All inspections: Surrey and Borders Partnership NHS Foundation Trust

This was a focused inspection, so we did not rate this service.

Surrey and Borders Partnership NHS Foundation Trust provides two acute hospitals for adults of working age and a psychiatric intensive care unit. Some patients are detained under the Mental Health Act 1983. Abraham Cowley Unit is one of the locations.

The wards are registered to provide the following regulated activities;

Assessment or medical treatment for persons detained under the Mental Health Act 1983.
Treatment of disease, disorder or injury.
Diagnostic and screening procedures.

At the Abraham Cowley Unit (ACU) there are three wards:

Clare Ward is a 20-bed male ward for patients from Elmbridge, Epsom and Ewell.
Anderson Ward is a 13-bed female ward for patients from Elmbridge, Epsom and Ewell.
Blake Ward is a 20-bed mixed gender ward for patients from Surrey Heath, Runnymede and Spelthorne.

The unit was last inspected on the 7 January 2020 and the service was found to be good across all key questions. However, we highlighted that the environment at the ACU was not fit for modern mental health care. This was due to the presence of dormitory accommodation which resulted in poor patient experience due to the poor communal bathroom areas, the drab and dreary environment and the overall risks to patient safety presented by the environment.

On 26 June 2020 we conducted an unannounced focused inspection looking at specific areas relating to ligature risks.

During this focused inspection we visited two of the three adult wards at the hospital. We visited Blake Ward and Clare ward at the ACU to inspect the key question ‘are services safe’, with a particular focus on ligature risks. The decision to inspect the hospital was taken following the deaths of two patients on Clare ward on 15 April and 10 May 2020. Both patients had died by means of fixing a ligature to fittings on the ward.

Following this inspection, we wrote to the trust to inform it of our concerns about the management of environmental ligature risks at The Abraham Cowley Unit. We wrote to the trust under section 31 of the Health and Social Care Act 2008. Section 31 of the Health and Social Care Act 2008 Act is an urgent procedure whereby CQC can vary any condition on a provider's registration in response to serious concerns. A letter of intent sets out our intention to take urgent action if the provider does not assure us that it will make the required improvements urgently. The trust responded to our letter on 14 July 2020 with an action plan to address the issues.

In the Section 31 letter we told the trust that we were concerned about the management of ligature risks as ligature risk assessments on one of the two wards inspected had not been updated following recent serious incidents. During our inspection on 26 June we found that new risks had been identified on Clare Ward following a re-assessment of ligature risks, but this re-assessment had not been completed for Blake Ward, despite the similarity of the ward environments. At the time of the inspection we were concerned that the learning from the incident reviews on Clare Ward had not been shared across the other adult wards at ACU. We asked the trust to ensure there was a robust system in place to share learning and immediate actions from adverse ligature incidents across the three adult wards. Following our Section 31 letter, the trust told us all three wards had now completed a full audit of ligature risks as of 12 July and that learning was now being shared through the hospital morning meeting, the afternoon safety call and the Situation Background Assessment Recommendation (SBAR) ward handover process. The SBAR ward handover process had also been revised across all wards to manage ligature risk.

We told the trust we were concerned that there was a lack of timely, pro-active action to address and mitigate the ligature risks identified for the adult wards at ACU. The trust had identified ‘quick-win’ actions to mitigate ligature risks, which had been completed on Clare Ward. However, the urgent works identified by the trust to remedy the ligature risks in the three categories of ‘quick wins’, ‘more extensive solutions’ and ‘no obvious solution’ had not all been addressed and had not been identified on the other two adult wards. We asked the trust to ensure there was a clear and measurable delivery plan to meet the works required to ensure effective controls in all three categories (‘quick win’, ‘more extensive solutions’ and ‘no obvious solution’) across all three wards. Following our Section 31 letter of intent, the trust confirmed that work required to complete immediate actions would be completed on Clare Ward by the 16 July and Blake and Anderson by the 21 August. It also confirmed that staff on Anderson and Blake had completed the additional training.

We told the trust we were concerned that initiatives to address the ligature risks described in the trust’s document, Safety Actions for ACU remained in discussion, in development, or ‘to be considered for a trial only’ and that these did not have a clear implementation date.

