Kent and Medway NHS and Social Care Partnership Trust

Updated 3 August 2023

We carried out this unannounced, comprehensive inspection of the acute wards for adults of working age and psychiatric intensive care units (PICU), forensic inpatient or secure wards, and wards for older people with mental health problems of this trust as part of our continual checks on the safety and quality of healthcare services. At our last inspection we rated the trust as good overall.

Following this inspection, we rated the trust good overall. In addition, we rated each of the key questions. We rated safe as requires improvement; responsive and well-led as good, and we rated effective and caring as outstanding.

During this inspection we inspected three of the Trust’s core services and rated all three as good.

We also undertook an inspection of how ‘well-led’ the trust was. We rated the trust as good.

Kent and Medway NHS and Social Care Partnership (KMPT) is a large mental health trust that provides mental health, learning disability, substance misuse and specialist services to approximately 1.8 million people across Kent and Medway. The trust works in partnership with Kent County Council and works closely with the local unitary authority in Medway. The trust is one of the largest mental health trusts in England and covers an area of 1,450 square miles. The trust has an annual income of £195 million and employs approximately 3,500 staff who work across 66 buildings on 33 sites. The trust provides services around key urban centres including Maidstone, Medway and Canterbury and more rural community locations. The trust services are commissioned by the Kent and Medway clinical commissioning group, and by NHS England, and by the Kent, Surrey, Sussex provider collaboratives.

The trust provides a range of mental health services including acute, rehabilitation and forensic in-patient services for working age and older adults. The trust provides community based mental health services such as outpatient and community clinics. The trust provides services for people experiencing mental health crisis such as crisis and home treatment teams and health-based places of safety.

The trust provides the following services

• Community-based services for adults of working age
• Long-stay/rehabilitation wards for adults of working age
• Forensic inpatient and secure wards
• Acute wards for adults of workings age and psychiatric intensive care units (PICU)
• Wards for people with learning disability or autism
• Mental health crisis services and health-based places of safety
• Community-based services for older people
• Wards for older people with mental health problems
• Community based services for adults with a learning disability or autism
• Substance misuse services
• Mother and baby mental health unit

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

• We rated safe as requires improvement; responsive as good, and we rated effective and caring as outstanding. We rated ‘well-led’ for the trust overall as good.
• We rated acute wards for adults of working age and psychiatric intensive care units as good. This had improved from the rating of requires improvement given at our last inspection. We rated wards for older people with mental health problems as good. This rating was unchanged since our last inspection. We rated forensic inpatient/secure wards as good. The rating for this service had gone down from the outstanding rating given at our inspection in October 2018. In rating the trust overall, we included the existing ratings of the nine previously inspected services not inspected during this inspection.
• Since the last inspection the trust had appointed a new chair and five new non-executive directors. The trust had also recently appointed a new executive director of nursing to take up post in 2022.
• The non-executive directors (NEDS) and executive directors provided high quality, effective leadership. Non-executive board members had a wide range of skills and experience. They all had experience as senior leaders in a range of organisations and brought skills such as a knowledge of finance, organisational development, legal, fire service, research, real estate, human resources, working in partnership and transforming services. The non-executive directors were well supported and provided appropriate challenge to the trust board.
• There were regular board visits to services by executives and non-executives. These visits had continued during the COVID-19 pandemic in virtual form, to ensure they remained connected with frontline staff.
• The trust leadership demonstrated a high level of awareness of the priorities and challenges facing the trust and how these were being addressed. The trust leadership had demonstrated an ability to adapt at a fast-changing pace during the COVID-19 pandemic. The trust’s use of information technology had been expanded quickly during the pandemic. A new public crisis line was created and many community teams began more flexible working including extended opening times into weekends and evenings.
• The trust had a clear vision and a set of values which staff understood. The trust had a three-year strategy which had been refreshed in 2020. Leaders were well sighted on the ambition of the new strategy and there was a focus on aligning the strategy with both local and national priorities.
• The board was supported by six other committees including the audit committee. There were clear lines of accountability and governance arrangements in place to provide ward to board assurance. The board met regularly and had a clear agenda for discussion. Committee discussions were robust and provided escalation when required. The board regularly discussed board assurance, quality, safety, workforce delivery, strategy, transformation, finance and commissioning.
• There was a range of mechanisms in place for identifying, recording and managing risks, issues and mitigating actions. Individual services maintained their risk registers which were submitted to the trust’s electronic risk management system. All staff had access to the risk register and were able to escalate concerns when required. Staff concerns matched those on the risk register.
• The trust continued to be financially stable and had strong financial expertise among the executives and non-executive directors (NEDS). The trust had an underlying deficit and was working with NHS England and other system partners to address and reduce this.
• The trust had responded positively to previous inspection findings in 2019 and findings from focused inspections in 2020 and 2021. Most of the required improvements from these inspections had been met.
• The board were committed to equality and inclusion. There was an active focus on equality, diversity and inclusion represented at board level. The trust had set itself a goal to become an anti-racist organisation. There were several staff networks who met regularly. These included Black Minority Ethnic (BME) staff network, LGBT+ staff network, the Faith network, and Disability networks.
• The trust was implementing a new engagement pool and engagement council for the users of the trust services to be more fully engaged and broaden the scope of patients’ representation.
• Trust executives were working with other providers in the strategic development of mental health services within the Integrated Care System (ICS). The trust leadership placed system and partnership working within Kent and Medway as a key objective. The ICS Mental Health Learning Disabilities and Autism Board was chaired by the chief executive officer (CEO) of the trust.
• Patients told us that staff treated them with compassion and kindness. They said that staff respected patients’ privacy and dignity. Patients said staff were attentive, non-judgemental and caring.
• The low secure services had implemented an anti-racism strategy. A number of working groups were set up to lead in different areas including; embedding a culture which promoted equality, developing a patient group to explore the impact of racism and to look at ways of being anti-racist allies.
• The acute wards for working age adults were part of the armed forces network (a multi-organisational group including mental health clinicians and armed forces agencies) and had recently completed a piece of work around the things to consider if a veteran was in a mental health setting.

