Kent and Medway NHS and Social Care Partnership Trust

We rated Mental health crisis services and health-based places of safety as good because:

• Staff managed risk well. All services had up to date risk registers and ligature audits. All staff had received recent training in safeguarding and all staff that we talked with were aware of the safeguarding reporting process. Staff received a de-brief from a psychologist after every serious incident to support their wellbeing and promote learning. Within all the crisis resolution home treatment teams, there were good medicines management practices, teams were supported by the hospital pharmacist who completed regular audits and reconcilliations.
• Mandatory training was 89% compliant, against the target of 85%.
• The teams were made up of a full discipline of mental health professionals including psychiatrists, nurses, support workers and occupational therapists.
• The teams felt fully supported and had direct management from an operational and clinical lead and all sites had access to a consultant psychiatrist when needed.
• We witnessed staff involving people in their treatment decisions by completing care plans with the patients and patients were given an information pack after assessment informing them of treatment and support services, how to complain and access to advocacy.
• The services had good working relationships with other organisations including the Police and Local Authorities.
• There were effective handovers and multi-disciplinary meetings in order to share information and issues constructively.
• Staff were very positive about the values of the trust and were very passionate about the teams they worked in and the client group.
• All 136 suites were accessible for people with disability or mobility issues.
• All services had access to a Mental Health Act Adminstrator.
• After every serious incident, patients were well managed and staff received a de-brief from a psychologist.

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.

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.

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

• All team bases that patients visited to meet with staff kept emergency equipment such as defribrillators and stored medicine at the base. All of the equipment was well-maintained and checked regularly. Each team demonstrated good medicines management practice.

• There had been a reduction of caseloads for the majority of staff and there was nobody on the waiting list for allocation of a care co-ordinator across the teams. Care co-ordinators were allocated the role of GP link worker and were the named contact for their aligned GP practice. There was evidence of productive mutual relationships and information sharing between the teams and GP practice.

• There was rapid access to a doctor in person or by telephone the same day and doctors had an ‘open door’ policy for advice. Each team had a duty system and policy in place. In line with trust policy, duty workers screened, evaluated and processed all mental health referrals on the day they were received within 9am and 5pm and undertook home visits as required. Each team operated a ‘drop in’ service that varied in frequency between teams of every 4-8 weeks’ occurrence.

• Staff were up to date with appropriate mandatory training. The average mandatory training rate for staff was 96%, which was above the trust average.

• Staff knew how to make a safeguarding alert and did this when appropriate. Staff were trained in level two safeguarding adults and children at risk with updates every two years. The teams reported incidents and recorded them appropriately on the trust’s incident reporting system. There were opportunities for staff to learn from incidents, complaints and patient feedback.

• We saw evidence of comprehensive assessments that were holistic, needs led and patient focused. The service complied with National Institute of Health and Care Excellence (NICE) guidelines regarding the use of antipsychotic medicines for people using the service and regular physical health checks were carried out. There was good evidence of a range of psychological therapies recommended by NICE and the service offered a range of support and educational groups for carers.

• We looked at 42 care records of people using the service on the trust’s electronic patient care record system and found that the quality of care plans were varied across the teams. The majority of the records included care plans that were up to date, personalised and holistic. However, in seven records the care plan was in the format of a letter and not located within the care plan section of the electronic patient care record system.

• Since our previous inspection we saw that improvements had been made to ensure that capacity to consent to treatment and information sharing was clearly and consistently recorded. Staff demonstrated a robust knowledge around the Mental Capacity Act and its five key principles.

• People using the service and carers were very positive about the care received, they felt that staff were respectful, compassionate and kind. During our inspection we observed caring staff interactions and saw that explanations and rationale were clearly given for treatment decisions and patient choice and preference were given high importance.

• Since our previous inspection improvements had been made to ensure that the teams effectively met assessment and treatment targets. One team was piloting a new system that enabled an earlier initial assessment of people using the service by support workers so that people using the service were seen within seven days of being referred.

• We saw evidence of very good team morale, staff described their teams as supportive, confident and experienced. Staff told us they enjoyed working in the teams and felt valued by colleagues and their line managers.

