• Organisation
  • SERVICE PROVIDER

Dorset Healthcare University NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Outstanding read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

All Inspections

30 April 2019 to 4 June 2019

During an inspection of Wards for older people with mental health problems

Our overall rating of the service stayed the same. The rating for safe improved from requires improvement to good and the rating for caring improved from good to outstanding.

We rated it as good because:

  • The service provided safe care. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance on best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that staff received training and appraisal. The staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
  • Herm and St Brelades wards had been awarded the Gold Standard Framework accreditation due to their excellence in end of life care. These wards were the first older people mental health wards in the country to be awarded this. The service met high standards of patient and carer involvement, meeting the wishes of the patients and providing peace of mind to carers and patients.
  • The service met all the needs of patients, including those under protected characteristics. Staff treated complaints and concerns seriously and investigated appropriately. Lessons were learned and shared across the teams.
  • The service was well-led and the governance processes ensured that service procedures ran smoothly. Leaders were visible on the wards and knew the patients well. Leaders were innovative, and where challenges presented themselves leaders were resilient and able to make positive changes.

However:

  • The garden at Herm and St Brelades had presented a hazard, so staff did not allow patients to use it. They had made requests to have the garden maintained but this had not been completed at the time of the inspection. We raised this with the trust leadership team who took immediate action to prioritise this. The lounge at Herm ward was not dementia friendly and patients did not always have their own bedrooms on Alumhurst ward, and there was limited private space for patients. The trust was aware of these issues and looking to eradicate shared sleeping arrangements and improve access to private space in the longer term.
  • The service did not always have enough nurses and doctors available. There were problems with the recruitment of registered nurses, particularly on night shifts, and doctors were not always immediately available out of hours.
  • Staff did not always manage medicines robustly. There were some missing checks of controlled drugs and emergency medications and gaps in the auditing process of medications on some wards. The trust did however provide assurance that systems were being improved and new electronic prescribing would rectify these issues.
  • Female patient accommodation on Alumhurst ward was composed of shared accommodation. Bedrooms and shared accommodation did have lockable storage facilities for clothing and possessions and the provider had taken action to mitigate the adverse effects of privacy or safety. Capital funding had been secured with a plan in place to remove all shared accommodation.

30 April 2019 to 4 June 2019

During a routine inspection

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

  • We rated the trust outstanding overall because over the past four inspections we have seen a consistent pattern of progressive improvement in the quality of core services that is reflected in the ratings of these services.
  • We rated the trust outstanding overall for the key question is the trust well-led due to the inspirational leadership provided by the senior team. In rating the trust overall, we took into account the current ratings for the services not inspected this time.
  • At this comprehensive inspection (2019) we found the trust had made the required improvements in the safe key question to increase its rating to good.
  • We rated the trust as outstanding overall for the key questions are services caring and are services well led. In addition, we rated the trust good for safe, effective and responsive. We rated one out of six core services that we inspected as outstanding overall which was community health services for adults.
  • We were particularly impressed by the strength, knowledge and integrity of the leadership at the trust. They had a comprehensive knowledge of current priorities and challenges and took prompt action to address them. The board was visible and supportive to the wider health and social care system. Reports from external sources including NHS England/Improvement and commissioners were consistently positive. The trust had quality and sustainability as its top priorities.
  • We were also impressed with the trust attitude towards and application of innovation and service improvement. The delivery of high-quality care was central to the trust values and all aspects of running the core services. We got a true sense of the trust’s main focus was on providing care that truly benefited patients and carers and supported the wider system. There was a dedicated quality improvement (QI) team which engaged frontline staff and empowered and inspired them to use innovative means of improving services.
  • There was a strong learning culture within the trust and staff showed caring, compassionate attitudes, were proud to work for the trust and were involved in the development and improvements within the trust. Staff embraced and modelled the values and behaviours in both mental health and community health services. Throughout the trust staff treated patients and each other with dignity and respect. Staff morale was high in the services. Staff told us they felt respected, supported and valued by their managers and the trust. Staff used creativity to ensure patients were treat well and their care needs listened to.
  • Staff, patients and carers were actively involved in the development of the services, and the trust were creative in engaging all the relevant people. Senior leadership in the trust had good relationships with partner organisations and were engaging positively in the wider health systems. The trust had a mixture of highly experienced and new senior leaders with the skills, abilities, and a commitment to provide high-quality services. The executives and non-executives presented as a strong unified board.
  • Two of the wards for older people with mental health problems (Herm and St Brelades) had been awarded the Gold Standard Framework (GSF). These were the first older adult’s mental health unit in the country to receive this award. All community hospitals in the trust were GSF accredited. The GSF is a systematic evidence based approach to ensuring all patients approaching end of life receive the best possible compassionate care in the best possible place. This meant patients approaching the end of their lives on these wards could remain on the ward rather than be transferred to another place to receive this care.
  • The trust had effective systems and processes in place for identifying risks and how to eliminate or reduce them. Staff had training in how to recognise and report abuse and applied it. The trust had an innovative focus on reducing incidents of falls and pressure ulcers and were committed to improving services by learning when things went well or wrong. The pharmacy management leadership team ensured patients were safe and good governance was in place. Medicines safety risks were identified, actioned and shared appropriately within the trust and with external partners. Learning actions from medicines incidents and audits were shared across the trust.
  • Excellent governance arrangements were in place in relation to Mental Health Act (MHA) administration and compliance. One of the non-executive directors had a legal background and was highly experienced and chaired the MHA monitoring group. Minutes demonstrated that it covered an appropriate range of subjects including monitoring of MHA review report findings. The trust ensured they were responsive in their approach to issues raised within these reports. There was clear, robust and effective multi-agency working arrangements around the MHA. A regular programme of MHA audits took place. Where MHA audits had identified gaps in knowledge the MHA lead provided targeted training and support.
  • Trust premises were clean and well maintained although several buildings were not fully fit for purpose. There was an estates strategy in place and the trust had a clear idea of what needed to be done but planning permission was required for many the changes which was proving difficult to get due to the nature of the buildings. We saw during our core service visit that the gardens in Herm and St Brelades wards were not dementia friendly and unsafe in some areas. However, this was addressed quickly and funding made available to improve these areas further. Staff were clear on their responsibility to mitigate safety and ensure dignity of patients in shared accommodation. During our well led inspection we saw many improvements had already been made to these areas.
  • Staff at all levels worked well with each other and external organisations to provide care and treatment to patients based on national guidance. Staff generally kept clear records of patients’ care and treatment and confidentiality was maintained. Patients had access to psychological support and occupational therapy. The physical healthcare needs of patients within mental health services was excellent. Patients in community health services benefitted from outstanding care and support from staff.

However:

  • Recruitment in some areas (e.g. community CAMHS) remained a struggle. The trust was working creatively with commissioners to resolve this and the implementation of a new care model in CAMHS services should ease some staffing pressures.

  • A bed was not always available when needed on return to the acute mental health wards. There had been some inappropriate placements on the wards, due to the wards not having control over bed management.

  • There remained shared accommodation on one acute mental health ward and some of the older people’s mental health inpatient wards. Bedrooms and shared accommodation did have lockable storage facilities for clothing and possessions and the provider had taken action to mitigate the adverse effects of privacy or safety. Capital funding had been secured with a plan in place to remove all shared accommodation.

30 April 2019 to 4 June 2019

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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

  • The service provided safe care and the ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
  • During our previous inspection we identified many ligature risks across the wards which had not been identified or mitigated effectively. During this inspection we found that ligature risks had been addressed and managed. The large garden was labelled as ‘yellow’ which meant patients had to request outside access due to increased risk. If individual patients’ risks were low they could access the garden on their own, but staff would accompany other patients as needed.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service was well-led and the governance processes ensured that ward procedures ran smoothly. Leaders were visible on the wards and knew the patients well. Leaders were innovative, and where challenges presented themselves leaders were resilient and able to make positive changes.

However:

  • Staff did not always ensure emergency medicines were consistently checked. We raised this at the time of the inspection and this was rectified immediately.
  • When patients were transferred to the seclusion suite on Haven ward from the other wards at St Ann`s hospital, they were escorted through the female corridor on Haven ward. The staff knew this could potentially compromise privacy and dignity at times and staff managed this very well. The trust monitored this each occasion that a patient had to be transferred through this route. This was due to the layout of the ward, and no alternative access was available.
  • Sometimes beds were used when patients went on leave and there were no beds for them on their return. The trust told us they were working hard to secure additional estates to create more beds to address this.
  • Patient accommodation on Chine ward was composed of shared accommodation. However, staff used good relational security, observations and risk assessments to keep patients safe (relational security is the knowledge and understanding that staff have of a patient and of the environment) and if a patient was assessed as high risk they would be admitted to a single room where possible.

30 April 2019 to 4 June 2019

During an inspection of Mental health crisis services and health-based places of safety

  • The service provided safe care. Clinical premises where patients were seen were safe and clean, and the physical environment of the health-based place of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • The mental health crisis service and the health-based place of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
  • Staff working in the mental health crisis teams developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The mental health crisis teams included or had access to a range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service was well-led and the governance processes ensured that procedures ran smoothly.

30 April 2019 to 4 June 2019

During an inspection of Long stay or rehabilitation mental health wards for working age adults

Our rating of this service stayed the same. The rating for safe improved from requires improvement to good. We rated the service as good because:

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

30 April 2019 to 4 June 2019

During an inspection of Community health services for adults

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

  • The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.
  • Individual care records were electronic, integrated and consistently managed. Patients were protected against the risks of unsafe or inappropriate care and treatment arising from incomplete patient records or inability to access electronic patient records. This was a marked improvement following the inspection in October 2015
  • Staff understood their responsibilities to raise concerns, record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate. There was evidence following incident investigations that duty of candour had been applied. Therefore, patients were protected by a strong comprehensive safety system with the focus on openness, transparency and learning when things went wrong.
  • Health and social care were truly integrated. Services were planned and met patient’s needs as care pathways were person-centred especially for patients with complex health and social care needs. Referral criteria to community services was clear and managed through a health and social care single point of access. This was a marked improvement on the last inspection in October 2015.
  • Leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Managers made sure they had staff with a range of skills needed to provide this and staff had appropriate training to meet their learning needs to cover their scope of work.
  • There was a drive to increase skills of staff to provide effective care and treatment for patients. This included volunteers who were recruited where required and trained and supported for the role they undertook.
  • There were good arrangements for supporting and managing staff to deliver effective care and treatment. The trust provided comprehensive clinical supervision for staff which they undertook regularly.
  • Staff from different health and social care disciplines worked together as a team to benefit patients. This multidisciplinary working supported effective care planning and delivery especially for adults with long term conditions and complex needs.
  • Staff understood and respected the personal, cultural, social and religious needs of patients. There was a strong patient-centred culture. We observed kind, compassionate and respectful interactions with patients and their relatives in both trust clinics and in their own home.
  • Feedback from people who used the service was continually positive. Patients, their relatives and carers we spoke with told us, without exception, that the staff were always kind. Staff looked for ways to communicate with patients and those close to them to reduce and remove barriers to communication.
  • Staff made efforts to involve patients and those close to them in decisions about their care and treatment through personalised care planning. Staff communicated well with patients so that they understood their care, treatment and condition, and any advice given. Staff took time to interact with relatives and carers. The home visit appointments and rehabilitation fitness sessions we observed did not feel rushed. Staff said that it is about “what is important” to patients and that patients had “ownership” of their care plan.
  • Services were tailored to meet the needs of individual patients and delivered in a way to ensure flexibility, choice and continuity of care. Patients received personalised care that was responsive to their needs. Patient records contained assessments that were carried out with the patient and those important to them.
  • The service worked with other health and social care providers to meet the needs of patients, particularly those with complex needs, long term conditions or life limiting conditions. The involvement of other services was integral to how services were planned and met patient’s needs.
  • Advanced care planning was well established in the community services.
  • The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers held, or were studying for, management qualifications and had community and primary care experience.
  • The trust had systems and processes to ensure staff met the duty of candour. Duty of candour was included in the trust's induction programme which ensured all new starters were provided with relevant information. Duty of candour has been integrated into the Root Cause Analysis and pressure ulcer training packages. This was a noticeable improvement from the last inspection in October 2015.
  • There were high levels of staff satisfaction. Staff felt positive and proud to work for the trust and spoke highly of the culture. Staff felt they were in a much better position since the last inspection in October 2015.
  • The trust was very proactive in supporting development opportunities for staff. There was also a strong emphasis on the safety and well-being of staff.
  • Staff were engaged so that their views were reflected in the planning and delivery of services. At the last inspection in October 2015, staff had felt that changes were made without consultation and without being made aware that changes were happening. At this inspection, staff were much more positive.

However:

  • The single point of access was triaged by a trained healthcare professional. In contrast, calls to the night nursing team are taken and collated by a healthcare assistant. Staff felt a trained member of staff at night to triage would provide a more comparable service to the single point of access team.