However:

• Several of the trust capital projects had experienced slippage due to insufficient leadership oversight and a lack of project management experience within the estates and facilities function. This had also led to a slow response to essential maintenance and repair across several core services. The trust leaders were open about this and were now aware of the issues and taking action. Additional oversight had been put in place; project management skills and experience had been brought into the estates and facilities directorate to ensure appropriate management of contract performance with the out-sourced maintenance company and a more flexible ‘handyman’ service had been established to quickly address low-level maintenance and repair issues.
• Despite these developments there were still outstanding maintenance, refurbishment and repair issues on all core services we inspected. The outstanding issues had been logged on the trust system by staff, but repairs had not been completed. The specific issues are described in the core service reports. They included a broken shower, a seclusion room awaiting repair before it could be used, a ward awaiting non-slip flooring, upgrading of vistamatic windows, and the safe provision of hot water for hot drinks for patients on several wards.
• Patients experiencing functional mental health concerns on Jasmine ward, reported that they did not always feel stimulated or engaged. We also found on Jasmine ward intermittent patient observations were not always carried out in line with the trust policy and there was not clear evidence that patients were involved in their care planning.
• Some staff we spoke with across several teams expressed concerns about speaking up and raising concerns to senior leadership. Some staff said they were reluctant to speak about their concerns because of fears of reprisals, or because they felt that their concerns would not receive a response from the senior team.
• Whilst the trust had a workforce strategy and was succeeding in the recruitment of international nurses, trust-wide there were a high number of vacancies with an overall staff vacancy rate of 15% against a target of 11.85%. Staff retention rates had declined across 2021 reaching 81.8% against a target of 87.3%
• The trust had an explicit commitment to equality and inclusion, however, the workforce race equality (WRES) data showed an increasing amount of racial bullying and harassment experienced by BAME staff. This had now increased to 42.9% from 35.6% in 2017.
• We received mixed feedback from patients regarding the food provided by the wards. Some patients were happy with the food provided, however others told us that the food portions were small and not of good quality. We observed staff prepare a cook chill meal on the forensic wards, and we could see portion sizes were small, with a small tray of chips identified for six patients as part of their lunchtime meal. The preparation of the food was carried out by the ward nursing staff and had a significant impact on their clinical time.

How we carried out the inspection

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic including on site and remote interviews by phone or online.

We inspected all of the trust’s mental health wards for older people which were open at the time of inspection, we inspected all the trust’s adult inpatient wards and psychiatric intensive care units (PICU) with the exception of three adult wards at Little Brook Hospital, we inspected both the trust’s forensic services at the Trevor Gibbens Unit and Allington Centre.

During the mental health wards for older people inspection, the inspection team:

• undertook a tour of all six wards across five locations to look at the quality of the ward environments. At the time of inspection Orchards ward was temporarily located at Littlestone Lodge and was due to return to a newly refurbished ward in December 2021.
• looked at 31 care records across all six wards
• looked at 48 prescription charts and inspected clinic and treatment rooms across all six wards
• attended and observed multi-disciplinary team (MDT) handover meetings on Woodchurch ward, Ruby ward, Sevenscore ward, Heather ward and Jasmine ward
• spoke with 39 members of staff including a volunteer, nurses, healthcare assistants, occupational therapists, occupational therapy assistants, administration staff, ward managers, deputy ward managers, junior doctors, matrons, a consultant, and pharmacists
• observed a group activity on Orchards, Ruby and Jasmine wards
• spoke with 11 patients across three of the six wards
• spoke with 15 carers/ relatives across five of the six wards
• reviewed a range of policies, procedures and other documents relating to the running of the service

For the adults of working age and PICUs inspection, the inspection team:

• visited seven wards at the three sites and looked at the quality of the ward environment and observed how staff were caring for patients
• spoke with 11 patients who were using the service both in person and via telephone calls
• spoke with 3 carers
• spoke with the ward managers for each ward
• spoke with 2 matrons
• spoke with 41 other staff members; including Deputy ward managers, speciality doctors, a consultant, a deputy chief pharmacist, an inpatient senior practitioner, nurses (including a student nurse and nurse apprentice), occupational therapists (including a lead occupational therapist, occupational therapy assistant and an occupational therapy student), healthcare assistants, a psychologist and an assistant psychologist, and a peer support worker.
• attended and observed a bed management meeting, and two handover meetings
• reviewed 10 incident records
• looked at 35 care and treatment records of patients
• carried out a specific check of the medicine management on all wards and 39 prescription charts
• looked at a range of policies, procedures and other documents relating to the running of the service
• reviewed community meeting minutes for all wards

For the forensic inpatient/secure services inspection, the inspection team:

• visited five wards across two hospital sites, looked at the quality of the ward environment, management of the clinic rooms, and observed how staff were caring for patients
• spoke with 21 patients and carers of people who were using the services
• spoke with the manager and/or matron of each ward
• spoke with 27 other staff members including nurses, clinical practice leads, a physical health lead nurse, social therapists, support workers, occupational therapists, psychologists, consultant psychiatrists, a clinical pharmacist, an assistant pharmacy technical officer, and a speech and language therapist
• spoke with six senior members of staff including the medical lead for forensic services, the head of nursing, the head of psychology services, the sexual safety lead for the service, and the drugs and alcohol lead for the service
• reviewed 22 care and treatment records of patients
• carried out a specific check of the medication management on Allington, Emmetts and Groombridge wards
• looked at a range of policies, procedures and other documents relating to the running of the service.

What people who use the service say

Patients told us that staff treated them with compassion and kindness. They said that staff respected patients’ privacy and dignity. Patients said staff were attentive, non-judgemental and caring. Patients also reported staff provided help, emotional support and advice when they needed it. Patients said staff treated them well and were responsive to their needs.