• We saw evidence of participation in research studies including ‘Improving the experience of Dementia and Enhancing Active Life’ (IDEAL) project which examined how social and psychological factors influenced the possibility of living well.

However:

• None of the interview rooms was fitted with alarms and staff did not carry personal alarms. The trust was addressing this and managers had put in requests for new personal alarms for their staff.

• There was a crisis service in place within the trust for older adults with a functional diagnosis such as psychosis or depression, but this was not available for people using the service with an organic diagnosis such as dementia. However, patients with dementia and their carers had access to an out of hours telephone service.

• Each team held a risk register and staff could contribute to this, however some items on the risk register had not been resolved and had no date for when this would happen.

• The service as a whole averaged 65% non-medical staff supervision rates for the previous 12 months which fell below the trust target of 100% for clinical supervision compliance.

We rated community-based mental health services for adults of working age as requires improvement because:

• Staff had high numbers of patients on their caseloads which meant that they were not always able to offer sufficient time to all patients to ensure that they were monitored and kept safe.
• There were registered nurse vacancies in the teams which placed extra strain on the staff and the provider had found it difficult to recruit to these.
• Staff had not met the trust’s target for the completion of mandatory training in 11 out of 24 courses.
• Not all staff were using the regular supervision times allocated because of the pressures of their workloads. The appraisal rates for staff were below the trust target of 90% at Swale (82%), Medway (72%) and Thanet (72%) CMHTs.
• Across the five community mental health teams that we visited there were 1290 patients who were waiting to be allocated to a permanent named worker who would act as their care co-ordinator. The trust was missing its target of 28 days to provide an initial assessment for patients who had been referred to the service. At the South West Kent team patients waited for 11 months before being able to access the team psychologist.
• There was a lack of clear service admission criteria for referrers to the service which meant that the teams were receiving inappropriate referrals. This delayed patients being matched to the right service.

.However

• Physical health checks had been carried out for many patients and the teams were working to ensure that all patients received them.
• Medicines were managed safely in all teams.
• There were good systems in place to safeguard patients and staff were knowledgeable about the Mental Health Act and the Mental Capacity Act and had received relevant training.
• The service had made improvements to the quality of care plans and risk assessments were in place for all patients which were being regularly reviewed.
• People who needed an urgent assessment from the teams could be seen quickly in protected time slots.
• There were effective team processes in place to address clinical governance, access and discharge, incidents and complaints, and risk. The teams had an open culture and all professional roles were working effectively and supportively in a multi-disciplinary manner.

We rated Kent and Medway NHS and Social Care Partnership Trust as good because:

• Following this most recent inspection, we rated five of the ten mental health core services as good and three as outstanding. This was a significant improvement on three that were rated good following the March 2015 inspection. Two core services had now moved from requires improvement ratings to good ratings. These were the wards for older people with mental health problems and community based mental health services for older people. Wards for people with a learning disability had moved from a good rating to an outstanding rating. The long stay rehabilitation mental health wards for working age adults had moved from a requires improvement rating to an outstanding rating. We also rated the substance misuse services as outstanding. This service had not been rated during the last inspection.

• Since we last visited in March 2015, the trust had developed and implemented a quality improvement plan. We found during this inspection the majority of actions had been implemented and services had improved along with people’s experience. For example, this was evident in the wards for people with a learning disability where improvements had been made in relation to safeguarding service users from abuse and improper treatment and premises and equipment. We also found significant improvements in the wards for older people with mental health problems.

• We observed staff to be caring, kind, compassionate and respectful towards patients, people who use services and their relatives/carers. Staff were dedicated and committed to their roles. We rated four of the ten core services as outstanding for the caring domain. The remaining six core services were rated as good for caring. We found patients were involved in decisions about their care and the involvement of their relatives/carers was encouraged. We found care planning to generally be good.

• Improvements had been made to protect patients from the unsafe management of medicines across the trust.

• The management and monitoring of the physical health care of patients had improved since our last inspection. We found on the acute wards for adults of working age and psychiatric intensive care units registered general nurses were employed to monitor physical health on a daily basis.