30 April 2019 to 4 June 2019

During an inspection of Community urgent care services

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

  • 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.
  • There were effective systems to protect patients from harm. Incidents were discussed regularly in team and governance meetings. There was an open culture of reporting, and learning was shared with staff to make improvements.
  • Infection risks were well controlled, and there was enough suitable equipment which staff were trained to use.
  • Staff worked together as a team to deliver effective, patient-centred care and improve patient outcomes. Treatment was planned and delivered in line with current evidence-based guidance.
  • Staff treated patients with kindness, dignity and respect. Patients were involved as partners in their care and were supported by staff to make decisions about their treatment.
  • The needs and preferences of different people, including the local population, were considered when designing and delivering services.
  • Patients were monitored to maintain their safety and meet their health needs. The trust aimed for all patients to be seen and assessed as fit to wait or, in the case of the urgent treatment centre, triaged within 15 minutes. The trust monitored performance against this 15-minute standard and it was consistently met.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • The leadership team was knowledgeable about quality issues and priorities, understood what the challenges were and acted to address them.
  • There was a strong culture of openness, transparency and teamwork within the organisation. Staff felt well supported by managers and told us that they encouraged effective team working across the hospital. Senior staff were visible, approachable and supportive.

However:

  • Unplanned lone practitioner working was not always recorded as an incident.
  • Not all patient waiting areas gave practitioners a clear view of patients.
  • Clinical audits were not done to demonstrate that care and treatment was provided in line with evidence-based guidance, standards and recent best practice guidance.

14th November 2017 to 6th December 2017

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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

A summary of our findings about this service appears in the overall summary.

14th November 2017 to 6th December 2017

During an inspection of Community health services for children, young people and families

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

  • The three services inspected improved from a rating of requires improvement to good overall.

However:

  • We also found areas for improvement in each of the services we inspected this time. See areas for improvement section above for details.

14th November 2017 to 6th December 2017

During an inspection of Community health inpatient services

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

14th November 2017 to 6th December 2017

During an inspection of Community end of life care

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

14th November 2017 to 6th December 2017

During an inspection of Forensic inpatient or secure wards

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

A summary of our findings about this service appears in the overall summary.

14th November 2017 to 6th December 2017

During an inspection of Child and adolescent mental health wards

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

A summary of our findings about this service appears in the overall summary.

14th November 2017 to 6th December 2017

During an inspection of Community mental health services with learning disabilities or autism

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

  • Services were safe. There were effective policies and procedures in place to ensure the safety of both staff and patients.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. Care and treatment followed current evidence based guidance.

  • Staff were caring. Patients were treated with kindness, dignity and respect and were involved as partners in their care where possible.
  • Services met the individual needs of patients.
  • There were effective systems in place to support the delivery of good quality care.

However:

  • Access to some treatments, for example, speech and language therapy, was sometimes delayed due to shortages of these staff.
  • There was a lack of involvement of patients, carers and their representatives in decision making about, and within, the learning disability service.

14th November 2017 to 6th December 2017

During an inspection of Community-based mental health services for older people

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

  • The core service improved overall from requires improvement to good.

14th November 2017 to 6th December 2017

During an inspection of Specialist community mental health services for children and young people

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

A summary of our findings about this service appears in the overall summary.

14th November 2017 to 6th December 2017

During an inspection of Mental health crisis services and health-based places of safety

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

Dorset HealthCare University NHS Foundation Trust has one health-based place of safety (HBPoS) (section 136 suite) that provides a service for the whole of Dorset. It is based at St. Ann’s hospital in East Dorset. The place of safety is for people who are detained under section 136 of the Mental Health Act. This power allows police officers to detain people who are believed to have a mental disorder, and take them to a place of safety for assessment.

There are crisis teams based at St. Ann’s hospital and the Forston clinic, covering East and West Dorset respectively. The crisis and home treatment teams provide short-term work to help support people at home when they are in mental health crisis, and support with earlier discharge from hospital. The teams aim to facilitate the early discharge of patients from hospital or prevent patients being admitted to hospital by providing treatment at home. In addition, the East Dorset crisis team has access to a day hospital, which also provides mental health support.

The Trust has a countywide street triage service that provides advice to police officers when they believe people might need immediate mental health support. The aim of this team is to ensure that people get mental health professional input in a timely manner whilst also diverting people from inappropriate police custody or section 136 of the Mental Health Act assessments.

The inspection in June 2015 rated mental health crisis services and health-based place of safety as Requires Improvement overall. The focussed inspection in March 2016 rated effective and responsive as requires improvement. At the March 2016 inspection, we told the Trust it must:

  • ensure that there were sufficient appropriately trained staff which are available to provide care to patients receiving services from the East Dorset Crisis Team
  • ensure cooperative and good working relations between the East Dorset Crisis Team and locality community mental health teams to ensure that patients requiring services can access the most appropriate service to have their need met in a timely manner
  • ensure staff follow the medicine management protocol
  • ensure they adhere to the code of practice with regards to HBPoS assessment times
  • ensure their internal policies meet the requirements of the Mental Health Act code of practice.

Before the inspection visit, we reviewed information that we held about these services, and asked a range of other organisations for information.

During the inspection visit, the inspection team:

  • visited the health-based place of safety (HBPoS) and both crisis teams
  • interviewed the team leaders and service lead for the crisis teams
  • spoke with the bed manager and a ward manager who had a role with the HBPoS
  • checked the medicines cabinets at the crisis team bases
  • spoke with 12 staff members including doctors, nurses, support workers, peer and carer support workers
  • spoke with police officers and the police mental health strategic coordinator
  • spoke with representatives from the three local authorities and the manager of the out of hours social work team
  • spoke with the senior management team with responsibility for these services
  • reviewed twenty six health care records
  • spoke with one carer of a man having support from the East Dorset crisis team
  • spoke with eight service users of the crisis teams and two former patients of the HBPoS
  • accompanied crisis team staff on two community visits
  • observed two handover meetings and one handover from police to Trust staff in the HBPoS
  • reviewed a number of policies, meetings minutes, assessments and other documents related to the running of crisis teams and HBPoS.
  • e able to respond quickly to service users when concerns escalated.
  • Staff in the crisis teams were able to offer a good range of interventions. Staff were experienced and qualified.
  • The east crisis team had addressed the issues we asked it to improve following the inspection in 2016.

  • Staff were kind, professional and respectful. Patients gave positive feedback regarding their care. There was good involvement of service users and carers in the crisis teams. The Trust sought feedback from service users.
  • Morale amongst the staff that we spoke with involved in the crisis teams and HBPoS was good.
  • The multi-agency group were considering a range of measures to reduce detentions under section 136.

14th November 2017 to 6th December 2017

During an inspection of Community-based mental health services for adults of working age

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

A summary of our findings about this service appears in the overall summary.

14th November 2017 to 6th December 2017

During a routine inspection

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

  • We rated effective, caring, responsive and well-led as good. We rated safe as requires improvement. Our rating for the Trust took into account the previous ratings of services not inspected this time.
  • We rated well-led at the Trust level as good. The senior team had led a very effective programme of improvement which had resulted in the majority of issues we had identified in our previous inspection being addressed.
  • The trust’s senior leadership team had the skills, knowledge, experience and integrity necessary for successfully overseeing a large, complex organisation.
  • We saw evidence of some excellent leadership at all levels across the trust with many dedicated, compassionate staff who were striving to deliver the very best care for patients.
  • Communication across the Trust had improved with the Board and senior managers being more visible to staff. There was also a noticeable improvement in the culture across the Trust, with increased openness and transparency and a clear desire in staff at all levels to learn and improve.
  • Staff within the services inspected were generally providing safe, effective, compassionate and kind care to patients.

However:

  • We rated safe as requires improvement. We identified a number of issues, some new and others on-going, primarily in relation to the safety of patients and staff at a smaller number of services. We require the Trust to take action to address those issues and will request an action plan from them to identify clearly how they will do so.

3 May 2017

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We did not rate this service at this inspection.

  • We inspected Chine ward as an unannounced, responsive inspection. The purpose of the inspection was to follow up specific concerns regarding patient safety. This was in relation to items on the ward that patients use to injure themselves and incidents involving ligature risks. A ligature point is anything that could be used to attach a cord, rope or other material for the purpose of hanging or strangulation.
  • The Care Quality Commission visited the ward in July 2016 as part of an investigation into the death of two patients. One death occurred in 2015 and the second death occurred in 2016. Both deaths related to ligatures.
  • CQC undertook a scheduled Mental Health Act visit in March 2017. At this visit, the Mental Health Act reviewer had significant concerns about the safety of the ward. Staff continued to report a number of incidents involving patients using ligatures in an attempt to harm themselves. We found 21 incident reports dating back to January 2017 that staff had not reviewed and signed off. Twelve of these incident reports related to ligatures. At the time of inspection the trust did not have a time scale for signing off or reviewing incidents. The trust told us they are currently revising their policy.
  • The Mental Health Act reviewer found a box of loose cables in a cupboard that patients could access. Patients could have used these cables as ligatures. This was a matter of concern because of the two deaths and a number of other incidents when patients who had used ligatures to harm themselves on the ward in 2016 and 2017. The Mental Health Act reviewer raised this with the manager who removed the box from the cupboard immediately. The Mental Health Act visit also found risk assessments were not always accurate and risks identified in the risk assessments were not always included in the care plans.
  • At the responsive inspection in May 2017, we saw Chine wards environmental risk assessment. We found that that the trust did not have a robust system in place to ensure that staff checked the environment regularly for general non-fixed ward items that patients could use as a ligature, such as loose cables. However, we found that the trust managed fixed ligature risks well.
  • At the responsive inspection in May 2017, we found that staff had removed the box of cables that the Mental Health Act reviewer had raised concerns about. However, we found additional loose cables in communal areas. For example, we found a single long cable in a cupboard in the patient’s television room, and several electrical cables in the patients’ computer room. We brought this to the attention of the manager who told us they did not know the single cable was there. The manager also checked with other staff members who confirmed they also did not know it was there, or whom it belonged too. Staff removed these cables whilst the inspection team were on site.
  • We spoke with the consultant who told us that he had identified ligatures as an area of concern on Chine ward. He told us he had joined a trust group that looked at fixed ligature risks across the trust. The consultant told us he had attended one meeting by the time of the inspection and that he wanted to widen the remit of the group to take account of non-fixed ligatures and encourage other clinicians to attend.
  • At the time of the the responsive inspection in May 2017, staff on the ward were was not reporting all incidents. We reviewed ten care records. We found several entries of actual self-harm. For example, one patient had attempted to strangle themselves several times in one day. Out of ten care records, we found that staff had not reported four incidents through the correct reporting process. One incident form had three separate incidents recorded on it, which could affect incident figures that staff submitted to the trust as staff reported these three incidents as one incident.
  • Staff had not updated care plans following repeated ligature attempts. For example, one patient regularly used shoelaces in an attempt to strangle them self. Staff had not addressed this as a pattern of behaviour and staff told us they would not consider discussing alternative shoes with the patient, because they would just use something else, for example a t-shirt. We raised this with the trust senior management team who assured us they would review patient risk. The trust has submitted a plan with this as an action.
  • In August 2016, the trust reported a death. A patient had used a plastic bag that the provider used for transporting laundry away from the ward, to suffocate herself. We discussed this with the ward manager who told us the clinical governance team had reviewed the incident and one of the lessons learnt was to revise the local prohibited items policy for Chine ward. The local policy now stated patients could not bring plastic bags onto the ward. At the responsive inspection in May 2017, staff told us that patients still brought plastic bags onto the ward when they had been shopping. However, staff said they would remove them if they found them and offer an alternative safer bag for patients to use.
  • At the Mental Health Act visit on 31 March 2017, we found 21 incident reports dating back to January 2017 that the manager had not signed off. Twelve of these incident reports related to ligatures. At the responsive inspection on 03 May 2017, this had not improved. We reviewed incident reporting for the period of February 2017 to May 2017. We found that the manager had not signed off 14 reports. Four of these incidents reports related to ligatures.
  • We raised this with the Trust senior management team who assured us they would review their current incident reporting policy. The trust provided us with an action plan of how they intended to mitigate any further risk to patients. This included how ward staff will ensure regular assessments of non-fixed ligature risks are carried out, how staff will be trained to carry out these assessments, and how the wards policy on incident reporting and learning from incidents will be improved, ensuring the ward is a safe place for patients.

We will return to the ward in due course to ensure that Dorset Healthcare University NHS Foundation Trust has implemented the actions identified.

1st February 2017

During an inspection looking at part of the service

We did not rate this service at this inspection.

The purpose of the inspection was to follow up the concerns raised at the Mental Health Act scheduled visit on the 23 January 2017 of Twyneham ward by Mental Health Act reviewers.

The concern raised from the Mental Health Act visit was patients who failed to attend the 9.00am meeting or groups held on the ward lost all or parts of their leave and that patients perceived the withholding of leave as punitive.