The initiatives described in this document included, but were not limited to, a remote monitoring product that uses infrared and optical sensors to monitor motor movement. This system also contains a medical device for vital signs monitoring that measures breathing and heart rate. The second initiative was a modern style of safety hinge and other visual aids to improve door safety.

We were concerned that effective controls to manage ligature risks remained in discussion with no real time scales for completion of remedial action several months after two serious incidents. We asked the trust to ensure that decisions about initiatives to minimise ligature risks are followed through and put in place in a timely manner. In response to our Section 31 letter the trust told us it would be installing the room monitoring system, a remote monitoring product that uses infrared and optical sensors to monitor motor movement and also contains a medical device for vital signs monitoring that measures breathing and heart rate. A site survey had already been completed and the trust has agreed to proceed with installation on the three wards commencing on 17 July 2020 with a planned completion date of 30 September 2020. The trust response confirmed that decisions had been made to place orders for the room monitoring system and the safe hinges, they stated that subject to board approval the order would be placed by the 17July 2020 and the works completed by the 30 November 2020

In the trust’s response to our Section 31 letter the trust told us it was improving the governance of ligature minimisation and this would be overseen by the board, the ligature minimisation policy would be redrafted with a system for checking people are competent. The observation policy had already been re-drafted; this was due to be discussed by the executive board at the next meeting. Both policies were reviewed and approved through the governance processes by 22/07/20 as per the action plan target date.

As our inspection was an unannounced inspection to look at specific issues we have not included a rating and have not altered the previous rating for this core service.

During this inspection, the inspection team

Visited Blake ward and Clare ward

Spoke with the ward manager covering both wards

Reviewed staff rotas

Reviewed shift handover documents

looked at care and treatment records of patients

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.

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.

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.

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.

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.

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

The wards had enough nurses and doctors and were safe and clean. 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.
Risk assessments were regularly reviewed and updated following incidents. Learning from incidents was happening and being shared across the core service.
The wards minimised the use of restrictive practices and followed good practice with respect to safeguarding. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment.
Staff followed best practice when storing, dispensing, and recording the use of medicines. Staff regularly reviewed the effects of medications on each patient’s physical health.
Staff understood and carried out their roles and responsibilities under the Mental Health Act and the Mental Capacity Act.
Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. Staff involved patients in care planning and risk assessment. They actively involved patients and families and carers in care decisions and actively sought their feedback on the quality of care provided.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

The wards at the Abraham Cowley Unit are not designed for modern mental health care. The staff had implemented many procedures to mitigate this but the physical construction of the building meant there were lots of blind spots which were difficult to observe easily and its layout did not fully promote dignity and privacy due to the dormitory bedrooms and communal bathrooms.

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

The service was adequately staffed and all the environments were well maintained and had adequate, safe furnishings. The service provided mandatory training in key skills to all staff and the majority of the staff had completed it. Staff completed and updated comprehensive risk assessments for each patient and patients’ allergies were clearly recorded.
Staff from all disciplines worked well together to benefit patients and were supported by managers through regular supervision meetings and appraisals. Staff knew how to protect patients from abuse and the service worked effectively with other agencies such as the local authority and police in a joint effort to protect patients. The new single point of access, which incorporated the crisis line, ensured calls to the crisis line were dealt with appropriately.
Staff understood their roles and responsibilities under the Mental Health Act and the Mental Capacity Act. Staff treated patients with compassion and kindness and supported their individual needs.
Patients were assessed in a timely manner and the services were accessible to all who needed it. Patients who needed support in a crisis were referred to the home treatment teams and assessed in a timely manner.
The service had a process to enable staff to implemented recommendations from reviews of deaths, incidents, complaints, and safeguarding alerts. However, this did not always ensure that staff were aware of events that had occurred outside of their own team.

However:

In the health-based places of safety we saw one occasion where the medical rationale for rapid tranquilisation for a patient was not recorded but the trust confirmed to us after our inspection that this was recorded. There were not complete records of observations of patients following the use of rapid tranquilisation.
Staff and patients reported that the Safe havens were on occasion closed on short notice due to staffing issues.
Despite action from the trust, there was still some uncertainty amongst staff as to who was responsible for storing and administrating patients’ own regular medication whilst in the health-based place of safety. Managers told us that a new policy was in the process of being written.