We received mixed feedback from patients regarding the food provided by the wards. Some patients were happy with the food provided, however others told us that the food portions were small and not of good quality. One patient told us that food was sometimes served cold and most patients told us that salad is not regularly included, despite feedback from patients for more of this.

Updated 30 July 2015

We rated the Knole Centre neurological rehabilitation ward for adults who require rehabilitation following an acquired brain injury or non-progressive neurological illness by Kent and Medway NHS and Social Care Partnership Trust (KMPT) as good because:

• Staff received training that was specific to the needs of their patients to assist them deliver good care and treatment.

• The ward had a system of governance in place to identify and monitored risks for patients. Staff learnt from incidents to ensure patient safety.

• Patients could access psychological therapies as part of their treatment. The ward had a wide range of staff that came from professional backgrounds to support patients. The ward used appropriate clinical outcome scores to show patients progress was monitored by quantifiable measures. Staff produced a yearly outcome report for the trust.

• Care plans were in place that addressed patients’ assessed needs and they were reviewed weekly by the staff team at the multi-disciplinary team meetings.

• Staff received training in the use of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

• Patients were treated with compassion, respect and dignity. They were positive about the way staff treated them. They were involved in the planning of their care. Their wishes and needs were integrated into their care plans.

• Patient were admitted based on their clinical need and beds could usually be available quickly. Patient usually stayed for a twelve week period and could have week end stays at home.

• There was a range of therapeutic activities available, on both an individual and a group basis. These included bespoke therapies like hydro therapy, exercise groups and walking practice.

• Ward managers provided good leadership and were visible and accessible to both patients and staff.

• The ward did not separate facilities for men and women, according to paragraph 16.9 of the Mental Health Act Code of Practice, and national guidance regarding the provision of same sex accommodation

• Staff members did not have access to all parts of the ward. Staff members did not have keys to all the doors and used adapted objects such as coins to turn the locks. This presented as a potential risk to patients and staff in the event of a fire.

• There were incidents where staff had not signed medication records to show that prescribed medication like thickening agents for patient’s food had been given to patients.

Updated 12 April 2017

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

• We looked at ten care records for people who used the service. All of these included a risk assessment and all records had been reviewed recently. The trust, in collaboration with partners, had developed the complex care response procedure across the teams which meant people who used services could receive a same day assessment of risk to reassess needs in order to prevent any further deterioration of mental state, which may have resulted in a hospital admission. Comprehensive assessments were documented in each of the care records we reviewed and were carried out at the person’s first appointment. All of the care records we reviewed had care plans. People’s needs were assessed and care was delivered in line with their individual care plans. Assessments were completed in a timely manner and the care plans were detailed, personalised, focused on maximising independence and holistic. All of the records we looked at had a health action plan included.

• The teams were situated in buildings that were clean and well-maintained. There were clear protocols available to guide staff on how to respond should an alarm be activated on site and staff we spoke with were able to describe the response guidance.

• There were sufficient staff to deliver care to a good standard and the staffing rotas indicated that there were sufficient staff in each of the teams. Staff we spoke to understood the vision and direction of the organisation. Staff felt part of the service and were able to discuss the philosophy of the service confidently All of the staff we spoke with were highly satisfied working in the service. The senior management team held monthly leadership forums where senior clinicians and managers came together from the service line and discussed, for example, the quality of service provision and service developments.

• People who used services told us they were supported well to live safely in the community and that their needs were met, including if they needed additional support. The teams offered a treatment model based on individual care and treatment pathways. People were supported through transitions between services, for example from children’s services to adult or from inpatient services to the community. People were involved in drawing up information to accompany them in their move. We observed interagency working taking place. Staff created strong links with primary care, the learning disability community teams, mental health acute inpatient services, social services and residential care homes being particularly positive examples.

• All of the people we spoke with and their relatives and carers complimented staff providing the service across the teams. People who used the service told us that they were treated with compassion, dignity and respect and that they were supported to make their own choices in their daily life. Staff we spoke with showed they knew the people who used services well. Staff told us confidently about their approach to people who used services and the model and philosophy of care practiced across all of the teams. They spoke about the emphasis they put on ensuring any treatment or support interventions were individualised and centred on the person and co-produced with them and their family or carer. Staffs’ approach was person centred, highly individualised and recovery orientated. People or their representatives told us they were fully involved with every aspect of their treatment and care planning.

• Key performance indicators and performance data was available to staff relating to waiting times from referral to assessment and onto treatment. Information on performance in key areas was collated and summarised by senior managers and published monthly. Staff participated in clinical audits to monitor the effectiveness of services provided. They evaluated the effectiveness of their interventions. The teams carried out audits against the National Institute for Health and Care Excellence (NICE) guidelines on promoting good health and preventing and treating ill health for people with learning disabilities and autism. Staff told us that they received feedback from incident investigations in regular team meetings and that they learnt key themes and lessons and developed action plans if they needed to make changes.

• People who used services and their families we spoke with all knew how to make a complaint, should they wish to do so. This included how to contact the Care Quality Commission. Staff confidently described the complaints process and how they would handle any complaints.

However:

• All relevant documentation about care planning was not filed in the care planning section of the electronic care records which made it difficult to locate information in a timely manner.

• There were 15 people waiting up to a year for psychology. We had concerns about psychology waiting lists during our inspection in 2015 and on this inspection we found improvements had been made however some people assessed as low risk were having to wait up to a year. These people were being supported by other community services and told to contact the mental health team should there be any concerns.