The concern about the restrictions on patients leave had been raised during a previous Mental Health Act visit in July 2015. Our concerns were thus known to the ward but no action had been taken to rectify this. On this previous visit the Mental Health Act reviewer had included references from the revised Code of Practice, which had introduced guidance on blanket restrictions.

The report in 2015 stated:

‘All patients were restricted from entering their bedrooms by them being locked on weekdays during the working day, other than for an hour at lunchtime.

All patients were normally required to attend a full daily group programme, or they would not be permitted to go out on ground or community leave. On the day of our visit this consisted of four groups of approximately 45 minutes a day for most patients.’

Following this inspection the trust stated in their action statement :

‘No service user who refuses to participate in their personalised group programme loses leave as a result of their non-participation or cooperation - .any such decision to rescind leave or restrict leave is based on factors other than the immediate presenting one of refusal to comply with their group programme. The decision is based on mental state examination, presence of identified relapse indicators or the presence of increased (known) risk factors.’

The Mental Health Act reviewers on their visit on 23 January 2017 found that those restrictions were still in place.

On this inspection (01 February 2017), we spoke with a range of staff and patients.

The four patients that we spoke with at this inspection and the four spoken with at the Mental Health Act reviewers’ visit in January 2017, were all unclear about the link between attending the morning meeting, the group therapy sessions and the restrictions on their leave. They told us that if they did not go to the groups they lost all or part of their leave and viewed this as punitive. They said that there was a three-stage warning system relating to their behaviour in the group and that if they received three warnings then they lost their leave. They said that the staff member in the team that made the decision about them going on the leave often was not one of the staff who took part in the group. They were concerned about the lack of information they received from staff about the restrictions on their leave.

We looked at information given to patients about their attendance at the groups in the handbook and in rules of the group and there was no information about the link between non-attendance at the groups and leave restrictions.

Staff members we spoke with were not clear about the link between the attendance at groups and leave and the decision making process. They told us they completed risk assessments about a patient’s current state of mental health if they did not attend groups. However, we could find no evidence in the care notes of risk assessments or rationale to rescind leave. Generally, risk assessments and care plans seen were not updated to reflect patients leave restrictions. Staff were unable to provide clear criteria for leave restrictions to ensure consistent working and decision making.

The consultant told us that he made decisions about leave and leave conditions and these were discussed at meetings of the multi-disciplinary team (MDT) following a review of the patient’s current health. The consultant stated that these decisions should not be changed without further discussion by the multi-disciplinary team. We saw these were reflected in the MDT notes in patients’ progress notes.

The consultant told us that he believed that there was a lack of communication within the wider team. Staff from a range of other professional groups also raised concerns about the management of the ward and the lack of effective working and communication within the staff team (across the range of professions).

On the 10 February 2017, we wrote to the trust detailing our concerns. We stated that patients and staff must have a clear shared understanding of the link between patient attendance at morning meetings and groups held on the ward and leave restrictions. We asked the trust to implement a policy that clearly identified how patients would be assessed and when and for what reasons leave would be rescinded. We stated that If there was any link between restricting leave and attendance at meetings, this must have a clear rationale and all staff and patients must understand this. All staff must receive training in how to apply the policy and who can make the decisions about restricting leave.

We asked the trust to forward the policy and provide assurance that all staff had an understanding of the policy and were applying it appropriately and assurance that all patients knew of the policy and had an understanding of how it would be applied and in what circumstances. We asked for this to be provided by the 24 February 2017.

The trust sent us an action plan to address our concerns on the 24 February 2017. The plan detailed how the ward manager had reviewed the policy and the plans in place to ensure clarity on rescindment of leave. A system was put in place whereby staff recorded when they had read the protocol and this was monitored by the manager.

On the 27 February 2017, staff and patients attended a training session about patients’ leave and the new protocol. They told us this was to ensure that all patients understood and were clear on the leave protocol. A copy of the attendance at the event was forwarded to us.

The trust was also in the process of updating the section 17 policy in line with code of practice. The deadline for completion was the end of March 2017 and the trust stated they would then forward the document to us.

As the trust acted promptly to address our concerns, we have taken the decision to take no further action at this present time. We will use this information to inform our future inspections and will return to the ward if we have any additional concerns.

We will return to the ward in due course to ensure the actions identified have been implemented.

14 December 2016

During an inspection of Substance misuse services

We rated substance misuse services in Dorset NHS Trust as Good because:

  • Staffing levels were good and there was managerial and team oversight of the safe management of caseloads.
  • Staff had visited the homes of all clients with children living at or visiting their home to ensure that the client had safe storage facilities for their medication. Staff in the prescribing teams reviewed prescriptions regularly.
  • Staff held multi-disciplinary meetings to discuss referrals, discharge, safeguarding and complaints. Assessments, reviews and interventions were well documented in all care records.
  • The teams responded quickly if patients phoned into the service to ensure they received a timely service from both teams in line with the requirements of the Commissioners. Staff members were proactive in contacting clients who did not attend their appointments. Staff held multi-disciplinary meetings to discuss referrals, discharge, safeguarding and complaints.
  • In CADAS west, there were a variety of rooms available for staff to see clients. Staff were able to call on interpreters if required, leaflets were available in different languages. There was good disabled access.
  • There were managerial systems in place to audit clinical notes to ensure risk assessments and care plans were updated and completed correctly, ensure staff received training and yearly appraisals.

However :

  • Managers did not ensure all staff had recorded staff managerial supervision sessions.
  • All clients had the opportunity to provide feedback about the services. Clients did not receive written feedback about the outcome of their complaint.
  • Clients in the CADAS east did not receive the same service as clients in CADAS west as there was no central hub where they could receive treatment.

15 -17 March 2016

During an inspection of Specialist community mental health services for children and young people

We found that the trust had made good improvement and that risk was now managed well. We have changed the rating of requires improvement given at the comprehensive inspection in June 2015 and have now rated specialist community mental health services for children and young people as good because:

  • The trust had appointed a transformation lead and held meetings with local managers to ensure consistent practice in the teams. They had ensured the implementation of the action plan the trust created following our last inspection.
  • The trust had put in place processes to help ensure practice was standardised across the teams.
  • The trust had implemented a risk assessment procedure for children and young people on the waiting list for treatment. Staff now considered risk as a team across the pathway.
  • The trust had put in place robust systems to ensure staff were up to date with mandatory training; 93% of staff had completed, mandatory training which met the target the trust had set.
  • The trust had set up meetings between local team leads and senior managers within the trust. This allowed practice to be shared.
  • Staff in the service were enthusiastic about the changes and were fully engaged in the improvements in the service.

However:

  • Although the trust had made progress and hired another 9.8 whole time equivalent staff and had more posts advertised, there were still significant waits for some children and young people.
  • While caseloads were now being reviewed, we found that some staff still had high caseloads.
  • While the trust had set a five day target for communication to carers, staff told us that they struggled to meet this target.

15-17 March 2016

During an inspection of urgent care services

Overall rating for this core service Good

We conducted this inspection following serious concerns found during our inspection in June 2015. We were pleased to note significant improvements in urgent care services provided by Dorset Healthcare University NHS Foundation Trust at Minor Injury Units (MIUs). We have now rated these services as “Good” because:

  • The trust encouraged staff to report incidents. They received feedback from incidents and there was evidence of learning and changes in practice in response to incidents. Staff managed medicines safely. Storage of medicines was secure and Patient Group Directives were current and appropriately authorised. Appropriately trained staff assessed patients in a timely manner to reduce risks to their health and wellbeing.This was known as triage process or triage assessment. Staff checked emergency equipment daily to ensure it was in working order.
  • Staff followed trust infection prevention and control practices. Nurses and emergency care practioners providing the care and treatment completed patient records accurately. Staffing numbers and skills were sufficient to staff the MIUs safely and the trust had discontinued the practice of staff working alone. All staff completed mandatory training and had a good understanding about the actions to take to safeguard vulnerable adults and children.
  • Staff had updated the MIU policies in line with national clinical guidelines which ensured patients received care and treatment that followed relevant nationalbest practice guidance The trust had introduced an audit programme to monitor patient outcomes, staff adherence to trust policiesand to support improvement of patient outcomes. Staff completed training relevant to their roles and received supervision and appraisals which ensured patients received treatment from staff who had the relevant skills and knowledge.
  • MIU services responded to the needs of the local population. In the event of an MIU having to close, staff followed procedures that ensured that patients were directed to appropriate health care facilities. Staff had a good understanding about meeting the needs of people with a learning disability and patients living with dementia. There was evidence the service responded and made changes to the service in response to complaints.
  • Governance processes reviewed performance, risks, incidents, complaints and audits and provided opportunity for staff views to be heard and trust wide information to be communicated to staff. Clinical leadership was present in all units and at a senior management level. The overarching senior professional lead supported the MIU service to make required changes and develop the service as well as support staff to have their views and opinions heard by the trust board.

However;

  • MIU services were not meeting the trust’s target of 95% of all patients receiving initial assessment within 15 minutes of arrival at the unit. It was not clear whether consideration had been made of the needs of the local population with regard to opening times at Portland MIU.
  • There was no clarity for staff as to whether paediatric equipment should be on emergency trolleys.
  • Recruitment was not completed to ensure there was no lone working in all units during their opening hours.

15 - 17 March 2016

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated long stay/rehabilitation mental health wards for working age adults as good because;

  • Staff on the three wards used safe procedures to manage medicines. Staff maintained emergency equipment to a high standard. Staff completed medicine audits in line with trust policy. All healthcare support workers that witnessed the administration of controlled drugs had completed the trust competency framework to enable them to do so safely.
  • Staff on all three wards provided patients with a full and comprehensive programme of therapeutic, recovery focused activities. Staff on Glendinning ward had created a new arts and crafts room and had audited the success of its patient led activities programme. Activity plans were patient led and designed around personal needs and choices.
  • Learning took place after incidents. The trust had introduced a new policy regarding legal highs. This and some collaborative work with the local police had significantly reduced the number of incidents regarding legal highs on the wards.
  • Patients we spoke with told us that they knew how to make a complaint and felt confident that staff would listen to them. Staff knew and understood how to use the trusts complaints procedure. Since our last inspection (June 2015) there had only been one complaint submitted across all three services.
  • Risk assessments were completed on admission and reviewed after every incident and during care programme approach (CPA) meetings.

However

  • On both Glendinning ward and Nightingale House there were multiple ligature points. We were concerned that the management of ligature risks was not robust.
  • Department of Health guidelines on same sex accommodation were not being followed on the ground floor of Nightingale Court. Female patients had to cross male areas to use bathroom facilities. There was no female only lounge. However, the bedroom areas on the lower ground floor did comply with single sex accommodation guidelines.

15 - 17 March 2016

During an inspection of Mental health crisis services and health-based places of safety

We rated E ast Dorset Crisis and Home Treatment Team and Health Based Place of Safety (HBPoS) as requires improvement because:

  • During this inspection (March 2016), although some progress had been made, this was not sufficient to amend the ratings that were awarded at the time of the comprehensive inspection in June 2015.
  • The trust had recruited two dedicated mental health support workers to operate the phone lines and there was a clear process describing its usage. However, at the time of our inspection, they did not have dedicated staff on duty due to staff sickness and two Bank support workers operated the phones lines. These staff members had not received any telephone specific training and one member of staff was observed not following the call escalation protocol correctly. At the time of the inspection, four registered practitioner posts remained vacant. Staff sickness rates for the year to February 2016 remained high at 8%. Only 88% of all staff had completed mandatory training – compared with the trust target of 95%. Not all staff received regular supervision- supervision compliance was at 85% in the east crisis team. The trust had not trained the bank support workers for telephone support but did provide an induction for one of them. As a result, one of the staff did not follow the escalation algorithm correctly. This meant the provider had not met the requirement notice to have sufficient appropriately trained staff available to provide care to people receiving services from the east Dorset crisis team.
  • We found the provider did not fully follow policies and procedures in managing medicines. This meant staff did not manage medicines in line with current legislation and guidance, including those related to storage and transportation. This meant the provider had not met the requirement notice to provide safe care and treatment to people receiving services from the East Dorset Crisis Team.

However:

• The trust had installed a new phone system with wall screens that captured data. Team leaders had access to call data that allowed them to monitor all calls. The trust had recruited two dedicated mental health support workers to operate the phone lines and there was a clear process describing its usage.

We did not collect sufficient evidence to make a rating on the key question of Safe.

Inspected not Rated

Are services safe?

We inspected but did not rate safe:

  • Staff working on the crisis line had not been trained specifically to do so
  • we observed staff who were not following the telephone support line process to ensure it was meeting the needs of patients using the service
  • staff were not following the trust’s policy and procedures on medicines management.

However:

  • The telephone call management system had been updated

We did not collect sufficient evidence to make a rating on the key question of Safe.

Are services effective?

