Bradford District Care NHS Foundation Trust

Updated 24 August 2022

We carried out short notice (24 hours) announced inspections of three of the community mental health services provided by this trust.

We inspected community mental health services for adults of working age because we rated them requires improvement at our last inspection. We inspected specialist community mental health services for children and young people because of the high-risk nature of this service, and because we have not inspected this service since 2014. We inspected crisis and health-based places of safety because of the high-risk nature of this service.

We also inspected the well-led key question for the trust overall because at our last inspection we rated the trust overall as requires improvement.

At this inspection community mental health services for adults of working age, and crisis and health-based places of safety were rated as good overall. In community adults of working age, the rating had improved from requires improvement. In crisis services the rating stayed the same with an increase in rating in the safe key question from requires improvement to good.

Specialist community mental health services for children and young people were given a rating of requires improvement overall, with a rating of good in the caring key question. The rating had gone down since our last inspection.

We did not inspect four services previously rated as requires improvement because we did not have intelligence which told us about risk in these services. We are continuing to monitor the progress of improvements to these services and will re-inspect them as appropriate.

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

• We rated services as requires improvement in the safe key question, responsive and effective as good, and caring as good. We rated the trust as good in well-led.
• We rated six of the trust’s ten mental health services, and three of the trust’s community health services as good.
• The trust had made a number of improvements since the last inspection, the ratings of the trust overall, acute wards and psychiatric intensive care units, and community mental health services for adults of working age had improved, the rating of crisis services had stayed the same.
• There were several areas of concern at the last inspection which the trust had made improvements to. This included; governance processes, oversight and management of risk and performance, a reduction in the use of restrictive interventions, improvements to serious incident reporting and oversight and management of supervision, appraisal and mandatory training.
• The trust had taken action to improve the safety of services, rapid improvement processes had been used where concerns had been identified. Daily lean management processes meant that leaders were aware of risks and concerns in front line services.
• We observed and were told about staff who were kind, caring and compassionate. Staff had received several compliments about their work.
• The trust had a focus on the wellbeing of staff, offering incentives as well as practical and emotional support. Staff spoke of a positive culture of openness and transparency from senior leaders and were encouraged to develop both their professional skills and be innovative in the services in which they worked.
• The trust was responsive to the diverse needs of the population it served, had awareness of and was working to reduce health inequalities.
• The trust engaged with partner organisations to be an active part of the integrated care system. The trust saw staff, governors, patients and carers as partners in care and worked to ensure their voices were heard in the improvement of services.
• The trust had an experienced and skilled leadership team and a board of non-executives who were passionate and from a range of backgrounds bringing diverse experience to their roles.
• Governance processes were effective and embedded with a clear ward to board structure for reporting.
• There were some areas of outstanding practice which included the trust’s work in the clinical incident stress debrief service.
• The trust had successfully embedded and managed a large vaccination programme for both adults and children.

However:

• The rating of the trust’s specialist community mental health services for children and young people had reduced from good to requires improvement since the last inspection. The trust were aware of the risks and issues in this service and staff told us that they were starting to see improvements and revised governance structures were in place, but these were not embedded at the time of the inspection.
• We rated four of the trust’s mental health services and one community health service as requires improvement. In rating the trust, we considered the current ratings of the eleven services we did not inspect this time.
• There remained issues in the services we visited in relation to the quality of documentation. Information about patients and their care and risks was not always accessible. In community mental health services for adults and for children and young people, risk assessments and care plans were not stored consistently and often stored in progress notes. Consent to treatment was not always recorded and paperwork relating to community treatment orders was not in line with the Code of Practice.
• The management of policies and processes needed improvement. Some policies were not in line with statutory codes of practice and important information on timescales and processes were not always included, this was particularly in respect of human resources policies, and those relating to the Mental Health Act.
• The duty of candour regulation was not fully applied in the incidents we reviewed because an early apology was not always given in line with the legislation and was not part of the trust’s processes. The trust did not have a specific duty of candour policy, although the process was outlined within other relevant policies.
• The trust had a focus on quality improvement and there were a number of initiatives in place. However, it was not always possible to track how outcomes and actions from some initiatives were monitored, such as actions from the board’s ‘go see’ visits and feedback from staff network groups.
• Information collated from the staff survey and workforce race and disability equality standards evidenced that the trust had further work to do in order to tackle inequalities in the workplace.
• The trust had an estate at Lynfield Mount hospital and in some community services which was no longer fit for purpose.
• The trust had governance processes in place to monitor areas of risk and concern. However, in some risks in front line community services such as staffing, and caseload levels were not always prioritised by the board.
• Waiting times in some services were too long. This included waiting times for adult and children’s neurological services and waiting times for dental treatment and therapies.
• The trust had begun to make improvements to their patient safety process including improvements in the investigation of serious incidents. However, incident investigations required further improvement on human and causative factors. Incidents were often found to be individual staff error and there were repeat themes in incidents where professional curiosity was lacking and risk thresholds were too high, and it was not possible to track how action had been taken to improve practice when these issues were managed at service level.