Updated 1 March 2019

• The team bases were safe for use by patients and staff.
• Patients who were prescribed anti-psychotic medicine received regular monitoring of their physical health.
• The service employed enough staff to meet the needs of the service. Staff felt supported by the trust, completed mandatory training, received supervision and had access to training opportunities.
• Staff had manageable caseloads that were reviewed regularly. They completed detailed risk assessments and had support from the multidisciplinary team when their patients presented as high risk.
• Staff had a good understanding of how to safeguard patients from abuse. They knew how to report incidents and were supported to gain learning from them.
• Staff had access to a secure system where they could access and record information regarding patients’ care and treatment. Staff could to access this system remotely to record important updates and support their time management.
• Staff carried out comprehensive assessments of patients’ needs and completed detailed care plans that addressed these identified needs.
• The service employed clinical psychologists and occupational therapists who provided a range of interventions to improve treatment outcomes and promote independence.
• The service had good links with internal and external agencies where patients, and their carers, could get support with social, dietary and physiological needs.
• The service carried out a programme of audits around clinical documentation and physical health monitoring of patients on anti-psychotic medicine.
• Patients, and their carers, were universally positive about the care and treatment they received. Staff knew their patients and treated them with compassion and respect.
• Patients, and their carers were fully involved in decisions about their care and treatment. The service offered them exceptional support in the early stages of their diagnosis.
• Admiral nurses supported families with all aspects of living with dementia. Healthcare assistants instilled hope in families by introducing them to emotional and practical support.
• The service actively collected feedback, from patients and their carers, about their experiences of the service. Responses received were extremely positive.
• The service was proactive in ensuring referrals were appropriately triaged and patients were seen and treated in a timely manner. All teams provided a duty service that could respond to emergencies.
• The service responded to patients’ individual needs. Patients had a choice in what services they received support from. It was proactive in engaging patients and provided satellite sites to support patients from rural areas.
• The service promoted dementia friendly communities and supported the concept of patients supporting each other. The service used feedback from complaints and compliments as learning opportunities.
• The service had experienced senior managers and team leaders who staff felt were supportive and approachable. Staff enjoyed their jobs and felt supported by their colleagues.
• The service maintained operational oversight through a well-structured schedule of meetings. Staff had access to an informative intranet site and the general public similarly had access to a user-friendly internet site.
• All teams were accredited, or in the process of applying for accreditation, to the memory service national accreditation programme. The service involved themselves in many innovative projects to improve patient experience.

However:

• Staff reported the current risk assessment template on the trust’s electronic care record system did not cover all risk areas common to older people with mental health issues. They also told us this same system could be hard to access, or respond slowly, during busy times.
• The service did not have a consistent approach to some areas of clinical practice, such as recording supervision; measuring outcomes for patients who attended groups; and recording patients’ capacity or consent to treatment.
• Due to commissioning arrangements, most areas of the trust were unable to provide a crisis service for patients with a diagnosis of dementia. Some teams were experiencing excessive waiting times for neuropsychology assessments.
• Some interview rooms did not provide adequate soundproofing to maintain patients’ privacy and confidentiality. The service did not always have appropriate dementia friendly signage and features and some sites did not provide enough parking for people with disabilities.

Updated 1 March 2019

• Teams were comprised a multi-disciplinary team of mental health professionals including psychiatrists, nurses, support workers, support, time and recovery workers, and occupational therapists. All services had access to a Mental Health Act Administrator.
• The teams felt fully supported and spoke consistently of an open, caring culture. There was a clear management structure in place. Teams had direct management from an operational and clinical lead, who were supported by senior leaders in the trust, and all sites had access to a consultant psychiatrist when needed. The 136 suites had a dedicated clinical lead who supported the staff working there.
• Overall, mandatory training was 95% compliant, well above the target of 85%.
• Staff managed risk well and there were effective processes in place. All services had up to date risk registers and staff knew how to access this and add to it. All staff had received recent training in safeguarding and all staff that we talked with were aware of the safeguarding reporting process. Staff received appropriate debriefs following incidents.
• All the teams had good medicines management practices, which were regularly audited. Each team had at least one medicines lead.
• Managers undertook regular audits to ensure processes were effective. Meaningful learning was shared within and across teams to improve practice.
• People told us staff involved them in their care and treatment, and we witnessed staff completing care plans with patients. We saw evidence that all patients had been offered a copy of their care plan. Patients were given an information pack on their first meeting with the crisis teams, informing them of treatment and support services, how to complain and how to access advocacy.
• The teams were committed to equality and diversity and each team had an equality and diversity lead. All 136 suites were accessible for people with disability or mobility issues.
• None of the crisis teams had waiting times which meant people were seen without delay.
• Staff told us about the different ways they tried to provide personalised support, such as matching staff with similar hobbies to people who were unwilling to engage and scheduling visits around school hours for people with children.
• The services had good working relationships with other organisations including the police, ambulance services and local authorities, with regular joint meetings and appropriate information sharing.
• There were effective handovers and multi-disciplinary meetings to share information and issues constructively. These were also a forum for learning from complaints, compliments and incidents and sharing good practice.
• Staff understood and were very positive about the values of the trust and could tell us how they incorporated the values into their work with patients.

However;

• Though overall mandatory training compliance was above the trust’s target at 95%, some staff had not received mandatory training in all the key areas identified as essential to their role. Immediate Life Support training compliance was low at 66%, though the trust was taking action to improve this.
• Although most of the risks from blind spots had been addressed since the last inspection, the bathroom at the Dartford health based place of safety still had a blind spot. This meant staff could not be assured of patient’s safety at all times in this area.
• The S136 rights leaflet being given to patients detailed a maximum detention period of 72 hours and not 24 hours which did not reflect changes in legislation in 2017.

Updated 21 July 2023

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

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

Right Support:

Model of Care and setting that maximises people’s choice, control and independence

The ward was located on the outskirts of Dartford. It was local to amenities, shopping centres and other activities so that people could access the local community, both escorted and unescorted.

People had independent access to the communal kitchen and laundry (where risk assessed as safe). People had their own en-suite bedrooms on the ward with shared access to communal areas including living spaces and a dining room. People could personalise their rooms and staff had supported them with this.

The ward environment was clean and well maintained. The ward furniture was homely and welcoming and there were spaces on the ward for people to see visitors or spend time alone.

Staff supported people to be independent. Staff focused on people’s strengths and promoted what they could do, so people had a fulfilling and meaningful everyday life.

People were supported by staff to pursue their interests and people said they had engaged in activities if they wanted to do.