We rated effective as requires improvement because:

  • The section 136 multi agency policy failed to reflect the requirements of the Mental Health Act 1983 Code of Practice
  • internal, multidisciplinary team relationships between the East Dorset Crisis Team and the community mental health teams had not improved.

However:

  • Mental health support workers who worked in the HBPoS had received appropriate training.

Are services caring?

Not inspected. See previous report of the June 2015 inspection published in October 2015 where this key question was rated as Good.

Are services responsive to people’s needs?

We rated responsive as requires improvement because:

  • Staff that did not maintain contact with a patient and did not record notes correctly
  • the issue of one HBPoS is currently under review as part of a new trust wide acute care pathway, the pathway has been created in consultation with staff, external agencies, patients and carers, however, this was not discussed at the time of the inspection.

Are services well-led?

Not inspected. See previous report of the June 2015 inspection published in October 2015 where this key question was rated as Good.

15th - 17th March 2016

During an inspection looking at part of the service

We found the trust had made improvements to the services where we had identified concerns during our comprehensive inspection in June 2015. However, the overall rating for the trust remains Requires Improvement as some of the work in services had not yet been completed.

Improvements were particularly evident in the minor injuries units and child and adolescent mental health services. Both of these had received a rating of Inadequate for Safe in our June inspection. Following this inspection, we have changed the ratings to Good overall for these services.

  • Urgent care services, which consisted the minor injuries units, had improved greatly. Staffing had been reviewed and there was no longer any lone working in the units. Safe systems of work had been introduced, including triage procedures and medicines management. Staff training and support had been improved. A senior professional minor injuries unit lead had been appointed to oversee the transformation. Staff felt engaged with the improvements and felt that leadership had improved.
  • Child and adolescent mental health services now considered risk at every point in the child’s pathway through services; this was evident in team meetings, records and from family members. Waiting lists were monitored and staff were enthusiastic about the changes and fully engaged in the improvements to the service.

Improvements were also found in the older people’s mental health wards and the long stay rehabilitation wards which led to their ratings also being changed to Good.

  • The trust had addressed concerns around privacy and dignity in older people’s mental health wards. This included addressing the culture on the wards as well as the environments. Staff were warm, kind and respectful when interacting with patients.
  • We found a full and comprehensive programme of therapeutic, recovery focussed activities across the long stay rehabilitation wards of Nightingale Court, Nightingale House and Glendinning ward. Glendinning ward had created a new arts and crafts room and had audited the success of its patient led activities program. Activity plans were patient led and designed around personal needs and choices. However, there were still some environmental concerns on the long stay rehabilitation wards that had not been addressed.

However, community mental health services for adults of working age, older people and the crisis teams had not made as much progress. Although some progress had been made, many of the issues that we had found previously were still present. The ratings for these services remained the same as Requires Improvement.

  • The community mental health teams and crisis team still had challenges with staffing and relationships between them still needed to be improved. Record keeping still had gaps. There was an action plan by the trust in place to address this and the trust has kept us informed of further progress since our visit. There had been progress in some areas including the introduction of a new crisis line and a staffing review which identified shortfalls in team sizes which was being addressed.
  • Community mental health teams for older people also had inconsistent record keeping. We were concerned that application of the Mental Capacity Act was not embedded in practice. Teams still worked in isolation and practice and elearning was not shared. However, a strategic review of older people’s mental health services was being undertaken and caseload sizes had been reduced.

We were unable to rate the key question of whether the crisis team and health based place of safety were Safe due to our methodology on this focussed return visit.

The trust had made considerable progress since our last inspection however the lack of progress in community mental health services meant that although four services had their ratings changed to Good, the overall trust rating of Requires Improvement remains the same.

We will continue to monitor the trusts actions to address those concerns.

15 – 17 March 2016

During an inspection of Community-based mental health services for older people

We rated Community-based mental health services for older people as requires improvement because:

  • The services had failed to make significant progress since our inspection in June 2015.
  • The quality of care records and risk assessments was inconsistent.
  • Understanding and application of the Mental Capacity Act (MCA) was not fully embedded in practice.
  • There was a lack of consistency in practice across teams. Good practice was not shared and teams still worked in isolation.

However:

  • A review of the service was being undertaken
  • Case load sizes had been reviewed and reduced
  • A review of psychology provision had been completed with the aim of improving access to psychological therapies.

Requires improvement

Are services effective?

We rated effective as requires improvement because:

  • The quality of recording in care records was of inconsistent quality. This included records that were incomplete, inaccurate and not contemporaneous. Most patients had risk assessments, but the quality of these varied, some were out of date and they did not always demonstrate a thorough understanding of risk or how it could be managed by linking them to care plans.
  • Patients did not always have assessments of physical health.
  • Understanding and application of Mental Capacity Act remained variable and was still not fully embedded in practice. The trust had developed a range of Mental Capacity Act  and Deprivation of Liberty Safeguards (DoLS) training. Across all older people community mental health teams, 40% of staff had undertaken the training. This was an improvement on the 13% of staff who had completed mandatory MCA and DoLS training at the time of the previous inspection.

However:

  • The care notes that we looked at in Blandford and Shaftsbury were generally of a good standard
  • A review of psychology services for older people had been completed which included recommendations for improved access.

Requires improvement

Are services well-led?

We rated well-led as requires improvement because:

  • Care record auditing processes were confusing and had not achieved consistency.
  • Morale had lowered in some teams and staff did not always feel engaged in the improvement process.
  • There was still a lack of cohesion between the community mental health teams for older people across the whole county. This meant that good practice was not being shared and localities continued to work in isolation from each other.

However:

  • Caseload sizes had been reviewed and reduced.
  • Senior managers had reviewed services and were developing a strategy for community mental health teams for older people.

15th -17th March 2016

During an inspection of Wards for older people with mental health problems

We rated wards for older people with mental health problems as good because:

  • The trust had addressed the concerns we had during our June 2015 inspection and had met the requirement notices.
  • Staff protected patient dignity and privacy when delivering care. Staff on Alumhurst ward had received training about privacy and dignity to ensure they regarded it as a priority. The trust had met the requirement notice to protect patients’ privacy and dignity by taking this action.
  • The trust had built a wall in Melstock House to protect the dignity and privacy of the patient in the bedroom next to the front door. The trust had met the requirement notice to protect patients’ privacy and dignity by taking this action.
  • All patient records we examined contained care plans that reflected the risks identified during the risk assessment process. The trust had met the requirement notice to ensure staff protected patients from poor care by documenting risks identified in patients’ care plans.
  • There were processes in place for checking safety and emergency equipment. Staff completed these checks and managers used a system to ensure that this was the case. The trust had met the requirement notice to protect patients from the risks associated with unsuitable or unsafe equipment or premises.
  • Clear fire evacuation procedures were in place for Alumhurst and Chalbury wards and staff knew what they were. The trust had met the requirement notice to protect patients from the risks associated with unsuitable or unsafe equipment or premises.
  • The trust made changes to ensure wheelchair access to the allocated disabled patient bedroom in Melstock House. The trust had met the requirement notice to protect patients from the risks associated with unsuitable or unsafe equipment or premises.
  • Managers at Chalbury and Alumhurst wards had found solutions to provide patients with sufficient access to outside areas. The trust had met the requirement notice to protect patients from the risks associated with unsuitable or unsafe equipment or premises.
  • Managers had discussed solutions and formulated plans for Alumhurst and Chalbury wards to move to locations that are more suitable. Managers were unable to provide a definite timeframe at the time of inspection. The trust had met the requirement notice to provide feedback to wards when responding to environmental risks managers had raised.

However:

  • The accommodation on Alumhurst ward breached health service same sex accommodation guidelines. Staff did manage the separation of genders as far as possible within the ward environment.

Are services safe?

We rated safe as requires improvement because:

  • The care environment at Alumhurst ward breached same sex accommodation guidelines.

However:

  • The trust had made a number of improvements from the last inspection; staff were aware of procedures in the event of fire, emergency equipment was now checked regularly and medicine management practices had improved.

Are services effective?

Not inspected. See previous report of the June 2015 inspection published in October 2015 where this key question was rated as Good.

Are services caring?

We rated caring as good because:

  • Staff were warm, kind and respectful when interacting with patients.
  • Staff prioritised and protected patients’ privacy and dignity when giving personal care.
  • Changes to the ward structure on Melstock House protected the dignity of the patient in the room closest to the entrance.
  • Care plans were holistic, person centred and included patients’ views, opinions and the patient’s wishes.
  • Numerous noticeboards on the wards contained information for patients, their carers and families.

Are services responsive to people’s needs?

We rated responsive as good because:

  • All wards had access to fresh air, either facilitated by staff or in areas that patients could access by themselves.
  • Alumhurst ward and Melstock House had a full activity timetable available for patients
  • All wards had disabled access for patients with mobility issues.
  • Patients had access to lockable storage for personal belongings.
  • Staff actively engaged with patients from diverse social groups; staff worked to ensure patients could observe their religious beliefs.

However:

  • There was no designated therapy or one-to-one room in Melstock House.

Are services well-led?

We rated well-led as good because:

  • On Alumhurst ward there had been significant changes to working practices to protect patients’ dignity and privacy; the ward manager had taken the role of privacy and dignity lead to drive these changes improvements.
  • There was good staff morale on the wards we inspected, the staff felt included in decisions made at ward level.
  • Staff told us they were aware of whom the senior managers of the service were. Chalbury ward staff told us that the trust chief executive had visited the ward on Christmas day.
  • Ward managers had the authority to manage their wards
  • Managers were able to submit items to the trust risk register.

However:

  • In spite of more information being available and efforts by the trust, staff still felt that senior managers did not keep them informed of strategic changes to older peoples’ care. This was particularly the case in relation to possible ward moves to different sites.

15th -17th March 2016

During an inspection of Community-based mental health services for adults of working age

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

  • When we returned to the trust on 16 and 17 March 2016 we found that, although the trust had an action plan dated March 2016, few improvements had been made since our previous inspection in June 2015.
  • There had been little demonstrable improvement in the quality of care plans and risk assessments in four teams. While we saw examples of good auditing of care records and assessments at one of the teams we visited, this was not replicated across other teams.
  • Staffing levels had not improved and we found that teams did not always have enough psychiatrist time for patients to be assessed and reviewed. There were still long waits for psychology support and some talking therapies. The trust had carried out a review of staffing and caseloads across all community mental health teams and found that staffing levels were not sufficient in some teams. The trust was in the process of developing an action plan to address shortfalls in individual teams.
  • We identified a number of concerns in relation to the safe management of medicines at Weymouth CMHT.
  • The trust had changed the way it investigated serious incidents. Staff told us the investigation process was now less punitive and they were able to learn from incidents. However, we found there was limited evidence of learning across teams.
  • Records viewed contained evidence of patients’ mental capacity in relation to consent to treatment. However, recording of consent to share information was poor. The majority of records viewed did not contain this information.
  • Staff morale varied across the teams, and some teams were positive whilst others felt over-stretched and stressed.

Requires improvement 

Are services safe?

We rated safe as requires improvement because:

When we returned on 16 and 17 March 2016 we found that only minimal improvements had been made:

  • there had been no changes to caseloads or skill mix
  • there was still not enough psychiatrist time available for assessments and reviews of patients
  • no improvements had been made to the quality of care plans and risk assessments in four of the five teams visited.

However

  • some of the soundproofing issues had been addressed and alarms placed in interview rooms
  • there had been improvements in staff mandatory training completion rates, which was now at 98% across the community teams.

Are services effective?

We rated effective as requires improvement because:

When we returned on 16 and 17 March 2016 we found that improvements had not yet been made:

  • care records were still not sufficiently person centred
  • access to psychological therapies had not improved
  • staffing shortfalls continued to affect the effective running of services, for example with a patient not being able to see a psychiatrist within the agreed time frame or having to wait long periods to have psychological therapies

Are services caring?

Not inspected. See previous report of the June 2015 inspection published in October 2015 where this key question was rated as Good.

Are services responsive to people’s needs?

We rated responsive as requires improvement because:

When we returned on 16 and 17 March 2016 we found that improvements had not yet been made:

  • Bournemouth East did not meet the trust’s referral to assessment four-week target for an average of 55% of patients. In Christchurch and Southbourne, only 56% of patients were seen within four weeks. The average across all teams was 80% of patients seen within four weeks
  • steps had been taken to improve soundproofing but this had not always been effective. There had been improvement at Weymouth with the addition of door seals but in Bridport, the addition of carpets in interview rooms had not reduced noise.

However:

  • the trust had carried out an audit of buildings to identify potential improvements to disabled access.

Are services well-led?

We rated well-led as requires improvement because:

When we returned on 16 and 17 March 2016 we found that improvements had not yet been made:

  • teams continued to operate in isolation from each other.
  • the trust did not have any governance systems in place to ensure consistency in practice across the community mental health teams
  • staff in some teams continued to feel under pressure and experience low morale.
  • best practice was not shared across teams. There was little evidence of service-wide learning from incidents.