How we carried out the inspection

• worked with experts by experience who talked to patients and their carers about their experience of using trust services.
• visited both specialist community child and adolescent mental health services at Fieldhead in Bradford and Hillbrook in Keighley.
• Visited three community mental health teams for working age adults; the City team, North team and the Aire Wharfe team.
• visited community crisis services; the first response service, the intensive home treatment teams and the psychiatric liaison service at Airedale General Hospital.
• visited trust headquarters to speak with senior leaders.
• spoke with a variety of staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, and managers.
• Attended and observed several meetings and committees held by the trust.
• reviewed several records relating to the care and treatment of patients.
• reviewed a variety of documents relating to the management of the trust and the services it delivers.
• held four focus groups with; staff network groups, staff side and two open staff drop in calls.
• reviewed a variety of information we already held about the trust.
• sought feedback from several of the trust’s stakeholders such as Healthwatch, the local authority, NHS England and Improvement and CCG’s.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

During our core service inspections, we spoke with 33 patients who had experience of using services who were either patients or carers. Feedback was mainly positive. We also gathered feedback from patients via Healthwatch colleagues.

Young people using child and adolescent mental health services spoke about feeling supported by professional and caring staff who were respectful, and managed confidentiality well. They said that staff listened and understand and were empathic to their needs and that teams were reliable and offered a variety of treatments.

Patients using crisis services described staff who were caring, understood their needs, responsive and who communicated with them well, they said that appointments were arranged quickly.

Patients using community mental health services for adults of working age had positive experiences. They described staff who provided emotional and practical support, said that they had access to doctors and had information about their medication. Some patients told us that the support they were offered had kept them out of hospital.

However,

Young people using child and adolescent mental health services told us that communication could be improved as there was not always a point of contact available. Young people and their families were frustrated by long waiting times.

Patients commented that continuity of care and changes of staff could improve in crisis services.

Patients using community mental health services for adults of working age told us that it could be difficult to access support from Somerset House at times.

Updated 29 July 2014

Bradford District Care Trust provides a range of adult community-based mental health services, including the assertive outreach team, community mental health teams and the early intervention service.

Adult community-based services were safe. Staff received appropriate training and they understood safeguarding procedures. Risk was managed effectively and communicated promptly on a daily basis. Although the number of community caseloads had increased overall, good line management and effective caseload management systems meant that they were well managed.

People’s care and treatment was planned and delivered effectively. Care was recovery-focused and people were supported to achieve positive outcomes. Assessments of people’s needs were thorough, and person-centred care plans were developed in partnership with people who used the service. Staff were supported well by their team managers and there was a good mix of professional backgrounds and skills in the teams. Multidisciplinary working was embedded across community services and information about people was shared appropriately. Staff received regular training and supervision.

Staff delivered care and support with kindness and compassion, and treated people with dignity and respect. People felt listened to and involved in decisions about their care, and their cultural needs were included in their care plans. People were also able to influence how the service was managed and developed.

