Surrey and Borders Partnership NHS Foundation Trust

Updated 8 September 2020

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

• Staff in the trust had worked hard to maintain the improvements that we found in our last inspection. The four core services that we inspected maintained their rating of good which means that all ten of the trust’s core services have a rating of good.
• During this inspection we inspected four core services and carried out a well-led review. In rating the trust we have taken into account the previous ratings of the six mental health services not inspected this time.
• We found that the trust was led by a highly skilled and experienced senior team, including the chair and non-executive directors. There was a strong patient-focussed, learning culture within the trust and staff showed caring, compassionate attitudes, were passionate and proud to work for the trust and were involved in the development and improvements within the trust.
• We found that the trust leaders had the skills, knowledge, integrity and experience to perform their roles and had a good understanding of the services they were delivering. Senior leaders were open and honest, presented and spoke with passion, compassion and authenticity.
• There was a clear vision, underpinned by a set of values that were well understood by staff across the trust. The trust values were embedded in a real commitment to people, both staff and patients, and in creating a value-driven organisation.
• Effective leadership from senior trust leaders and leaders in the community-based mental health services for working age adults was enabling staff to manage the separation of health and social care teams following the local authority taking back management of social care staff (this happened shortly before the inspection). The trust was supporting team leaders effectively and monitoring the impact on patients.
• The trust had made improvements to the therapeutic programmes offered to patients within its inpatient wards since our last inspection. Both the variety of activities and their availability to patients across seven days per week had improved.
• The trust was developing a digital strategy which supported the overall clinical strategy. This ensured that both strategies were aligned and focused on improving patient care and supporting staff to deliver care.
• Generally, staff completed comprehensive risk assessments and managed risks well. Physical and mental health needs were assessed and monitored, and care plans were holistic and recovery orientated. Staff followed good practice with respect to safeguarding.
• Patient safety incidents were managed well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons with their teams and the wider organisation.
• Staff provided a range of care and treatment interventions suitable for the patient groups and these were consistent with national guidance on best practice.
• Staff across all the services we inspected were kind, compassionate, supportive and respected the dignity of patients. Feedback from people using services and their relatives and carers was positive. Staff ensured that the emotional and spiritual needs of people who used services were addressed, along with their mental and physical healthcare needs.
• Since the last inspection, the trust had appointed a Director of Workforce and was working to attract recruits to the organisation with a newly launched workforce strategy.
• Staff across the trust were confident and willing to develop their services, using quality improvement methods. Staff were proud of the areas in which they worked. They felt encouraged and supported by the trust leaders to try out new ideas and improve the experience of people using their services.
• The trust had positive and collaborative relationships with external partners and was actively engaged with the local health economy in shaping services, including patients, staff, equality groups and local organisations.

However

• The wards at the Abraham Cowley Unit remained unfit for the purpose of delivering modern mental healthcare. The patient experience remained poor due to the dormitory accommodation, communal bathroom areas, drab and dreary environment experienced by most patients. The staff had worked hard and implemented many procedures to manage the overall environmental risks however, the physical design of the building and the wards meant that staff found it difficult to maintain patients’ dignity and privacy. We saw that the trust was continuing to consider options to replace the hospital and the board was moving forward with a longer-term plan. However current patient experience continued to be affected by the poor environment at the Abraham Cowley Unit.   

• We noted that there were areas in governance and assurance that would benefit from a full review. The last formal governance review had taken place in 2016 and the trust informed us that they were working on commissioning such a review within the timescale set for NHS trusts.

Updated 12 April 2019

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

• Patients were kept safe because staff assessed risks and worked with patients to make plans for times of crisis.
• There were low levels of staff vacancies. Staff caseload numbers had come down to levels which allowed them the time to carry out all their role and support patients on their caseload.
• Staff understood how to protect patients from abuse, and complaints and incidents were effectively investigated and learning shared with the team.
• Patients had care plans which were based on their assessed needs. Patients had access to a range of specific treatment pathways and therapeutic interventions for patients that were all evidence-based and aligned with the National Institute for Health and Care Excellence (NICE) guidelines.
• Managers made sure they had staff with a range of skills needed to provide high quality care. Staff were positive and supportive of each other’s well-being, and received regular supervision.
• Patients and carers said that the service had a positive impact on their wellbeing. They spoke positively about the attitudes and the contacts they had with staff. The service delivered a variety of additional workshops and training to equip patients and carers with skills and tools to understand their mental health and better manage their conditions.
• The service worked with youth advisors to get feedback about the service and involved them in making improvements to the service.
• The trust had a vision for what it wanted to achieve in transforming the performance of the service. Staff, patients and other stakeholders were aware and included in the vision.
• There were robust governance processes in place with team forums to discuss clinical and business matters, and regular meetings with other stakeholders in the CAMHS pathway.