However:

  • staff told us that there had been an improvement in the way serious incidents were investigated.

22 - 26th June 2015

During an inspection of Mental health crisis services and health-based places of safety

We rated mental health crisis services and the health-based place of safety as requires improvement because:

  • We found conflicting and contradictory evidence about staffing and sickness levels in the east Dorset crisis team. However, we found evidence to indicate that this had a marked adverse effect on the team’s ability to provide a robust home treatment service.
  • The telephone call management systems, set up specifically to deal with calls at night, did not function effectively and patients experienced difficulties accessing the east Dorset crisis team if experiencing a crisis, posing a potential significant risk.
  • There were poor relationships between the east Dorset crisis team and the community mental health teams. Communication was ineffective and as a result people using services could experience delays in receiving support from the most appropriate team.
  • In the east Dorset crisis team not all contributions from the multidisciplinary teams’ members were considered equally valuable.
  • There were several areas of concern related to poor morale, staff shortages and confusion about the crisis team model in the east Dorset crisis team. We found areas of good practice with clinicians delivering services in east Dorset but this was inconsistent. There was consistent examples of good and outstanding practice in the west Dorset crisis team.
  • Both crisis teams fell well below the trusts target for completion of mandatory training in basic life support, breakaway techniques and the Mental Capacity Act.
  • We had some concerns that the training needs of staff expected to work in the health based place of safety were not adequately met in relation to the application of section 136 of the Mental Health Act.
  • Journey times to St. Ann’s hospital, for people living in west Dorset ranged from one hour through to over two hours, traffic dependant. Reports we looked at showed that 90% of transport was provided by the police, in either a car or van and not an ambulance. This meant comparatively long journeys, often in the back of a police van, for people from the West of Dorset.

However,

  • It is important to state that we found areas of very good practice. The layout and furniture of the health based place of safety was designed to promote people’s safety, and privacy and dignity as far as possible. There was equipment available to deal with medical and psychiatric emergencies. All people had a risk assessment carried out when they were seen by the crisis teams, or were seen in the health based place of safety. People working with the crisis teams had their level of risk reviewed regularly. Staff knew how to identify and report safeguarding concerns. Staff knew how to report incidents. Staff were offered debriefing when serious incidents occurred.
  • Peoples’ needs were assessed and care was delivered in line with their individual care plans. The street triage initiative had been effective in reducing the number of people detained under Section 136 of the Mental Health Act, and the number of people referred to the crisis response team. Within the first six months, peoples’ presentation at the health based place of safety reduced by 20% and in the following six months by 32%. There were strong and firmly established relationships between the provider and the police which were conducive to positive outcomes for people using services and the staff.
  • Staff were caring, compassionate and motivated and there was good, professional and respectful interactions between staff and people using the crisis services, when we shadowed staff, during our inspection. Patients commented positively about how kind the staff were towards them.
  • We noted all groups of people, including young people under 16 years of age are able to use the health based place of safety. We saw evidence that in all but one occurrence in May 2015, the police did not use police custody cells for people, once detained under section 136 of the Mental Health Act.
  • In addition, people using the crisis services across Dorset had access to the recovery education centre which offered many courses to enable people to understand their experiences, manage their recovery and also how to support others with their journey. The west Dorset crisis service had a peer led carer’s project. There was availability of crisis house beds across Dorset which provided as an alternate to an inpatient admission.
  • The senior management team was fully committed to making positive changes. We saw that the management team had put a robust plan in place to address deficiencies identified in order to develop and implement improvements to the service.

We did not provide a rating for 'safe' for mental health crisis and health based places of safety due to conflicting and contradictory evidence which meant a definitive, robust judgement could not be made.

22-26th June 2015

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

  • We rated the acute wards for adults of working age and psychiatric intensive care unit at Dorset Healthcare University Foundation Trust as outstanding because:
  • We found very caring, compassionate and motivated staff, and, saw good, professional and respectful interactions between staff and patients during our inspection. Patients commented positively about how kind the staff were towards them. We found that staff promoted egalitarian relationships with patients and showed empathy consistently. We saw evidence of initiatives implemented to involve patients in their care and treatment. We saw that all of the acute wards used the Safe wards interventions to ensure they provided a contained and therapeutic environment for patients.
  • A service model and acute care pathway which optimised patients’ recovery, comfort and dignity was in place. There was a varied, strong and recovery orientated programme of therapeutic activities, many of which were instigated at the suggestion of patients. People with lived experience of mental health conditions delivered a series of educational and skills based workshops and programmes, directly on the wards for patients in partnership with staff. We noted the service was responsive to listening to concerns or ideas made by patients and their relatives to improve services. Bed management processes were very effective and patients were able to access an acute and PICU bed when required.
  • Wards were kept clean and well maintained and patients told us that they felt safe. There were enough, suitably qualified and trained staff to provide care to a good standard. We found that patients’ risk assessments and formulations were robust and person centred and that the service had strong mechanisms in place to report incidents and we saw evidence that the service learnt from when things had gone wrong. However, the provider should review the description of the word seclusion while describing de-escalation on RIO in order that the intervention is accurately described and review availability of outside space on Seaview ward for non-smokers.
  • The assessment of patients’ needs and the planning of their care was individualised and had a strong focus on recovery. Most staff had a good understanding of the Mental Health Act 1983 (MHA), the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice. We saw throughout all of the wards that the multi-disciplinary teams were involved in assessing and delivering patient care. We found motivated and supportive ancillary staff on all of the wards. However, the provider should maximise use of the physical health teams, review input from psychology in order to offer patients a good selection of psychological therapies, review procedures for acquiring advance directives from patients and address training across all staff groups on the new Mental Health Act Code of Practice.
  • Staff morale was good and they were well supported and engaged. There was visible and strong leadership team which includ ed both clinicians and managers. Governance structures were clear, well docum ented, adhered to by all of the wards and reported accu rate l y. Mana gers and t heir teams were fully committed to making positive chan ges. Each ma n ager had developed a ward business plan which included submissions to secure capital funds in order to develop and implement i mprovements to the serv ice.

23 to 26 June 2015

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated long stay rehabilitation mental health wards for working age adults as requires improvement because; 

  • We found patients were not protected against the risks associated with the unsafe use and management of medicines on Glendinning ward by ensuring the record of the administration of medication is accurate.
  • The physical environments on two of the wards did not promote privacy for patients.
  • We were concerned that the management of ligature risks in Nightingale House was not robust.
  • Emergency equipment was not consistently maintained and the frequency of audits of controlled drugs was not in line with the trust's policy. There were also problems with the arrangements for the management of legal highs.
  • Although there was a range of therapeutic activities available, on both an individual and a group basis, there were mixed views about whether there were enough activities on offer and about their quality. On some wards patients were unable to complete shopping or cooking tasks as part of their rehabilitation programme.

However;

  • We found that patients were positive about the way staff treated them. We observed that patients were treated with compassion, respect and dignity. and involved in the planning of their care.
  • Staff understood the trust’s vision and values and these were embedded into day to day working practices. The rehabilitation wards were well-led, ward managers were visible on the wards and there was good governance systems in place to manage the service and provide information to the trust's senior team.
  • The ward layouts allowed for easy observation of patients and were clean.
  • All three wards worked closely together to ensure that patients were admitted to the ward that best met their needs. Patients needs were assessed after admission. Care was then delivered in line with their individual care plans. Patients could access psychological therapies as part of their treatment. The wards had a wide range of staff from different professional backgrounds to support patients. These included nursing, medical, occupational therapy and psychologists.
  • The wards used appropriate clinical outcome scores. The outcome measures were completed by the multidisciplinary team and allowed patients progress to be monitored by quantifiable measures. We saw evidence of regular, effective and well-staffed multi-disciplinary team meetings on all three wards.
  • Staffing levels were in line with the levels and skill mix determined by the trust as safe.

23-26 June 2015

During an inspection of Forensic inpatient or secure wards

We rated Dorset Healthcare University NHS Foundation Trust as good because:

The ward did not have robust processes for reducing the risks to patients and staff. This included risks in the environment, gaps in policies for and implementation of procedural security, and the unsafe use of sharps bins. However, all patients had a risk assessment carried out which was reviewed regularly by the multidisciplinary team. Medication was administered and managed safely. Incidents were reported and investigated. Recruitment was ongoing, and bank staff were used to cover nursing and support worker vacancies. Staff had completed most of their mandatory training but there were gaps.

Patients had their needs assessed, and care plans developed in response to this. Patients had their physical healthcare reviewed every three months by a dedicated physical healthcare team in the hospital. Records were stored securely and could be shared with the community team. There was a structured activity programme five days a week. Staff received supervision, appraisal and training. Detained patients had their rights under the Mental Health Act explained to them, and had access to an independent Mental Health Act advocate (IMHA). The Mental Health Act was implemented correctly in most cases, and any errors were rectified. Patients who received a service from the Pathfinder service had regular psychological support. For other patients there was limited access to psychologists and occupational therapists on the ward.

Patients were mostly positive about the staff and the service, and said they felt safe on the ward. Patients had their care discussed with them. Patients had access to an advocacy service. Patients had been involved in deciding on the decoration of the refurbished ward, and an open day had been held for patients’ relatives before it reopened. A patient on the ward was peer representative and attended ward and forensic service meetings, and was able to raise patients concerns. Although patients were mostly positive about their care, they were less certain about the blanket policy of locking doors during the day and what they saw as compulsory attendance at groups.

Patients had their own room, and a lockable draw and locker for valuable or contraband items. There was a kitchenette where patients could make their own drinks. There was a structured activity programme that ran five days a week. The service had a car to support patients to access services in the community. There were rooms on the ward for patient activities, and outdoor space. The service routinely reviewed the care, needs and risks of all inpatients. It also reviewed all referrals, people on its waiting list, and patients in services outside the trust team. With the exception of nursing staff and support workers all staff worked across both inpatient and community services. There were no delayed discharges at the time of our inspection. Patients were aware of the trust’s complaints policy. The trust had no secure inpatient facilities for women, so any woman requiring this would have to be admitted out of area.

Staff were mostly positive about their managers and the staff they worked with. They felt able to speak out and voice their concerns. The ward had participated in the Royal College of Psychiatrists’ quality network for forensic mental health services annual review cycle. The service had individual groups that focused on the three parts of the service: inpatient, community (which included referral and out of area patients) and the Pathfinder service. These fed into an overarching governance group that monitored the quality of the whole forensic service. All the groups included clinical and managerial staff. The inpatient group was attended by a peer representative, who was a patient on the ward. The forensic service used information from and fed into the governance systems within the trust.

23-25 June 2015

During an inspection of Child and adolescent mental health wards

We rated child and adolescent mental health wards as good because:

  • The ward was a safe and clean environment. Environmental risks were assessed and managed appropriately.
  • Staffing levels were appropriate to the need of the patients and additional staff could be used when necessary. All staff were up to date with their mandatory training. Staff had received safeguarding training and understood the trust’s safeguarding policy.
  • There had been no serious incidents in the past six months.
  • Care records were generally well documented, holistic and recovery oriented.
  • Physical health examinations were carried out on admission and patients received ongoing physical health care.
  • The trust is part of Reading University’s children and young people's improving access to psychological therapies (CYP-IAPT) programme.
  • The ward had a full multi-disciplinary team. Staff had regular supervision and 80% had received appraisals in the last 12 months.
  • Young people were treated with respect and dignity by staff. The young people we spoke with told us that staff were supportive and caring. Patients on the ward had access to specialist children’s advocacy and independent mental health advocacy.
  • Average bed occupancy on Pebble Lodge over the past six months was 69% and beds were usually available when needed for young people in Dorset. There had been no delayed discharges from the ward in the past six months.
  • The patients were able to attend regular education at the on-site school which had recently been rated outstanding by Ofsted. Age appropriate activities were available on the ward.
  • The CAMHS service ran the Wave project which provided free surfing to young people with mental health problems.
  • There was very positive feedback from stakeholders regarding the responsiveness of the unit to the needs of young people and commissioners of services.
  • The ward had a strong multi-disciplinary leadership team which ensured that staff received mandatory training, regular supervision and appraisals and there were sufficient suitably trained staff in place. Systems were in place to ensure that staff were trained in and understood safeguarding, incident reporting and the requirements of the MHA and MCA.
  • The ward was a member of the quality network for inpatient CAMHS (QNIC).

However:

  • The clinic room fridge was out of order and awaiting parts. The pharmacy medication history verification and reconciliation section had only been completed on one of the seven medication charts we reviewed.
  • Clinical staff told us that outcome measures were not being used consistently and that there was poor compliance with recording.
  • Clinical staff told us they were not currently doing any clinical audits.
  • Patients detained under the Mental Health Act were not being informed of their rights in complete accordance with the Code of Practice.