Adult community-based services were responsive. The trust’s follow-up of people after discharge had improved since last year, and people were being provided with the right care at the right time. In addition, we did not find any issues with appointments or waiting times. Services were planned and delivered in a way that took account of the different needs of local communities. The relevant community teams were involved before people were admitted to hospital, during their stay in hospital, and in planning and supporting their discharge back into the community. We also saw evidence of trust-wide learning from complaints and incidents, for example through updates from team managers and trust-wide emails. This information was also included and discussed at monthly team meetings.

We found that teams were well-led by their team managers and that staff were aware of the trust’s vision and strategy.  We found evidence of responsible governance, and that the trust had an oversight of key risk areas, as identified on their risk register.

Updated 29 July 2014

There were effective systems in place for reporting patient safety incidents and the service compiled and reviewed safety information from a range of sources. Staff were however unclear about the lone working policy. Risks were not always recorded in the electronic care notes system in an effective way.

There was a system in place for assessing people’s needs, however, the service did not have an effective audit programme in place. The service environments were suitable for young people and families. Written information was not always available in appropriate formats.

The different professionals in community services worked well together and made sure that people’s needs were met. These staff had access to effective training, managerial and clinical supervision and appraisal.

All of the people that we spoke with were positive about the staff and the care they received. Feedback from young people and their families was however not used effectively.

The team had a range of therapies, collaborations, outreach programmes and specialty roles. There was also a good system in place for managing referrals and waiting lists safely and effectively.

The transition of young people to adult mental health services  and concerns and complaints were effectively managed.

Staff felt supported within the team and from service and executive level staff.

Clinical dashboards and safety information was managed effectively at governance level, however systems for ensuring that policies and procedures were up to date were not effective.

Updated 12 February 2018

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

• The service provided safe care and treatment to patients. Staff were competent in reporting and learning from incidents and safeguarding concerns. Staff were also supported to develop competencies and their professional practice.
• Multidisciplinary teams delivered evidence based care and treatment across the service. Services were planned and delivered to meet the needs of patients, including tailored services for patients with specific needs.
• Staff delivered outstanding care to patients. This was supported by comments and feedback received from patients, observations of caring interactions, and examples of where staff were able to go ‘over and above’ to deliver person centred care.
• There was a positive, patient centred culture within the service where staff felt supported by leaders to deliver good quality patient care.

However:

• Governance processes did not always provide assurance about performance or practice within the service. Examples of this included management and clinical supervision not being consistently practiced or documented. Other examples of this included incomplete data being provided around role specific training for staff.

Updated 24 August 2022

We carried out this unannounced inspection of the community health service for children, young people and families, provided by this trust as we had concerns about the quality of the service provided.

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

• The service did not have enough staff, there were several unfilled vacancies and staff were holding caseloads much larger than recommended by national guidance. Staff sickness and turnover levels were high.
• The service was unable to meet mandated contacts for children and young people. Aspects of the service were in business continuity which meant that not all services were being provided. There were waiting lists in place in the looked after children’s team which meant that children waited for individual health assessments longer than they should, and this was not in line with national guidance.
• We reviewed 29 records during the inspection. Whilst the majority of records were detailed and consistent, we had concerns that five of the records did not meet the trust's standard in evidencing what action had been taken to address concerns in relation to risks such as domestic violence or mental health concerns. Managers were aware that this was an area of improvement for the service and were undertaking a records audit at the time of the inspection.
• The service worked on a risk-based approach whereby children were placed into four tiers dependent on need. We were concerned that in some cases late identification of health conditions and disabilities could occur for those children in lower tiers of need due to lower levels of oversight for these families.