However:

• While the service had significantly improved its waiting time for assessments and could meet its target for generic assessments, it was not reaching its target for waiting times to treatment. In many treatment pathways, the trust was not matching the national standard of 18 weeks from referral to treatment.
• There was variance in where staff recorded clinical information on the trust’s electronic information system which meant that, in some records, information was not easily located.
• The trust management information reporting did not accurately reflect the current configuration of the four teams.
• The CAMHS completion rates for appraisal, at 86%, was lower than the trust target of 93%.

Updated 28 July 2016

We rated Surrey and Borders Partnership NHS Foundation Trust community mental health services for patients with learning disabilities or autism as Good because:

• Staff were very positive about the quality of team work and mutual support.
• People who used the service and their carers told us they knew how to make complaints. The overwhelming majority also told us they did not feel they had any need to complain.
• Patients told us they liked working with staff from the service and felt staff always had time for them.
• Staff involved patients and relatives in planning patients’ care and support. Care records showed that staff used professional interpreters when necessary to ensure that patients and their relatives could give their views and make decisions.
• Relatives were given the opportunity to speak privately to staff about any concerns about their caring role. They described a flexible service which responded very quickly when a decline in a person’s mental health placed additional stresses on family and carers.
• The teams offered a range of nursing and psychological interventions to meet patients’ needs and worked with them, their family and support networks to improve patients’ mental well-being and quality of life.
• Care records included information on how patients’ physical health was monitored. Staff ensured that all patients received appropriate physical health checks. This included patients who were prescribed medicines which required them to have physical health checks to ensure there were no adverse side effects.
• Relationships between clinicians from different disciplines were constructive and staff told us they felt they were encouraged to make an active contribution to case discussion.
• Care plans were comprehensive and included details of the person’s background, social circumstances and health needs. Each person had a recovery and support plan which had information about the person’s mental health needs, their physical health needs, the support they could expect from the team and how they wished to be supported towards recovery.
• Staff told us they received regular supervision and appraisals.
• Staff were competent and well-trained.

However:

• Across all services caseloads were being managed but not all services were using a consistent system. At the Kingsfield Centre and Ramsay House clinicians managed their own caseload size and the service relied on the individual clinicians’ subjective views with no clear multi disciplinary team oversight.
• None of the six services had undertaken recent ligature audits for the consultation rooms. Staff felt that this had not been a risk up to the point of the inspection and used risk assessments to try to ensure that patients with high risk behaviours were seen in their own environments.
• The service in Aldershot did not promote a positive perception for patients with a learning disability who used the service. The waiting rooms were shared with the mainstream mental health services and were clinical and unwelcoming. The staff attempted to make the best of the environment but there was no appropriate signage or visible information suitable for people with learning disabilities.
• Staff in the community teams for people with a learning disability did not have mandatory training provided in basic issues of working with adults with a learning disability such as autism awareness.
• Staff across the services told us they had not been fully consulted about the proposed divisional changes and development of the new model of intensive support teams. Although they were positive about the direction of travel, staff consistently told the inspection team that they felt alienated from the change process. This had a significant impact on the morale of the staff teams. Staff told us they loved working in their teams and we observed passion in relation to working with the patient group. However, this was affected by the reported concerns regarding the lack of inclusion in the change process.