23-25 June 2015

During an inspection of Wards for older people with mental health problems

We rated wards for older people with mental health problems as requires improvement because:

  • On all wards, staff did not monitor safety and emergency equipment adequately. Although there was a system in place to do this, staff did not complete the checks consistently and there were gaps in the recording of the checks.
  • The trust were not monitoring fire risk on Chalbury ward to ensure clear safe fire evacuation if needed. Although efforts were being made by ward management to ensure safety for patients, there were no completed fire evacuation procedures. The trust had drafted a fire evacuation procedure. However they had not completed it nor made it available to staff. Following the inspection the trust provided us with plans in progress. Training was being arranged for staff, however this was not imminent and due to on-going risks around the environment and position of this unit this meant the patients remained at risk.
  • Staff did not always ensure that risks identified in risk assessments were reflected in the patients' care plans. This meant that, although regular staff understood the risks for their patients, this was not being communicated to new or temporary staff.
  • Staff were not always protecting the privacy and dignity of patients on some wards, and were not making sure that privacy and dignity was a high priority.
  • Due to two wards being on the first floor, patients had poor access to outside space and fresh air. Staff told us this had been escalated to the trust but had not been assured action would be taken.
  • One ward had single sex dormitories, beds separated by curtains only. As some patients had been admitted longer than nine months ago, this sleeping environment did not provide adequate privacy.
  • The layout of one ward allowed wheelchair access, and two rooms were identified as disabled bedrooms. However the doorframes were too narrow to allow access to these bedrooms by wheelchairs.
  • We found ward managers were visible and supportive on the wards. However there was little engagement by senior trust managers in these services. There was no clear corporate strategy for older people with mental health problems.

23rd – 25th June 2015

During an inspection of Community-based mental health services for adults of working age

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

  • We found considerable variance in the quality and completeness of care plans and in how up-to-date they were. We identified safety concerns in relation to the standard of care planning and risk assessment and management at some teams. Allocation and management of caseloads varied between teams, and this meant that some staff held high caseloads.
  • Some teams did not have the right numbers of staff or skill mix to safely meet all the requirements of the service. Variance in performance and quality across teams, and gaps in critical aspects of service provision, were issues which had been identified eighteen months previous to our inspection through the Trust’s own internal investigations, following serious incidents. These issues had not been addressed at the time of our inspection.
  • We saw some good examples of learning from incidents and actions to to improve safety at a local team level. However, we were concerned that there was limited evidence of wider learning for the community teams to improve safety following serious incidents.
  • Staff demonstrated good understanding of safeguarding processes and were able to give examples of when they had acted effectively to protect people in their care.Teams had robust lone working procedures, which helped to ensure staff safety when out in the community. However, not all staff were up to date with their mandatory training. This training included areas of learning essential for safe practice such as safeguarding vulnerable adults, basic life support, moving and handling, and fire training.
  • The availability of different professional disciplines varied across teams. In some teams gaps in staffing potentially impacted on the effective running of those services. We identified widespread delays from assessment to treatment and long waiting times for people requiring essential psychological therapies as part of their treatment.
  • We identified a number of concerns in relation to the Trust meeting its legal obligations under the Mental Capacity Act 2005 (MCA). Mental capacity assessments and best interest decisions were not always recorded. Consent to sharing information was not always clearly documented. The majority of front line staff had not had training in MCA.
  • People using services and their carers were treated with kindness, dignity and respect. Without exception, the staff we met were conscientious, professional and committed to doing the best they could for the people in their care. Staff also supported each other well and treated colleagues with kindness, dignity and respect. Staff in different roles told us they felt valued and appreciated by their colleagues, and all staff spoke positively of their immediate peers and line managers. Carers told us they were kept up to date and involved in assessments and decision making processes concerning their family members who used services.
  • We observed people were actively involved in planning their own care, during home visits we undertook with staff. People were supported to access independent advocacy services if and as needed. Teams took a proactive approach to engage with people who found it difficult or were reluctant to engage with mental health services. People were able to provide feedback on the service they received. There was a comprehensive range of information provided for people who used services, and staff were able to obtain information in different formats and languages to support people’s different communcation needs.
  • Some of the staff we spoke to during our inspection could not tell us about the organisation’s values. Lack of shared focus and direction meant some of the community teams seemed to operate in isolation from other community teams and the wider organisation. High caseloads, disconnect from the senior management team and the wider Trust, and the effect of serious incidents and the subsequent investigation processes, had all contributed to low morale in some of the teams we visited.
  • We identified examples of innovation in many teams and a commitment from all staff to deliver quality services, but saw insufficient evidence of best practice sharing across different community teams, which would have allowed for greater improvements in quality across those teams and the wider Trust. This was particularly evident in the response to and learning from serious incidents.
  • We saw positive evidence of the integration of adult social care and health care in some teams, which were able to deliver a more effective, holistic service due to their shared knowledge and expertise. All non-management staff told us they got effective support and supervision from their team managers. Staff were well supported by their peers and spoke positively about ther immediate teams. We saw excellent examples of innovative projects and practice at many different teams, which demonstrated staff’s willingness to improve the quality of service they delivered.

23 - 26 June 2015

During an inspection of Community mental health services with learning disabilities or autism

We rated Community services for people with a learning disability provided by Dorset Healthcare University NHS Foundation Trust as good because:

  • Infection control issues were discussed in team meetings and there are named staff to champion infection control.
  • Most staff had caseloads within the levels set by the trust. Where staff had caseloads over the amount expected by the trust, this was being addressed.
  • We found some examples of positive risk taking with people who use the service to improve their safety. Staff were aware of how to report incidents when they arose and we saw evidence of points of learning being discussed in team meetings.
  • The majority of the records we reviewed contained up to date and holistic plans, but there were inconsistencies in the quality and presence of care plans in some care records.
  • We observed the use of evidence based models of therapy being used during the inspection.
  • Staff were skilled, qualified and worked together within multi-disciplinary teams to provide a caring service to people who use the service.
  • We found evidence of staff helping to create resources for other health care providers to enable positive healthcare outcomes for the people who use their service.
  • People who use the service and their carers reported that staff were caring and professional and  that they felt involved in their care and supported by staff. We found appropriate systems in place to ensure staff could respond effectively to changes in the needs of people who use the service.
  • We found leaflets on a variety of relevant topics in the locations we visited as well as access for people with differing mobility needs.
  • People we spoke with who used the service felt that they were aware of how to make complaints if necessary and the trust were creating an easy read complaints leaflet.
  • Staff reported feeling supported by the local and senior management in their service and incorporated the values of the trust in their everyday work.
  • We found examples of innovative practice that the teams were undertaking to help improve the care received by people who used the service within the trust, and with other healthcare providers.

23-25 June 2015

During an inspection of Specialist community mental health services for children and young people

We gave an overall rating for specialist community mental health services for children and young people of requires improvement because:

• In two of the CAMHS services we visited we found that there was not an effective system in place to assess the risks to young people whilst they were waiting for assessment or treatment.

• Two of the community CAMHS teams were unable to provide a service to children and young people within target waiting times due to vacancies and staff sickness.

• We were told by the staff and service managers that caseloads were reviewed regularly at the weekly multi-disciplinary meetings. We reviewed the minutes of the multi-disciplinary meetings for May 2015 and could find little evidence that caseloads had been reviewed at these meetings in two of the teams we visited..

• Insufficient numbers of staff were up to date with their mandatory training. The trust had a target of 85% of staff to have completed mandatory training. No CAMHS team had reached 85% for all mandatory training and there were some mandatory training courses with very low levels of attendance.

• Fourteen of the 26 care records we reviewed did not contain up to date care plans.

• There were backlogs in administrative work in one service which had delayed referrals of young people to other services.

• Staff shortages and vacancies prevented the CAMHS community services from delivering all the psychological therapies recommended by NICE.

• The community CAMHS services did not meet their waiting list targets for assessment or treatment.

• The trust could not provide us with detailed information regarding the number of young people waiting for tier two assessment or treatment or how long they had waited.

• Feedback we received from local stakeholders was critical of the wait for treatment that young people had to experience after referral to community CAMHS and was also critical of delays in the crisis service responding to urgent assessments.

• Four of the seven parents of young people who used the community CAMHS services we spoke with told us that they were not satisfied with the amount of time their child had to wait for assessment and treatment after the initial referral.

• There were not effective systems in place to ensure staff received mandatory training, to manage the waiting lists and to ensure there were sufficient staff.

• There was not an effective system in place to assess the risks to young people whilst they were waiting for assessment or treatment.

• There was not an effective system in place to ensure consistency in standards and work processes across the different community CAMHS teams.

However:

  • safeguarding was good and we saw clear evidence of learning from incidents. All staff we spoke with received regular supervision. There were weekly team meetings and multi-disciplinary meetings. The community CAMHS teams and children’s learning disabilities team had built very good working relationships with the local schools. The consultant psychiatrist at the children’s learning disability service carried out regular joint clinics with a consultant paediatrician. The trust is part of Reading University’s CYP-IAPT (children and young people's improving access to psychological therapies) programme. The North Dorset community CAMHS team had set up a CAMHS advisory telephone service for professionals in North Dorset. Nine of the eleven young people or carers we spoke with said the staff they worked with were supportive. The three parents of young people who used the North Dorset service we spoke with gave us extremely positive feedback regarding the service. They praised the team psychiatrist and support workers and told us that both their children’s and their own support needs had been met by the service. The staff we spoke with spoke respectfully of the young people and their carers and were able to give us many examples to demonstrate their understanding of the individual needs of the young people who used the service. The trust produced age appropriate and accessible information leaflets. Toys and books were available in waiting rooms. The multi-disciplinary leadership teams at the children’s learning disability service and at North Dorset community CAMHS worked very well and enabled those teams to deliver high service standards. Staff generally were positive and engaged. The trust responded very positively and quickly when we raised concerns about the risk assessment process for cases on the waiting lists following our visits. The trust took prompt action to review and reduce the highest risks and has drawn up an action plan to review all the waiting lists, caseloads and the risk assessment process.

23-25 June 2015

During an inspection of Community-based mental health services for older people

We rated Dorset Healthcare University NHS Foundation Trust as requires improvement because:

  • There was limited access to psychological therapies. Patients who could have benefited from specialist psychological therapies were not always offered them. These included patients whose mental health difficulties were not responding to medication.
  • Understanding and application of the Mental Capacity Act was variable and was not embedded in everyday practice in all teams.
  • Caseload sizes varied between teams and in several teams they were very high.
  • The quality of care plans was varied across the service. Some were not holistic, personalised or recovery orientated.
  • The quality of risk assessments was varied across the service and not all risks identified fed through to the patients care plan.
  • There was a lack of strategic oversight for older people’s mental health and patients did not receive an equitable service across the county. There was no clear strategy for older adults with functional illness.
  • There was no formal structure to share good practice across older people’s mental health services.

However:

  • The intermediate care service for dementia (ICSD) was a specialist crisis service for people with dementia in east Dorset. The team consisted of a team manager, nurses, a full time occupational therapist (OT), support workers and consultant psychiatrists. It was generally a nurse led service, operating 7am – 9pm, to prevent hospital admission, support discharge from hospital, support carers, families, residential and nursing homes and general hospital settings for up to six weeks. The team could provide intensive support up to four times per day, were able to access day hospital places and had an emergency social care budget to access emergency respite for up to two weeks. The ICSD provided very good crisis support for patients with dementia, although this was not available to patients in the west of Dorset.
  • Deterioration in health was discussed as part of risk reviews at weekly multi-disciplinary team (MDT) meetings. This meant that all team members were aware of individual patients’ risks.
  • None of the teams we visited had waiting lists. Assessments were carried out within the four week target in all teams, and new assessments were discussed at the weekly MDT meeting.
  • There was little use of bank or agency staff.
  • Patients were allocated a care co-ordinator within a week.
  • There was good medicine management amongst the teams and safe lone-working procedures.
  • NICE guidance was being adhered to.
  • Staff were friendly, kind and respectful and the interactions we witnessed were patient-centred, collaborative and compassionate. Patients and carers told us that they felt involved and were asked for their opinions and feedback.

23 -26 June 2015

During an inspection of Community health services for adults

Overall this core service was rated as ‘good’. We found that community health services for adults were ‘good’ for effective ,caring, responsive and well led but ‘required improvement’ to be ‘safe’.