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%.

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.

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

We rated all five domains – safe, effective, caring, responsive and well-led – as good. Following this inspection all ten of the trust’s core services were rated as good. In rating the trust, we took into account the previous ratings of the six mental health services not inspected this time.
Eleven of the 12 care homes provided by the trust are rated good and one is rated requires improvement.
Since the last well-led inspection in 2017 the trust has continued to make improvements.
Staff at all levels and across all services had renewed pride and confidence in their work and spoke with energy and enthusiasm about the improvements that they were delivering.
There was stronger leadership at executive, divisional and service delivery levels throughout the trust.
The trust had more robust operational systems and processes. The trust had responded to emerging issues in service quality with considered, well-executed and in-depth supportive plans for improvement.
The trust had introduced a culture of quality improvement.
The trust had continued to modernise and improve the environments from which they delivered community and inpatient services.

However:

The wards at the Abraham Cowley Unit in Chertsey were not suitable for modern mental health care. The staff had implemented many procedures to mitigate this but the physical construction of the building meant there were blind spots which were difficult to observe easily and its layout did not fully promote dignity and privacy due to the dormitory bedrooms.

We found the following issues that the service provider needs to improve:

The unit had a heavy reliance on temporary staff. Permanent staff had not been co-ordinated and allocated across Anderson ward and Blake ward. Temporary staff may not be as familiar with patients or procedures on the ward as permanent staff. This may potentially have an adverse impact on the quality of care provided to patients.

Agency staff on Anderson ward were not familiar with the ward procedures and on the day of our inspection did not have access to the patient electronic records. This prevented staff from being able to access patients’ care plans and risk assessments.

During the inspection, we observed nurses discussing confidential patient related information in the presence of other patients.

There was no evidence of risk assessments undertaken for patients attending the shared dining room. Risk assessments of patients on Anderson ward were not always updated following patient incidents.

There was no clear management process for staff and patients at mealtimes. It was not clear to staff who remained on the ward, which patients or staff had left the ward to go to the dining room. Some staff allowed all patients to eat in the dining room, whilst others were using RAG (red, amber or green) risk levels to determine which patients were safe to eat the dining room. Staff who escorted patients back to the ward did not communicate their remaining patients’ needs or risks to the staff members remaining in the dining room.

Staff on Blake ward were unclear as to whether windows in the dormitory should be opened or closed and were not all able to communicate the latest policy decisions surrounding the windows.

We fed back our immediate concerns to members of the trust executive team, members of which subsequently provided us with an improvement plan to address the immediate concerns we had raised.

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.

Following this re-inspection we have changed the rating of well led at provider level from requires improvement to Good. We rated Surrey and Borders Partnership NHS Foundation Trust as good overall for caring, effective, responsive and well led because:

The trust had a clear set of values and a vision and the trust had strong leadership, with effective leaders and managers. The board presented as passionate and engaging and were open and transparent. Executive directors and non-executive directors understood their roles and responsibilities.
The trust values included involving people in their work and involvement groups were embedded in governance arrangements. The trust had set up initiatives to get feedback from patients and carers.
The trust had robust governance structures in place. This meant that from ward to board there was a good understanding of the challenges facing the trust. Areas for improvement were recognised and work was carried out to make all the necessary changes. Key performance indicators and quality standards were set by the trust board annually. These included clinical priorities for improving services. The trust monitored progress against each of the key performance indicators and quality standards at the council of governors, executive board, operational board and trust board meetings. The trust had a systematic programme of clinical and internal audit which was used to monitor quality and systems to identify where action should be taken.
The trust had made considerable improvements in the quality of care and treatment provided at all of their care homes for people with a learning disability. In addition reporting systems and internal assurance reports had been strengthened which ensured members of the trust board were well versed in any developments, concerns or issues relating to the care homes.
The trust board had a thorough and current oversight of all incidents and complaints. The board examined and analysed all incidents and complaints through regular and detailed board reports.