However:

• Staff teams worked collaboratively and were encouraged to share ideas and give feedback on service development. Staff supported people to live healthier lives and thought of different ways to engage harder to reach service users.
• Staff treated children, young people and their families with compassion and kindness. Staff were passionate about the roles they performed and wanted to provide high quality care. Service users were encouraged to give feedback, which was largely positive. Staff recognised the importance of mental and emotional health as well as physical health and offered appropriate support and information to families.
• The service was beginning to consider and introduce some innovative ways of working to meet the needs of the local population.
• Leaders at all levels of the service were knowledgeable and passionate and sought to drive improvement. Strategies and development plans reflected the needs and challenges of the service and there were clear action plans in place detailing how improvement would be made. Staff were satisfied with their roles in the service and felt valued and supported.

How we carried out the inspection

During the inspection visit, the inspection team:

• visited six locations

• carried out six home visits and one school visit

• spoke with the general manager and assistant general manager for the service

• spoke with 55 other members of staff including, service managers, school nurses, health visitors, staff nurses and nursery nurses

• spoke with nine service users including one young person

• observed the running of one baby clinic and one immunisation session

• looked at 29 care and treatment records of service users

•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: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

During the inspection we spoke with nine service users, including one young person. We also observed interactions between staff, young people and their families during 10 appointments including at an immunisation clinic, school nurse clinic, baby clinics and home visits.

Service users told us that staff were friendly, helpful and approachable and would always give advice and respond to queries. They also told us staff were accommodating at rearranging appointments to support service users. We observed staff providing reassurance and support to those with concerns or worries. The majority of those using the service told us that staff were helpful, approachable and available to give advice and support. Staff took time to explain about the service and ensure service users knew what support was available to them. Service users were regularly requested to give feedback about the service to aid improvement, but staff were clear that they needed to do more to gain feedback from children and young people.

Updated 12 February 2018

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

• The service provided a welcoming and clean community dental service that was well regarded by the patients we spoke with.
• A range of clinics were offered including: clinics for emergency dental care, clinics for those patients who were unable to leave the house, dental care for patients who, because of their particular needs, could not be seen by a general dental practitioner, and mobile care for hard to reach groups, such as the homeless.
• Staff appeared motivated and had systems and processes in place to support them, including access to equipment they needed, and enough time, to enable them to see and treat patients safely.
• The service was well-led by a team of senior leaders who ensured there were adequate governance, risk and quality management systems in place to ensure safe care of patients and that the service continually strived to meet the needs of its local population.

Updated 11 June 2019

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

• The service used innovative approaches to provide integrated person-centred pathways of care that involved other service providers.
• The service was responsive to the needs of the local population and engaged well with hard to reach groups and ethnic minorities to provide individualised care. There was a proactive approach to understanding the needs and preferences of different groups of people.
• The service used technology innovatively to ensure people had timely access to treatment, support and care. The Gold Line gave round-the-clock telephone support to patients and carers who needed help, reassurance or advice.
• People were truly respected and valued as individuals. They were empowered as a partner in their care practically and emotionally by an exceptional distinctive service.
• Carers were seen as active partners in peoples’ care. Staff were fully committed to working in partnership with people and making this a reality for each person.
• Staff found innovative ways to enable people to manage their own health and care and delivered holistic patient centred care.
• We found that without exception staff were passionate about the care they delivered and were determined to give the best care they could to patients and their relatives. Staff understood and respected the personal, cultural, social and religious needs of patients and their families and took these into account in the way they delivered services. We saw staff delivering holistic patient centred care.
• There was a positive culture with good relationships between staff who worked well together. They worked with partner organisations effectively to provide seamless patients care.
• The service was well led. Staff spoke highly of the clinical lead and their line managers and said they felt supported. Staff were proud to work for the service and were focused on the needs and experience of patients and families who used the service.
• We found the service was continually striving to improve. There was a positive culture of learning, continuous improvement and innovation.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service made sure staff were competent for their roles and provided training and development to other staff providing care for patients at their end of life.
• Staff understood how to protect patients from abuse and 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. Staff followed best practice when prescribing, giving, recording and storing medicines.

However:

• Although the service managed patient safety incidents well, not all staff were familiar with how to locate and complete an incident report.
• Staff did not complete the ‘Comfort and Dignity Care Plan’ for all patients who were identified as entering their last days of life.
• We had some concerns around staff who updated patients’ records on return to the office. This meant the records were not completed contemporaneously and this may impact on the patients shared care. Staff confirmed there had been no incidents because of this.