• All inpatient wards had weekly activity programmes. The acute and PICU wards had access to therapies seven days a week. The introduction of the therapeutic staffing model had helped increase the number of activities available.

• The trust had a patient advice and liaison service that offered advice and support to people wanting to make a complaint.

• The trust were proactive in their responses to concerns identified and raised during the inspection. The trust were open and transparent and provided prompt updates.

• We received very positive feedback about the leadership of the trust from staff and stakeholders. The chief executive had had a positive impact on the culture of the organisation and staff morale and engagement had improved.Directors and managers demonstrated commitment and enthusiasm about the trust and were passionate about their work. The trust had met the fit and proper persons test.

However:

• At this inspection, of ten core services visited (services for substance misuse were not rated on our last inspection); we rated two as requires improvement. These were acute wards for adults of working age and psychiatric intensive care units and Community-based mental health services for adults of working age. We still had concerns about the acute wards for adults of working age and psychiatric intensive care units. We found one ward was not complying with the guidance on same-sex accommodation. We also found a number of ligature risks that had not been identified in risk assessments on one ward. A ligature risk is an anchor point which may be used to self harm. We found there were still issues with staffing and some wards had excessive vacancies and relied on bank and agency staffing. Patient risk assessments were not always reviewed or updated following incidents and care plans were not always recovery focussed. Within the community based mental health services for adults of working age staff still had high caseloads. This was an issue we found in March 2015. Across the teams visited there were large numbers of patients waiting to be allocated to a named worker and have their care co-ordinated. The trust was missing the target of 28 days to provide an initial assessment for patients who had been referred to the service.

• We have changed the rating of the forensic inpatient /secure wards from outstanding to a good rating. This is because we found ligature risks on the wards. There were beds on a ward that were not fixed to the floor and posed potential ligature risks. Staff were not sighted on these risks.

• Staff working on the wards for older people with mental health problems were inconsistent in their application of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS).

• We found the governance systems in place did not always provide the board with sufficient assurance. For example, there were inconsistent rates of staff supervision and appraisal taking place.

• We found there was no direct sub-committee of the board that related to the Mental Health Act. We were concerned about where governance for the Mental Health Act sat within the trust.

We rated forensic inpatient and secure services at Kent and Medway NHS and Social Care Partnership Trust as good because:

· The use of seclusion was minimal and staff used least restrictive practice. Staff aimed for a least restrictive environment in the best interests of the patients.

· Staff completed robust and comprehensive risk assessments for patients, which they reviewed regularly. Staff used recognised risk assessment tools designed for forensic services. Risk assessments demonstrated patient involvement and staff working collaboratively with patients.

· There was good physical health provision. Staff used the modified early warning score to monitor and improve the physical health of patients. A male and female GP from a local surgery visited the ward each week. The service employed a dietician to ensure that patients’ nutrition and hydration needs were met. However, patients and staff told us there were difficulties accessing dentists for patients.

· There was a comprehensive range of individual and group activities that met the National Institute for Health and Care Excellence guidelines. Patients were involved in planning the weekly activities during weekly community meetings.

· Each team had regular team meetings. Ward managers met regularly to share learning and discuss service development. We saw good, effective team working across the service.

· We observed caring, supportive and positive interactions between staff and patients. Staff demonstrated knowledge and understanding of individual patient needs. Patients told us that staff were non-judgemental, calm and patient. We heard examples of staff going above and beyond their duty to ensure that patients’ needs were met.

· Patients were involved in their care planning and care plans were comprehensive and recovery focussed. Staff used the ‘My Shared Pathway’ care planning tool to ensure person centred care planning. Patients were involved in ward rounds and completed a ‘Have Your Say Ward Round’ form prior to the meeting. We saw examples of how the service had responded to feedback from patients on ‘You said, we did’ boards. The service held quarterly patient forums.

· We observed a placement review panel attended by stakeholders and staff from the service. The meeting had been set up to reduce the number of out of area placements for patients.

· Wards had a range of rooms and equipment to support patients’ care and treatment. A patient described how the service had made changes to the environment to accommodate their needs.

· Staff were passionate and committed to their work. All staff reported good morale and feeling supported by their managers. Staff told us that senior managers were visible in the service.