Staff worked with people to plan for when they experienced periods of distress and staff did everything they could to avoid restraining people.

Staff enabled people to access specialist health and social care support in the community. They supported people to attend dental, optician, and other physical health appointments.

Right Care:

Care is person-centred and promotes people’s dignity, privacy and human rights

Most people received kind and compassionate care. Staff protected and respected people’s privacy and dignity. People and their relatives said that staff looked after them well and treated them with respect.

Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. People told us they felt safe.

People’s care, treatment and support plans reflected their range of needs, and this promoted their wellbeing and quality of life.

Right Culture:

The ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. People and their relatives knew what their goals were and where they planned to move to.

Staff placed people’s wishes, needs, and rights at the heart of everything they did.

People and those important to them, including advocates, were involved in planning their care. Relatives told us they were invited to meetings and were kept updated by the family engagement and liaison lead.

Staff ensured risks of a closed culture were minimised so that people received support based on transparency, respect, and inclusivity. Staff were welcoming and the ward environment was calm and inviting.

People told us that leaders on the wards were visible and approachable. Staff used clinical and quality audits to evaluate the quality of care. People and governance processes helped the service to keep people safe, protect their human rights and provide good care, support and treatment.

However:

The service had not always ensured that staff had sufficient training to support and meet the needs of people who used the service. Most staff that we spoke with told us that they had generic mental health backgrounds with little to no previous experience working with people with learning disabilities and autistic people. Although there were various training opportunities including an induction, which was also available to existing staff, and autism training delivered on the ward, these were not mandatory, and some staff were not able to identify the specific needs of people using the service. Since inspection we were told that some support staff had years of experience working with people with a learning disability and autistic people, both within the Trust and at other services. The service also had five, out of nine nurses who were registered learning disability nurses. The impact of this meant that we could not be assured that the provider was ensuring that all staff had the right skills and understanding to provide the right care to people with a learning disability and autistic people. At the time of inspection, three members of staff were not up to date with the mandatory training course Immediate Life Support.

The ward had a blanket restriction on garden access, and as such there was limited access to outdoor space. The garden doors were the boundary of the locked ward and as such, people using the service accessed this under the supervision of staff or, if unescorted, in pre-booked hourly slots.

Some people told us that staff sometimes had an attitude and were rude when they spoke with them. One person gave an example of a staff member who told them they were “busy” when they asked them for something. During our Short Observational Framework (SOFi) at lunch time we initially observed two staff sitting on a line of chairs on the wall opposite to the dining tables where people were sat eating lunch and this did not create a warm and inclusive atmosphere. During the earlier tour, a staff member told us that this was where staff sat to observe people during mealtimes.

There was a lot of information on notice boards around the ward which was not always in easy read. Some people told us that they found the information on noticeboards quite overwhelming, and one person told us that they do not take anything in from these notice boards. We observed one person asking staff for help finding information on a notice board as they said they could not read it.

People told us that due to staff toilets and a linen cupboard being on the same corridor as their bedrooms, the noise from the opening and closing of these doors often woke them at night. People told us that they had raised this but that nothing had been done. We saw that this had been raised in a recent MDT meeting when discussing the experience of people using the service.

People prescribed paraffin-based skin products did not have a fire risk assessment in place.

The fridge on the ward had been broken since January and medicines were being stored in another ward on the same site. The provider had a new fridge ready to be installed, however at the time of the inspection, the fridge had still not been made accessible to staff to use and store medicines which required refrigeration.

We did not always see the clear involvement of people recorded in nursing care plans, such as physical health care plans, as these were not always completed from the person’s perspective.

Background to inspection

On 28 March 2023 we carried out this unannounced comprehensive inspection at Brookfield centre and announced activity on 4, 5 and 6 April 2023 at both Brookfield centre and Tarentfort centre. This was in response to several sexual safeguarding notifications received from the local authority and the Trust. We decided to inspect to ensure that the services were safely caring for people and managing any risk appropriately. The service was also due a current inspection due to the time since the last inspection.

Kent and Medway NHS and Social Care Partnership Trust provide care and treatment for people with a learning disability and autistic people at Brookfield Centre, Dartford. Brookfield centre was a 13 bedded locked rehabilitation inpatient service for males aged 18 and over with a learning disability, offending behaviour and mental health or other complex needs. This ward was often a step down service for people previously at Tarentfort Centre, which was a low secure environment for people with a diagnosis of learning disability and autistic people. There were 12 people using the service at the time of our inspection and all 12 people were detained under the Mental Health Act.

Brookfield Centre is registered to provide the following regulated activities;

• assessment or medical treatment for persons detained under the Mental Health Act 1983
• treatment of disease, disorder or injury

Brookfield centre sits under the Forensic and Specialist service directorate of the Trust and had the same overseeing senior leadership team as the Tarentfort Centre which was also inspected at the same time. Tarentfort Centre was previously considered under the core service of Wards for Learning Disability and Autism, though due to commissioning changes since the last inspection, this centre is reported under Forensic inpatient and secure wards core service.

We previously inspected this core service in January 2017 and we rated the wards as Outstanding, in all five domains and overall. At this inspection, we told the Trust that it should take action to ensure that staff receive regular ongoing training on the Mental Health Act. We found that this was now in place and staff we spoke with were able to tell us about the Act and its principles.

Mental Health Act Reviewers also visited the site to carry out a review within the same timeframe and completed a separate report of their visit.

What people who use the service say

People told us that they felt safe on the wards and that they could always find nursing staff when they needed them. People told us that they were also able to speak to psychologists, social workers, and doctors when they needed to.

People told us that most staff were nice, kind and treated them with respect. One person told us that “staff were nice people, treated us nicely and cared about us”. Although, four people told us that staff sometimes had an attitude and were rude when they spoke with them. One person gave an example of a staff member who told them they were “busy” when they asked them for something. Three out of the four people who told us this said that they experienced this from bank staff, not permanent staff.