Our key findings are:

  • Process and procedures were followed to report incidents and monitor risks. Individual localities had quality dashboards which monitored safety information such as healthcare associated infections, avoidable pressure ulcers acquired in care, safety information related to workforce and patient experience Learning from risks, incidents, near misses was shared with staff.
  • The environment was clean.Trust premises for community locations were well maintained. Equipment was available for patients in their homes and was usually delivered promptly Patients whose condition deteriorated were appropriately escalated and action was taken to ensure harm free care.
  • There was a high vacancy rate for night nursing team staff. This team felt they were overworked with not enough capacity with one team to cover a very large geographical area.There were waiting lists for therapy and rehabilitation services due to staff shortages. The staffing across other teams were mostly safe.
  • Care plans reviewed within district nursing teams were were not always person centred and did not demonstrate active involvement of the patients in risk assessments and goal planning.The information found in home notes was not always consistent. Staff told us that they did not receive any training or support on mobile working and it was not effective due to poor internet connectivity.
  • Staff across all services described anticipated risks and how these were dealt with. Safeguarding protocols were in place and staff were familiar with these.
  • Community services for adults took into account guidance from the National Institute for Health and Care Excellence (NICE). There was well established multidisciplinary team working across almost all the community services we visited, Staff had statutory and mandatory training, and described good access to professional development opportunities.
  • Incidents of pressure ulcers varied throughout the period and a plan was in progress to reduce avoidable pressure ulcers.
  • Discharges from the intermediate care and Integrated Community Rehabilitation teams ICRT were affected due to delays in transition to social care services for patients awaiting long term care package.Staff told us that these delays could sometimes be more than six weeks and this eventually affected the teams’ ability to accept new referrals.
  • Staff spent much of their time in trying to obtain accurate information about patients from referrers including GPs and acute hospitals.They said that often the important information such as patient’s medical history, medication was not received and referral forms were not fully completed .
  • Patient feedback was collected and used in planning many of the services we visited, most frequently through surveys or focus groups. Feedback from patient surveys was very positive. Lessons from incidents and complaints were usually shared within the staff.
  • Patients received compassionate care that respected their privacy and dignity. Patients told us they felt involved in decision making about their care.We found staff were caring and compassionate. Without exception, patients we spoke with praised staff for their empathy, kindness and caring.
  • There were effective governance arrangements and most of the staff felt supported by managers.The culture within community services was caring and supportive. Most staff were actively engaged and the service supported innovation and learning.
  • Elements of the trust’s vision and strategic forward plan had been implemented in community services. Staff were focused on achieving key outcomes and these were linked to the trust’s vision and strategy.

23 -26 June 2015

During an inspection of Community health services for children, young people and families

Overall this core service was rated as ‘requires improvement’. We found that community health services for children, young people and families were ‘good’ for effective, caring and responsive and ‘requires improvement’ to be safe and well led.

Our key findings are:

  • Staff did not demonstrate a consistent understanding or value of incident reporting. Some were not clear what should be reported and six staff from different professions said they were discouraged from using it. Incident analysis showed a high proportion of no or low harm incidents however which can indicate a safe reporting culture. There was evidence of high incident reporting rates in paediatric speech and language therapy, dentistry and sexual health services. Serious incidents were investigated to deliver improvements in practice.
  • There were shortages of staff in school nursing, sexual health services and health visiting services. This was due to unfilled vacancies and, in some cases, high sickness levels.
  • Medicines were not always checked or kept safe within sexual health services, which presented a risk to both patients and staff. There were clear procedures for the use of medicines for immunisation programmes however and for emergency medicines within dental services.
  • There was low compliance with mandatory training in basic life support, adult safeguarding and fire safety. There were alert systems to prompt staff to attend updates training updates, but only a minority of teams had achieved over 85% compliance with all mandatory training.
  • Patient records were comprehensive, clear and informative. They showed evidence staff addressed the needs of children and young people. Electronic records were used in all services, however with different systems used by services, there was variation in how safely they captured all the important information about children and young people’s care and treatment.
  • Safe infection control practices were seen in most situations.
  • Business continuity plans were not robust with clear guidance to help staff know when to implement escalation procedures.
  • There were safe systems and practices to safeguard children and young people from abuse.
  • There were effective systems for supporting prompt referrals and working collaboratively to deliver the care required when a child or young person needed additional health or welfare support.
  • Staff delivered programmes of assessment, care and treatment in line with standards and evidence based guidance. Patient outcomes were monitored based primarily on contact-measures but satisfaction surveys were also used to find out if patients and people using the services thought they had been effective.
  • There had been some delays in reviewing the health of children in care, but this had been identified and action taken to clear the backlog of assessments.
  • Children, young people and families received care, treatment and support from competent staff, qualified and trained for their roles. Access to training was good and new staff felt supported in their roles. Staff worked well with colleagues and with professionals in other disciplines to deliver a joined up service.
  • Care pathways were based on recommended best practice and new guidance was incorporated into updated ways of delivering care. Arrangements were in place to support children moving between services and parents told us these were helpful and effective.
  • Patients were asked for their consent before treatment was delivered.
  • People spoke highly of the caring and kind staff, and the way they listened to their concerns. They were involved in decisions about their care, given time to consider options and put at ease if they were anxious.
  • Staff coordinated care for the whole family and were committed to helping meet people’s emotional, social and welfare needs as well as their health needs.
  • Clinics and services were located in places where people could access them, and delivered at a range of times to accommodate people’s different preferences. Community health services delivered a timely service to children, young people and families.
  • Locally, staff set up health and support groups required in their areas, for example to meet the needs of minority groups. Systems were in place to identify those who may be vulnerable and to provide targeted care.
  • The school nursing service had reduced capacity to deliver public health improvement programmes, and some clinics and education sessions had been cancelled. This meant that some children and young people might not receive the support they needed at the right time.
  • There had not been many complaints received by these services, but staff told us where complaints had resulted in changes to practice. Guidance on how to make complaints was not readily available however in the clinics we visited.
  • Staff felt well supported in their teams and able to contribute to service development.
  • There was a lack of clarity in the governance structures and staff were not sure that resources were adequately allocated to monitor and report on quality, safety and outcomes for people. The risk register was not consistent with staff concerns and there was not a strong culture for reporting and learning from all incidents and complaints. Services had carried out ad hoc audits, where they had identified a need, but there was no overall audit or service evaluation programme.
  • Staff were committed to working together to provide a high quality of service. They were empowered to implement improvements in service delivery.

Dorset Healthcare University NHS Foundation Trust provides community health services for babies, children, young people and their families in Dorset, Bournemouth and Poole. These services include health visiting, school nursing, therapy services, services for looked-after children, sexual health services and services for children and young people with long term conditions, disabilities or complex needs. As part of this inspection we included the dental urgent care service and the intermediate minor oral surgery service.

We spoke with 108 staff for this inspection, reviewed 37 sets of care records and an extensive range of service documents. We received feedback forms from three people using the service and spoke with, or observed care and treatment for 53 parents, children, young people or carers.

23-26 June and unannounced 9 July 2015

During an inspection of Community health inpatient services

We rated this service as requires improvement. Improvements were required to ensure safe, responsive, effective and well-led inpatient services for patients. We found staff were caring and compassionate and treated patients with respect. We rated caring as good.

We found that there were variations in the quality of services across the 11 locations we visited. The services at Swanage, Blandford, Wimborne and Alderney were a better standard but we had concerns about inpatient services at other locations, particularly at St Leonard’s and Bridport hospitals. Surgical services were good across all locations, where provided, including Bridport hospital.

  • There were processes and procedures which were followed to report incidents and monitor risks. All locations had quality dashboards which recorded healthcare associated infections, avoidable pressure ulcers acquired in care, and safety information related to staffing numbers.
  • Essential and emergency equipment such as resuscitation trolleys and suction facilities were available and overall managed safely. However at Bridport and Westminster hospitals, improvement was needed to ensure these were fit for purpose.
  • The overall standards of cleanliness and infection control were good in eight of the 11 hospitals where infection control procedures were followed. There were significant shortfalls in these locations where staff did not follow infection control procedures and the management of infected materials.
  • There were clear procedures for the management of medicines. Medicines were managed safely most of the time. Although we found issues with safe storage of some medicines including those on the resuscitation trolleys.
  • The process for assessing risks such as pressure ulcers, falls and malnutrition were completed and care plans developed to manage them effectively.
  • All hospitals used a recognised tool to determine if patients were at risk of deterioration of their health. This system had been used appropriately such as advice from doctors was sought appropriately.
  • The trust had effective systems in place to gather information from patients, and used these to improve patients’ care. We found staff were caring and willing to go the ‘extra mile’ in supporting patients with their emotional needs.
  • Patients’ feedback was consistently positive about their care, treatment and the community was keen to retain this local service.
  • There were not always adequate staff to meet the needs of patients in a safe and consistent way and this could impact on patients’ care.
  • The quality of patient records was variable. Records were securely stored on an electronic patients’ record system, but not all agency staff had access and trust staff had limited access to records as patients moved across services.
  • Staff followed guidance from the National Institute for Health and Care Excellence (NICE). This included the five steps to safer surgery to ensure surgical procedures were undertaken safely and effectively.
  • Staff recognised the equality and diversity of patients when providing care, although written information was only available in English.
  • Therapists carried out thorough assessments of patients, however due to shortage of therapists; patients did not always receive therapy in a timely way such as out of hours and weekends.
  • We found there was strong ethos of multi-disciplinary working. Multi- disciplinary team meetings were held and led by a consultant, where patients and their relatives were involved in decision about their care and discharge planning.
  • Although there were some internal audits, these were not always linked to improvement in quality and safety or patient outcomes.
  • Governance across the service was not robust, not all risks were identified or managed appropriately.
  • There was a process which staff followed in dealing with concerns and complaints and responses were sent to patients.

23 - 26 June 2015

During an inspection of Community end of life care

We rated end of life care as requires improvement because:

We found improvements were required in the responsiveness and strategic leadership of end of life care services. The safety and effectiveness of services were good and staff providing end of life care across the trust were compassionate and caring.

  • We found planning and delivery of end of life care was inconsistent across the geography of the trust, based upon historical commissioning arrangements.
  • The generalist palliative care service, commissioned in Bournemouth and Poole, was more responsive than the community nursing service in West and North Dorset as they could support both health and social care needs of patients. If personal care services were not available to support a discharge in rural Dorset these patients did not have timely access to end of life care in their preferred place of care.
  • The generalist palliative care teams did not use an objective tool to measure its daily capacity to support patients. The team had a waiting list, and so patients were sometimes waiting to access the end of life care to meet their needs.
  • The strategy, and strategic objectives, for end of life services was still in development. Service leads articulated a vision and priorities for end of life care services across the trust, but this had not been shared with staff.
  • There was no evidence of regular reporting on the quality of end of life services to the board.
  • Priorities for improvement focused on achieving the Gold Standard Award standards, but progress had been slow.
  • Staff in end of life care services were aware of their responsibilities. They raised concerns and reported incidents and used the systems were in place for reporting and learning. They had received mandatory training to support safe care and were aware of safeguarding and how recognise and respond to concerns.
  • Appropriate equipment was available to support the delivery of safe end of life care.
  • Facilities for end of life care in community hospitals were a good standard, and where they fell short of this, plans were in place to make improvements. Mortuary viewing rooms were not used by staff, because they were not fit for purpose.
  • There were processes in place for the safe management of medicines. All staff were trained in the use of one model of syringe driver. There was a palliative care drug administration chart available, but this was not used across all services.
  • Patient records were stored securely on electronic patient records and an end of life assessment proforma was used as part of the Gold Standard Framework. There were some inconsistencies in the records reviewed.
  • Staffing in end of life care services was adequate and staff across teams prioritised end of life care. There was limited medical cover for patients admitted to a community hospital out of hours.
  • End of life care was planned and delivered in line with best practice guidance. The trust had responded to the withdrawal of the Liverpool Care Pathway by introducing a new communication care plan around end of life care.
  • We found that pain assessment took place on a continual basis and staff were responsive to this.
  • Staff had access to relevant training and support. All the teams we spoke with valued the expertise of the specialist palliative care team and used this service often as a learning resource and for referrals where patients had complex symptoms that were difficult to manage.
  • Our observation of practice, review of records and discussion with staff confirmed there was effective multidisciplinary team (MDT) working practices. Staff worked collaboratively to understand and meet the range and complexity of people’s needs
  • A combination of electronic patient records and paper forms in patient homes were used. There were some inconsistencies in the information recorded, such as preferred place of death. The trust had audited Do not attempt cardio-pulmonary resuscitation and found they were well completed. However, at inspection we found that almost half those reviewed did not include a clear explanation as to why patient or relative was not involved in the decision.
  • Staff had a good understanding of Mental Capacity Act (2005). However, some were still awaiting formal training. Recording of decisions needed to be more detailed.
  • Staff treated patients with dignity, respect and kindness. Relatives we spoke to told us that staff delivered compassionate care and that staff were very attentive to their needs and that of the dying person.
  • Care plans had been developed to be used with patients in vulnerable circumstances, such as people with a learning disability.
  • People felt confident to raise complaints and concerns and these were dealt with in a timely way.
  • There was an open and supportive culture with staff being very engaged, open to new ideas and interested in sharing best practice in end of life care.

23-26 June and unannounced 9 July 2015

During an inspection of urgent care services

We rated caring as good but found safety inadequate and the effectiveness, responsiveness and leadership of urgent care services/minor injury units required improvement.