Updated 2 July 2014

End of life services were safe. There were arrangements in place to minimise risks to patients, including health risks and risks of harm to the patient. In general, staffing levels were safe and there was on-going monitoring to make sure that the number of staff on duty was flexible and met patients’ needs.

Arrangements were in place to manage and monitor infection control, medicines, and the safeguarding of people from abuse. There were also dedicated teams to support staff and make sure that policies and procedures were implemented.

Staff knew the process for reporting incidents, near misses and accidents and were encouraged to do so. In addition, learning from incidents was shared between teams and across the organisation.

Services were effective, evidence-based and focused on the needs of patients. We saw some examples of very good collaborative work and innovative practice.

We also found evidence that patients approaching the end of life were identified in the right way. Care, including effective pain relief, was delivered according to their personal care plans, which were regularly reviewed. Patients in the last days of life were identified quickly and appropriate action was taken.

The majority of staff were up-to-date with mandatory training and there were systems in place to make sure that staff received regular appraisals. However, the clinical supervision of staff varied across the service and some staff did not have regular protected time to reflect on clinical practice.

End of life services were caring. Patients and relatives told us that staff supported them well and we observed that staff were compassionate and caring. Staff were also aware of the emotional aspects of caring for people with end of life illnesses, and made sure that specialist support was provided for people where needed.

The service understood the needs of the people it cared for, and developed services to meet those needs. There were systems in place to make sure that patients were able to access the right care at the right time, and that services were flexible enough to fit in with patients’, and their families’, lifestyles. This included, for example, their individual preferences, spiritual, ethnic and cultural needs. We saw excellent examples of staff making sure that the needs of patients with a learning disability accessing end of life care were understood and taken into account.

Systems were in place to encourage patients and their carers and/or families to provide feedback. There were also complaints procedures available and we saw that complaints were handled effectively.

End of life services had a clear vision and strategy to improve and develop high-quality end of life care. Managers and staff understood the roles and responsibilities of governance and quality performance. While most staff were aware of the trust’s vision and strategy, not all staff knew about these.

Local managers provided good leadership and support, and most staff felt engaged with senior management. There was a positive culture in the service and staff felt that the leadership models encouraged them to be supportive of each other and compassionate towards people who used the service. In addition, staff were encouraged to raise problems and concerns about patient care without fear of being discriminated against.

People were encouraged to give their views on the service. We saw that these were heard and acted on, and that information on patients’ experience was reported and reviewed, alongside other performance data. Where issues were identified, action plans were put in place to make improvements to patient care.