People told us that they had activities such as cinema, football, golf, pool, and basketball. Although some people said that staff shortages sometimes affected their leave and activities. They did tell us that when this happened staff spoke with them to let them know and usually rearranged this.

People said that they could phone their relatives to keep in contact and that the service facilitated visits. People told us that staff kept their relatives up to date on their care.

People told us that they felt comfortable on the ward, had their own access to their bedrooms and a kitchen and laundry room (if risk assessed as safe) and liked that they could use their e-cigarettes in their bedrooms. People told us that the ward was always clean and that their bedrooms were cleaned daily. Although, one person told us that they had to be signed out by staff to use the fenced garden and that they were limited on how long they could spend there.

People told us that they were involved with their care planning and that if they wanted, they had copies. People were also included in their ward rounds and told us that their discharge plans were discussed during this.

People had contact with advocates or knew how to contact them if they needed. People told us that they were read their rights under the Mental Health Act regularly. People knew how to make a complaint and told us that the ward manager was approachable and sorted problems out for them. People told us that they had a community meeting every week where they could raise concerns and issues.

Some people did raise issues with noise and told us that due to staff toilets and a linen cupboard being on the same corridor as their bedrooms, the noise from the opening and closing of these doors often woke them at night. People told us that they had raised this but that nothing had been done.

Some people told us that they found the information on noticeboards quite overwhelming, and one person told us that they do not take anything in from these notice boards.

There was mixed feedback about the food, most told us it was average, and some told us it was good. People told us that they got to choose the food they wanted from the menu and could also use the kitchen to make their own food (if risk assessed as safe).

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

Relatives told us that they were satisfied with the care their relatives received. They felt that the service had made good progress with each of their family members and gave positive praise for their involvement and communication with staff from the service.

Updated 24 February 2022

Updated 12 April 2017

We rated the long stay/rehabilitation mental health wards for working age adults as outstanding because:

• All six of the rehabilitation units were clean, well maintained, and without exception patients told us that they felt safe.

• The service model optimised patients’ recovery, comfort and dignity. The patients’ care plans were robust, recovery focussed and person centred. There was a clear care pathway through the service with associated treatment and therapy options. The recovery star approach was firmly embedded and used in all of the rehabilitation units. Some units used this as the basis for planning care needs. There was a varied, strong and recovery-orientated programme of therapeutic activities available every week in each of the units. Patients had an excellent level of access to a wide variety of psychological therapies either on a one to one basis or in a group setting. All patients and staff told us that the ability to self-cater enabled them to gain vital knowledge and skills in preparation for their discharge and more independent living.

• There were enough suitably qualified and trained staff to provide care to a very good standard. Staff had the skills to deliver high quality care and treatment. Throughout the rehabilitation units the multidisciplinary teams were consistently and pro-actively involved in patient care and everyone’s contribution was considered of equal value.

• Staff managed risk well. They made and recorded robust risk assessments. Staff were confident in how to report incidents. They told us about changes they had made to service delivery as a result of feedback following incidents. Lessons learnt were shared across all of the rehabilitation service.

• There was evidence of best practice in the application of the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). All staff we spoke with had a good understanding of the MHA, the MCA, Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice. The majority of the units cared for people detained under the MHA, where units had no patients currently detained, we looked at records retrospectively.

• The staff were kind, caring, passionate about their work and involved patients fully in decisions about their care. We saw good, professional and respectful interactions between staff and patients during our inspection. Staff showed patience and gave encouragement when supporting patients. We observed this consistently throughout the inspection. Patients told us that they were the priority for staff and that their safety was always considered. The atmosphere throughout the units was very calm and relaxed. Staff were particularly patient focussed and not rushed in their work so their time with patients was meaningful. Staff were able to spend time individually with patients, talking and listening to them. We did not hear any staff ask a patient to wait for anything, after approaching staff. We saw evidence of initiatives implemented to involve patients in their care and treatment. Patients told us that the staff across the rehabilitation service consistently asked them for feedback about the service and how improvements could be made. The service was particularly responsive to listening to concerns or ideas made by patients and their relatives to improve services. We saw that staff took these ideas into account and used them when they could.

• All staff had good morale and they felt well supported and engaged with a visible and strong leadership team, which included both clinicians and managers. Staff were motivated to ensure the objectives of the trust and the service were achieved.

• Governance structures were clear, well documented, followed and reported accurately. There were controls for managers to assure themselves that the service was effective and being provided to a good standard. Managers and their teams were fully committed to making positive changes. We saw that changes had been made to maintain improvements in quality through the use of audits. The service had clear mechanisms for reporting incidents of harm or risk of harm and we saw evidence that the service learnt from when things had gone wrong.

• We inspected these services previously in March 2015 and not all the essential standards were met. The rehabilitation wards were rated as inadequate in the safe domain. During this inspection visit we found that considerable improvements had been made in these areas and the essential standards had now been met.

However:

• The provider should consider the skill mix of qualified and non- qualified posts as staff commented that there is little career progression opportunity from Band 5 to Band 6 nurses and from Band 3 to Band 4 support workers.

• The provider should consider whether all staff should wear personal alarms at all times on the wards.

• The provider should review which team is responsible for up-loading care programme approach review meeting minutes on to the electronic care record system. Currently the community mental health teams are responsible and the compliance % is under target. The staff at the rehabilitation units have expressed an interest in taking this task over to ensure the target is met.

Updated 24 February 2022

Updated 3 August 2023

We carried out an unannounced focused inspection of the acute wards for adults of working age and the psychiatric intensive care unit (PICU) provided by Kent and Medway NHS and Social Care Partnership Trust (KMPT), because we received information that gave us concerns about the safety of the service.