Updated 28 July 2016

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

• All premises were clean, well equipped and well maintained. Clinic rooms were well stocked and had appropriate equipment to complete physical health checks. Patient Led Assessments of the Care Environment (PLACE) scores were high for cleanliness and privacy, dignity and wellbeing.
• New referrals were seen within trust timescales at eight out of the nine teams; urgent referrals were seen on the same day. The service took referrals for people under 65 years if they had a diagnosis of early onset dementia. All teams operated a duty system, the Frimley service ran from 8am to 8pm.
• The trust had recently established an intensive support team to provide support within nursing homes to prevent unnecessary hospital admissions. Teams ran clinics at GP practices and nursing homes for the convenience of people who used the services.
• Care plans were up to date on the computerised recording system. Care records for people using services contained up to date risk assessments. Staff used appropriate outcome measures, such as HONOS (Health of the Nation Outcome Scales).
• People using services reported being involved in care planning and were able to say what was in their care plan. People who use services told us that staff treated them with kindness and respect and worked in a caring manner. People using services were given detailed information on dementia and each team had leaflets on advocacy, how to make a complaint and external support agencies.
• People using services had access to psychology and psychiatric support at all teams. Each team was made up of a wide range of health professionals including nurses, social workers, psychologists and occupational therapists.
• Staff appraisals, supervision and mandatory training were all up to date or scheduled. Staff had completed Mental Health Act and Mental Capacity Act training.
• Teams all had good links with external agencies such as Age UK and the Alzheimer’s Society. All teams had gone through the Memory Services National Accreditation Programme (MSNAP); eight teams were accredited and the remaining team was still awaiting the outcome of their application for accreditation. The Aldershot team had won awards for their involvement in research. Staff followed the trust’s lone working policy. Staff reported all incidents on the trust incident reporting system and staff across all teams shared learning. There were low staff vacancies across the service.

However:

• Team and individual caseloads across the service were high.
• Some staff reported a lack of engagement with senior management within the trust and the wider trust organisation.

Updated 1 May 2020

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

• Clinical premises where patients were seen were safe and clean. The physical environment of the health-based places 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 no too high to prevent them from giving patient the time they needed. Staff assessed and managed risk well and followed good practice with respect to safeguarding. Staff knew how to report incidents, there was learning from when things went wrong, and lessons were shared with staff.
• Staff working for the mental health crisis teams worked with patients, families and carers to develop care and treatment plans. They provided a range of treatments that were informed by best practice guidance and suitable to the needs of the patients.
• The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients, such as consultant psychiatrist, nurses and psychologists Staff worked well together as a multidisciplinary team and with relevant services outside the organisation, such as local third sect or partners that support patients’ wellbeing and recovery.
• 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 and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The mental health crisis service and the health-based places of safety were easy to access. 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 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. The services did not exclude patients who would have benefitted from care. The service did not have any waiting lists. Patients who required urgent care were seen promptly.
• The service had a clear plans and priorities of how it aimed to improve the mental and physical wellbeing of people who use the service. Managers and staff worked hard to ensure the service ran smoothly. There were effective, multi-agency arrangements to agree and monitor the governance of the mental health crisis service and the health-based places of safety.

However:

• Staff did not always ensure emergency equipment was fit for use. The emergency bag at Farnham Road hospital had expired items in it, and staff were unaware of this.
• Mandatory training for basic life support and immediate life support was low at 69% and 67% respectively, which was below the trusts’ target of 90%. This meant that staff may not be able to respond sufficiently in the event of a medical emergency.
• The service did not always store medicines safely. Staff did not always ensure patients who were prescribed antipsychotics were routinely monitored. Staff did not always document blood results for patients on clozapine. Medication keys were not always managed safely. Patient’s allergy status was not always documented in patient’s prescription charts. Post inspection the trust took immediate action to review and revise their medicines management processes across the service.
• Staff at home treatment teams did not always complete a crisis or contingency plan for patients who were or may be in crisis. Of the 12 care records we reviewed across the home treatment teams, half of them did not have a crisis plan.
• The healthcare assistants at the health-based places of safety did not always receive clinical supervision in line with trust policy. The average clinical supervision rate was 49% across both health-based places of safety.
• The service and the teams did not have a robust system for monitoring and reviewing risks. This meant that risks were not always identified, and actions taken to mitigate risks were not being recorded and reviewed in a systematic way.

Updated 25 April 2018

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

The unit had a bespoke calming suite, which was adapted specifically to suit the needs of the client group, and had its own operational policy to ensure it was managed safely. The staff team from The Deacon unit had been heavily involved in the development of this area and in the design and manufacture of some of the furnishings so it could be specifically tailored to the nature of some of the clients that may use the service.

The unit had a cohesive and effective relationship with the Intensive Support Service (ISS), which meant that if additional staff were required they were able to cross-cover. When the unit had fewer patients, the surplus staff were employed within the ISS team to support people in the community. This arrangement also worked in the opposite way when required. This meant there were only two shifts in the three months preceding the inspection that were not covered.

The unit followed the NHS England “stopping the overmedication of people with a learning disability” agenda (STOMP LD). This is a three-year agenda started in 2016 which is designed to make sure people get the right medicine if they need it and that people get all the help they need in other ways as well.