We found the following issues that the provider needed to improve:

One of the wards contained dormitories. The dormitories were poorly lit during the day and had restricted space around the bed areas also we observed clinical conversations happening in bed spaces while patients were opposite, this meant the conversations were easily overheard
The layout of all wards meant that observing patients was challenging for the staff. In particular the semi-circular layout of Blake ward and the position of the ward office at one end made it particularly difficult to ensure all areas of the ward were easily observed.
When we looked at the care records we found 14 of the 23 sets reviewed did not have a care plan that was recovery orientated or highlighted the individual patient’s full range of strengths and weaknesses. In addition five of the patient’s on Clare ward did not have any care plans in place.
The modified early warning score (MEWS) was being inconsistently applied to the patient’s. Out of the 23 sets of care records reviewed none of the MEWS charts observed were being scored at the time of the inspection.

However we found the following areas of good practice:

Safety was being considered on a regular basis when the ward managers had twice daily safety calls with the service line leads. This ensured that discussions around safe staffing levels and the skill mix of the staff on each ward was reviewed and addressed. It also reviewed how staff were managing keys and personal alarms safely.
Wards used a reporting system for incidents called Datix and the staff on the wards had regular "Datix huddle" meetings to review the incidents for each of the wards over the previous seven days.
On Blake ward there was a multi disciplinary conference call every day which was attended by the consultant, associate specialist, the ward doctor, representatives from the home treatment team, the community mental health teams and the ward nursing team.
We could see that supervision was happening and ward managers had developed their own method to make sure supervisions were happening. Appraisal levels were at 100% across all three wards in March 2017.

Due to the issues described as concerns above, the CQC issued a letter of concern, highlighting these issues. The management team addressed these issues and created a plan and response by the 21 April 2017. We revisited the hospital on the 27 April 2017 and found that the issues that were not influenced by changing the environment of the hospital had been addressed. The care plans and risk assessments for patients had all been reviewed and updated and physical health monitoring was taking place and being recorded consistently.

However the dormitories and the physical layout of the ward remained as described in this report

We found the following issues that the provider needed to improve:

the ward was regularly accommodating female patients in rooms in an area of the ward assigned to male patients.
the ward design hampered staff’s ability to observe patients safely.
the bed space areas in the communal dormitories were restricted and there were low levels of light during the daytime which presented a hazard to patients
not all staff working with patients had completed the trust’s dementia awareness training.

However we found the following areas of good practice:

staff were knowledgeable about the needs of the patients on the ward and the shifts were filled by permanent staff.
all patients had comprehensive risk assessments and had their risks regularly reviewed by the multidisciplinary team.
all patients had current care plans which were personalised to their assessed needs.
staff monitored patients’ physical health regularly using recognised health assessment tools.
patients had good access to psychological interventions and occupational therapy on the ward

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.

We rated mental health crisis services and health based places of safety as requires improvement because:

The outstanding compliance action from our previous inspection in 2014 concerning suitable systems to assess and manage risks had not been completely addressed. This was due to the recent introduction of a new database and lack of staff knowledge and understanding in its use.
In some areas, rates of mandatory training were low, particularly around medicines management and we found that two patients had not had allergies recorded on documentation.
There was inconsistency across the crisis resolution home treatment teams concerning completion of contingency plans, discharge planning and reporting incidents.
There was inconsistency of staff completing the electronic risk assessment tool. The risk assessment tool did not have a system to identify the level of risk and was therefore dependent upon the clinical judgement of staff.
There were inconsistencies in the systems used by the crisis resolution home treatment teams. We witnessed an ineffective use of resources due to the amount of time spent in meetings.
A significant number of patients on caseloads were inpatients. The length of stay for inpatients was significant and often in excess of 12 weeks. This affected staff capacity for new referrals.
The police liaison group meetings were attended by senior managers within the trust and we were told that this information was not always cascaded to staff in a timely or effective manner.

There was a high level of agency staff used in the teams which could affect the staffing levels for the health based place of safety at Farnham Road Hospital, Guildford.

There was a lack of cohesive support for patients who contacted the service outside of normal working hours and were diverted to the crisis line. There was mixed feedback from patients and carers regarding the effectiveness and helpfulness of the crisis line. Some patients told us that they found the Samaritans to be more helpful.