The trust provides assessment and treatment for adults of working age with mental health issues in nine acute wards and one PICU, based in three hospital sites across the trust. Littlebrook Hospital, based in Dartford, has four wards; Amberwood is a 17 bedded male-only acute ward, Pinewood is a 16 bedded female-only acute ward, Cherrywood is a 17 bedded female-only acute ward, Willow Suite is a 12 bedded male-only PICU. Priority House, based in Maidstone, has three wards; Boughton is an 18 bedded male-only acute ward, Chartwell is an 18 bedded male-only acute ward, Upnor is an 18 bedded female-only acute ward. St Martin’s Hospital, based in Canterbury, has three wards; Bluebell is an 18 bedded male-only acute ward, Fern is an 18 bedded female-only acute ward, Foxglove is a 16 bedded female-only acute ward.

During this inspection we visited all three acute wards and the PICU at Littlebrook Hospital, Boughton and Upnor wards at Priority House, and Fern and Foxglove wards at St Martin’s Hospital.

We inspected the key lines of enquiry relating to safe and well-led. Following this inspection, the ratings for safe and well-led went down. We rated safe as ‘inadequate’ and well-led as ‘requires improvement’. This meant that the overall rating for the service also went down to ‘requires improvement’. Previously, the service was rated ‘good’ overall and for the key questions of effective, responsive and well-led, and ‘requires improvement’ for the key question of safe.

Following this inspection, we served the trust with a Warning Notice, because we found that significant improvement was needed to ensure that all staff followed local and national recommendations to complete and record post dose vital sign monitoring, following the administration of rapid tranquilisation to patients. We were concerned that staff were not always aware of any potential impact these medications had to patients’ health, meaning that patients were exposed to the risk of harm. The Warning Notice required the provider to make improvements to meet the legal requirements set out in the Health and Social Care Act by 22 June 2023.

Our key findings were:

• In all three hospitals we found that physical health checks following the administration of oral and intramuscular ‘as required’ medicines for rapid tranquilisation were not always happening and/or recorded.
• At St Martin’s and Littlebrook Hospitals we found that some patients’ care plans did not include guidance which informed staff how to support patients to manage their medical conditions.
• At St Martin’s Hospital we found that medical staff did not always complete the relevant core assessment.
• At Priority House we found that ‘as required’ medication was frequently used, however, we did not always find records to explain why the administration of these medications was necessary. In some cases the records did not justify the use of these medicines.
• At Littlebrook Hospital and Priority House we found that individual risk assessments and care plans were not always being reviewed and updated following incidents.
• At Littlebrook Hospital and Priority House we found inconsistencies in how staff implemented actions from environmental risk assessments and audited ligature risks.
• Many staff were unable to access the online incident reporting system that the trust had recently introduced.
• At St Martin’s Hospital we found that patients had limited access to showers on the wards.
• At St Martin’s Hospital we found gaps in the staffing rotas on Fern ward with many unfilled shifts on the rota.
• In all three hospitals we found issues with restrictive practices. There were inconsistencies in how staff recorded and reviewed blanket restrictions.
• Governance arrangements were not always robust.

However,

• In all three hospitals, most patients told us that they felt safe, the wards were clean and staff treated them with kindness and respect.
• We received positive feedback from family members of patients at Littlebrook Hospital.
• We noted some positive interactions and caring support from staff at Fern ward, St Martin’s Hospital, and Boughton ward, Priority House. We also found that staff at Cherrywood Ward, Littlebrook Hospital, understood patients’ needs well.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about the service.
During the inspection visit, the inspection team:

• visited eight wards at three hospital sites and looked at the quality of the ward environment
• spoke with 35 members of staff, including senior managers, ward managers, doctors, members of the multidisciplinary team, nurses and health care assistants
• spoke with 28 patients who were using the service
• spoke with 4 family members
• looked at 35 care and treatment records of patients
• reviewed the medicines administration records and associated care records for 41 patients
• looked at a range of policies, procedures 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

The patients we spoke with told us that they felt safe in all three hospitals, and that the wards were clean. Most of the patients told us that overall, there were enough staff on the wards, and felt that staff were trained to support them well. They also told us that they regularly saw doctors and had their medications promptly when needed. However, some patients at St Martin’s Hospital felt that staff spent a lot of time in the office.

Most of the patients told us that staff were polite, kind and respectful.

Most of the patients told us that they had not been restrained while on the wards. However, some raised concerns about the restrictive practices in place. For example, a patient at Boughton ward, Priority House, told us that the garden was hardly ever open.

We received positive feedback from family members of patients at Littlebrook Hospital.

Updated 12 April 2017

We rated substance misuse services in Kent and Medway NHS and Social Care Partnership Trust as outstanding because:

• Bridge House was exceptionally clean and well maintained and without exception, patients told us that they felt safe. The ward was well equipped and fixtures and fittings were provided to a high standard.

• There were enough suitably qualified and trained staff to provide care to a very good standard. The provider employed some staff with lived experience of addiction which further enhanced the skill mix and diversity of staff available. Skilled staff delivered care and treatment. Throughout the ward the multidisciplinary team was consistently and pro-actively involved in patient care and everyone’s contribution was considered of equal value.

• We found that patients’ risk assessments and care plans were robust, recovery focussed and person centred. The assessment of patients’ needs and the planning of their care was thorough, individualised and recovery focused. Staff considered and met the needs of patients at all times.

• Staff were confident in how to report incidents and they told us about changes they had made to service delivery as a result of feedback following incidents.

• All patients received a thorough physical health assessment by both the consultant and a nurse on admission to the ward and staff identified and managed risks to physical health. Patients had an excellent level of access to a good variety of psychological therapies either on a one to one basis or in a group setting. The service model optimised patients’ recovery, comfort and dignity. There was a clear care pathway through the service with associated treatment and therapy options. The patient successful completion rate for the detoxification programme was over 96% during the preceding year. There was a varied, strong and recovery-orientated programme of therapeutic activities available every week. Aftercare for all patients was arranged before admission to Bridge House. This included aftercare in the community with specialist teams or longer term residential rehabilitation. The ward offered ex-patients and their families and friends the opportunity to contact staff for support and/or information after discharge

• Staff interacted with patients and their approach was kind, respectful and professional at all times. Staff continually interacted in a positive and proactive way. The atmosphere was really welcoming, friendly and warm. Staff were particularly enthusiastic, dedicated and motivated by their work. Staff spoke respectfully about their patients at all times and demonstrated an excellent understanding of their issues with a non-judgemental approach.