Risks to physical health were identified and managed effectively by trained staff. The service used a standardised system called Modified Early Warning System (MEWS) to monitor and record the physical health of patients.

Staff carried out a range of assessments with patients on admission to the unit and throughout their care and treatment. These included, but were not limited to, physical health assessment, medication assessment, functional behaviour assessment and analysis.

Carers felt involved in contributing to patient’s care plans. Carers told us they felt staff knew the patients very well. Carers were invited to attend care programme approach meetings, and were aware of plans and goals for discharge.

Staff expressed a caring approach when they were talking about the patient group and it was clear there was an understanding of the patients’ individual presenting needs and how best to support them on a daily basis.

As part of the transforming care programme for people with learning disabilities, the service was discharge oriented. Staff were committed to achieving a sustained reduction in the number of patients admitted to the wards.

Records shown to us by the trust showed that in the 12 months leading up to the inspection the service had received no complaints and had received multiple compliments from family members and carers.

There was high staff morale across the clinical team. All the staff we spoke with were enthusiastic and proud about their work and the care they provided for patients on the unit. The clinical team were motivated to inspire and support staff to succeed. Staff described strong leadership on the ward and said that they felt respected and valued.

  There was an effective incident feedback loop and ward staff were aware of outcomes from incidents that had occurred on the unit which had been discussed by the clinical team.

Updated 1 May 2020

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

• The environment was well-maintained, clean and well-equipped. The service had enough nurses and doctors to support patients safely during the day. Staff assessed and managed risks well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• All patients had care plans based on their assessed needs which were regularly reviewed. Patients were offered a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation unit. This included access to psychological therapies, to support patients to care for themselves, develop and relearn everyday living skills, and to them take up meaningful occupation.
• The service had access to the full range of specialists required to meet the needs of patients on the unit. Managers ensured that these staff received training, supervision and appraisal. The unit staff worked well together as a multidisciplinary team and with those outside the unit 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. Carers we spoke to confirmed this.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service was well led and the governance processes ensured that unit procedures ran smoothly.

However:

• The service had lower staffing numbers after five o’clock and this made it difficult to safely manage the environment and support patients when the service was busy.
• The service did not fully reflect its philosophy of rehabilitation and recovery in the care planning system. There was inconsistency in how patient recovery goals were described and recorded within the care planning system.
• At the time of inspection staff were not regularly using a recognised outcome tool, such as health of the nation outcome scales (HoNOS), during admission to reflect the patients’ progress. Post-inspection the trust informed us that the service has introduced an evidence-based outcome measure at Margaret Laurie House.

Updated 12 April 2019

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

• Staff stored, dispensed, administered and recorded patient medicine appropriately. Staff received support from pharmacists, who visited each ward regularly. Clinic rooms on all wards were fully equipped with accessible resuscitation equipment and emergency drugs which staff checked regularly.
• Staff we spoke with knew what type of incidents they should report and knew how to report them. Staff attended a weekly meeting on their ward, that focused solely on sharing information and learning about recent incidents.
• Patients had good access to physical healthcare. Staff could obtain support from a range of health professionals, such as a physical health lead nurse, dietitians and physiotherapists.
• Managers from all three sites met once a week for a bed management meeting to discuss planned and potential patient admissions, discharges and transfers within the service. All wards held weekly multidisciplinary meetings to review the care and treatment for individual patients.
• Staff treated patients in a caring, respectful and responsive manner. Staff displayed a high level of understanding of the individual needs and abilities of patients. Patients and carers we spoke with told us they were happy with the care provided by staff.
• Staff involved patients and carers when formulating care plans and risk assessments. Staff invited carers to attend weekly multidisciplinary team meetings to discuss developments in the care of their relative.
• Staff could access interpreters as needed. Staff had attempted to support one patient who did not communicate in English by learning some basic phrases in their preferred language.
• The internal environment in each ward had level access and therefore was suitable for people with restricted mobility. Two of the three units within The Meadows (called Bluebell 1 and Bluebell 2) had been assigned to accommodate patients with dementia. The environment within the two Bluebell units had been adapted with dementia friendly colour schemes, fittings and signage.
• Ward managers and matrons in this core service had the skills, knowledge and experience to perform their roles. Staff told us they felt able to raise concerns and propose suggestions to improve the service without fear of being victimised.
• Staff on Spenser ward had secured funding for a pilot project to study the therapeutic benefits of dog therapy in an inpatient setting for older people. The aim was to examine the effects of dog therapy sessions on patients with an affective disorder, such as depression.