However:

The trust had addressed most of the compliance action from the previous inspection in 2014 regarding risks in two of the units used as health based places of safety. These units were no longer in operation.
We saw supportive and caring relationships between staff and patients within the crisis resolution home treatment teams and medical staff were actively involved in patient care.
The crisis resolution home treatment teams had access to crisis beds to prevent acute hospital admission and staff worked closely with staff at Crisis House.
All patients and carers in contact with the crisis resolution home treatment teams were given information packs about the service. Staff gathered feedback from patients and used the information to improve services.
Some teams included nurse prescribers. Staff told us that there were opportunities for professional development including personality disorder training and non-medical prescriber training.
All record keeping was electronic with no paper records.
Staff demonstrated a sound understanding of the trust’s lone working policies.
Three crisis resolution home treatment teams had taken part in a University of London crisis resolution team optimisation and relapse study. Staff involved in the study had provided positive feedback. The trust was one of 14 NHS trusts throughout England taking part in this study.
There was dedicated staffing at Farnham Road Hospital. The places of safety were clean and well maintained with sufficient lines of visibility. Staff treated patients in the places of safety with dignity and respect. In Farnham Road Hospital, patients could listen to the radio, watch television, engage in interactive activities and communicate with staff using the communication window.
Both places of safety accepted patients of all ages and we observed staff efforts to engage a young person by using activities. Farnham Road Hospital was the designated place of safety for those aged under 18 but the Abraham Cowley Unit took under 18s where necessary.
People who displayed difficult and challenging behaviour were not turned away and we observed such behaviour being well managed. Staff received annual training in de-escalation and the prevention and management of violence.
The organisational policy concerning the health based place of safety had been updated in February 2016 to reflect the changes to the Mental Health Act 1983 Code of Practice 2015.
The places of safety had a clear and comprehensive standard operational procedure which was based on the multi-agency agreement. There were good working relationships with the police and ambulance service at the senior level.
There was a commitment and clear leadership at all levels to improve access to places of safety. The trust had signed up to the multi-agency agreement with Surrey police and was involved in the Surrey Mental Health Crisis Care Concordat. Ambulances were used to convey patients to a place of safety in a majority of cases.

Efforts had been made at Crisis House to create a homely and non-restrictive environment and patients were involved in their care. Regular liaison took place between the staff at Crisis House and the referring crisis resolution home treatment team.

There were two dedicated lines for incoming calls to the crisis line and contact could be made using text messaging.

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.

We rated Surrey and Borders Partnership NHS Foundation Trust as requires improvement because:

The board did not have a thorough oversight of incidents and complaints. Whilst the board discussed individual, high profile cases and received annual reports of incidents and complaints, there was no detailed regular report to the board which examined and analysed all incidents and complaints. This meant that board members were not aware of all trends or hot spots and could not adequately challenge each other on what needed to change or the lessons that should be learned from serious incidents and complaints.
The trust had weaknesses in their systems for reporting and learning from incidents. Some incidents logged by staff were not signed off by managers which resulted in a backlog. This means that the initial actions and learning from some incidents were not captured and documented.

The trust’s seclusion policy did not reflect the updates to the changes to the Mental Health Act Code of Practice.

There was no consistent use of a recognised risk assessment tool or consistent recording of patient risk across all core services. In the community child and adolescent mental health service and the mental health crisis and place of safety teams there were poor risk assessments.

Medicines management practice was inconsistent across the trust. Issues included controlled drugs discrepancies on two wards and out of date drugs on three wards. Fridge temperatures were not recorded correctly at three sites.

There were weaknesses in the trust’s oversight of its social care homes for people with a learning disability. Six of the trust’s social care homes have been rated as requires improvement by separate CQC inspections in the past year. Prior to our inspections, the trust’s quality assurance systems had highlighted some concerns at these services but had not identified all of the concerns or the severity of some of the issues.

However:

The trust had carried out a comprehensive review of its inpatient services and health based places of safety since our last inspection. The trust had closed wards and units that were not safe or no longer suitable for inpatient mental health services and had opened a new purpose built unit for adult acute services, the psychiatric intensive care unit and a health based place of safety.