Updated 15 December 2021

Updated 12 February 2018

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

• The service building was clean and tidy and all necessary testing in relation to health and safety such as fire, electrical wiring and gas safety had been completed.
• There were contingency plans in place in the event of the service building or electronic systems being unavailable.
• The people who used the service that spoke with us told us staff were kind, caring and were aware of their needs and that they were involved in decisions about their care and treatment.
• The people who used the service were able to given feedback via surveys and user groups.
• Two patients worked as volunteers at the service.
• Staff made efforts to engage with patients who had not attended appointments or were reluctant to engage with mental health services.
• The trust had policies and procedures in place to protect people from discrimination, unfair treatment, harassment and bullying.
• Staff assessed and monitored patients’ physical health and encouraged them to attend appointments with other services such as GP appointments.
• Staff encouraged patients to live healthier lifestyles by taking exercise, eating healthily and smoking cessation and there were posters and leaflets in the waiting area giving advice on a wide range of health conditions such as cancer and diabetes. The service provided breast screening in conjunction with another external organisation.
• Staff were knowledgeable about safeguarding, knew how to report incidents and received information about learned lessons from incidents, complaints and patient feedback to improve practice within the service.
• The trust reported there were no serious incidents in the 12 months prior to our inspection.
• Staff knew what their responsibilities were under the duty of candour in relation to being open, honest and transparent with people when things go wrong.
• Staff received training in equality and diversity and the trust had policies to protect people from discrimination, unfair treatment, bullying and harassment
• There were sufficient numbers of staff to meet the needs of the patients, there was no freeze on staff recruitment, and sickness absence figures were at 2.12% which was better than the trust’s target of keeping levels down to 4%.
• The multidisciplinary team comprised a wide range of professionals and there were effective meetings and handover arrangements within the team.
• Staff were experienced and qualified to do their job.
• Staff had access to specialist training for their role and managers identified their training and development needs.
• The service’s medicines management arrangements were effective and were in line with the National Institute for Care and Health Excellence, Royal College of Psychiatrists, Faculty of Intellectual Disabilities and Stopping the Over-Medication of People with Learning Disability and Autism guidance.
• The service had an effective lone working process to ensure staff were safe when they were working in the community.
• Pathways used by the service included mental health, behaviour, maternity, ophthalmology, respiratory and dementia.
• Patient care records were holistic, person-centred and recovery orientated.
• The service used positive behaviour support plans for patients, which were tailored to meet patients’ individual needs and centred around reducing their behaviours that challenged.
• Staff received mandatory training in the Mental Capacity Act and had a good knowledge of the Act.
• The service made effective and appropriate use of best interests decisions and capacity assessments and supported patients to make their own decisions.
• Staff were appraised and agreed with the trust’s visions and values.
• The numbers, experience and role mix of staff meant the service could meet patients’ needs.
• Staff morale and job satisfaction were positive, there was a good level of support from peers and managers, staff felt proud to work for the trust.
• The trust recognised staff’s success and staff within the team had won awards from the trust and a member of staff had won a national learning disability award.
• Staff could add items to the service and trust risk registers and knew where to access the trust’s whistleblowing policy.
• The service worked with the local police to raise awareness of issues associated with learning disabilities, a health care support worker supported the service and trust with the delivery of learning disabilities awareness training for first year student nurses and a speech and language therapist led a quarterly communications champions' network forum and ran consultancy clinics during which staff could discuss patient cases.
• The service worked with external care providers and services to promote the use of information technology to older people to enable them access to various forms of online support. It also delivered learning disability awareness sessions to acute hospitals.
• The service had run training sessions to local support providers around active support and behavioural monitoring and had positive and proactive champions and communication champions networks that shared best practice around the use of positive behaviour support and communication methods for people with a learning disability.
• The service participated in one of the Commissioning for Quality and Innovation’s national audits in relation to ensuring patients were able to access national physical health checks.

However

• Staff compliance rates for required training in level three safeguarding children and adults, managing violence and aggression – breakaway and basic life support were below 75%.
• The garden area that was situated at the top of a grassy bank with a steep incline with insufficient protection to prevent people falling.
• Mental Health Act training was not a mandatory training requirement for staff at the service.
• The service were unable to provide accurate data in relation to the number of cancelled appointments, numbers of patients subject to community treatment orders and numbers of complaints.
• The service had insufficient monitoring arrangements in place to ensure mandatory training was within the trust’s 80% compliance target, clinical supervision was taking place, all care plans and risk assessments were reviewed at least every six months in line with the service’s policy and all initial risk assessments were included in care records. The trust did not monitor compliance with staff supervision.

Updated 11 June 2019

• The service provided safe and effective care, there were sufficient numbers of staff who were adequately supported through supervision and appraisal and staff were very knowledgeable about their areas of work.
• Managers provided extensive support to staff and were approachable, visible and always helpful. Staff and managers clearly had a lot of respect for each other and worked well together.
• Staff used best practice in treatment and care offered.
• Staff treated patients with compassion and kindness. They showed a good understanding of patients’ needs and they made efforts to involve families and carers wherever they could.
• The service work closely with the community to ensure they were able to reach individuals that might need the service. They offered a wide range of appropriate interventions and activities which met the needs of patients.
• The service had implemented an effective incident reporting system and they ensured that they shared information gathered using this process. They used lessons learnt from incidents and complaints and patient and carer feedback to make changes to services where appropriate.