However:

• Staff had not adhered to trust policy in establishing a robust physical observations baseline for new patients. The trust’s policy stated an expectation that all newly admitted patients should have physical observations carried out by staff at least twice daily during their first three days of admission. On Spenser ward, none of the eight records we reviewed had had a baseline established in line with trust policy.
• Team meetings and supervision sessions took place only sporadically on The Meadows and Victoria ward. Managers from both wards cited pressures caused by staffing vacancies and the high demands of their patient groups as reasons for their team meetings not taking place at the scheduled monthly intervals. This core service did not meet the trust’s target rate for appraisal compliance.
• Patients on Victoria ward did not have easy access to a garden.
• This core service had a significant level of staffing vacancies. Staff we spoke with cited the impact of vacancies on the team and the running of the service as their primary concern. They spoke of the extra stress placed on substantive staff when the ward was operating with a high proportion of bank or agency workers.
• Staff appeared to have limited knowledge of specific learning from the review into a death within this core service in 2016.
• Most patients on Spenser ward were placed in one of three shared dormitories. Proposed plans to redevelop the Abraham Cowley Unit incorporated the removal of dormitories on Spenser ward.

Updated 1 May 2020

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

• All the ward environments were clean, furnished and most were well equipped. The wards at Farnham Road Hospital were purpose built for modern mental health care. 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.
• 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 local clinical audit of care plans and the environment to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
• The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

• The wards at the Abraham Cowley Unit were not fit for purpose. The physical construction of the building was outdated and there were lots of blind spots which were difficult to observe. There were multiple comers across all the wards which meant that it was difficult for staff to easily maintain visibility across the wards. However, staff had implemented many procedures to try to manage patients safely.
• The layout of the Abraham Cowley Unit did not support the maintenance of dignity and privacy due to the dormitory bedrooms and communal bathrooms. On Blake ward there were gender separate sleeping areas however it remained non-compliant with the Mental Health Act Code of Practice due to the access to bathrooms/shared corridors. Patients across all wards at The Abraham Cowley Unit told us they did not feel like it was a relaxing environment and they had little privacy on the wards.
• The female lounges at the Farnham Road hospital did not have any televisions or any activities for patients, they were underused by the female patients as they were locked so not freely accessible.
• The wards were not regularly documenting gaps in medication administration using the incident reporting system, this was dealt with at a local level by ward managers but there was no overall view of medication gaps which might pick out themes and trends.
• At ward level supervision was happening but the wards had no overall system of reporting supervision levels back to the board so there was no way of the organisation ensuring itself that supervision was happening regularly across the wards.

Updated 17 July 2017

We rated Substance Misuse Services as good because:

• The ward and the community team bases were clean and well maintained. Within the community services, all group, clinic and interview rooms were in a separate area that could only be accessed by staff, these rooms were all soundproofed and private

• Care records and risk assessments within the community services were detailed, personalised and up to date.

• All services had sufficient staffing respect to client caseload.

• The medicines management was good in all community services and all staff followed the Trust policy.

• There were good and effective handovers between all teams during morning briefings and change of shift.

• At Windmill House, there were excellent working links with internal departments at St Peter’s Hospital Site, such as the diabetes clinic and accident and emergency.

• Staff were able to book interpreters through the trust and were able to use the same interpreter for continued key work sessions.

• Staff felt that the trust’s vision relating to substance misuse had improved and now appeared to have become more prominent on the trust’s agenda.

• All service managers had a local risk register that was reviewed and updated regularly. This was then fed into the trust organisational risk register.

• All service managers felt very supported by their line manager and felt very connected to and part of the trust.

• Everyone we spoke to told us that they were confident that they could raise issues without fear of concern and knew the correct processes to follow if they wished to complain or whistleblow.

Updated 1 May 2020

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

We rated safe, effective, caring, responsive and well-led as good.

• The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff at five of the six services assessed and managed risk well.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• 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.
• The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude patients who would have benefitted from care.
• The service was well-led and the governance processes ensured that that procedures relating to the work of the service ran smoothly.

However:

• Staff at Epsom CMHRS were not regularly reviewing all patient risk assessments or updating them to reflect changes in risk.
• Staff did not always follow good personal safety protocols when lone working. Team records showed that staff were attending patient meetings without collecting a personal alarm.