Access to physical healthcare and monitoring of physical health had improved in the trust since our last inspection.

There were good waiting times and response times particularly for community services.

The trust had good leadership, with strong and effective leaders and managers. They presented as passionate and engaging and were open and transparent.

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

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.

We rated specialist community mental health services for children and young people as good because:

Services were caring and effective at matching therapies or treatments to people’s presenting needs.

Patients were able to be involved in service development, including recruitment and training of staff. This had a positive impact on the experience of people using the service.

Managers were good at developing services to respond to the needs of the local population.

However:

Risk assessments for many patients were incomplete, absent or hard to access. This could have led to poor care for patients. Risk assessments that were there were hard to find.

Staff and managers were not always following the lone working policy and this has the potential to put staff at risk.

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

Staff assessed and managed risks well. Staff responded appropriately to patients whose health had deteriorated.

The teams learned from incidents and shared information about incidents with other teams.

Teams contained highly skilled and motivated professionals from a full range of disciplines. Each team benefitted from an excellent level of access to psychiatry and psychology input. Staff received necessary mandatory and specialist training and were supported via regular supervison sessions.

Patients had access to Surrey County Council’s enablement service, from which they could benefit from intensive and temporary support.

Patients and carers we spoke with told us that they were happy with the way they were treated by staff and how staff involved them in the provision of care.

Patients we spoke with had been involved in the recruitment and induction processes for new staff.

Every team met and/or exceeded its targets to assess routine and urgent referrals.

There was a robust system in place to attempt to re-engage patients who failed to attend appointments.

The staff at North East Hampshire Community Mental Health Recovery Service (CMHRS) had gone to great lengths to engage with the large local Nepalese community.

All 12 teams were well managed and benefitted from effective support from the service managaer and senior management team.

The teams made good use of the trust’s personality disorder forum, which provided specialist consultancy and advice to help staff to respond to the needs of an increasing number of patients who had a diagnosis of personality disorder.

However:

There were some concerns that alarm systems within interview rooms were not adequate to minimise risks to staff from aggressive patients.

Confidentiality was not adequately safeguarded within the premises of Spelthorne CMHRS, due to inadequate sound-proofing and the necessity for members of the public to walk through the staff office in order to access the interview and meeting rooms. Also, the level of sound-proofing within the premises used by Reigate and Woking CMHRS teams was in need of improvement.

There was a very strong unpleasant odour within the building used as the premises for Spelthorne CMHRS.

The level of disabled accessibility at the premises used by Spelthorne, Reigate and Woking CMHRS teams was in need of improvement.

The premises used by Spelthorne, Reigate and Woking CMHRS teams had an insufficient number of rooms for interviewing and treating their patients.

We rated April Cottage as good because:

The physical environment of April Cottage was clean, well-maintained and kept people safe.
The patients interviewed reported they felt safe, protected from avoidable harm whilst at the same time they had their own freedom to take risks.
The multidisciplinary team worked well together. There were sufficient staff to ensure safe levels of nursing were maintained.
All staff were trained in positive behaviour support and this was incorporated into the model of care.
There was clear evidence that the patient was at the centre of their care. Each patient had a folder which contained their likes/dislikes, aspects of their life and issues that were important to their life
Patients we spoke with reported that they felt involved in decisions about their care, supported to make decisions in their lives and were treated well with compassion, dignity and respect.
Patients we spoke with were aware of how to make a complaint. The complaints process was available in an easy read format. Patients were supported with individual issues which tended to be resolved informally.
Staff were clear about their roles and what they were accountable for and had a positive working relationship with local commissioners.
Morale was high, all staff were looking forward to moving to their new premises. The service had been nominated for ‘team of the year’ award.

However:

Risk assessments and physical health assessments were undertaken but were not presented in a standardised way. In addition, the therapeutic activities programme was poor as it was low-key and not based upon an occupational therapy assessment of peoples’ needs.