However:

• We had some concerns about the way information was recorded and stored on the new electronic patients recording system and it was not clear if patients were routinely offered a copy of their care plan.
• Whilst the sites that we visited were clean and well maintained, some clinics and storage areas were cluttered and untidy.
• Waiting time for a memory assessment in some areas were high.

Updated 15 December 2021

Updated 11 June 2019

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.

• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability (and/or autism) and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.

• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.

• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

• Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

• The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Staff did not review the blanket restriction mandated by the trust in relation to bathrooms and shower rooms.
• The trust did not have an effective system to record and monitor supervision. The service did not have local arrangements to support that staff received regular supervision in line with trust policy.

Updated 11 June 2019

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

• The service did not always deliver safe care. Risk assessments of the environment did not include all potential risks, had not been reviewed as required and the trust had not taken action to mitigate all those risks. There were no nurse call alarms on any of the wards for patients to use and no standard procedure for giving patients access to an alarm. The service had blanket restrictions in place that were not based on an individual assessment of risk and need. Staff did not adhere to trust policy in searching patients and monitoring their mail. Staff did not clearly evidence that they had used long term segregation appropriately or that they had followed best practice and trust policy in doing so. The seclusion room contained a safety hazard.
• The service was not always well led. Senior managers did not have sufficient oversight of the issues in their service and ensure staff were adhering to trust policy in relation to searching, mail monitoring and long-term segregation. Systems and processes in place to enable good governance of the wards were not always effective. The trust did not have robust systems in place to monitor and safeguard patients in long term segregation. Staff supervision was not effectively monitored and the electronic record system did not enable staff to effectively document seclusion episodes or the monitoring of rapid tranquilisation.

However:

• There were sufficient staff to meet the care and treatment needs of patients. Staff and patients reported they felt safe on the ward. The wards were clean and the environment was well maintained.
• Staff undertook comprehensive assessments of patients’ physical and mental health needs and used these to develop care plans in collaboration with patients. Staff provided a range of treatment interventions suitable for the patient group and used recognised rating scales to monitor outcomes. Staff across all disciplines worked well together and teams had effective working relationships with external agencies.
• Staff treated patients with kindness and respect. Staff understood the individual needs of patients and supported them to manage their condition and treatment. Staff involved patients in their care and treatment and won awards for their innovative practice in patient care. The service provided carers with the opportunity to be involved in their relative’s treatment and to provide feedback on the care they were receiving.
• The service was responsive to patients' needs. Staff planned for discharge from admission and discharge only occurred when a patient was ready to move on. A transition team supported patients from pre-admission to post-discharge. Patients had access to facilities to meet their needs and reported the food was of good quality. The trust ensured patients had access to spiritual support and interpreters where required. Patients knew how to complain and staff handled complaints appropriately.
• Staff spoke positively about managers within the service and most staff felt respected and supported. Staff reported morale was generally good and that all members of the multi-disciplinary team felt their voice was heard and opinion respected. Staff were not afraid to speak up and felt able to raise concerns if needed.

Updated 12 February 2018

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

We rated long-stay or rehabilitation wards for working age adults as requires improvement because:

• The service did not always have enough staff. The trust reported that 80 shifts were not filled in the 12 month period between 01 July 2016 and 30 June 2017. Between 01 January 2017 and 31 July 2017 56 shifts fell below the safe minimum staffing levels and three shifts did not have a registered nurse on duty. Staff told us that registered nurses could not always have dedicated time with patients.
• Half of the patients’ care plans reviewed did not contain information about interventions and support required to meet patients’ needs. None of the records reviewed contained care plans with evidence of patient involvement or completed outcome measures. Staff had not ensured that they informed two patients of their rights under the Mental Health Act regularly. Training rates for Mental Health Act were low at 41%. Training in the Mental Capacity Act had not been consistent and although this was at 94% at the time of inspection, it had been 65% prior to our inspection.
• The clinic room was cluttered and this could impact on how quickly emergency equipment could be accessed when needed. A bottle of alcohol was stored with controlled drugs in the clinic room.
• The service did not have an allocated member of staff to complete patient observations each shift. When patients were on leave and missed physical health monitoring, staff did not always record whether they offered these checks again when patients’ returned.
• The therapy kitchen was not fully accessible for disabled people because no areas of the kitchen had lowered worktops. Staff did not always respect patients’ privacy; two patients told us they did not knock on their bedroom doors before opening and entering.