· There was a quality and clinical governance co-ordinator for the service who supported managers with governance to ‘allow managers to concentrate on clinical issues. The co-ordinator sent monthly reports about key performance indicators, incidents, training and audits.

· All wards were participating in the ‘Safewards’ initiative which promoted wards feeling safe and calm. The service had adopted the 15 steps challenge which asks a series of questions to guide first impressions of the ward to improve the quality of patient care.

However:

• We found that the service had acted on most of the recommendations made at the previous inspection. However, building work was still ongoing at the time of our visit which meant that the trust had not addressed all of the issues raised.
• We saw that although building work to protect patients and staff against risks associated with unsafe or unsuitable premises had started, it had not been completed. This meant that the trust was not compliant with Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• During our inspection in March 2015, we recommended that the service expedite the approval to extend the perimeter fence on Penshurst ward to include the tennis courts, to increase the size of the outside area for restricted patients. However, although building works were taking place, there were still concerns regarding the seclusion room and the outside area at Penshurst.
• We saw limited progress with our recommendation from our inspection in March 2015, to implement the capital works programme for anti-ligature at the Trevor Gibbens Unit. There were multiple risks including one that had not been identified.
• Although there were high levels of staff completing mandatory training, we saw that low numbers of band five staff and above had completed the safeguarding adults level two training.
• Staff told us that only serious incidents were recorded on the electronic reporting tool. Other incidents were recorded in the patient’s electronic records. This meant that opportunities for learning and identifying themes could be missed.
• Although staff told us they received regular supervision, the quality of record keeping was inconsistent across the wards.
• The outdoor area for patients on the extra care area on Penshurst ward did not demonstrate dignity and respect.

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.

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

• Cherrywood ward at Littlebrook Hospital was not complying with guidance on same-sex accommodation.

• Patients’ bedrooms on the psychiatric intensive care unit, Willow Suite, contained multiple ligature risks.

• Some areas of the service had excessive vacancies and relied heavily on bank and agency staff. Some staff did not meet the trust’s target for completion of mandatory training or have access to regular supervision.

• Patients’ risk assessments were not always reviewed or updated following risk related incidents. Episodes of patient being secluded were not always recorded in line with the trust’s seclusion policy.

• Patients’ care plans did not always address a full range of needs; were not always recovery focussed and patient involvement was not always recorded. Psychological assessments or treatment was not available to patients on the psychiatric intensive care unit, Willow Suite.

• Staff did not always have sufficient knowledge of the Mental Health Act Code of Practice and the Mental Capacity Act. Documentation was not always completed in line with these Acts.

• Staff were not always using systems in place to document and monitor when patients were taking Section 17 leave.

• The trust’s no smoking policy was presenting issues for patients and staff. These included episodes of physical aggression, inconsistencies in following the policy, and increased risks of patients smoking in bedrooms. Patients’ outside areas were not always accessible or therapeutic.

• Some managerial decisions had been counter-productive. These included salary incentives that excluded some staff; lack of clarity on wards providing same-sex guidance; and inconsistencies in following the no smoking policy.

However:

• All wards had clinic rooms and emergency medical equipment for staff to respond to medical emergencies. Seclusion rooms were equipped in accordance with the Mental Health Act Code of Practice.

• All ward environments were clean and well-maintained with systems in place that ensured environmental issues were identified promptly. Patients and staff had access to alarm systems to ensure they could summon support if they felt at risk.

• Staff had good observation systems in place to ensure that patients were kept safe. Staff were able to manage distressed patients safely. They had access to calming rooms and only used restraint as a last resort. Staff received restraint training that eliminated the need to restrain patients in a face down position.

• Staff had a good understanding of the processes of incident reporting and raising safeguarding issues. The service regularly discussed incidents and learnt from them.

• Patients received ongoing monitoring of their physical health needs from registered general nurses who were trained in recognising physical health concerns. The service received support from pharmacists to ensure that medicines were managed effectively.

• The service had recently introduced therapeutic staffing. This model integrated occupational therapists and psychologists into staff teams and provided patients with a wider range of structured activities seven days a week.