• The trust carried out a monthly friends and family test, asking how likely a patient would be to recommend the services to family or friends if they needed similar care or treatment. All patients asked in December 2016 said they were extremely likely to recommend the service.

• All patients and staff told us that the quality and range of food offered was of a high standard.

• All staff had good morale and told us that they felt well supported and engaged with a visible and strong leadership team, which included both clinicians and managers. Staff were motivated to ensure the objectives of the organisation and of the service were achieved.

• Governance structures were clear, well documented, followed and reported accurately. These are controls for managers to assure themselves that the service was effective and being provided to a good standard. Managers and their team were fully committed to making positive changes. Changes were carried out to ensure that quality improvements were made, for example through the use of audits. The service had clear mechanisms for reporting incidents of harm or risk of harm and we saw evidence that the service learnt from when things had gone wrong.

However:

• Staff could not be sure that patients were able to securely store all of their possessions in their bedrooms as there were no locks on the doors.Although no patients or staff raised any issues or concerns about bedrooms doors not being lockable, we did consider that the security of patients’ belongings could be compromised.

Updated 3 March 2021

The community mental health teams for adults of working age form part of the trust’s mental health services in the community.

We undertook an unannounced, focused inspection of this service because we had received information that raised some concerns about the safety and quality of the service. We visited four (of 10) of the trust’s community mental health teams:

• South West Kent
• Dartford, Gravesend and Swanley
• Dover and Deal
• Medway

Staff in the teams work with people at the team bases, satellite services and patients’ homes.

Our overall rating went down. We rated the service as requires improvement because:

• Across all the teams we inspected, staff did not always assess and manage risk well. We reviewed 31 patient records, which were a mix of Care Programme Approach (for people with complex or severe mental health problems) and standard care (for people with more straightforward needs) records and found that risk assessments and risk management plans were basic and did not have complete and detailed information. Crisis plans had not always been completed and, where they existed, they lacked detail. This meant that patients and carers may not have received the support they needed.
• Patients who did not require urgent care did not always receive timely treatment. Some types of treatment were not provided because there were not enough staff to learn how to provide it and then provide it. This meant some patients were left waiting for the care they needed. For example, specialist treatment for people with complex mental health needs.
• Although teams and individual members of staff had manageable caseloads, they could not provide all the care their patients needed (for example, specialist treatment for bipolar disorder) and some patients who needed non-urgent care were not part of caseloads because they were still on a waiting list to join a waiting list for specialist treatment.
• Trust-wide governance processes did not always ensure that key issues were picked up and addressed in a timely manner. In the months prior to our inspection, the South West Kent team had experienced difficulties with lack of leadership, affecting patient care (for example, patients did not see their care coordinators often enough) and poor staff morale. Trust systems had not identified this as an issue early enough which had resulted in a lack of appropriate, timely support being provided to the team and further deterioration and risk in the team.

However:

• Patients who required urgent care were assessed and treated promptly by staff. The criteria for referral to the service did not exclude patients who would have benefitted from care.
• Staff monitored patients on waiting lists well to ensure that patients who required urgent care were seen promptly.
• The teams were well led at local level. Staff morale and culture was positive and supportive in the teams including the South West Kent team where a new leadership team had recently been introduced.

Background to inspection

This inspection was unannounced and was undertaken because we had received information that raised concerns about the safety and quality of the service. It focused on the areas of safe, responsive and well-led.

We last inspected the service as part of a comprehensive inspection between 9 October and 29 November 2018. Prior to this inspection, the overall rating for the community mental health teams for working age adults was good.

The inspection took place during Covid-19 tiered restrictions and we only looked at specific areas of concern and we did not look at all the key lines of enquiry. We did look at enough lines of enquiry across enough of the teams to re-rate the core service. We re-rated safe and well-led as requires improvement and this meant the overall rating for the core service now becomes requires improvement.

The teams form part of the trust’s mental health services in the community. They provide a specialist mental health service for adults of working age (18-65) with significant mental health needs. Staff provide patients with care co-ordination and recovery-focused interventions, including psychological therapies. The teams also support patients with complex mental health needs who require an assertive outreach approach to meeting their needs. The teams operate from 9am-5pm Monday to Friday. The teams comprise multidisciplinary teams of health care professionals, including psychiatrists, psychiatric nurses, psychologists, occupational therapists and support workers. The service primarily receives referrals from GPs, but also other parts of the mental health system, such as acute and crisis mental health services. The single point of access team manages urgent referrals for the community mental health teams and operates 24 hours a day to receive referrals by email, text or telephone.

The trust has 10 community mental health teams (CMHT) for working age adults:

• Swale CMHT - Sittingbourne Memorial Hospital
• Maidstone CMHT - Albion Place Medical Centre
• Medway CMHT - Britton Farm
• South West Kent CMHT - Highlands House
• Dartford, Gravesham and Swanley CMHT - Arndale House
• Dover and Deal CMHT – Coleman House, Dover and Bowling Green Lane, Deal
• Thanet CMHT – The Beacon
• Canterbury and coastal CMHT – Laurel House, Canterbury and Kings Road, Herne Bay
• Shepway CMHT – Ash Eaton, Folkestone
• Ashford CMHT – Eureka Place

The trust has a nominated individual.

How we carried out this inspection

You can find 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

The team that inspected the four community mental health teams comprised five CQC inspectors, two inspection managers, a head of hospital inspection, four specialist advisors and an expert by experience.

Before the inspection visit, we reviewed information that we held about the service.

During the inspection, we reviewed 31 patients’ records, observed meetings and the duty service, spoke with staff and patients, and reviewed complaints, incidents and policies.

We also reviewed information such as performance data and policies supplied to us by the trust, both during and after the inspection site visit.