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

Staffing levels were good and staff were appropriately trained and qualified. The service encouraged their professional development.
Patients received a high level of physical care. The service was committed to monitoring physical healthcare and aimed to reach the standard expected on a general acute ward.
Patients’ care was planned and assessed in line with their needs. Dedicated staff from all disciplines ensured that care met a wide range of needs. Patients and their relatives were involved in decisions regarding care delivery.
Patients who were detained under the Mental Health Act or subject to treatment under the Mental Capacity Act were treated in line with legislation.
Patients were treated with dignity and respect. Staff took an interest in their lives and spent time to make patients feel comfortable.
The service was responsive to individual needs. Patients and carers were listened to. Care was delivered based on suggestions and feedback.
Staff teams worked well together and were dedicated to improving the lives of their patients. Staff felt supported to raise concerns and these were addressed appropriately.

However:

One ward was not meeting guidance on the requirement to provide same-sex accommodation.

The service did not always share best practice. This meant that patient care and environmental standards varied across each ward. An example of this was an uncontrolled falls risk on one ward
Staff told us that they did not feel connected and involved in learning and innovation from other areas of the trust.

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

The unit was safely staffed. There was a stable staff team, low vacancy rates and low sickness levels. Staff were in the main up to date with mandatory training. Supervision was robust and appraisal rates were high at 89%.
A thorough ligature risk assessment had been undertaken by the trust following concerns on previous CQC visits. The trust was clear that risks were adequately assessed and those that remained were proportionate to a rehabilitation environment.
Processes around safeguarding, complaints and incidents were in place and generally robust. All staff were aware of the procedures.
Recognised rating scales were used to assess and monitor progress. The health of the nation outcome scales, the camberwell rehabilitation assessment, and the model of human occupation outcome scale were used regularly. The unit worked within the recovery model to enhance patients’ independence and skills.
Patients and carers spoke positively about staff and the unit and reported feeling supported and safe. Staff treated patients with respect and attended to individual needs.
Carers were involved and invited to meetings on a regular basis with the patients’ consent.
Care records were good. All records contained an up to date risk assessment and crisis and contingency plans. Care plans were available in all records and were in the main holistic and recovery focussed.
There was a well led leisure based activity programme and staff were committed to facilitating this. Patients were involved and helped to plan activities.
Discharge planning started on admission. Of the 20 discharges in the last 12 months most patients had moved on to more independent living.
Team morale was good and all staff reported a supportive team and good leadership.
Regular team meetings took place and agendas were comprehensive and minutes were thorough.
The unit had a strong student mentorship programme. It had close links with the university of Surrey to maintain a good teaching environment.

However:

There were no alarm systems or call buttons in the unit, apart from the downstairs shower room. The building spanned three floors and had mixed sex corridors. There was a risk, especially at night, that staff or patients who needed help on the upper floors could not call for assistance.
The 0.5 psychology post had been vacant since December 2015 and recruitment had been unsuccessful. This left a significant gap in service provision.
There was a lack of non leisure based activities. Intensive vocational support was not evident.
An acute care pathway review was underway and the model of rehabilitation provided was being reviewed. Staff felt unsettled and uninformed about the future of the unit.The unit did not have accreditation for inpatient mental health services.

Overall we rated these services as requires improvement because:

The storage, dispensing, administration and disposal of medication was not safe on every ward and we found that record keeping and documentation of safe medicines practice was not robust on a number of wards.

Patients’ risk assessments were not always completed with sufficient detail and had not been updated following incidents. Ward ligature risk assessments did not always include information on action taken to mitigate risks, dates for work completion or the responsible person. Some additional risks were found which had not been identified by the service.

On some of the wards there were blind spots where patients could not be observed and there was no plan to mitigate against these risks.

The quality of care plans was inconsistent on some wards. Although all patients did receive a full physical health check and assessment within 72 hours of admission.

Patients’ privacy and dignity were not promoted on four of the seven wards as patients did not all have access to make a telephone call in private.

Patients returning from leave might have to transfer to a new ward which would disrupt their continuity of care.

Mandatory training and appraisal rates were very low in some areas. This could impact on staff being up to date with essential training, which enables them to carry out their work safely.