  • The quality of clinical leadership needed to improve in most of the minor injury units (MIU), and there was insufficient leadership of urgent care services across the trust. We found visible and positive clinical leadership at Blandford and Swanage MIUs which resulted in a locally well led and organised service. However, at Weymouth, Portland and Bridport MIUs we found some serious issues.
  • The trust governance frameworks did not always operate effectively for MIUs. There were insufficient processes for proactively identifying, assessing and managing risks and seeking staff views. There was insufficient auditing of quality or learning across the service.
  • There was no clearly defined system for ensuring timely clinical assessment of patients arriving at the MIUs. This meant the service was not assessing and responding to potential risks, and patients could be waiting for some time without clinical assessment, when possibly needing urgent or more acute care and treatment. This was not in line with the trust’s service operational policy or national guidance.
  • There were staff shortages across the service and on occasions agency staff were lone working without adequate support or induction. There was variation in the experience and skills of staff employed in the units and the required qualifications and competency checks were unclear and inconsistent, particularly for lone workers.
  • There was an electronic incident reporting system in place, and some evidence of learning from incidents, but the process was not clearly understood or used by staff at all units.
  • Not all staff were up to date with safeguarding training and some staff did not know about, or respond appropriately to, the child protection flags on the electronic patient records system.
  • Resuscitation equipment was not always regularly checked or fit for use and not all staff had completed updated training on intermediate life support. Maintenance and testing of some pieces of electrical equipment was out of date.
  • Medicines were well managed in many units, and there was monitoring of storage of refrigerated medicines. However, the service had identified insufficient pharmacy support and some medicines were not stored securely. Although recently updated on electronic systems, some staff were using out of date patient group directions to administer medicines to patients.
  • We observed staff following infection control policies and procedures, but there was little evidence of auditing of the environment and staff practice to ensure this was implemented consistently.
  • We found some out of date NICE guidance but some updated treatment protocols were available for use in some of the MIUs. We were told of up to date guidelines held electronically, but these were not always accessible or used by staff, particularly agency staff. There was little auditing of adherence to guidance or monitoring of patient outcomes.
  • There were inconsistencies in clinical supervision and continuous professional development with some staff receiving more support and funding than others, depending on their location.
  • The environments of some minor injury units were cramped and reception areas compromised privacy and confidentiality. The poor signage to some units potentially led to patients attending acute hospital when not needed.
  • MIUs achieved the government’s four hour waiting targets but they did not provide clinical assessments on patients arriving in the department within the 15 minute timescale. Some MIUs had to close when there was insufficient staff to provide the service, and there was little or no xray services at some of the locations.
  • There was limited understanding of, or adjustments for, the needs of people with a learning disability and staff had not attended dementia training.
  • MIU staff had a variety of managers, some had no specific knowledge or experience in emergency nursing, and accountabilities were sometimes unclear to staff. Although staff enjoyed their jobs in MIU, some felt isolated and undervalued by the trust.
  • The MIU staff were unclear about the vision and strategy for the service. They were aware of a clinical services review being undertaken across Dorset, but did not feel informed or consulted.
  • The service specification was outdated and not being followed as it did not reflect the current service provided by the MIUs.
  • There was a clear process for patients to raise complaints and some, but not always, evidence of learning and improvement in the service as a result of complaints.
  • There were good links with acute services and appropriate referrals. There were examples of close working with GPs but some inconsistencies.
  • Verbal consent was obtained for care and treatment and this was sometimes recorded in patient records. Staff demonstrated understanding of the Mental Capacity Act (2005).
  • Nurses were caring and compassionate across all MIUs we visited. Patients spoke highly about the staff and were involved in decisions about their care and treatment.

23-26 June 2015

During an inspection of esb.services_rated.community forensic mental health services

We rated Dorset HealthCare University NHS Foundation Trust as outstanding because:

The Pathfinder service worked collaboratively with patients with complex psychological needs and potentially high risk behaviour. Feedback from patients about staff and the service they received, and how this had improved their quality of life, was extremely positive. Staff actively engaged patients in their care. Care plans were person centred and patients were involved in the care planning. Staff had recently been provided with laptops, so they could write care plans when meeting with patients.

The Pathfinder service worked with patients with a personality disorder who were at risk of offending, to improve their outcomes, and at significantly cheaper cost being in hospital. The service was psychologically led and worked with patients around their risk behaviour. They used evidence based tools to measure the outcomes for patients. The Pathfinder service focused on supporting and supervising staff, so that they were able to effectively provided treatment and support to patients with complex psychological needs. Patients had their needs assessed, and care plans developed in response to this. Patients had access to psychological and occupational therapy. All staff had supervision and support, and were able to discuss their concerns in regular staff meetings. A multidisciplinary team of staff provided care for patients. Staff worked with external agencies to manage risks. Records were stored securely and could be shared with the inpatient service when necessary. Care was person centred, but this was not always reflected in the community care plans. Patients had access to Mental Health Act advocacy (IMHA) services. Staff had an understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards.

All patients had risk assessments which were reviewed regularly, and crisis and contingency plans. Staff knew how to report safeguarding concerns. Medication was administered and managed safely. Incidents were reported and investigated . Caseloads were manageable. There were staffing vacancies, but these were managed within the multidisciplinary team. There was a lone worker policy, but staff were not clear about its implementation.

Patients received occupational therapy and psychology services. The service routinely reviewed the care, needs and risks of all its patients. It also reviewed all referrals, people on its waiting list, and patients in services outside the trust. The team worked with other agencies, which included the police and probation services. The community team had close links with the inpatient ward and most of the multidisciplinary team, with the exception of nursing staff and support workers, worked across both services. There were no delayed discharges at the time of our inspection. The trust did not have any secure inpatient facilities for women, so any woman requiring this would have to be admitted out of area.

Staff were positive about their work within the team, and felt able to raise their concerns. There were positive relationships between managers and lead clinicians within the service. The service had individual groups that focused on the three parts of the service: inpatient, community (which included referral and out of area patients) and the Pathfinder service These fed into an overarching governance group, that monitored the quality of the whole forensic service. All the groups included clinical and managerial staff. The inpatient group was attended by a peer representative, who was a patient on the ward. The forensic service used information from these groups and fed into the governance systems within the trust. The Pathfinder service had been implemented as part of a national initiative to improve outcomes and reduce risk when working with offenders with a personality disorder.

23 -26 June 2015

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

Overall, we rated the trust as requires improvement because:

  • The services that the trust provided varied in their quality. We had particular concerns about the child and adolescent mental health services, minor injuries units, and mental health crisis and rehabilitation services. We found some significant variance in the quality of care delivered between teams and across the trust.
  • The child and adolescent mental health services (CAMHS) in Weymouth and Portland and in Bournemouth and Christchurch did not assess risks to young people waiting for assessment or treatment effectively. Also, the teams were unable to meet the waiting time targets because of the number of vacant posts and staff who were on sick leave.
  • At Weymouth, Portland and Bridport minor injuries units there was a lack of clinical leadership. There was no clearly defined system for triage and clinical assessment of patients arriving at the units. This meant that the service was not assessing and responding to potential risks, and patients could be waiting for some time without clinical assessment, when possibly needing urgent or more acute care and treatment. This was not in line with the trust’s service operational policy or national guidance. In addition, there were staff shortages and a lack of an appropriate skill mix across the service, and on occasions agency staff were working alone without adequate support or induction.
  • We found conflicting and contradictory evidence about staffing and sickness levels in the east Dorset crisis team. However, we found evidence to indicate that staffing issues had a marked adverse effect on the team’s ability to provide a robust home treatment service.
  • The telephone call management systems, set up specifically to deal with calls at night, did not function effectively and patients experienced difficulties accessing the east Dorset crisis team if experiencing a crisis, posing a potential significant risk.
  • At Nightingale House and Nightingale Court patients were not able access comprehensive rehabilitation programmes in the community; they were unable to do their weekly shopping and cooking. During the inspection we saw that some patients on these rehabilitation wards spent much of their time smoking rather than engaging in meaningful activities. There were high levels of detention under the Mental Health Act on all rehabilitation wards and some patients had been detained on the wards for a considerable length of time which is unusual on rehabilitation wards.
  • We found inconsistencies in the planning and delivery of a number of services across the trust.
  • There were deficiencies in monitoring and checking safety and emergency equipment across older people’s mental health services and in inpatient wards in community hospitals
  • The quality of patient records in community health services was variable. A combination of electronic and paper patient records were in use where care was delivered in patients’ homes. In community health care inpatient services, records were stored securely on SystmOne. However, there were inconsistencies within SystmOne due to how it had been set up, which meant that staff had limited access to some parts of the system as patients moved across services and not all agency staff had access it.
  • The governance frameworks did not always operate effectively for minor injuries units. There were insufficient processes for proactively identifying, assessing and managing risks and seeking staff views. There was insufficient auditing of quality or learning across the service.

However:

  • The trust responded very quickly and positively when we raised concerns about the risk assessment process for children and young people on waiting lists in the Weymouth and Portland and Bournemouth and Christchurch child and adolescent mental health services and took prompt action to review and reduce the highest risks. The trust drew up an action plan to review all waiting lists, caseloads and the risk assessment process, and has kept us updated on the positive progress with this.
  • The trust responded quickly and positively when we raised concerns about the safety of services delivered in Weymouth and Portland minor injuries units. It assured us that only experienced clinicians would work at these units and that if safe cover could not be found the units would close. All units would have a band six nurse at all times as a minimum. The trust also told us that it is considering how it could provide band 7 shift leaders in each unit. The opening hours at Portland would be changed, with no weekend working, and there would be receptionist cover during opening hours.
  • There was visible and positive clinical leadership at Blandford and Swanage minor injuries units, which resulted in a locally well led and well organised service.

In addition:

  • We observed outstanding care and treatment in both inpatient mental health services and the forensic community services.
  • In inpatient mental health services we found that the model of care and acute care pathway optimised patients’ recovery and that there was a strong emphasis on recovery-orientated therapeutic programmes, many of which were instigated by patients.
  • The forensic community Pathfinder service worked with patients with a personality disorder who were at risk of offending to improve their outcomes and at significantly lower cost than being in hospital. The service was psychology led and worked with patients around their risk behaviour. The staff within the community forensic services went out of their way maintain contact with patients placed on wards out of the area and worked hard to bring patients back into the area as soon as they could, including supporting the maintenance of relationships with relatives.
  • The trust had a relatively new board (executives and non-executives), with the majority having been appointed only since the arrival of the chief executive in 2013. The director of nursing had been in post for ten months before our inspection and a new medical director was due to take up post immediately after our inspection. The leadership team was positive, passionate, energetic and open and transparent. We concluded that they were a cohesive team who respected one another and shared a common purpose.
  • The executive team, along with the senior managers, were aware that the trust needed to improve and we found that, despite many of them only recently coming into post, they had been very active in working quickly to address and identify issues. They had engaged well with staff, developing a new vision, ‘to lead and inspire through excellence, compassion and expertise in all we do’, which was underpinned by the principle of doing ‘better every day’. In addition, they had engaged positively with stakeholders, an aspect for which the chief executive had taken specific responsibility.  This included creating active relationships with the clinical commissioning groups (CCGs), NHS England, local authorities, and visiting groups of GP's.  They had been successful in changing attitudes and fostering positive relationships – so much so that commissioners and other stakeholders now held the trust in high regard and were positive about the future, whereas previously they had held a very different view. It was clear that there was a cohesive strategy based around driving improvements in clinical practice and working in partnership with patients, staff and stakeholders; we saw clear evidence of this in several areas across the trust.
  • We found that the trust had developed an impressive, high quality and detailed governance system to support it to achieve its vision and this was in the process of being rolled out, although it was not yet fully embedded across all services. We found those systems were robust and we were confident that, given time, areas of concern could be identified speedily and managed well.
  • In addition, the trust had recently moved to a locality-based delivery model to promote integration of both physical health and mental health services. This model was in the early stages and was developing well for some services but not so well for others, resulting in some variation in the quality of services and some services feeling fragmented as a result. For example, staff felt there was now a lack of strategic focus for people with functional illness across older people’s community services. Staff questioned whether the child and adolescent mental health service was too small to be split across localities and they felt that there was insufficient leadership of urgent care services.
  • We found good practice across the services that we inspected, with a caring, enthusiastic and committed workforce that in the main treated patients in their care with dignity and respect.
  • Although we found some care that gave us cause for concern, as identified above, throughout the inspection the trust was very receptive to any comments that we made and we saw immediate and appropriate action taken when we raised a concern.
  • We have not taken any enforcement action and are confident that the trust will quickly address all areas of concern identified in the requirement notices detailed in this report.

We did not provide a rating for the 'safe' domain for the mental health crisis and health based places of safety core service due to conflicting and contradictory evidence which meant a definitive, robust judgement could not be made.

Dorset HealthCare University NHS Foundation Trust requires improvement. However, we saw that it was well led by its new leadership team and was in the process of deploying effective systems that we were confident would result in the delivery of improved, high quality services for the patients it serves in the future.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

 

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.