote high quality care. They had a good oversight of their ward’s performance.

However:

• Staff on Windermere, Glade and Fern wards did not regularly review or consider the restrictions on a patient’s ability to freely access the ward’s garden or lounge areas.
• Staff were not fully compliant in all mandatory training units.
• Staff did not always complete Mental Capacity Act documentation fully or with sufficient detail.
• Wards did not display a notice to tell informal patients that they could leave the ward freely.
• Staff on the wards felt disconnected from the wider trust and from the older people’s wards in the different localities. They had limited knowledge of the trust’s vision and values.

Updated 21 February 2020

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

• Ligature risk assessments in place did not identify or mitigate all the ligature risks on the wards. The seclusion suites were not an en-suite facility and the use of receptacles was common practice and there was no method by which to offer patients food, drink or medication if it was not safe for staff to enter the room.
• There were substantial and frequent staff shortages which placed patients and staff at risk of harm because the wards did not have enough nurses and allied health professional staff to ensure the service was safe and to provide the required levels of therapeutic activity to patients. Staff had not completed required levels of mandatory training in some areas that affected the quality of patient care.
• The trust had not undertaken a recent risk assessment in relation to the access and administration of emergency medication that acts as an antidote to benzodiazepines as recommended by the national resuscitation council guidance. Staff at Swallownest court did not always follow infection control procedures.
• The service was not always well led because the governance processes were not always effective. The trust was not aware of some the issues we found during the inspection and there was not a joined-up approach to the management of risk and best practice across all care groups.
• Staff completed clinical audits, but these were not entirely effective because they did not highlight all risks and concerns.
• Staff did not always complete a contemporaneous record for all patients because they did not always record patients’ care accurately including records of seclusion, enhanced observation, capacity to consent to treatment and discharge plans.

However:

• Staff minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, care plans informed by a comprehensive assessment. Staff had a good basic knowledge of the Mental Health Act and Mental Capacity Act. Overall, they discharged their responsibilities well.
• Managers ensured that staff received supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Updated 12 January 2017

We have rated substance misuse services as good overall because:

• All locations were clean and well maintained, clinic rooms were clean and equipment was regularly serviced with stickers visible detailing when the next service was due. The risk assessments we saw reflected the needs of the clients and were in date.

• Controlled drugs were stored appropriately and contracts were in place for the collection of clinical waste.

• Assessments were seen to be detailed and contained both a physical health assessment and an assessment of substance use. Recovery plans were seen to be strength based and recovery focused.

• The service employed a range of staff disciplines through the trust and partner agencies which meant clients had access to a range of medical and psychosocial interventions recommended by national guidance.

• Staff assessed clients’ physical health care needs. Staff communicated with GPs concerning physical health and prescribed medications and the systems used linked up so that notes could be shared.

However:

• We were unable to find risk assessment for three clients in the records we inspected; one of whom had been using services for a number of years.

• Mandatory training compliance was at 78% which was below the trusts benchmark of 90%. Only 58% of staff had attended the resuscitation level one training.

• The care plan template in use did not reflect the four domains recommended by the Department of Health, drug misuse and dependence guidelines. This created inconsistency in the quality of the recovery plans and meant some recovery plans were more holistic than others.

• 58% of the records we looked at did not contain signed consent for information to be shared with the National Drug Treatment Monitoring System.

Updated 21 February 2020

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

• The service was not consistently providing safe care. Staff did not assess and manage patient risks well. Staff did not consistently make plans for patients who might experience a mental health crisis in the community. The low compliance with mandatory training in specific modules and high caseloads in specific teams meant that the service did not have enough staff to keep patients safe. Fire risk assessments were not provided for one of the seven locations we inspected.
• The service was not consistently providing effective care. Most care records did not have evidence that staff worked with patients and families and carers to develop individual personalised, holistic and recovery orientated care plans or updated them as needed. Staff had not ensured that patients’ physical health was assessed and monitored appropriately.
• The service was not consistently well-led. Our findings from the other key questions demonstrated that governance processes did not operate effectively at team level to manage performance and risk well. Managers had identified the main areas of concern in record keeping, however actions taken had not sufficiently addressed these concerns by the time of inspection. Managers had not made sure staff understood and knew the trust’s vision and values. The trust has not ensured compliance with fundamental standards in this service over several years and the core service has been rated as requires improvement overall after each of four inspections since 2015.

However:

• Staff were caring. Staff were attentive and treated patients and families with compassion and kindness. Patients and carers were positive about the service. Staff involved patients and families in making decisions about their care and in shaping the future of the service.
• The service was responsive to peoples’ needs. Waiting times for interventions including therapy and specific assessments were not excessive. Staff were able to see patients in a range of settings including in local and town centre facilities, primary care location and in patients’ own homes. Staff treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and wider service.