However:

• The ward was open access and had the appropriate restrictions expected for a rehabilitation ward. Patients had open access to a therapy kitchen and could make their own meals and drinks at anytime. The service had facilities, activities and encouraged access to work to promote mental health rehabilitation and recovery. The service was clean, had good furnishings and was well maintained.
• Feedback from patients and observations showed that staff knew patients and their needs well. Staff were polite, respectful and supportive. They involved patients and their families, carers, advocates and care co-ordinators in multi-disciplinary meetings well.
• Staff managed and mitigated risks well. Patients risk assessments contained detailed information on risks and staff understood regular risk assessments of the care environment. Staff used de-escalation techniques and the service reported only three incidents of physical restraint in a 12-month period.
• The service reported no delayed discharges, serious incidents or safeguarding referrals and complaints in a 12-month period.
• Senior leaders were visible in the service and understood the services. Staff had opportunities for leadership development and they felt supported and valued.
• The trust provided opportunities for staff to participate in seminars on research, conferences and specialised learning events.

Updated 11 June 2019

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

• Staff did not always follow their processes for maintaining and checking emergency equipment and drugs. Also, staff did not always follow best practice when dispensing and recording medication to reduce the risk of error and patient harm.
• Staff had implemented blanket restrictions on both wards including the use of plastic cups, locked bedroom doors and outdoor spaces on the Dementia Assessment Unit and daily room searches on Bracken Ward with no audit or review.
• Not all staff understood the Mental Capacity Act. Staff did not record capacity and best interest decisions in some patients’ records. Staff did not make deprivation of liberty safeguards applications when needed. Staff did not monitor the progress of applications to supervisory bodies.
• Staff reported issues with the entering and accessing of information on the new electronic patient record system.
• Trust governance processes were not always effective in ensuring staff applied policy and practice consistently across the services. There was lack of evidence of mental capacity compliance audits and there was no overarching policy for the management of ‘guest’ patients on Bracken Ward.

However:

• Patients assessments were comprehensive, evidence based and contained detailed physical health assessments. Care plans and risk assessments were holistic and reflected individual patient need.
• Ward environments were accessible to all patients including patients who had difficulties with mobility or a disability. There was a range of facilities available to patients and a range of inclusive activities.
• Both wards were clean, well equipped, well furnished, well maintained and fit for purpose.
• Staff involved patients and their carers and families in all aspects of their care. Patients and carers told us they were treated with kindness, dignity and respect and staff demonstrated a knowledge and awareness of the individual needs of patients.
• Managers made sure staff teams incorporated a range of skills needed to provide high quality care. Staff were supported with regular appraisals, supervision, team meetings and opportunities to develop and innovate.
• Concerns and complaints were taken seriously. Staff had a good understanding of the duty of candour. Complaints would be investigated, lessons learnt and shared.
• Managers had processes and procedures in place to monitor and meet key performance indicators in relation to training, supervision, appraisals and bed management.

Updated 27 May 2020

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

• The service provided safe care. The trust had taken significant action to improve the safety on the wards. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers supported staff with appraisals and opportunities to update and further develop their skills. Eighty seven per cent of staff within the service had received regular supervision at the time of our inspection. However, on Fern ward this was lower with 59% of staff receiving regular supervision. The ward staff worked well together as a multidisciplinary team and with those outside the ward.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They involved patients, families and carers in care decisions.
• The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
• The service was well led, and the governance processes ensured that ward procedures ran smoothly.

Updated 15 December 2021