• Staff had regular meetings and handovers where they discussed patients’ care needs in detail.

• Staff treated patients with dignity and respect. Staff had a good understanding of patients’ needs and listened to their views. Patients had access to recovery groups that encouraged them to maintain their independence. The service was committed to involving families and carers.

• The service employed discharge facilitators to address issues preventing discharge. In the last six months the service had significantly reduced its use of private beds. They also employed dedicated staff to improve patients’ access into the trust’s psychiatric intensive care unit.

• Patients had access to a wide range of therapy rooms and activities which were available seven days a week. Patients were able to access their bedrooms during the day and had access to mobile phones and rooms to see visitors in private.

• All wards displayed a wide range of patient information including how to complain. Patients knew how to complain and staff knew how to manage complaints. Patients could access interpreters and chaplains and were provided with information on local services.

• Staff knew the trust’s vision and values and agreed with them. They enjoyed their roles and morale was generally high. Staff felt supported by managers and colleagues and had opportunities for career progression.
• Ward managers had effective governance systems to enable them to monitor training, supervision and staffing levels. Staff had the use of effective systems to record incidents and safeguarding issues.

We rated wards for people with learning disabilities or autism as outstanding overall because:

• At this inspection, we found the trust had made improvements to the quality and safety of the service and care and treatment given to patients. We have rated each domain as outstanding.

• There was a truly holistic approach to assessing, planning and delivering care and treatment to patients. Care plans were comprehensive, personalised and recovery oriented with clear goals set to support patients through their care and treatment pathway.

• A proactive approach to anticipating and managing risks to patients was embedded, recognised, and owned by all staff. Patients and their carers were actively involved in managing their own risks through the use of risk assessment tools and worked collaboratively with staff.

• All patients had a detailed positive behaviour support plan in place. Staff applied effective proactive strategies to de-escalate or prevent patients challenging behaviour and applied reactive strategies when needed as per patients positive behavioural support plans.

• Staff were focused on the use of preventative approaches and de-escalation with minimal use of all restrictive interventions. Staff used de-escalation or positive behaviour support proactively. Between 1 April 2016 and 30 September 2016, there had been no episodes of restraint or rapid tranquilisation across the service.

• All patients had a comprehensive physical health assessment. The service had fully implemented the use of ‘The Lester Adaptation Tool’. Physical healthcare needs were incorporated into patients’ care plans and were comprehensive and detailed.

• There was a continued drive by the clinical team tried to reduce the use of medications. Patients from wards for people with learning disabilities or autism were not on any high dose antipsychotic medication or multiple medications for psychosis.

• Occupational therapists worked with patients to formulate intervention and treatment plans. All patients had access to an extensive activities programme that was individual and therapeutic. Each patient’s treatment programme was tailored to their individual needs.

• Patients had access to a wide range of evidenced based psychological therapies as recommended by the National Institute for Care and Excellence as part of their care and treatment delivered on a one to one or group basis.

• The service was discharge oriented and committed to achieving a sustained reduction in the number of patients admitted to the wards. Staff undertook thorough pre-admission assessments, to ensure only patients who could not be managed in the community were admitted to the wards. Pro-active discharge planning took place from the point of admission. The service worked in conjunction with the patient and partner agencies to facilitate discharge as soon as was safely possible.

• Staff were encouraged to review practice and actively engaged in activities to monitor and improve patient outcomes.

• Patients spoke very highly of the staff and the quality of care they received. They told us that staff were caring and supportive and they felt empowered as partners in their care. The service ran a number of projects to engage and support relatives, friends and carers.

• Staff were open and transparent, and fully committed to reporting all incidents and near misses. All staff were engaged in reviewing and improving safeguarding systems across the service to ensure improvements in safety and a continuous reduction in harm and abuse. Learning was based on thorough analysis and investigation.

• Staff were passionate about their work and were clearly very proud about the wards they worked on. Staff felt valued by the trust and there was high staff morale across the service.

• Staff from the multidisciplinary team worked in equal partnership and clearly respected and values each other’s decisions. Staff continuously demonstrated they were motivated and dedicated to deliver the best care and treatment they could for patients.