However:

The application of the Mental Health Act was well managed, people were informed of their rights and there was good access to advocacy.
Staff understood the principles of the Mental Capacity Act and understood how to make a decision in a person’s best interest.
Locally wards were involved in undertaking audit and used outcome measures for patients.
Each ward had a therapy service and programme over seven days and extended hours support.
Staff spoke positively about their managers. They felt managers were visitble, supportive and approachable. Staff were able to describe the trust’s vision and values.

The trust was led by a committed board, executive team and senior managers. People who use the services, staff and external stakeholders told us that senior staff were generally open, accessible and willing to learn. We heard of many new initiatives and the trust was constantly looking for ways to improve its services.

Before and during our inspection, people told us that most staff treated them with kindness, dignity and respect.

Many of the staff we spoke to enjoyed working for the trust and felt they had opportunities to professionally develop and to engage with the future direction of the work of the trust.

We also found good collaborative working relationships with partner agencies such as social services.

The main challenge for the trust is that the governance processes are not yet fully supported by robust quality assurance systems. Many of these systems are new and may not always identify poorly performing services in a timely manner so that the focus could be given to ensuring the necessary improvements were made. This meant that although the trust understood its broad areas of risk it did not always know all of its service “hot spots”.

This has meant that in each domain there are areas of very positive work such as the safe staffing initiative which has improved the assurance around staffing levels for inpatient services and yet there are variations between divisions and also between services in the same divisions. This has led to variations in the quality of care and the need for different areas of improvement across the services.

We inspected 10 adult social care services provided by the trust as part of this comprehensive inspection and found that four of them were now compliant. The remaining six had all improved since our last inspection and separate draft reports were being sent to the trust.

As a consequence there are a number of compliance actions relating to different services and it is our view that the trust needs to take steps to improve the quality and safety of their services. We will be working with them to agree an action plan to help improve the standards of care and treatment.

There were processes for reporting, responding to and learning from incidents; and action had been taken in response to serious incidents. There were environmental risks within all of the acute admission wards, such as ligature points but these had been assessed and were being managed and addressed.

Staff were friendly and respectful and people were given opportunities to be engaged in decisions about their care. People using the services were supported by multi-disciplinary teams who worked well together. People who used the services were positive about the therapy services they received.

Staff at the Mid Surrey assessment and treatment centre were not clear about when the use of interventions constituted seclusion. This meant that the necessary safeguards were not put in place to keep people safe. The wards had resuscitation equipment, but in Delius ward at the Mid Surrey assessment and treatment centre this was not always regularly checked to ensure it was adequately maintained, and up to date.

The inpatient services and home treatment teams worked well together to ensure that people received the right care at the right time. Inpatient wards had high occupancy levels which could mean that people were admitted to a service quite a distance from their home.

Staff felt they were well led by their immediate managers and were aware of the values and visions of the trust.

Staff in the older people’s services delivered services in a thoughtful and compassionate manner and people who used the service were positive about the service they received from staff.

We received positive feedback from people and families of people who used the service. We observed positive interactions and skilled dementia care being delivered in inpatient settings. We saw that staff who worked across the services showed commitment to people who used the service. In the community mental health teams for older people we saw that staff showed a sensitive and respectful approach which was reflected in comments by people who used the service. Staff from the community teams and inpatient services worked well together.

We found however that there were variations in the inpatient services, not only between sites but also between wards on the same site. Willow ward at Woking Community Hospital had made significant improvements and was now fully compliant. At Farnham Road Hospital, Albert ward was working well but Victoria ward needed to improve in a number of areas that could affect the care and welfare of people using that service. Quality assurance processes such as health and safety audits had not identified all the areas for improvement on Victoria ward including the fact that 18 out of the 20 call bells were not working.

Another area of concern in services for older people were that patients admitted to the inpatient services had not always had comprehensive assessments including tissue viability and falls, which meant that risk was not clearly identified at the Meadows and Victoria ward and so care plans were not always in place. This meant that there was a risk that patients would not have all their needs met. The introduction of “quality matrons” were supporting ward staff to address these issues but further work was needed.

Staff across the older people’s services told us that they felt supported by the leadership locally. However, some staff in inpatient services told us that they felt there was a disconnect with higher level leadership across the trust.

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.

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

These reports, under our old approach to inspection, involved us assessing a whole provider against the standards we expect.

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.

All Inspections

However: