Dorset Healthcare University NHS Foundation Trust

Evidence appendix Sentinel House Date of inspection visit: Nuffield Industrial Estate 30 April 2019 to 4 June 2019 Nuffield Road Poole Date of publication: BH17 0RB 31 July 2019

Tel: 01202 277000 www.dorsethealthcare.nhs.uk

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust. Facts and data about this trust

The trust had 19 locations registered with the CQC (on 9 April 2019). Registered location Code Local authority St Ann's Hospital RDY10 Poole Alderney Hospital RDY22 Poole Poole Community Health Clinic RDY62 Poole Pelhams Clinic RDYEE Bournemouth Weymouth Community Hospital RDYEF Dorset Westhaven Hospital RDYEG Dorset Bridport Community Hospital RDYEJ Dorset Forston Clinic RDYEW Dorset Westminster Memorial Hospital RDYEY Dorset Yeatman Hospital RDYFC Dorset Victoria Hospital, Wimborne RDYFE Dorset Swanage Community Hospital RDYFF Dorset 30 Maiden Castle Road RDYFT Dorset 49 Alumhurst Road RDYFX Bournemouth The Junction Sexual Health Clinic RDYGE Bournemouth Linden Community Support Unit RDYKW Dorset Sentinel House RDYNM Poole Blandford Community Hospital RDYX4 Dorset Portland Hospital RDYY1 Dorset

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The trust had 448 inpatient beds across 30 wards, eight of which were children’s mental health beds. The trust did not provide information on the number of acute outpatient, community mental health and physical health clinics that they had per week.

Total number of inpatient beds 448 Total number of inpatient wards 30 Total number of day case beds 19 Total number of children's beds (MH setting) 8 Total number of children's beds (CHS setting) 0 Total number of acute outpatient clinics per week Not Provided Total number of community mental health clinics per week Not Provided Total number of community physical health clinics per week Not provided

The methodology of CQC provider information requests has changed, so some data from different time periods is not always comparable. We only compare data where information has been recorded consistently.

Is this organisation well-led?

Leadership The trust board had a number of relatively new executive members who had an appropriate range of skills, knowledge and experience to perform its role. All the executive team except the chief operating officer (COO) were in permanent posts, with a permanent appointment expected to be made in the coming months. The chief executive officer (CEO) had recently been appointed, and was previously the COO. The CEO and trust chair had a positive working relationship which encouraged healthy cohesion and challenge across the board. The CEO had a clear dynamic plan for further leadership development which involved getting the team to work collaboratively and identifying what was needed in terms of coaching and development. We saw good evidence of integrity throughout the board and senior leadership team. The trust considered and reviewed leadership capacity on an ongoing basis. The chair had recruited strong and experienced non-executive directors (NED’s) with a range of experience including finance. Other NEDS had Legal, Logistics and Procurement, Journalism and medical sciences backgrounds. The NED’s did not have a clinical background but were fully able and confident to escalate and challenge clinical issues through the executive team. There was a clear feedback loop throughout the board and the executive team which reflected empowerment and maturity. The Board had relevant financial expertise across the executives and non-executives. Executives had a sound understanding of the trust’s financial position and areas of opportunity. The director of finance and strategic development was an experienced director of finance with previous NHS and private sector experience, and had been in post since September 2016. Fit and Proper Person checks were in place and the files were well ordered and well managed. We did see that the trust chair had not signed off all the files, however this was immediately rectified once this was fed back to the trust.

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The executive board had one (14%) black and minority ethnic (BME) member and three (43%) women. The non-executive board had no (0%) BME members and three (38%) women. The trust had created a leadership structure that had an identified lead for mental health services and community health services. There was an ongoing programme of board visits to services which were welcomed by the staff teams. The trust senior leadership team were visible and approachable. Leadership development opportunities were available, including opportunities for staff below team manager level, and we considered the development opportunities and drive for excellence through development exemplary. Leadership development opportunities included three core programmes: • Aspiring leaders (bands 4-6 who wish to develop into leadership roles) • Essential leaders (band 7 plus who want to build on knowledge and skills) • Senior leaders (directors and their direct reports. Helped to lead change and improvement). This was an outstanding piece of work, with further opportunities for staff at all grades to develop and take on leadership positions. In addition, the trust sent one member of the finance team on the HFMA developing talent programme every year and the deputy director of finance and head of finance encourage staff to attend other HFMA events utilising the trusts credits appropriately. The trust had recently amended their training support package for those studying for professional accounting qualifications. This had resulted in more staff enrolling on courses, especially junior staff studying to become AAT qualified. The trust had a leadership forum which included operational and support services senior managers. This group nurtured collaboration between teams and met at least once a quarter to discuss issues such as cost improvement planning (CIP) and transformational schemes. The trust leadership team had a comprehensive knowledge of current priorities and challenges across all sectors and took action to address them. There was a good level of accountability from pharmacy management to support governance and patient safety throughout the trust. Medicines safety risks were identified, actioned and shared appropriately within the trust and with external partners. Learning actions from medicines incidents and audits were shared across the trust. Recent growth in the pharmacy team meant that clinical pharmacy support was more widely available across the trust in community teams, inpatient wards and mental health services. The pharmacy department had a senior leadership team that supported and led the department. There was a pharmacy workforce plan and structure which allowed for development and succession. Pharmacists were trained to be independent prescribers and advanced clinical practitioners. The chief pharmacist was part of the Dorset-wide medicine optimisation transformation group, along with leads from other NHS trusts in the county, head of medicines optimisation at Dorset CCG and the local pharmaceutical committee to represent community pharmacy.

Vision and strategy The trusts vision and values were: ‘To lead and inspire through excellence, compassion and expertise in all we do’.

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The vision was that Dorset HealthCare would lead and inspire both locally and nationally. The ambition was to inspire patients, partners, local people and professionals alike, by achieving excellent clinical outcomes, supporting people with compassion and kindness, and by being experts in their roles. They were also guided by a clear statement of purpose. This purpose set out what they did and why they do it, and helped everyone to feel part of the same organisation when they delivered such a diversity of services. The purpose was: • To provide integrated healthcare services to empower people to make the most of their lives • We care when you’re unwell, we support your recovery and we give you the knowledge and confidence to stay as healthy as possible. The values were: • Working together for patients • Respect and dignity • Commitment to quality of care • Compassion • Improving lives • Everyone counts • Commitment to learning

The Trust had a 5-year strategy (2015 to 2020) called “better every day” which set out clear strategic objectives including financial sustainability and the links to the Dorset Clinical Services Review (CSR). The trust was currently reviewing the strategy and engaging with all stakeholders including staff and the public. The trust established a transformation programme in November 2017 aligned with the delivery of the trust strategy. This programme implemented the strategy and reported delivery progress including any issues with projects to the trust board on a quarterly basis. The trust was fully engaged in the local strategy and had excellent relationships with partners and was working closely on how to improve pathways of patients across different providers, including the development of an integrated care system (ICS) involving five organisations and led by the trust. There also was a robust process for the development and monitoring of CIP, which included working closely within the developing ICS to develop joint plans where possible. The trust had a long term financial planning document which included a financial strategy and a detailed one-year financial plan which was aligned to its workforce and capacity/activity plans. Annual plans were aligned with the trusts strategy as well as the Dorset CSR, and system operational and financial plans. Finance staff were embedded in the trusts operational directorates to assist in the delivery of the financial strategy. Staff within the trust understood the current vision and values and had been involved in their creation. The values were clearly embedded in the services that we inspected, and staff were able

Page 4 to describe how they applied to their work. The trust strategy was in the process of being refreshed, the process of this involving the board of governors from the very inception who ensured good engagement with patients and the public in order to ensure a new clear vision and set of values with quality and sustainability as the top priorities. The current trust strategy was robust and realistic for achieving trust priorities. The trust used creative means to ensure staff and patients were also able to contribute to the development of the strategy. The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders. This included active involvement in sustainability and transformation plans. The trust had planned services to consider the needs of the local population. The leadership team regularly monitored and reviewed progress on delivering the strategy and local plans. The medicines optimisation strategy was part of the Dorset-wide medicines optimisation transformation group workplan. Pharmacy leaders across the county were working together on the following topics: • One acute network • Integrated Community and Primary Care Services • Prevention at scale • Leading and working differently • Digital Dorset • Urgent care New integrated community and primary care (ICPCS) roles for pharmacists and pharmacy technicians had been developed, with the aim to support people to take their medicines safely and effectively at home. Pharmacy staff understood this strategy and the priorities for medicines optimisation. Regular team meetings were held to answer any questions and concerns that developed in the new service. The medicines optimisations strategy was aligned to national recommendations, such as development of an interoperable county wide electronic prescribing and medicines administration system, use of non-medical prescribers and specialist pharmacists. Delivery of this plan was more advanced in community services than mental health.

Culture The trust had appointed a Freedom to Speak Up Guardian and provided them with sufficient resources and support to help staff to raise concerns. We saw examples of support and guidance provided by the guardian who demonstrated enthusiasm, integrity and energy for the role. Staff told us they felt safe to raise concerns and understood whistleblowing procedures. Previously it had been identified that there were pockets of bullying identified in some of the service areas, however the trust had identified this and were taking measures to tackle this difficult issue. There was a strong sense that the culture was just and the leadership was compassionate. Staff felt equality and diversity was promoted in their day to day work and when looking at opportunities for career progression. Staff networks were in place promoting the diversity of staff. Page 5

The following illustration shows how this provider compares with other similar providers on ten key themes from the 2018 NHS Staff Survey. Possible scores range from zero to ten – a higher score indicates a better result.

The four largest ethnic minorities within the trust’s catchment population were: White Other (40%), Asian/Asian British (21%), Mixed Multiple Ethnic Origins (18%), and Irish (11%). The Workforce Race Equality Standard (WRES) became compulsory for all NHS trusts in April 2015. Trusts must show progress against nine measures of equality in the workforce. 1. The percentages of White and BME staff in each of the Agenda for Change (AfC) pay bands 1 to 9, and at Very Senior Manager (VSM) level (including executive board members), compared with the percentage of staff in the overall workforce: In 2018, there were 5713 staff, 94.4% were white and there were 5.1% visible BME staff. Staffing included: 67.2% white clinical, 4.2% BME clinical, 28.1% white non-clinical, and 1.1% BME non-clinical. In 2017, there were 5792 staff, 94.4% were white and there were 5.0% visible BME staff. Staffing included: 68.2% white clinical, 4.1% BME clinical, 26.8% white non-clinical, and 0.9% BME non-clinical. 2. In 2018, White candidates were 1.75 times more likely than BME candidates to get jobs for which they had been shortlisted. This has increased from 1.69 times more likely in 2017. 3. In 2018, BME staff were 1.51 times more likely to be disciplined1 when compared with White staff. This has increased from 1.19 times more likely in 2017. 4. In 2018, White staff were 0.95 times less likely to take part in voluntary training than BME staff.

1 Workplace Race Equality Standard Page 6

5. The percentage of BME staff on the board was 7% compared with 11.5% BME staff in the overall workforce. The percentage difference between the board voting membership and overall workforce was -8.7% for white and 2% for visible BME. The trust had a WRES standard and equality and inclusion implementation scheme. A key part of the WRES came from the staff survey to make sure they had quality data. The trust produced an annual report on equality and diversity. Results of the staff survey such as experiences around the organisation treating staff with disabilities were a key focus. The trust identified that reporting around bullying harassment and discrimination could be improved. Generally, there was good reporting of serious incidents but there could be better lower reporting of incidents. Further priorities included promotion of LGBT, women’s rights and people from BME backgrounds to further their careers. Executives and the board were aware of quality issues and ensured that equality and inclusion fit in everywhere and that it remained relevant. The annual equality and diversity report fed into the trust board. The trust had a positive and active ongoing focus on equality and diversity. There was ongoing work with the transgender community in order to promote and circulate information and training materials to support service delivery. The trust also provided resources on the trust’s intranet around sexual orientation and transgender. There was also participation in the ‘Bourne Free’ event in 2018, which is Bournemouth’s LGBTQ Festival and for leadership training the trust used a film produced by Dorset LGBT Network. The trust plan to launch rainbow lanyards and pin badges in a campaign led by the communications team during the next Bourne Free festival in 2019 as part of the NHS Employers Rainbow campaign alongside Royal Bournemouth and Christchurch Hospitals NHS Foundation trust. The trust held regular LGBT staff network meetings and appointed an LGBT lead who has represented the trust at several national and regional conferences and the trust Equality and Diversity steering group meetings are attended by the LGBT lead. The trust reported that LGBTQ+ had the highest profile within the trust following disclosure levels among staff. It had been noted that disclosure categories are set nationally and do not currently allow for staff to record themselves as transgender. The trust plan to focusing on uncovering the high percentage of ‘undefined’ declarations and work alongside national data collection systems to ensure categories reflect diversity in the community. The Patient Friends and Family Test asks patients whether they would recommend the services they have used based on their experiences of care and treatment. The trust scored between 94.4% and 96.6% for patients recommending it as a place to receive care. This was higher than the England average for six of the six months in the period (August 2018-January 2019). The trust was lower than the England average in terms of the percentage of patients who would not recommend the trust as a place to receive care in six of the six months.

Trust wide responses England averages Total Total % that % that England England eligible responses would would not average average not recommend recommend recommend recommend August 674025 19654 95.7% 1.5% 90.0% 3.5% 2018

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Trust wide responses England averages Total Total % that % that England England eligible responses would would not average average not recommend recommend recommend recommend September 785324 18945 94.4% 2.0% 89.6% 3.8% 2018 October 689704 23368 94.9% 1.2% 90.1% 3.3% 2018 November 699532 21641 95.1% 1.1% 89.5% 3.6% 2018 December 646751 16842 94.7% 1.2% 88.8% 4.1% 2018 January 702972 21081 96.6% 1.2% 90.2% 3.4% 2019

The Staff Friends and Family Test asks staff members whether they would recommend the trust as a place to receive care and also as a place to work.

The percentage of staff that would recommend this trust as a place to work in Q2 18/19 stayed about the same when compared to the same time last year. The percentage of staff that would recommend this trust as a place to receive care in Q2 18/19 stayed about the same when compared to the same time last year. This provider has reported a vacancy rate for all staff of 4% as of 31 December 2018. This rate was not comparable to the last inspection. This provider reported an overall vacancy rate of 7% for registered nurses at 31 December 2018. The vacancy rate for registered nurses was not comparable to the last inspection. This provider reported an overall vacancy rate of -1% (over-establishment) for nursing assistants. The vacancy rate for nursing assistants was not comparable to the last inspection.

Registered nurses Health care assistants Overall staff figures

Vacancies Vacancies Vacancies

Establishment Establishment Establishment

Vacancy rate (%) rate Vacancy (%) rate Vacancy Core service (%) rate Vacancy

CHS - Community 38.0 154.9 25% 4.3 147.6 3% 46.1 326.3 14% Inpatients Page 8

Registered nurses Health care assistants Overall staff figures

Vacancies Vacancies Vacancies

Establishment Establishment Establishment

Vacancy rate (%) rate Vacancy (%) rate Vacancy Core service (%) rate Vacancy

Other - PMS service 0.0 2.0 0% N/A N/A N/A 0.5 3.6 14%

CHS - Urgent Care 0.3 31.6 1% 2.8 7.0 40% 6.0 51.3 12%

MH - Mental health crisis services and 7.1 42.9 17% 2.0 18.0 11% 8.1 65.6 12% health-based places of safety

CHS - Sexual 1.1 15.0 7% 0.0 2.0 0% 1.9 21.4 9% Health

MH - Specialist community mental health services for 2.3 32.0 7% 2.4 26.9 9% 11.0 176.9 6% children and young people

MH - Community mental health services for people 4.9 39.6 12% -1.1 9.9 -11% 4.4 94.8 5% with a learning disability or autism

CHS - Adults 30.8 462.2 7% -3.7 304.6 -1% 56.2 1235.2 5% Community

CHS - Children, Young People and 17.6 192.9 9% 1.1 53.7 2% 15.6 314.7 5% Families

MH - Community- based mental health 1.9 106.0 2% 2.9 35.9 8% 11.1 216.5 5% services for adults of working age

Other -1.7 24.4 -7% 3.4 93.4 4% 17.7 454.5 4%

MH - Community- based mental health 3.6 95.8 4% 3.5 48.4 7% 7.7 180.5 4% services for older people

MH - Other -0.7 54.3 -1% 1.3 28.3 4% 4.9 131.4 4% Specialist Services

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Registered nurses Health care assistants Overall staff figures

Vacancies Vacancies Vacancies

Establishment Establishment Establishment

Vacancy rate (%) rate Vacancy (%) rate Vacancy Core service (%) rate Vacancy

MH - Long stay/rehabilitation mental health wards 1.3 21.0 6% 0.4 31.1 1% 1.7 60.5 3% for working age adults

MH - Secure wards/Forensic -0.8 9.2 -9% 2.0 22.0 9% 1.2 33.7 3% inpatient

Other - ASC service 1.0 4.6 22% -4.7 38.4 -12% -2.3 46.6 -5%

MH - Wards for older people with -1.1 48.3 -2% -11.4 86.6 13% -10.4 144.0 -7% mental health problems

MH - Child and adolescent mental -0.9 10.2 -8% -2.8 14.6 -19% -3.1 30.8 -10% health wards

MH - Acute wards for adults of working -8.2 77.5 -11% -14.4 87.1 -17% -21.8 172.9 -13% age and psychiatric intensive care units

Trust total 96.4 1424.4 7% -12.0 1055.7 -1% 156.3 3761.0 4% NB: All figures displayed are whole-time equivalents

Between 1 January 2018 and 31 December 2018, of the (510921) total working hours available, 15% were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. The main reasons for bank and agency usage for the wards/teams were vacancies. In the same period, agency staff covered 6% of available hours for qualified nurses and 1% of available hours were unable to be filled by either bank or agency staff. Core service Total hours Bank Usage Agency Usage NOT filled by bank or available agency Hrs % Hrs % Hrs % MH - Wards for older people with mental 79800 9412 12% 3037 4% 619 1% health problems MH - Acute wards for 120228 11938 10% 7140 6% 880 1% adults of working age

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Core service Total hours Bank Usage Agency Usage NOT filled by bank or available agency Hrs % Hrs % Hrs % and psychiatric intensive care units MH - Secure wards/Forensic 14604 1873 13% 51 <1% 322 2% inpatient MH - Other Specialist 33900 3561 11% 653 2% 40 <1% Services MH - Long stay/rehabilitation 31896 7921 25% 516 2% 242 1% mental health wards for working age adults MH - Child and adolescent mental 13752 846 6% 38 <1% 271 2% health wards CHS - Community 216741 38886 18% 20986 10% 2373 1% Inpatients Trust Total 510921 74437 15% 32421 6% 4747 1%

Between 1 January 2018 and 31 December 2018, of the (727272) total working hours available, 27% were filled by bank staff to cover sickness, absence or vacancy for nursing assistants. The main reasons for bank and agency usage for the wards/teams were vacancies, long sickness, and level 2/3 observations. In the same period, agency staff covered 3% of available hours and 2% of available hours were unable to be filled by either bank or agency staff. Core service Total hours Bank Usage Agency Usage NOT filled by bank or available agency Hrs % Hrs % Hrs % MH - Wards for older people with mental 168432 38916 23% 5188 3% 1759 1% health problems MH - Acute wards for adults of working age 178332 62492 35% 8421 5% 5400 3% and psychiatric intensive care units MH - Secure wards/Forensic 38304 9866 26% 17 <1% 824 2% inpatient MH - Other Specialist 19644 9880 50% 1239 6% 88 <1% Services MH - Long stay/rehabilitation 50088 8643 17% 128 <1% 177 <1% mental health wards for working age adults MH - Child and adolescent mental 31212 9283 30% 470 2% 982 3% health wards

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Core service Total hours Bank Usage Agency Usage NOT filled by bank or available agency Hrs % Hrs % Hrs % CHS - Community 241260 55000 23% 9888 4% 7433 3% Inpatients Trust Total 727272 194080 27% 25351 3% 16663 2%

This provider had 364.5 (10%) staff leavers between 1 January 2018 and 31 December 2018. This turnover rate was not comparable to the last inspection.

Core service Substantive Substantive staff Average % staff staff (latest Leavers (over the past leavers (over the month) 12 months) past 12 months) Other - PMS service 3.1 0.6 22% MH - Child and adolescent mental 34.1 5.0 15% health wards MH - Community mental health services for people with a learning 90.4 11.8 13% disability or autism Other 448.9 52.0 12% CHS - Community Inpatients 277.4 37.6 12% MH - Mental health crisis services 57.6 7.0 12% and health-based places of safety MH - Community-based mental health services for adults of working 206.3 23.4 12% age CHS - Adults Community 1184.8 124.5 11% MH - Specialist community mental health services for children and 168.5 18.3 11% young people CHS - Children, Young People and 297.7 27.2 9% Families MH - Acute wards for adults of working age and psychiatric 195.5 18.2 9% intensive care units MH - Secure wards/Forensic 32.5 3.0 9% inpatient MH - Other Specialist Services 125.1 8.9 7% MH - Community-based mental 173.0 10.1 6% health services for older people MH - Wards for older people with 154.4 9.4 6% mental health problems CHS - Sexual Health 20.3 1.3 6% CHS - Urgent Care 45.9 2.1 5% MH - Long stay/rehabilitation mental 59.7 3.0 5% health wards for working age adults Other - ASC service 48.8 1.3 3% Trust Total 3623.9 364.5 10% Page 12

The sickness rate for this provider was 4.9% between 1 January 2018 and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 5.4%. This sickness rate was not comparable to the last inspection.

Core service Total % staff sickness Ave % permanent staff (at latest month) sickness (over the past year) MH - Mental health crisis services 6.8% 8.6% and health-based places of safety MH - Child and adolescent mental 2.9% 7.2% health wards MH - Wards for older people with 7.9% 7.0% mental health problems

MH - Other Specialist Services 9.3% 6.6%

Other - ASC service 6.5% 6.4%

CHS - Community Inpatients 7.0% 5.7%

CHS - Children, Young People 7.3% 5.2% and Families MH - Specialist community mental health services for 4.6% 5.1% children and young people MH - Community-based mental 3.5% 4.9% health services for older people

CHS - Adults Community 5.6% 4.8%

MH - Acute wards for adults of working age and psychiatric 4.9% 4.8% intensive care units MH - Community-based mental health services for adults of 4.7% 4.3% working age MH - Community mental health services for people with a 4.4% 4.2% learning disability or autism

Other 3.0% 3.6%

MH - Long stay/rehabilitation mental health wards for working 1.6% 3.6% age adults MH - Secure wards/Forensic 3.4% 3.3% inpatient

CHS - Urgent Care 4.0% 3.0%

Other - PMS service 3.1% 2.7%

CHS - Sexual Health 0.3% 1.6%

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Core service Total % staff sickness Ave % permanent staff (at latest month) sickness (over the past year) Trust Total 5.4% 4.9%

The compliance for mandatory and statutory training courses at 29 January 2019 was 91%. Of the training courses listed 12 failed to achieve the trust target and of those, two failed to score above 75%. The trust set a target of 95% for completion of mandatory and statutory training. The trust’s training completion data was based on a rolling basis depending on training repeat requirement. The training compliance reported for this provider during this inspection was not comparable to the previous year. Key:

Below CQC 75% Met trust target ✓ Not met trust target 

Training Module Number Number YTD Trust of eligible of staff Compliance Target staff trained (%) Met

Equality and Diversity 4896 4892 100% ✓ Moving and Handling Theory Level 1 3634 3627 100% ✓ Infection Control - No Repeat 378 378 100% ✓ Prevention and Management of Violence and 470 459 98% ✓ Aggression Paediatric Immediate Life Support 32 31 97% ✓ Information Governance 4895 4689 96% ✓ Safeguarding Adults Level 1 1430 1369 96% ✓ Safeguarding Children Level 1 1430 1367 96% ✓ Basic Life Support - Taught 929 891 96% ✓ Conflict Resolution 2807 2662 95% ✓ Infection Control - 3 Yearly 4127 3827 93%  Mental Capacity Act 2258 2101 93%  Safeguarding Adults Level 2 3469 3221 93%  Safeguarding Children Level 2 2058 1904 93%  Immediate Life Support 61 56 92%  Safeguarding Children Level 3 1411 1280 91%  Basic Life Support - eLearning 2275 2065 91%  Moving and Handling Practical Level 2/3 1298 1182 91%  Fire 4897 4385 90%  Enhanced Life Support 205 176 86%  Mental Health Act 679 373 55%  Medicines Management 1306 138 11%  Total 44945 41073 91% 

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The trust’s target rate for appraisal compliance was 95%. At the end of last year (1 April 2017 to 31 March 2018), the overall appraisal rate for non-medical staff was 95%. This year so far, the overall appraisal rate was 91% (as at 28 January 2019). Six of the 20 core service achieved the trust’s appraisal target this year so far. The services with the lowest compliance were ‘MH - Long stay/rehabilitation mental health wards for working age adults’ with 71%, ‘MH – Other Specialist Services’ with 83% and ‘MH – Secure wards/Forensic inpatient’ with 83%. The rate of appraisal compliance for non-medical staff reported during this inspection is not comparable to the last inspection.

Core Service Total number Total % % appraisals of permanent number of appraisals (previous non-medical permanent (as at 28 year 1 April staff requiring non-medical January 2017 – 31 an appraisal staff who 2019) March 2018) have had an appraisal Other - ASC service 41 41 100% 100% Other - PMS service 3 3 100% 100% CHS - Sexual health 39 39 100% 97% MH - Wards for older people with 127 125 98% 100% mental health problems CHS - Community Inpatients 260 253 97% 95% CHS - Urgent Care 45 43 96% 96% MH - Community-based mental health 174 164 94% 95% services for older people Provider wide 35 33 94% 94% MH - Community mental health services for people with a learning 84 78 93% 98% disability or autism MH - Mental health crisis services and 44 41 93% 98% health-based places of safety CHS - Adults Community 1125 1043 93% 94% CHS - Children, Young People and 324 297 92% 96% Families Other 1209 1088 90% 96% MH - Child and adolescent mental 31 28 90% 85% health wards MH - Community-based mental health 177 155 88% 94% services for adults of working age MH - Specialist community mental health services for children and young 129 112 87% 89% people MH - Acute wards for adults of working age and psychiatric intensive 143 118 83% 92% care units MH - Secure wards/Forensic inpatient 24 20 83% 91% MH - Other Specialist Services 134 111 83% 90% MH - Long stay/rehabilitation mental 49 35 71% 94% health wards for working age adults Total 4197 3827 91% 95%

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The trust’s target rate for appraisal compliance was 95%. At the end of last year (1 April 2017 to 31 March 2018), the overall appraisal rate for medical staff was 100%. This year so far, the overall appraisal rate was 100% (as at 28 January 2019). Five of the five core services (100%) achieved the trust’s appraisal target. The rate of appraisal compliance for medical staff reported during this inspection was not comparable to the last inspection.

Core Service Total Total % % number of number of appraisals appraisals permanent permanent (as at 28 (previous medical medical January year 1 April staff staff who 2019) 2017 – 31 requiring an have had an March appraisal appraisal 2018) CHS - Children, Young People and Families 11 11 100% 100% MH - Other Specialist Services 3 3 100% 100% Other 72 72 100% 100% CHS - Adults Community 1 1 100% 100% CHS - Sexual Health 4 4 100% 100% Total 91 91 100% 100%

The trust’s target of clinical supervision for non-medical staff is 95% of the sessions required. Between 1 April 2017 and 31 March 2018, the average rate across all 13 core services in this service was 79%. The rate of clinical supervision reported during this inspection was not comparable to the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide.

Core service Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%)

Provider wide 40 40 100% MH - Community mental health services for people with a learning disability or 105 96 91% autism MH - Community-based mental health 198 177 89% services for older people MH - Community-based mental health 232 197 85% services for adults of working age MH - Specialist community mental health 162 135 83% services for children and young people MH - Wards for older people with mental 86 69 80% health problems

Other 292 234 80%

MH - Other Specialist Services 153 111 73%

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Core service Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) MH - Acute wards for adults of working 139 96 69% age and psychiatric intensive care units MH - Mental health crisis services and 68 38 56% health-based places of safety MH - Long stay/rehabilitation mental 44 22 50% health wards for working age adults MH - Child and adolescent mental health 29 14 48% wards

MH - Secure wards/Forensic inpatient 20 7 35% Trust Total 1568 1236 79%

The trust did not provide clinical supervision data for medical staff in this service. Pharmacy staff had annual appraisals and regular one to one meetings. Pharmacy staff felt confident to raise concerns and report incidents and were supported in their roles and development. Learning from medicines incidents was shared across the trust. Patient’s medicines needs were identified at the point of discharge and those needing support at home were referred to the ICPCS team. Patients could be given medicines leaflets in different formats, for example large font or easy read.

Governance In April 2019, the trust was categorised as having 'maximum autonomy' by the NHS Improvement Single Oversight Framework. The trust had effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees, team meetings and senior managers. Leaders regularly reviewed these structures. There was not a separate finance committee as the executive team believed the matter was too important to delegate to a separate committee. Those detailed conversations were therefore held at board level. Papers for board meetings and other committees were of a good standard and discussion of issues raised from committees by the board was robust. Board meetings were held bi-monthly with board seminars held in the intervening months. The seminars enabled the management team to focus on specific issues including trust strategy, workforce, finance or board development. Board members understood their remit and could challenge each other appropriately. Executives and NEDS had clear portfolios that they were able to demonstrate a good level of oversight and understanding. Non-executive and executive directors were clear about their areas of responsibility and were very capable members of the board. The trust had identified a number of data quality issues and so there was an improvement programme in place. The trust was comfortable that data quality was of a standard to run the organisation safely despite there still being some issues around timely access to centrally stored data, such as supervision and appraisal rates. Excellent governance arrangements were in place in relation to Mental Health Act (MHA) administration and compliance. One of the NEDS had a legal background who was highly

Page 17 experienced and chaired the MHA monitoring group. Minutes demonstrated that they covered an appropriate range of subjects including monitoring of MHA review report findings. The trust ensured they were responsive in their approach to issues raised within these reports. There was clear, robust and effective multi-agency working arrangements around the MHA. A regular programme of MHA audits took place. Where MHA audits had identified gaps in knowledge the MHA lead provided targeted training and support. The trust was working with third party providers effectively to promote good patient care. The trust was part of the Dorset Medicines Optimisation Transformation Group. This group comprised leaders of pharmacy organisations across the county, with the aim to integrate services so patients were supported to receive safe and effective medicines in their own homes. Governance was provided via the medicines management group, chaired by the medical director. New medicines were evaluated at the medicines management group before a new drug application was taken to the area prescribing committee for approval. The trust had a medicines safety officer, who investigated and reported on all medicines incidents. Patient Group Directions (PGDs) due for renewal were assigned to a lead pharmacist and a service lead clinician for review before presentation at the medicines management group for approval. Service leads were responsible for ensuring staff had the required training to work under a PGD. The trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months. The trust took appropriate action following complaints. Complaints we reviewed were investigated fully and responses were respectful and detailed. Even if complaints were not upheld the trust apologised to the complainant that they had not felt they had received an appropriate level of care.

In Days Current Performance What is your internal target for responding to* complaints? 3 99% What is your target for completing a complaint? 21 79% If you have a slightly longer target for complex complaints please N/A N/A indicate what that is here

* Responding to defined as initial contact made, not necessarily resolving issue but more than a confirmation of receipt **Completing defined as closing the complaint, having been resolved or decided no further action can be taken

Total Date range

Number of complaints resolved without formal process*** in the 306 1 January 2018 – 31 last 12 months December 2018 Number of complaints referred to the ombudsmen (PHSO) in 0 1 January 2018 – 31 the last 12 months December 2018 **Without formal process defined as a complaint that has been resolved without a formal complaint being made. For example PALS resolved or via mediation/meetings/other actions

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This trust received 4077 compliments during the last 12 months from 1 January 2018 to 31 December 2018. This was not comparable to the last inspection. CHS – Adults Community had the highest number of compliments with 43%, followed by CHS – Community Inpatients with 12% and MH – Community-based mental health services for older people with 10%. Dorset Healthcare University NHS Foundation Trust has submitted details of two external reviews commenced or published in the last 12 months (1 January 2018 to 31 December 2018). NHS England had commissioned NICHE to carry out an independent review into a homicide which occurred in 2016. The review was underway and was yet to be published.

Management of risk, issues and performance Where cost improvements were taking place, there were arrangements to consider the impact on patient care. Managers monitored changes for potential impact on quality and sustainability. The Trust had delivered all their statutory financial duties for the last 2 years in line with national requirements and the trusts auditors did not flag any issues or concerns to NHS Improvement (NHSI) Last year the trust had approximately £7 million surplus to reinvest. In summary: • no changes had been required to the reported position post external audit in the last 5 years. • Internal audit had raised no significant concerns during 2017/18 or 2018/19. • Divisional managers were accountable for the delivery of services within budget but delegated the management of budgets to budget holders. Both groups were required to physically sign off their budgets prior to the start of the financial year. • The management accounting structure was aligned to the trusts divisional structure. • NHS Improvement had previously reviewed the trusts corporate reporting and governance arrangements and considered them to be of a high standard. • All financial reporting was completed from the financial ledger and regular reconciliations were completed between systems such as ESR and the financial ledger. • The business planning and budget setting process was clear and involved individual meetings with budget holders, divisional managers and directors before the Trust budgets were formally signed off by the senior management team, executive committee and finally at the trust board meeting. • All savings schemes had a quality impact assessment which must be signed off by the director of nursing, medical director, service manager and budget holder.

Financial forecasts were completed with the views of the budget holder, divisional manager and finance business partner. There was a clear message that forecasts were to be realistic and that there shouldn’t be any surprises. The director of finance met regularly with the audit committee chair outside of committee meetings. The relationship was very open, honest and supportive with NEDs often raising questions with the director of finance, deputy or wider finance team members directly. An agency report was produced each month and circulated to all budget holders. The nature of reporting to the audit committee, executive team and board was clear, with the trust reviewing and making improvements to its reporting in-year, as well as seeking feedback from

Page 19 users about how it can continue to improve. Committees and sub-committees had terms of reference which were regularly updated to ensure that their roles and responsibilities were clear. Finance partners were embedded within operation teams to ensure that they received the required financial management support and guidance. The relationship between the Trust and NHSI was good with the trust being open about the financial risks it was facing and how it intended to mitigate those risks. There was a clear risk management framework and an approved risk appetite statement. Separate risk registers were updated which fed into the corporate risk register. The finance risk register was discussed monthly at either the board meeting or seminar. Risks were reviewed by the risk management lead who also moderated the risk registers submitted by operational and corporate teams. The Board Assurance Framework (BAF) process and format had been reviewed by NHSI and was considered as being comprehensive and effective. There was a clear governance arrangement round it in that it was reviewed at board every quarter but the report went to the executive performance and risk group, audit committee and quality governance committee Each director took a lead on the risk areas to ensure the actions are completed. All high-level risk clearly identified. The trust identified staffing and workforce as the biggest risk, and were engaged in creative means of attracting the necessary workforce. There was also a need to invest in improved IT systems to be able to release clinical time and redesign pathways. The trust used a specialised IT programme which all staff had access to for the reporting and monitoring of risks and incidents. This system was available to all staff and enabled real time reporting. There was a high level of reporting using the risk management system. The trust had systems in place to identify learning from incidents, complaints and safeguarding alerts and make improvements. The governance team regularly reviewed the systems. Senior management committees and the board reviewed performance reports. Leaders regularly reviewed and improved the processes to manage current and future performance. Risk registers accurately reflected the risks that staff in local teams identified in their team meetings and that we observed on inspection. Staff had access to the risk register and could effectively escalate concerns as needed. Staff concerns matched those on the risk register. The Medicines Safety Officer (MSO) role was held by a senior pharmacist. Medicines alerts were received and actioned as appropriate with a summary of actions and learning fed back to the medicines management group and service leads. The trust also linked in with MSOs at the adjoining trusts to share information about medicines alerts. The Medicines Safety Officer was informed of every incident involving medicines and developed education and learning for local teams as well as trust wide newsletters and advice. The Chief Pharmacist was the Controlled Drug Accountable Officer and attended the local Controlled Drug Local Intelligence Network meetings. Pharmacy and medicines risks were recorded on divisional or corporate registers, with appropriate actions and response dates. For example, variance on medicines reconciliation rate, medicines training for staff, insulin errors. We found a number of errors within the core services which had not been picked up at local service level, and fed this back to the trust at the time of inspection. The trust assured us they were taking action on this immediately and we were also provided assurance that risks around medicines errors would significantly reduce with the introduction of electronic prescribing.

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However there remained a number of shared accommodation on one acute mental health ward and some of the older people’s mental health inpatient wards. Bedrooms and shared accommodation did have lockable storage facilities for clothing and possessions and the provider had taken action to mitigate the adverse effects of privacy or safety. Capital funding had been secured with a plan in place to remove all shared accommodation. Planning permission was required for many the changes. We saw during our core service visit that the gardens in Herm and St Brelades wards were not dementia friendly and unsafe in some areas, however this had been addressed quickly and funding was now available to improve these areas further.

Historical data Projections Financial Metrics Previous financial Last financial This financial Next financial year (2 years ago) year (1 April 2017 year (1 April 2018 year (1 April 2019 (1 April 2016 to 31 to 31 March to 31 March to 31 March March 2017) 2018) 2019) 2020) Actual income £261m £247m £261m £260m Actual surplus (£1.3m) £6.0m £3.7m £(2.1m) (deficit) Actual costs/expenditure - £262m £241m £257m £262m full Planned budget or (£4.1m) £(1.6m) £3.5m £(2.1m) (deficit)

The trust has submitted details of six serious case reviews commenced or published in the last 12 months. Team/ Reference Outstanding Ward/ Recommendations Actions Taken Number Actions Unit S25 Health Robust handover if mother Robust handover completed Communication Visiting and unborn move country Disguised Compliance of Emergency , Voice of the child information uploaded onto the Department (ED) CAMH important in establishing intranet for staff reports from S how injuries have occurred Health visitor antenatal acute trusts CMHT, Agencies need to be alert assessment: Male in the home under review with LAC to risk of making template included on System intention of being Team assumptions about One. Compliance included in able to send judgements of others health visiting service record electronically. Need for professional keeping audit Include curiosity re males in Corporate caseload issues. Line Professional household manager has put in place clear challenge in Should be lead worker if line of accountability and all staff Safeguarding more than one worker in made aware of their training same agency is involved responsibilities packages. Began development in August 2018

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Team/ Reference Outstanding Ward/ Recommendations Actions Taken Number Actions Unit Child R CAMH All practitioners should be Information re this shared with Work re suicide S, aware of responsibilities re CAMHS teams on CAMHS prevention School LSCBs Hard to Engage MDM meeting agenda and pathway led by Nursing Policy to include that every Business as Usual Meetings. LSCB - full , LAC Practitioner is aware of Information sent out to HV & SN participation by Nursing their ability to call a Teams and through Children Dorset meeting to discuss non- and Families DMG and Think HealthCare. engagement with peer Family Safeguarding Group professionals Attachment Workshop Joint Ensure that multiagency learning event for LAC Team practitioners understand and HVs. Well attended in the impact of attachment January and February 2018 disorders upon children Workshop attended by Named and families. Nurse, CAMHS Lead and Adolescent Risk and Named Doctor for organisation. Suicide prevention. Research disseminated across DCH Children’s Services. LSCB Pan Dorset approach

S26 Health Learning Synopsis Strengthening of record keeping Ongoing Visiting Pending within health visiting and school workplan re Review training offer to nursing. Clinical Audit Group dissemination of ensure sufficient focus on designing new assessment PPNs within new Parental alcohol use, form. Record keeping audit health visiting misuse and functioning updated re ongoing assessment transformation alcoholics, impact upon and updating of action plans. and to school parenting capacity, and Final report disseminated nursing teams. children’s welfare and how throughout the Trust in August Use of SystmOne to manage difficult 2018. preferred conversations. Mandatory training reviewed dependent on Seek reassurance that and action focus delivered in all safeguarding information sharing programmes delivered by having SystmOne protocols between Safeguarding Children Team. module built. Midwifery and Primary Meeting with Midwifery Leads to Work Care are robust and that develop a working agreement commenced Jan information of relevance to with MASH between services 2019 safeguarding is shared Escalation guidance to be produced for staff. Draft completed Oct 18 but escalation policy under review following JTAI. Joint safeguarding escalation guidance to be developed once escalation policy revised by LSCB

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Team/ Reference Outstanding Ward/ Recommendations Actions Taken Number Actions Unit BDH9, Health Level 1 and 2 training for March 2018 Level 2 training B&P Visiting health visitors on engaging updated with current NICE potential perpetrators of guidelines. However, some domestic abuse to be challenge sent back regarding reviewed this recommendation as not DHC guidance for entirely in line with NICE Information Sharing from guidance which advocates for Police to Health where professional judgement around there is Domestic Violence addressing domestic abuse with & there are children in the perpetrators. family to be revised to Policy revised March 2018, incorporate health visitor analysis of risk and action recording of planning documentation • analysis of risk, requirement incorporated. Links • proposed professional with S25 record keeping intervention and outcome recommendation - record following receipt of each keeping templates and audit Public Protection activity now includes clearly Notification (PPN). recording action plan / Preceptorship programme timeframes / outcomes Training post qualification March 2018 disguised for Health Visitors on compliance information Disguised Compliance to disseminated and available on include the learning from the intranet. Disguised Serious Case Reviews on compliance already in this presentation preceptorship training Health Visitors who work programme but has been directly with children and refreshed. families, to undertake Domestic abuse is listed on the specific update training on mandatory training for HVs in Domestic Abuse risk their annual training schedule assessment and (one day). professional practice development, every 3 years as a mandatory requirement. S31 LAC, Published report pending. Awaiting published report School Synopsis of Learning Nursing pending. , CAMH S

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Team/ Reference Outstanding Ward/ Recommendations Actions Taken Number Actions Unit Child O CAMH The Practice Learning Synopsis of learning S, Points of the Review need disseminated to DHC services. School to be shared widely for Synopsis of learning placed on Nursing agencies and individuals intranet with summary for staff & to consider how they could link to full document. Case write influence day to day up placed in Quality Matters practice. staff bulletin. Remind staff in all partner Safeguarding leads have agencies of the attended Mental Health importance of listening to management meetings & and taking appropriate Consultant forums to present action when concerns are Child O learning. CMHT teams raised by family members. advised to address family Further promotion of Think concerns by patient Family messages and how assessment/ re assessment. this translates into practice Practitioners reminded to ensure is needed across services. that all family member concerns Awareness of the risks are shared with Children’s associated with cannabis Social Care. use needs to be promoted Children included on AMH with practitioners to templates including meetings ensure this is included in and supervision templates to assessments where remind practitioners to Think cannabis use is known or Family. Verification that all AMH discovered. practitioners, including Crisis support have completed level 3 mandatory training. Safeguarding children practice guidance for Adult Mental Health Services published & disseminated to the Mental Health Managers meeting and to teams via individual CMHT safeguarding links. Mandatory level 2 training for adults & children reintegrated. Child behaviours in children experiencing emotional abuse practice guidance document developed and circulated to mental health manager's meeting. Phase 1 of the dual diagnosis training has been rolled out. A total of 114 attendees have had the training. Phase 2 are planned to be delivered from January 19. Feedback has been overwhelmingly positive. Joint working practices between DHC and AWP as part of new service provision are now in place.

We analysed data about safety incidents from three sources: incidents reported by the trust to the National Reporting and Learning System (NRLS) and to the Strategic Executive Information

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System (STEIS) and serious incidents reported by staff to the trust’s own incident reporting system. These three sources are not directly comparable because they use different definitions of severity and type and not all incidents are reported to all sources. For example, the NRLS does not collect information about staff incidents, health and safety incidents or security incidents. Between 1 January 2018 and 31 December 2018, the trust reported 115 serious incidents. The most common type of incident was ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’ with 52. Twenty-eight of the apparent/actual/suspected self-inflicted harm incidents occurred in MH – Community-based mental health services for adults of working age.

We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was not comparable with STEIS with 101 reported. There were an additional 14 incidents reported to SIRI than reported to STEIS, this included six incidences of ‘Apparent/actual/suspected self-inflicted harm’ and eight incidences of ‘Pressure ulcer.’ Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systematic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. The trust reported zero never events during this reporting period.

The number of serious incidents reported during this inspection was not comparable to the last

inspection.

units

r people with mental mental with people r

based mental health health mental based health mental based

- -

Total

Other

Adults Community Adults

Community Inpatients Community

–

health problems health

–

Other Specialist Services Specialist Other

based places of safety of places based

–

services for older people older for services

CHS CHS

Community Community

CHS CHS

Wards for olde for Wards

Children, Young People and Families and People Young Children,

– –

MH MH

Acute wards for adults of working age age working of adults for wards Acute

–

–

services for adults of working age working of adults for services health and services crisis health Mental

and psychiatric intensive care intensive psychiatric and

–

–

MH MH MH

MH MH

MH MH CHS CHS

Type of incident reported MH Apparent/actual/suspected self- 1 1 4 28 6 2 3 1 6 52 inflicted harm meeting SI criteria Pressure ulcer meeting SI criteria 24 5 29 Slips/trips/falls meeting SI criteria 12 2 5 19 Disruptive/ aggressive/ violent 2 3 5 behaviour meeting SI criteria Treatment delay meeting SI criteria 2 2 Pending review (a category must be 2 2 selected before incident is closed) Confidential information 1 leak/information governance breach 1 meeting SI criteria

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units

r people with mental mental with people r

based mental health health mental based health mental based

- -

Total

Other

Adults Community Adults

Community Inpatients Community

–

health problems health

–

Other Specialist Services Specialist Other

based places of safety of places based

–

services for older people older for services

CHS CHS

Community Community

CHS CHS

Wards for olde for Wards

Children, Young People and Families and People Young Children,

– –

MH MH

Acute wards for adults of working age age working of adults for wards Acute

–

–

services for adults of working age working of adults for services health and services crisis health Mental

and psychiatric intensive care intensive psychiatric and

–

–

MH MH MH

MH MH

MH MH CHS CHS

Type of incident reported MH Sub-optimal care of the deteriorating 1 1 patient meeting SI criteria HCAI/Infection control incident 1 1 meeting SI criteria VTE meeting SI criteria 1 1 Failure to obtain appropriate bed for 1 1 child who needed it Accident e.g. collision/scald (not 1 1 slip/trip/fall) meeting SI criteria Total 28 2 19 10 31 6 2 3 8 6 115

Trusts flagging for risk in the number of suicides of patients detained under the Mental Health Act (all ages) (exception reporting only) (Remove before publication) Between October 2017 and September 2018, the trust notified CQC of the suicide of one patient detained under the Mental Health Act. Providers are encouraged to report patient safety incidents to the National Reporting and Learning System (NRLS) at least once a month. The average time taken for the trust to report incidents to NRLS was 20 days between 1 January 2017 and 31 December 2018. The highest reporting categories of incidents reported to the NRLS for this trust for the period 1 January 2017 and 31 December 2018 were ‘implementation of care and ongoing monitoring/review’, ‘self-harming behaviour’, and ‘patient accident.’ These three categories accounted for 4338 of the 7331 incidents reported. ‘Other’ accounted for 71 of the 79 deaths reported. Eighty-eight percent of the total incidents reported were classed as no harm (50%) or low harm (39%).

Incident type No harm Low harm Moderate Severe Death Total

Implementation of care and 46 953 685 1684 ongoing monitoring / review Self-harming behaviour 648 704 19 2 1373 Patient accident 790 470 18 1 2 1281

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Incident type No harm Low harm Moderate Severe Death Total

Disruptive, aggressive behaviour (includes patient- 581 122 1 704 to-patient) Access, admission, transfer, discharge (including missing 421 234 19 5 679 patient) Medication 486 66 1 553 Other 186 107 6 2 71 372 Treatment, procedure 224 76 13 313 Consent, communication, 91 11 2 1 105 confidentiality Infrastructure (including staffing, facilities, 64 11 1 76 environment) Infection Control Incident 23 43 6 1 73 Medical device / equipment 35 10 45 Patient abuse (by staff / third 32 11 1 44 party) Clinical assessment (including diagnosis, scans, 12 7 3 22 tests, assessments) Documentation (including electronic & paper records, 6 1 7 identification and drug charts) Total 3645 2826 775 6 79 7331

Organisations that report more incidents usually have a better and more effective safety culture than trusts that report fewer incidents. A trust performing well would report a greater number of incidents over time but fewer of them would be higher severity incidents (those involving moderate or severe harm or death). Dorset Healthcare University NHS Foundation Trust reported more incidents from 1 January 2018 to 31 December 2018 compared with the previous 12 months. There were a higher number of incidents resulting in moderate harm and death. Learning from incidents was well managed with good process for review and escalation to inform decision making. Duty of candour was applied appropriately.

1 January 2018 – 31 December 2018 Level of harm 1 January 2017 – 31 December 2017 (most recent) No harm 3136 3645 Low 2480 2826 Moderate 738 775 Severe 10 6 Death 27 79 Total incidents 6391 7331

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The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there have been two ‘prevention of future death’ reports sent to Dorset Healthcare University NHS Foundation Trust. Details of which can be found below. MH – Mental health crisis services and health-based places of safety. Date of report: 19 April 2018 A person died because of a combination of multiple drugs (Codeine, Zopiclone, Amitriptyline and Mirtazapine) and ethanol intake. The Coroner’s concerns were: • The person suffered with their mental health and had been engaging with Dorset Healthcare University NHS Foundation Trust (DHC) since 2009. On the 25th August 2017 the person was admitted to Royal Bournemouth Hospital having taken an overdose of medication. The person was assessed by the Psychiatric Liaison Team who are part of DHC and was discharged to the Crisis team within DHC. • The person was seen daily by the Crisis team and during the visits they decided to change the medication regime so that the administration of this was supervised by the Crisis team staff. This decision was made in relation to the medication for their mental health. The person was however also prescribed medication for physical health. On the 3rd September the person sadly died from an overdose of the prescribed medication. • Evidence was given that although the GP is written to when there is a change in regime regarding the mental health medication, there is no action taken in relation to the physical health medication. This may be a matter for the GP to resolve but if a patient’s access to medication is to be immediately changed by DHC employees, this should be addressed in relation to all medication not just mental health medication. • I heard evidence from the Psychiatric Liaison Team Lead and the Crisis Team Lead that there does not appear to be a policy in place at the Trust to deal with the communication of the supervision of physical health medication. If there is such a policy, they advised me that they are not aware of it. The following learning / recommendations were given: • Once the access to medication has been identified as a risk to a patient and there is a need for the taking of it to be supervised, access to, and the taking of, all medication, not just mental health medication should be supervised. • There are concerns that there is no policy in place in relation to the supervision of prescribed physical health medication when a decision has been made to supervise the administration of prescribed mental health medication. I would therefore request that DHC review their policies regarding the supervision of all medication a patient is prescribed and when and how to alert GP, or other treating practitioners, regarding changes to medication regimes and supervision. • If there is already such a policy in place to deal with both physical health and mental health medication, then I would request that refresher training is undertaken to ensure all staff are made aware of the policy and the procedures to be adapted in such circumstances. MH – Specialist community mental health services for children and young people. Date of report: 13th December 2017

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A person died because of hanging at home. The coroner’s concerns were: • In relation to the transfer from Pebble Lodge to Riverside, it appears that a Form 1 was submitted to Riverside on 15th June but that the referral was closed on 6th July. There appeared to be confusion by some as to whether this was being followed up. • The community care plan that was in place from 14th July had no dates for tasks to be completed or for meetings to take place, by way of example at the time of death a medical review appointment was still not in the diary. • Different people described risks in different ways, terminology such as low, medium, or high were used to describe risk but others used significant or low and even on the date of discharge risks were described in different ways. • Part of the care plan was for there to be communication by text; up until the time of death there was only one text sent which was effectively confirming an appointment for after the person’s death simply stating, ‘how are you.’ I was told that there is no current training or guidance given to staff. • This case highlighted some of the difficulties in transferring children to an in-patient unit out of the area and then arranging to transfer them back to the area. The following learning/recommendations were given: • In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure. As well as clarifying this process with all providers concerned consideration should be given that a clear documented process is put in place for in-patient transfers so that all those involved understand clearly the situation and the decision made in relation to the patient. • Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so again expectations are managed and everyone knows exactly what the plan is and when actions will occur. • That the issue of inconsistent terminology when assessing risk is reviewed to ensure a consistent approach. In this case there were a number of different phrases and gradings used to determine the deceased’s risk. • That consideration should be given to training and/or guidance issued for staff communicating with young persons by text or by any means of social media. • Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in-patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient out of area. Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team. The trust provided assurance around the regulation 28 recommendations and identified learning taken from them.

Information management

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The board received holistic information on service quality and sustainability. Leaders used meeting agendas to address quality and sustainability sufficiently at all levels across the trust. Staff said they had access to all necessary information and were encouraged to challenge its reliability. Team managers had access to a range of information to support them with their management role. This included information on the performance of the service, staffing and patient care. Staff had access to the IT equipment and systems needed to do their work, however the trust had difficulties accessing data quickly, extraction of data being difficult. There was an intelligent working programme to pull data sets together into a single data warehouse for the Integrated Care Service which would allow better access to greater data sets in as close to real time as possible. The trust was also in the process of rolling out a programme of electronic prescribing, which although would be initially disruptive, would fundamentally improve how medication was managed overall. There had been no data security breaches. Password were changed every 90 days. The trust was investigating single sign-on opportunities and complex non-expiring passwords which lived for 365 days. The financial information received by the Board included a balance of board and divisional level detail and covered both actual performance and future-looking projections. Monthly financial forecasts were produced and included in board reporting information from month 3 onwards. The trust was particularly proud of the work undertaken by its costing team which sat within finance. Service Line Reporting had been in use for some time and was regularly used when considering investments and potential savings schemes. The trust was also at the forefront of a programme to develop Patient Level Costing Information for Community and Mental Health providers. The trust was currently building a system which would triangulate regular quality and operational performance information with expenditure to help to review whether there were links between increased expenditure and patient outcomes. There was a programme of internal clinical audit to monitor medicines optimisation processes and medicines. The chief pharmacist reported controlled drug (CD) incidents to the CD local intelligence network and submitted quarterly occurrence reports.

Engagement Communication systems such as the intranet and newsletters were in place to ensure staff, patients and carers had access to up to date information about the work of the trust and the services they used. Patients, carers and staff had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The trust consistently scored higher than the national average in the community mental health survey in all categories: • In the September 2017-November 2017 Community Mental Health Survey, the trust scored 8.3 out of 10 for patients having been told who was in charge of organising their care and services, which was better than the average range of 6.4 to 8.3 out of 10. • In September 2017-November 2017 Community Mental Health Survey, the trust scored 8.8 out of 10 for patients feeling they were treated with respect and dignity by NHS mental health services, which was better than the average range of 7.9 to 8.6 out of 10.

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• In September 2017-November 2017 Community Mental Health Survey, the trust scored 8.5 out of 10 for patients knowing who to contact out of office hours if they have a crisis, which was much better than the average range of 6.1 to 8.0 out of 10. • In September 2017-November 2017 Community Mental Health Survey, the trust scored 7.6 out of 10 for patients having been involved as much as they wanted to be in decisions about which medicines they receive, which was better than the average range of 6.5 to 7.5 out of 10. • In September 2017-November 2017 Community Mental Health Survey, the trust scored 7.4 out of 10 for patients having had a member of their family or someone else close to them involved as much as they would have liked, which was better than the average range of 6.2 to 7.3 out of 10. The trust had a structured and systematic approach to staff engagement and staff were involved in decision making about changes to the trust services. The trust was actively engaged in collaborative work with external partners, such as involvement with sustainability and transformation plans (STP’s). External stakeholders said they received open and transparent feedback on performance from the trust. The STP had a number of joint working groups, and Dorset Healthcare were engaged in working on driving system-wide efficiency and utilising productivity opportunities. The Trust shared significant amounts of financial, cost improvement, activity and demand and capacity information with its partner organisations utilising a portal tool which all parties in the STP had access to. The Dorset ICS engagement group was a regular meeting that was established by Dorset Healthcare. Service managers were encouraged to reach out to their colleagues from other organisations to share best practice and learn from mistakes. The council of governors was strong and they were seen as being both ambassadors for the trust as well as critical friends to the senior trust leadership team. All parts of the trust board meetings were open to the public and 10+ governors plus members of the public were routinely in attendance. Patient feedback cases were discussed at the board meetings and these involved patients and members of the public speaking at the board. The trust had held stakeholder engagement meetings recently in a number of the localities in the county. The CEO or members of the executive team had led those meetings. The trust held a Mental health forum which had individuals from police, fire, councils and church groups in attendance. Multi-disciplinary pharmacy teams were embedded into some ward teams. This supported timely supply of medicines, input into prescribing decisions and provision of medicines information to patients. Integrated community and primary care pharmacists and pharmacy technicians were aligned with community teams and provided support to people in their own homes. Patients could be referred by their GP or identified at discharge from hospital for more support. Information about mental health medicines and conditions was available in a variety of languages and formats, including easy read.

Learning, continuous improvement and innovation

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NHS trusts can take part in accreditation schemes that recognise services’ compliance with standards of best practice. Accreditation usually lasts for a fixed time, after which the service must be reviewed. The trust did not report any trust-wide accreditations; however, a number of accreditations were achieved specific to core services. The trust actively participated in national improvement and innovation projects. Quality improvement was embedded and integral to day to day working. Staff were encouraged to make suggestions for improvement and gave examples of ideas which had been implemented. There were excellent organisational systems to support improvement and innovation work and staff had training in improvement methodologies. There were clear principles around putting people first, open, transparent and accountable. External organisations had recognised the trust’s improvement work. Individual staff and teams received awards for improvements made and shared learning. There were excellent examples of innovative practices and continuous improvement initiatives. Dorset Healthcare’s criminal justice liaison service which, in conjunction with Dorset police and other relevant partners worked towards reducing the number of people in crisis who were detained in police custody. This initiative provided a holistic age appropriate response seven days a week. This service was set up in 2014 with street triage and won the Health Service Journal Patient Safety Award in July 2018. A YMCA homeless project was set up to provide semi-supportive accommodation for homeless patients with mental health issues. There was a veterans and families support service to reduce health inequalities for veterans by improving access to services and individual care and treatment. One member of staff was awarded the MBE around their work with military personnel. This included the development of local care pathways tailored to address the mental health issues of veterans and setting up of a hub group, bringing together charities and organisations to provide targeted help for serving and ex-service military personnel. There was a dedicated quality improvement (QI) team which was having a very positive impact in its early stages. The project was staff led and involved ideas for improvement using tools, evidence and techniques. The quality improvement initiatives were aligned to trust strategic objectives. QI workshops had been held to establish what could be removed from the system that didn’t add value. Training in QI was delivered into the trust induction to embed into the culture. Staff were very enthusiastic and wanted to be involved. There was a peer specialist embedded in the QI team. Some examples of QI were: • Smoking cessation was a challenging subject so they engaged the patients to discuss why it was so problematic. • ‘Deal with heels’. The tissue viability nurse did a piece of work around heel pressure. • Named nurse model which involved self-directed nursing to reduce inconsistencies. • Collaborative Learning in Practice (Clip) model. Coaching based approach to supporting student nurses in clinical areas. • Physical health clinic set up by occupational therapists in the community mental health teams. • National collaborative around observations in mental health services

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• The Weymouth community nursing team was part of the pressure ulcer improvement collaborative with NHS Improvement. • ‘Dragon’s den’ staff innovation competition. This was an innovation competition where staff presented their proposal for investment in a dragon’s den style event. The trust was actively considering the challenges around climate change, and discussed this in the trust board meetings. The estates team were considering the sustainability impact on their buildings and looking how to improve this, the trust aiming to achieve zero carbon emissions by 2015. Also, there was consideration of the use of electric cars and current use of electric bicycles within the integrated care service and community services. The trust had been awarded Disability Confident employer status and plan to apply to the next stage which was ‘Leader’. Herm and St Brelades wards were the first older adult’s mental health unit in the country to receive the Gold Standard Framework (GSF). All community hospitals in the trust were GSF accredited. The trust had set up ‘The Retreat’ drop in centre which was an out of hours service to help support avoidance of admission to accident and emergency or use of the health-based place of safety, thereby relieving pressure in these services and providing timely holistic support. The chief pharmacist and MSO attend and feedback from regular regional and national meetings on issues relating to medicines optimisation. This information was used to review the organisations own medicines processes. Learning and improved processes from medicines incidents were circulated throughout the trust via bulletins, newsletters and face to face training.

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Community health services

Community health services for adults

Facts and data about this service

Dorset Healthcare University NHS Foundation Trust is the healthcare provider for community health services for adults in the county of Dorset and surrounding areas, serving a population of over 750,000 people and employing around 5,000 staff. The trust provides healthcare services including: district/community nurses, community matrons, specialist nurses, rapid response and intermediate care services, rehabilitations services, health visitors, school nursing, end of life care, sexual health promotion, diabetes and dietetic education, audiology, speech and language therapy, dermatology, podiatry, orthopedic services, wheelchair services, anti-coagulation services, pulmonary rehabilitation, early discharge stroke services, Parkinson’s care and community oncology. These services are provided in hospital, local communities and in people’s own homes. In September 2018, the trust launched the single point of access system. This was one telephone number for health and social care professionals, including GPs, to refer into the community services. It provides clinical conversations at the point of making a referral to agree the course of action focused on the patient’s need. The county of Dorset is divided into geographical localities, North, East and West. Within these localities, services are provided with a multidisciplinary approach using a hubs system. Each locality could have several hubs. The hubs were at different stages of development, with Poole hub the most established. They triaged all community services and were developing standardised processes to ensure consistent integrated care. The trust has 11 hubs spread across the county consisting of integrated health and social care teams (services working together to ensure people can plan their care to achieve the outcomes that are important to them). The social care teams are managed by the relevant local authority but work in partnership with health. A list of specialist community health services for adults provided by Dorset Healthcare University NHS Foundation Trust is shown below:

Location / Team/ward/s Services provided Address (if site name atellite name applicable) 30 Maiden Castle 30 Maiden Comm Brain Providing care, therapy and advice to patients with an Road, Castle Road Injury Service acquired brain injury Dorchester, DT1 2ER. Therapy team incorporating the following groups: Alderney Hospital Balance, Strength and Exercise Group Falls Clinic Ringwood Road, Alderney Alderney Upper Limb Group Parkstone, Hospital Therapy Higher Level Stroke Group Poole, Dorset, BH12 Lower level stroke Group 4NB Therapy only falls clinic Blandford Blandford Blandford Community Community Hospital A service that provides a range of outpatient services Hospital, Milldown Road, Blandford Hospital Outpatients Forum, Dorset Blandford Blandford Blandford Community A service that provides Physiotherapy Services including Community Hospital Hospital, Milldown Hydrotherapy Pool Road, Blandford Hospital Physiotherapy Forum, Dorset Page 34

Blandford Blandford Blandford Community A service that provides day Surgery, Minor Operations Community Hospital Hospital, Milldown and Procedures Road, Blandford Hospital Theatres Forum, Dorset Blandford Community Blandford Community Provide specialist care to patients with a diagnosis of Community Parkinson's Hospital, Milldown Parkinson's Disease Road, Blandford Hospital Nurse Forum, Dorset Provides assessment, support and treatment for people Blandford Dorset MSK - with musculoskeletal disorders. Specialist orthopaedics Blandford Community Community Orthopaedic staff work from clinics across Dorset, and offer a range Hospital, Milldown Road, Blandford Hospital Service of treatments, including injections, epidurals, hand and Forum, Dorset wrist splints, acupuncture and physiotherapy. Provides rehabilitation support at home and in hospital to help people recover. Our physiotherapists, Blandford occupational therapists and rehab assistants offer Blandford Community ICRT- Community assessment, care and therapy for patients across Hospital, Milldown Blandford Road, Blandford Hospital Dorset. This support means that some people can avoid Forum, Dorset a stay in hospital, while others can be safely discharged from hospital as soon as possible. Provide the diagnosis, treatment, fitting, maintaining and repairing of orthoses for children and adults in line with Blandford Orthotics Blandford Community the agreed access criteria. Provide appropriate orthotics, Community (Musculoskele Hospital, Milldown this includes but not restrictive to elastic/fabric, custom Road, Blandford Hospital tal) made splints, footwear and insoles to facilitate the Forum, Dorset treatment and rehabilitation of the patient Provides support for people living with persistent pain, Pain Service - helping them to lead as fulfilling and independent lives Blandford Dorset Blandford Community as possible. The service deals with all forms of chronic Community Community Hospital, Milldown pain, including musculoskeletal (muscles, bones and Road, Blandford Hospital Pain Service joints), neurological (nervous system), internal organs Forum, Dorset (DCPS) and unexplained pain. Bridport Community Bridport Bridport Hospital, Community Hospital A service that provides a range of outpatient services Hospital Lane, Hospital Outpatients Bridport DT6 5DR Bridport Community Bridport Bridport A service that provides Minor Operations, General Hospital, Community Hospital Hospital Lane, Surgery, Day Surgery (endoscopy) Hospital Theatres Bridport DT6 5DR Provides assessment, support and treatment for people Bridport Community Bridport Dorset MSK - with musculoskeletal disorders. Specialist orthopaedics Hospital, Community Orthopaedic staff work from clinics across Dorset, and offer a range Hospital Lane, Hospital Service of treatments, including injections, epidurals, hand and Bridport wrist splints, acupuncture and physiotherapy. DT6 5DR Provide the diagnosis, treatment, fitting, maintaining and repairing of orthoses for children and adults in line with Bridport Community Bridport Orthotics the agreed access criteria. Provide appropriate orthotics, Hospital, Community (Musculoskele Hospital Lane, this includes but not restrictive to elastic/fabric, custom Hospital tal) Bridport made splints, footwear and insoles to facilitate the DT6 5DR treatment and rehabilitation of the patient Diabetes Forston Clinic, Forston Provides support for people across Dorset living with (Nurse Charminster. Dorset. Clinic Diabetes by helping to control and manage their Specialist) DT2 9TB condition on a day to day basis.

Community & Provides specialist dietary advice and support for people Pelhams Specialist with a wide range of illnesses and conditions. Dietitians Pelhams Clinic, Kinson Community Clinic Dietetic can offer help to address: Centre, Millhams Service •malnutrition Page 35

•food allergy and intolerance Road, Bournemouth, •irritable bowel syndrome Dorset •diabetes •obesity •nutritional deficiencies •enteral nutrition (feeding through tubes). Provide assessment, management and treatment for adults and children with skin conditions treating conditions such as Pelhams Clinic, •acne Pelhams Kinson Community Dermatology •eczema Centre, Millhams Clinic •psoriasis Road, Bournemouth, •nail and scalp disorders Dorset •rashes •inflammatory disorders. Pelhams Clinic, Pelhams Kinson Community Vasectomy Undertake vasectomies Centre, Millhams Clinic Road, Bournemouth, Dorset Poole Poole Community Community Comm Brain Providing care, therapy and advice to patients with an Clinic Health Injury Service acquired brain injury Shaftesbury Road Clinic BH15 2NT Provides support for people living with persistent pain, Pain Service - Poole helping them to lead as fulfilling and independent lives Dorset Poole Community Community as possible. The service deals with all forms of chronic Community Clinic Health pain, including musculoskeletal (muscles, bones and Shaftesbury Road Pain Service Clinic joints), neurological (nervous system), internal organs BH15 2NT (DCPS) and unexplained pain. Portland Hospital Portland Portland Castle Road, A service that provides Physiotherapy Services Hospital Physiotherapy Castletown, Portland, Dorset Provides assessment, support and treatment for people Dorset MSK - with musculoskeletal disorders. Specialist orthopaedics Portland Hospital Portland Orthopaedic staff work from clinics across Dorset, and offer a range Castle Road, Hospital Castletown, Portland, Service of treatments, including injections, epidurals, hand and Dorset wrist splints, acupuncture and physiotherapy. Provide the diagnosis, treatment, fitting, maintaining and repairing of orthoses for children and adults in line with Orthotics Portland Hospital Portland the agreed access criteria. Provide appropriate orthotics, (Musculoskele Castle Road, Hospital this includes but not restrictive to elastic/fabric, custom Castletown, Portland, tal) made splints, footwear and insoles to facilitate the Dorset treatment and rehabilitation of the patient Sentinel Anticoagulatio Provides a community anticoagulation services at multiple venues and see around eight patients each hour 13 locations House n Service per clinic. Monitoring INR. Provides services for adults and children who are Audiology Poole NHS Healthcare affected by hearing loss, distressing tinnitus and balance Sentinel (including walk Centre, First Floor, disorders. This includes hearing assessments, hearing House in repair Boots, Dolphin Centre, aid fittings, follow-ups and repairs, tinnitus counselling service) Poole, Dorset and balance assessment/treatment. Therapy team incorporating the following groups: Bournemouth Balance, Strength and Exercise Group Sentinel & Poole Falls Clinic Ringwood Road, House Poole, Dorset Therapy Team Upper Limb Group Higher Level Stroke Group

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Lower level stroke Group Therapy only falls clinic Bridport Community Bridport Hospital, Sentinel Hospital A service that provides Physiotherapy Services Hospital Lane, House Physiotherapy Bridport DT6 5DR Chronic Wareham Hospital, Sentinel Fatigue Provide Clinical services for People with Moderate and Streche Road, House Syndrome - severe CFS/ME Dorset Wide Wareham, Dorset Wareham Provides nursing care and treatment for people with Bridport Community Comm complex, long-term conditions in their own homes; these Sentinel Hospital, Hospital Matrons West include mental and physical health needs, from wound House Lane, Bridport DT6 Dorset management and diabetes to kidney failure and heart or 5DR lung conditions. Provides specialist dietary advice and support for people with a wide range of illnesses and conditions. Dietitians can offer help to address: Community & •malnutrition Sentinel Specialist •food allergy and intolerance 9 locations House Dietetic •irritable bowel syndrome Service •diabetes •obesity •nutritional deficiencies •enteral nutrition (feeding through tubes). Community The Acorn Building, St Sentinel Oncology support and treatments to patients within their Cancer Leonards Hospital, House own home and within a clinic setting Nurses Ringwood Road Provides nursing care and treatment for people with Sentinel Community complex, long-term conditions in their own homes; these include mental and physical health needs, from wound 4 locations House Matrons management and diabetes to kidney failure and heart or lung conditions. Kings Park Hospital Community Provide support, management and monitoring for people Sentinel Gloucester Road Neurology with long term neurological/neuromuscular conditions House Bournemouth (excluding stroke) Service Dorset 11 Shelley Road, Sentinel Complex Leg Service to provide treatment of complex leg ulcers Boscombe, House Ulcer Service across multiple locations Bournemouth, Dorset Provide assessment, management and treatment for adults and children with skin conditions treating conditions such as Sentinel •acne Dermatology •eczema 2 locations House •psoriasis •nail and scalp disorders •rashes •inflammatory disorders. Provide assessment, management and treatment for adults and children with skin conditions treating conditions such as Bridport Medical •acne Sentinel Dermatology Centre, West •eczema House (Medical) Allington, Bridport, •psoriasis Dorset •nail and scalp disorders •rashes •inflammatory disorders. Sentinel Provides support for people across Dorset living with Diabetes Diabetes by helping to control and manage their 14 locations House condition on a day to day basis.

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Provides nursing care and treatment for people with Sentinel District complex, long-term conditions in their own homes; these include mental and physical health needs, from wound 57 locations House Nursing management and diabetes to kidney failure and heart or lung conditions. Dorset Bladder & Sentinel Provides a nurse-led service to support people across Bowel 11 locations House Dorset with bladder and bowel problems. Continence Service Dorset The Atrium Health Centre, 7, Weymouth Sentinel Bladder & Provides a nurse-led service to support people across Avenue, Dorchester, House Bowel Service Dorset with bladder and bowel problems. Dorset (Team Base) Provides assessment, support and treatment for people Dorset MSK - Sentinel with musculoskeletal disorders. Specialist orthopaedics Orthopaedic staff work from clinics across Dorset, and offer a range 4 locations House Service of treatments, including injections, epidurals, hand and wrist splints, acupuncture and physiotherapy. Dorset MSK - Provides assessment, support and treatment for people Sentinel Orthopaedic with musculoskeletal disorders. Specialist orthopaedics staff work from clinics across Dorset, and offer a range Multiple locations House Service of treatments, including injections, epidurals, hand and (Medical) wrist splints, acupuncture and physiotherapy. Provides medical assessment and treatment of patients with non-complicated ear, nose and throat conditions offering help with problems such as: Sentinel Ear, Nose + - hearing loss - ear infections 3 locations House Throat - vertigo and balance problems - severe ear wax - sleep apnoea and snoring - persistent sore throat and swallowing problems Heart Failure Sentinel A service that provides assessment and care for people Various community Specialist with potential heart-related problems such as chest pain, House locations Nurse palpitations, black-outs and breathlessness Provides rehabilitation support at home and in hospital to help people recover. Our physiotherapists, Bridport Community occupational therapists and rehab nurses offer Hospital, Sentinel ICRT- Bridport assessment, care and therapy for patients across Hospital Lane, House Dorset. This support means that some people can avoid Bridport a stay in hospital, while others can be safely discharged DT6 5DR from hospital as soon as possible. MDT Community Rehabilitation to provide Admission DCC Local Office, Sentinel ICRT- avoidance to the community and supported discharge to Loring Road, House Christchurch the Hospitals (acute and Community Palliative Care and Christchurch Community Therapy Provides rehabilitation support at home and in hospital to help people recover. Our physiotherapists, occupational therapists and rehab nurses offer Dorset Local Office, Sentinel ICRT- assessment, care and therapy for patients across Acland Road, House Dorchester Dorset. This support means that some people can avoid Dorchester, Dorset a stay in hospital, while others can be safely discharged from hospital as soon as possible. Provides rehabilitation support at home and in hospital to help people recover. Our physiotherapists, occupational therapists and rehab nurses offer Purbeck Local Office, Sentinel ICRT- assessment, care and therapy for patients across 19 Bonnets Lane, House Purbeck Dorset. This support means that some people can avoid Wareham, Dorset a stay in hospital, while others can be safely discharged from hospital as soon as possible.

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Intermediate MDT Community Rehabilitation to provide Admission Sentinel Care - avoidance to the community and supported discharge to 2 locations House the Hospitals (acute and Community Palliative Care and Bournemouth Community Therapy) Sentinel Intermediate Ringwood Road, Poole Intermediate Care Team House Care - Poole Poole, Dorset St Leonards Hospital, Sentinel Night Nursing Providing a community nursing service from 8pm to 8am 241 Ringwood Road, House Service St Leonards A service that provides detailed information and support North Sentinel to help you understand what frailty means for you and Village Surgery, Gillett Bournemouth House your loved ones and help you to feel confident in Road, Poole, Frailty Team managing this health condition. Provide the diagnosis, treatment, fitting, maintaining and Maple Place repairing of orthoses for children and adults in line with Orthotics Orthotics Dep Sentinel the agreed access criteria. Provide appropriate orthotics, (Musculoskele St Marys Road House this includes but not restrictive to elastic/fabric, custom tal) Poole made splints, footwear and insoles to facilitate the Dorset treatment and rehabilitation of the patient Out Patient Musculoskelet Sentinel Provides assessment of musculoskeletal conditions, Various community al House treatment plans/self-help guidance hospitals Physiotherapy services - Pain Service - Provides support for people living with persistent pain, Dorset helping them to lead as fulfilling and independent lives Sentinel Community as possible. The service deals with all forms of chronic 3 locations House pain, including musculoskeletal (muscles, bones and Pain Service joints), neurological (nervous system), internal organs (DCPS) and unexplained pain. Provides specialist assessment, advice and treatment to help reduce foot and lower limb pain, and to maintain or Podiatry Sentinel improve the health of people’s feet. Our podiatry service clinics and (previously known as chiropody) cares for people who 40 locations House home visits have an injury or medical condition that puts them at risk of developing potentially serious foot problems, such as infections, ulcerations or amputations. Wareham Hospital, Sentinel Pulmonary Exercise and advice Streche Road, House rehabilitation Wareham, Dorset Atrium Health Centre, Dorchester, Shelley Speech Sentinel Service that provides Speech and Language therapy to Road, Blandford Therapy House adults Hospital, Poole Adults Community Health Clinic Support, education and advice for people across Dorset Wareham Hospital, Sentinel Stroke who have suffered a stroke, as well as for their families Streche Road, House Services and carers Wareham, Dorset A clinical hub that provides remote monitoring of patients with COPD and heart failure and their associated Parkstone Health physiological symptoms. The patients take personal Centre, Mansfield Sentinel Telehealth readings using peripheral equipment in the comfort of Road, Parkstone, House their own home. The clinicians within the hub promote Poole, Dorset self-management of the conditions via telephone contact. Juniper Lodge, Tissue Sentinel Providing specialist tissue viability care, both within the Poundbury West Viability House community and the hospital setting Industrial Estate, Service Dorchester

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Vocational services provide support for people with a long-term health condition which is affecting their work options, and help them to achieve their vocational goal. The occupational therapists (OTs) offer assessment, advice and treatment to help people across Dorset with: Sentinel Vocational • remaining in a current job or exploring alternative work The Buckland Centre, House Services options 9 Shelley Rd • returning to paid work, voluntary work or education • taking up training opportunities for employment. Support is delivered through one-to-one sessions, group work, workshops and workplace visits according to individual needs. Wareham Wareham Hospital, Sentinel Hosp A service that provides Physiotherapy Services Streche Road, House Physiotherapy Wareham, Dorset The service is available to anyone with a long-term Acorn Building, St condition or illness which affects their mobility, and who Leonard's Community Sentinel Wheelchair meets eligibility criteria. We carry out assessments and Hospital House Service provide wheelchairs, cushions, seating and accessories, Ringwood Road, St along with any modifications required Leonards St Leonard's St Leonards Community Hospital St Leonards A service that provides Physiotherapy Services Physiotherapy Ringwood Road, St Leonards St Leonard's St Leonards Appointment based service at weekends operated from Community Hospital St Leonards Treatment Wimborne CH. Appointments for patients come via the Ringwood Road, St Centre ambulance service Leonards Provides assessment, support and treatment for people Swanage Community Swanage Dorset MSK - with musculoskeletal disorders. Specialist orthopaedics Hospital, Queens Community Orthopaedic staff work from clinics across Dorset, and offer a range Road, Swanage, Hospital Service of treatments, including injections, epidurals, hand and Dorset wrist splints, acupuncture and physiotherapy. Provide the diagnosis, treatment, fitting, maintaining and repairing of orthoses for children and adults in line with Swanage Community Swanage Orthotics the agreed access criteria. Provide appropriate orthotics, Hospital, Queens Community (Musculoskele this includes but not restrictive to elastic/fabric, custom Road, Swanage, Hospital tal) made splints, footwear and insoles to facilitate the Dorset treatment and rehabilitation of the patient Swanage Community Swanage Swanage Hospital, Queens Community Hospital A service that provides a range of outpatient services Road, Swanage, Hospital Outpatients Dorset Swanage Community Swanage Swanage Hospital, Queens Community Hospital A service that provides Physiotherapy Services Road, Swanage, Hospital Physiotherapy Dorset Swanage Community Swanage Swanage Hospital, Queens Community Hospital A service that provides X-ray services Road, Swanage, Hospital Radiography Dorset Swanage Community Swanage Swanage A service that provides day Surgery, Minor Operations Hospital, Queens Community Hospital and Procedures Road, Swanage, Hospital Theatre Dorset Victoria Provides specialist dietary advice and support for people Victoria Hospital, Community & Hospital, with a wide range of illnesses and conditions. Dietitians Victoria Road, Specialist Wimborne can offer help to address: Wimborne, Dorset

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Dietetic •malnutrition Service •food allergy and intolerance •irritable bowel syndrome •diabetes •obesity •nutritional deficiencies •enteral nutrition (feeding through tubes). Dorset Victoria Bladder & Victoria Hospital, Provides a nurse-led service to support people across Hospital, Bowel Victoria Road, Dorset with bladder and bowel problems. Wimborne Continence Wimborne, Dorset Service Provides assessment, support and treatment for people Victoria Dorset MSK - with musculoskeletal disorders. Specialist orthopaedics Victoria Hospital, Hospital, Orthopaedic staff work from clinics across Dorset, and offer a range Victoria Road, Wimborne Service of treatments, including injections, epidurals, hand and Wimborne, Dorset wrist splints, acupuncture and physiotherapy. Provides rehabilitation support at home and in hospital to help people recover. Our physiotherapists, Victoria occupational therapists and rehab assistants offer Victoria Hospital, ICRT- East Hospital, assessment, care and therapy for patients across Victoria Road, Dorset Wimborne Dorset. This support means that some people can avoid Wimborne, Dorset a stay in hospital, while others can be safely discharged from hospital as soon as possible. Victoria Wimborne A service that provides assessment and care for people Victoria Hospital, Hospital, Community with potential heart-related problems such as chest pain, Victoria Road, Wimborne Cardiology palpitations, black-outs and breathlessness Wimborne, Dorset Wimborne Victoria Victoria Hospital, Hospital Hospital, A service that provides Physiotherapy Services Victoria Road, Physiotherapy Wimborne Wimborne, Dorset 2 Victoria Wimborne Victoria Hospital, Hospital, Hospital A service that provides X-ray services Victoria Road, Wimborne Radiography Wimborne, Dorset Victoria Wimborne A service that provides day Surgery, Minor Operations Hospital, Hospital 2 locations and Procedures Wimborne Theatre Westhaven Hospital Provides a community anticoagulation services at Westhaven Anticoagulatio Radipole Lane, multiple venues and see around eight patients each hour Hospital n Service Weymouth, per clinic Dorset Provides nursing care and treatment for people with Westhaven Hospital complex, long-term conditions in their own homes; these Westhaven Community Radipole Lane, include mental and physical health needs, from wound Hospital Matrons Weymouth, management and diabetes to kidney failure and heart or Dorset lung conditions. Provides rehabilitation support at home and in hospital to help people recover. Our physiotherapists, Westhaven Hospital occupational therapists and rehab nurses offer Westhaven ICRT- Radipole Lane, assessment, care and therapy for patients across Hospital Weymouth Weymouth, Dorset. This support means that some people can avoid Dorset a stay in hospital, while others can be safely discharged from hospital as soon as possible. Provides rehabilitation support at home and in hospital Westminster to help people recover. Our physiotherapists, Westminster Hospital, ICRT- Memorial occupational therapists and rehab assistants offer Abbey Walk, Shaftesbury Hospital assessment, care and therapy for patients across Shaftesbury, Dorset Dorset. This support means that some people can avoid

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a stay in hospital, while others can be safely discharged from hospital as soon as possible. Westminster Westminster Hospital, Westminster Memorial A service that provides Physiotherapy Services Abbey Walk, Physiotherapy Hospital Shaftesbury, Dorset Weymouth Community Weymouth Provides a community anticoagulation services at Anticoagulatio Hospital Community multiple venues and see around eight patients each hour n Service Melcombe Avenue, Hospital per clinic Weymouth, Dorset, Provides assessment, support and treatment for people Weymouth Community Weymouth Dorset MSK - with musculoskeletal disorders. Specialist orthopaedics Hospital Community Orthopaedic staff work from clinics across Dorset, and offer a range Melcombe Avenue, Hospital Service of treatments, including injections, epidurals, hand and Weymouth, Dorset, wrist splints, acupuncture and physiotherapy. Provides nursing care and treatment for people with complex, long-term conditions in their own homes; these Yeatman Hospital, Yeatman Community include mental and physical health needs, from wound Hospital Lane, Hospital Matrons management and diabetes to kidney failure and heart or Sherborne, Dorset lung conditions. Provides nursing care and treatment for people with complex, long-term conditions in their own homes; these Yeatman Hospital, Yeatman District include mental and physical health needs, from wound Hospital Lane, Hospital Nursing management and diabetes to kidney failure and heart or Sherborne, Dorset lung conditions. Dorset Bladder & Yeatman Hospital, Yeatman Provides a nurse-led service to support people across Bowel Hospital Lane, Hospital Dorset with bladder and bowel problems. Continence Sherborne, Dorset Service Provides rehabilitation support at home and in hospital to help people recover. Our physiotherapists, occupational therapists and rehab assistants offer Yeatman Hospital, Yeatman ICRT- assessment, care and therapy for patients across Hospital Lane, Hospital Sherborne Dorset. This support means that some people can avoid Sherborne, Dorset a stay in hospital, while others can be safely discharged from hospital as soon as possible. Provide the diagnosis, treatment, fitting, maintaining and repairing of orthoses for children and adults in line with Orthotics Yeatman Hospital, Yeatman the agreed access criteria. Provide appropriate orthotics, (Musculoskele Hospital Lane, Hospital this includes but not restrictive to elastic/fabric, custom tal) Sherborne, Dorset made splints, footwear and insoles to facilitate the treatment and rehabilitation of the patient Provides support for people living with persistent pain, Pain Service - helping them to lead as fulfilling and independent lives Dorset Yeatman Hospital, Yeatman as possible. The service deals with all forms of chronic Community Hospital Lane, Hospital pain, including musculoskeletal (muscles, bones and Pain Service Sherborne, Dorset joints), neurological (nervous system), internal organs (DCPS) and unexplained pain. Yeatman Hospital, Yeatman Yeatman A service that provides Physiotherapy Services Hospital Lane, Hospital Physiotherapy Sherborne, Dorset

(Source: Universal Routine Provider Information Request (RPIR) – P2 Sites tab) Our inspection was announced (staff knew we were coming) to ensure that everyone we needed to talk to was available. From the list of the services above, we visited the following teams and services during our inspection:

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• Community nursing teams at Whitecliff surgery, Moordown medical centre and Sixpenny Handley surgery. • Poole, Bridport and Blandford hubs • St Leonards community hospital • Night community nursing team • Tissue viability service • Parkinson’s service • Community neurology service • Stroke clinic • Wheelchair service • Speech and language therapy services • Integrated community rehabilitation team

During this inspection we spoke with 52 members of staff including senior managers for the community services, medical consultant, nurse consultant, senior nurses, community matrons, advanced nurse practitioners, specialist nurses, district/community nurses, therapists, specialist therapists and support workers. We spoke with 12 patients and their relatives/carers. We reviewed 13 sets of patient records. We observed the care and treatment of patients in the stroke clinic setting and in 10 patients’ homes. We also looked at and analysed data about the organisation, and information provided to us by the trust. The last inspection of community health services for adults by the Care Quality Commission was in October 2015.

Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Mandatory training The service provided mandatory training in key skills to all staff and most staff were compliant with the majority of mandatory training. The UK Core Skills Mandatory training framework guided trust mandatory training. The framework set out training outcomes and recommendations on how training could be achieved and updated. For community staff, it was agreed through the trust resuscitation group, that staff updated their basic life support training through eLearning as they had no access to defibrillators or airways. The main responsibility of community staff was to identify an emergency situation and summon the emergency services at the same time as delivering basic cardiopulmonary resuscitation. Staff felt that mandatory training was aligned to their role in community working. Mandatory and statutory training completion rates The trust set a high target of 95% for completion of all mandatory and statutory training. A breakdown of compliance for mandatory training courses from 29 January 2018 to 29 January 2019 at trust level for qualified nursing staff in community services for adults is shown below:

Training module name 29 January 2018 to 29 January 2019

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Staff Eligible Completion Trust Met trained staff rate target (Yes/No) Equality and Diversity 444 444 100% 95% Yes Moving and Handling Theory Level 1 17 17 100% 95% Yes Safeguarding Children Level 3 5 5 100% 95% Yes Basic Life Support - Taught 32 33 97% 95% Yes Information Governance 424 445 95% 95% Yes Immediate Life Support 18 19 95% 95% Yes Conflict Resolution 417 444 94% 95% No Mental Capacity Act 407 433 94% 95% No Infection Control - 3 Yearly 411 444 93% 95% No Moving and Handling Practical Level 2/3 366 400 92% 95% No Fire 404 444 91% 95% No Basic Life Support - eLearning 377 413 91% 95% No Safeguarding Adults Level 2 407 453 90% 95% No Safeguarding Children Level 2 399 448 89% 95% No

In community services for adults the 95% target was met for six of the 14 mandatory training modules for which qualified nursing staff were eligible. However, it should be noted that the eight modules that did not reach the trust target were close to 95%. Staff confirmed they were able to access mandatory training and usually had time to complete this, although at times it was difficult due to workload. Managers kept records of mandatory training and reminders to update training were sent from the electronic system to staff. Staff in the wheelchair service could book time in their diaries to complete their mandatory training. A record of training was held centrally by the service manager, who also sent updates to staff when training was due. A breakdown of compliance for mandatory training courses from 29 January 2018 to 29 January 2019 at trust level for medical staff in community services for adults is shown below:

29 January 2018 to 29 January 2019 Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No) Conflict Resolution 1 1 100% 95% Yes Equality and Diversity 1 1 100% 95% Yes Fire 1 1 100% 95% Yes Infection Control - 3 Yearly 1 1 100% 95% Yes Information Governance 1 1 100% 95% Yes Moving and Handling Theory Level 1 1 1 100% 95% Yes Safeguarding Adults Level 2 1 1 100% 95% Yes Basic Life Support - eLearning 1 1 100% 95% Yes Safeguarding Children Level 2 1 1 100% 95% Yes Mental Capacity Act 6 7 86% 95% No

In community services for adults the 95% target was met for nine of the 10 mandatory training modules for which medical staff were eligible. One member of medical staff had not completed the Mental Capacity Act training and this brought the completion rate down to 86%.

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(Source: Routine Provider Information Request (RPIR) – Training tab)

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The trust had a safeguarding policy that reflected relevant safeguarding legislation which staff were aware of and knew how to access. Staff told us about the different forms of abuse and how and when they would make a safeguarding referral. We saw information in the offices of various teams providing information about how to raise a concern which included a flowchart and relevant telephone numbers. Staff understood their role and responsibilities to report safeguarding incidents and could give us examples of incidents they had reported. Staff were aware of the process they needed to follow to report safeguarding concerns to make sure patients were protected from abuse. Staff described actions they took when they had a safeguarding concern and told us of examples where they had raised safeguarding concerns about patients. Most staff had received updated safeguarding training and were almost compliant with the trust’s target. Staff received effective training in safeguarding systems, processes and practices. All staff were required to hold level two safeguarding training for both adults and children. It should be noted that the two modules that did not reach the trust target were close to 95%. Safeguarding training completion rates

The trust set a high target of 95% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses from 29 January 2018 to 29 January 2019 at trust level for qualified nursing staff in community services for adults is shown below:

29 January 2018 to 29 January 2019 Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No) Safeguarding Children Level 3 5 5 100% 95% Yes Safeguarding Adults Level 2 407 453 90% 95% No Safeguarding Children Level 2 399 448 89% 95% No

In community services for adults the 95% target was met for one of the three safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses from 29 January 2018 to 29 January 2019 at trust level for medical staff in community services for adults is shown below:

29 January 2018 to 29 January 2019 Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No) Safeguarding Adults Level 2 1 1 100% 95% Yes Safeguarding Children Level 2 1 1 100% 95% Yes

In community services for adults the 95% target was met for two of the two safeguarding training modules for which medical staff were eligible.

(Source: Universal Routine Provider Information Request (RPIR) – Training tab)

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Cleanliness, infection control and hygiene The service controlled infection risk well. Infection control practice and processes in patients’ homes were managed safely. Staff were bare below the elbow in line with trust policy. This promoted effective hand washing and prevented long sleeves from touching patients, therefore reducing the risk of spreading infection. We saw staff washing their hands and using hand gel before and after patient contact and using personal protective equipment. This was in line with the National Institute of Health and Care Excellence (NICE) Quality statement 61, (statement three). We saw three months results of hand hygiene audits for all community teams. Most teams scored 100% with the lowest being 81%. There were action plans formulated when the score was not 100%. Many observations of hand washing took place in patient’s homes. However, if the patient did not have taps which could be turned off without touching, this affected the score. This gave false negative scores but was outside the control of staff. There were safety systems, processes and practices which were implemented and communicated to staff to ensure the safety of patients. The trust had an infection control policy that staff could access on the staff intranet and refer to for information. We saw personal protective equipment was available at the locality base where services operated from. Staff used personal protective equipment during patient visits and outpatient clinics. Staff told us they could access this equipment and would carry a small stock when visiting their patients in the community. Sharp instruments were disposed of safely. The service provided patients with safe sharp bins to dispose of sharp instruments in their own homes. We found these to be used to a safe level and not overfilled in both patient’s own homes and in clinical areas. Clinical waste was managed safely and appropriately. We saw clinical waste was separated from regular waste into the correct colour coded bags in separate bins to prevent the spread of infection. There were systems to prevent and protect people from a healthcare-associated infection. In the wheelchair service, standards of cleanliness and hygiene were maintained using a system of checks to help prevent and protect patients from healthcare-associated infections. When used wheelchairs were returned from a patient, they were taken to a new on-site facility to be deep cleaned before being returned to the equipment store. This included the pressure cushions. Each piece of equipment returned to the store with a certificate showing who had cleaned it, and who had checked it. This provided an audit trail in the event of an infection concern.

Environment and equipment The service had suitable premises and equipment and generally looked after them well. We visited various departments and clinical areas and found them to be visibly clean, well-organised and tidy. All environments we visited were safe for patients to visit for care and treatment. We saw corridors were uncluttered with equipment stored away safely. We found that furniture was clean and in good condition, fully wipeable and compliant with the Health Building Note (HBN) 00-09: Infection control in the built environment. Equipment was not always serviced and maintained to ensure it was safe for use. The trust had an asset register for all community equipment. This showed where the equipment belonged, when it was last serviced and the date of the next service. On the asset register were 19 pieces of

Page 46 equipment listed belonging to district/community nurses that had passed their servicing date, with two going back to January 2010. This included equipment such as doppler machines (to scan for pulses), blood pressure machines and scales. While we were not assured that regular maintenance was carried out for this equipment and could have produced inaccurate recordings for patients. When brought to the attention of the trust, action was taken as this had already been highlighted in the Medical Devices section of the Internal Audit Annual Report dated March 2018. However, the wheelchair service used a bespoke electronic system to manage all wheelchairs for the trust. This included the client base, stock availability, planned maintenance, repair and booking of appointments. The service provided for patients covered a whole life, from adapted car seats for babies to complex bespoke electric wheelchairs for tetraplegic patients. When wheelchairs were no longer required, the service assessed them for reconditioning and reuse or salvaged usable parts. Staff had access to equipment to provide care and treatment to patients in their home. Staff told us the process of how to order equipment for patients, what happened if it failed in a patient’s home, how this would be reported and managed safely. Community nurses had access to wound care dressings from the trust formulary. They carried a small selection of dressings to prevent any delays when assessing patients for the first time. When a wound had been assessed and the dressing was chosen, these were requested through a prescription for the patient or their family/carers to collect. Device alerts were cascaded, actioned and recorded. Staff told us these were discussed at team meetings and actioned accordingly. Safe manual handling practice was carried out in patient’s homes. Manual handling risk assessment plans were completed for complex patients with mobility aids such as hoists. We saw examples of detailed manual handling plans including information to ensure safe operating procedures when managing a complex manual handling situation with equipment.

Assessing and responding to patient risk Staff used their professional and clinical judgement to undertake risk assessments for patients. The trust had undertaken a pilot audit for documentation called ‘What Matters Most?’ in February 2019. This empowered health professionals to assess patients’ needs and undertake risk assessments relevant for the patient using their clinical judgement rather than pre-set timescales and templates. This meant risk assessments were personalised for individual patient needs. In the 13 sets of notes we reviewed, we saw that risk assessments were updated as necessary. There was a system to escalate concerns about a deteriorating patient. Community nursing teams used a scoring system to detect the early deterioration of patients. The national tool, national early warning score was used to identify and monitor deteriorating adult patients. We were assured that patients at risk of deterioration and sepsis would be detected and treatment given in a timely manner. Staff carried equipment to undertake basic observations of vital signs (pulse, blood pressure, respiratory rate, temperature and oxygen saturation). Staff also told us they used their clinical knowledge and judgement and if they felt a patient had deteriorated, they would have an urgent discussion with the patients GP. The patient would be discussed at the community nursing patient safety handover. However, in an emergency, staff would call for an ambulance and stay with the patient.

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Staffing The service usually had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Community nursing staffing levels and skill mix were planned and reviewed using a tool called the Benson model. This looked at caseload need and complexity, available workforce, regular clinics and travel time. This ensured patients received safe care and treatment and staff did not work excessive hours. In the community nursing service, the senior nurse on duty reviewed visits and staffing levels. They allocated uncovered visits to other staff who had capacity to take these on. If necessary, senior staff would undertake visits to patients to cover any unallocated visits. Staff also told us they worked extra shifts for colleagues in the event of sickness. Staffing remained an issue for the Trust who worked hard to promote recruitment and developed their own staff. Staff told us that ‘on the whole, staffing was ok’ at the moment despite vacancies. District Nursing teams in Weymouth and Bournemouth had the highest levels of registered staffing vacancies. The trust developed a plan whereby the team was supported by the quality improvement and tissue viability teams. The trust also developed an escalation matrix to provide guidance and action to manage ongoing issues with demand and/or capacity, used in conjunction with trust policies and business continuity plans. District/Community nurses safely managed their caseloads and there were systems and processes to match the workforce with demand for the service and patient need. The trust was piloting a patient acuity tool QuESTT in combination with the Benson model which ensured fair distribution of complex patients among staff. However, there were two incidents reported in February for lack of suitably trained/skilled staff. For example, staff were not able to complete their allocated visits during working hours. However, this was due, in part, to the merging of Portland with the Weymouth West caseload. Community matrons told us their caseload ranged from 10-40 patients. On the whole they felt it left more time for them to be proactive with patients care and prevented unnecessary GP visits and avoided admission to hospital.

Staffing levels for district/community nursing were planned for out of hours and weekends. Each district nursing team covered from 8 am until 8 pm when the night nursing team took over. Any patients who required a visit but had not been seen were passed to the night team. Also, any patients who telephoned the service and needed to be seen were visited. If the night team did not see the patients before 8 am, they were passed back to the relevant team at 8 am. All calls to the night nursing team were triaged and prioritised. This was undertaken by a healthcare assistant, not a trained nurse. Staff felt a trained member of staff at night to triage would provide a more comparable service to the single point of access team. Arrangements for using bank and agency staff kept patients safe. These staff were used to cover any unfilled shifts and the provider tried to use the same bank and agency staff to maintain continuity. However, where there were unfilled shifts, all visits were prioritised to make sure the most urgent patients were seen. The registered nurse vacancy in the community for February was 27.2 whole time equivalents (WTE) with the highest vacancies occurring in Poole Central 13%, Weymouth and Portland 11.5% and Christchurch 11.4%. The new starters in March for the community was 3.9 WTE The trust had staffing on the risk register and had ongoing plans for recruitment and retention, engagement and motivating staff. The trust was considering the use of apprenticeships options. The trust ensured any team considered vulnerable through staffing issues was supported by an experienced lead.

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Arrangements for handovers and shift changes ensured that people were safe. We attended several different district nurse handovers. Following learning from a serious patient safety incident, the district nurses used a ‘Patient Handover – Standing Agenda’ The aim of this was to pool knowledge and experience or raise any concerns about patients, note deterioration or change in patients’ condition and discuss care plans. Handover was conducted using the ‘SBAR’ method; • Situation, what is happening now. • Background, what happened in the past that was relevant. • Assessment, what it’s the problem in your view. Clinically assess the patient. • Recommendation, what do you think needs to happen now? All patients visited that morning were discussed, for example a nurse was unable to obtain a blood sample, so another nurse offered to try, a drug was re-prescribed for a patient, the state of a patients wound that was being redressed regularly and two new patients on the caseload. Further discussion was then held about the patients to be visited in the afternoon. Staff worked flexibly to support teams. Staff told us they worked for other teams to cover sickness and absence. For district nurses, patients who required a visit but had not been seen in the day time were passed to the night team. During the night, if the night team were unable to see a patient before 8 am, they were passed back to the relevant team to be visited in the day. Annual staffing metrics The trust had a target vacancy rate of 8%. From January 2018 to December 2018, the trust reported an overall vacancy rate of 6% in community health services for adults. Across the trust the overall establishment rates, vacancy rates, annual turnover and annual sickness rate for the staff groups were:

Annual average Annual vacancy Annual turnover Annual sickness rate Staff group establishment rate rate

All staff 1225.8 6% 11% 4.8%

Qualified 461.0 6% 11% 4.8% nurses Nursing 306.7 3% 10% 5.5% assistants

Medical staff 4.0 -1% 19% 3.6%

Allied Health 253.8 6% 11% 3.9% Professionals

(Source: Universal Routine Provider Information Request (RPIR) Staffing data P16 – P21)

During the reporting period from January 2018 to December 2018, community services for adults reported that there were three cases where staff have been either suspended or placed under supervision. Two staff have been suspended and one was moved wards.

A breakdown of all cases can be seen in the table below. Outcome Number of cases Suspended 2 Moved Wards 1

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Total 3

(Source: Universal Routine Provider Information Request (RPIR) – P23 Suspensions or Supervised)

Quality of records Individual care records were electronic, integrated and consistently managed. Community teams had access to records held by the patient at home and to central records through the electronic system. Care records across community adults’ services were multidisciplinary and integrated and could be accessed by all staff. This meant there very little risk that confidential patient information could be accessed by unauthorised persons. All patients received a basic pack on their first visit which included information on pressure ulcers, contact details, a visit record sheet, an explanation of the district nursing service and a copy of their care plan. Other information such as risk assessments were held on the electronic system. Staff could complete the records on their laptop if time allowed during the visit. We reviewed 13 sets of patient notes. All notes were stored securely on electronic devices which were encrypted. Each member of staff had an individual log in to access the records systems to maintain security. Notes were multidisciplinary, so healthcare professionals involved could see previous treatment and interventions which had been carried out by other community health service teams. This helped when patients were transferred between teams. Patients were protected against the risks of unsafe or inappropriate care and treatment arising from incomplete patient records or inability to access electronic patient records. This was an improvement following the inspection in October 2015 Information needed to deliver safe care and treatment was available to healthcare staff in a timely and accessible way. We observed clinicians when they prepared care plans, patients were asked their views first and care planning started with ‘I want to…’ and their personal goals integrated into care plans. Carers views were then sought. We saw that care plans were recorded electronically and updated as necessary. The quality of people’s care records was audited. The trust had undertaken a pilot audit for documentation called ‘What Matters Most?’ in February 2019. What matters most empowered health professionals to assess patients’ needs and then undertake risk assessments relevant for the patient using their clinical judgement rather than pre-set timescales and templates. Preliminary results of the pilot showed that patients felt more engaged, staff felt they had more time to spend with patients and had an increase in job satisfaction using their clinical judgement. At this time there was no evidence to suggest an increase in clinical complications or problems being missed. Further work was being undertaken to evaluate the data. The results for February 2019 were unable to be compared as this was the first audit of this kind. Results were generally encouraging with; • Is there evidence in the record that the patient has been involved in agreeing the care plan? 98% of the responses answered yes. • Has the assessment been continued/updated over time? 96% of the responses answered yes. • Have actions in the care plan been reviewed as regularly as specified? 96% of the responses answered yes. • Is there an entry in the record for each shift/visit? 100% of the responses answered yes.

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However, if any of (risk assessments for falls, thrombosis risk (Venous thromboembolism), pressure areas (Skin bundle) and nutrition (Malnutrition Universal Screening Tool)) were not completed, is it indicated that the assessments are not completed are not required at this time? This scored 64%. This meant the reason why the assessment was not required had not been recorded. Staff documented the care given to a patient in their home. Staff completed the paper records held by the patient at the time of the visit. Further records were kept on the electronic recording system which was updated when staff had time, sometimes at the end of their shift. Occasionally, this meant staff completing records in their own time. These notes were accessible to other health professionals including other community teams and GPs. When people move between teams, services and organisations, all the information needed for their ongoing care was shared appropriately. All teams had access to all electronic notes for transition to other services. The community neurology team had a yearly clinical meeting to discuss the patients transitioning from paediatric services to adult services. Staff reported they felt this was beneficial for staff and patients.

Medicines The service followed best practice when prescribing, giving and recording medicines. Medicines were appropriately prescribed, administered and/or supplied to patients in line with the relevant legislation, current national guidance or best available evidence. The district nurses did not carry any medicines with them except for Adrenaline (medicine used in an emergency for anaphylactic shock). Medication was not stored in cars overnight. On a visit with a district nurse, we observed a nurse assisting a patient with their administration of their insulin in their home. The prescription was clear, the batch number of the insulin was recorded, and administration signed for. The teams used a red box for all anticipatory medicines (known as ‘just in case’) for palliative care patients. We saw these medicines had appropriate doses prescribed and documented that they had been discussed with the patient and their carer. Patients received specific advice about their medicines. We observed nurses giving clear and specific advice to patient about their medicines particularly when it was new to the patient.

Safety performance The NHS Safety Thermometer allowed teams to measure harm and the proportion of patients that are ‘harm free’ during their working day. For example, at shift handover or during ward rounds. This is not limited to hospitals; patients may experience harm at any point in a care pathway and the NHS Safety Thermometer helped teams in a wide range of settings, from acute wards to a patient's own home, to measure, assess, learn and improve the safety of the care they provided. The Safety Thermometer was used to record the prevalence of patient harm and provided immediate information and analysis for frontline teams to monitor their performance in delivering harm-free care. Measurement at the frontline was intended to focus attention on reducing patient harm. Data collection took place one day each month, a suggested date for data collection was given but services could change this. Data must be submitted within 10 days of the suggested data collection date.

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Trust data from the Patient Safety Thermometer showed in April 2019, the service reported 41 new pressure ulcers, 13 falls with harm, no new catheter-related urinary tract infections and two new venous thrombosis cases. This meant the community teams delivered 91.7% of harm free care in April 2019 for 1,358 patients.

Incident reporting, learning and improvement The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Staff understood their responsibilities to raise concerns, record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate. Staff told us they had a good understanding of incidents and felt confident to report them. Staff received feedback when they had reported an incident and it had been investigated. They all understood their responsibility to raise concerns, report patient safety incidents and near misses. Staff showed us the electronic incident reporting system and gave examples of when they had used it. Community health services for adults reported 471 incidents from January to March 2019. This was evidence of a good safety culture. Of this total, 46% were no or low harm, 32% were moderate harm, 0.2% were major and 0.6% were catastrophic. Pressure ulcer incidents accounted for 35% of reported incidents and medication errors 4%. There was evidence following incident investigations that duty of candour had been applied. We saw letters written to patients expressing duty of candour following investigations. Lessons were learned and shared through discussion. Staff told us incidents, investigations (including root cause analysis) and lessons to be learned were shared at team meetings. For example, there had been an issue with manual handling for a patient and this was addressed, and the patient received a hoist the next day.

Never events

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From 1 January 2018 to 31 December 2018, the trust did not report any never events for community services for adults.

(Source: Strategic Executive Information System (STEIS))

Serious Incidents (STEIS)

In accordance with the Serious Incident Framework 2015, the trust reported 20 serious incidents (SIs) in community services for adults, which met the reporting criteria set by NHS England from 1 January 2018 to 31 December 2018. A breakdown of the incident types reported is in the table below:

Incident Type Number of Incidents

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Pressure ulcer meeting SI criteria 16 Treatment delay meeting SI criteria 2 HCA/Infection control incident meeting SI criteria 1 Apparent/actual/suspected self-inflicted harm meeting SI 1 criteria Grand Total 20

Source: Strategic Executive Information System (STEIS)) Serious Incidents (SIRI) – Trust data

From January 2018 to December 2018, trust staff within community services for adults reported 28 serious incidents. The most common types of serious incidents were pressure ulcer meeting SI criteria and treatment delay meeting SI criteria.

The number of the most severe incidents recorded by the trust incident reporting system is not comparable with that reported to Strategic Executive Information System (STEIS). This gives us less confidence in the validity of the data. There were eight additional incidents reported to SIRI compared to STEIS, these were all incidences of pressure ulcer meeting SI criteria.

There were no unexpected deaths within this service.

Incident type Number of incidents Percentage of total Pressure ulcer meeting SI criteria 24 86% Treatment delay meeting SI 2 7% criteria HCA/Infection control incident 1 4% meeting SI criteria Apparent/actual/suspected self- 1 4% inflicted harm meeting SI criteria Total 28 100%

Site 1 – Sentinel House

Incident Type Number of Incidents

Pressure ulcer meeting SI criteria 23 Treatment delay meeting SI criteria 2 HCA/Infection control incident meeting SI criteria 1 Apparent/actual/suspected self-inflicted harm meeting SI 1 criteria Grand Total 27

Site 2 – St Leonards

Incident Type Number of Incidents

Pressure ulcer meeting SI criteria 1 Grand Total 1

(Source: Universal Routine Provider Information Request (RPIR) – Serious Incidents tab)

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We reviewed a selection of incidents and serious incidents from the community which included the investigation report and evidence of actions taken. Most incidents in the community related to pressure ulcers. Learning from these types of incidents was demonstrated through participation in NHS Improvements campaign called ‘Stop the Pressure’. This was part of a wider programme as part of the pressure ulcer improvement collaborative, to deliver improvement in the incidence of avoidable grade 3 and 4 pressure ulcers in 2017/18. The trust produced a poster to show the focus of their improvement work. Managers told us they received internal training to investigate serious incidents. Locality managers sat on the root cause analysis and serious incident panels who reviewed all investigations and action plans. Staff were also encouraged to attend these panels to ‘learn from them and be part of the panel’. Managers told us ‘It’s a platform for people to have a discussion, learning and identifying trends and they can then take that away with them to their teams’. For example, a theme identified was multiple visits for patients from healthcare assistants when it should have been a trained nurse. Work had been undertaken with district nurses around standard setting in particular situations, i.e. wound care.

Is the service effective?

Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. The trust did not have a specific policy to manage some long-term conditions. However, the trust managed stroke patients with the range of national policies and guidelines. For example, Royal College of Physicians national clinical guidelines for stroke, National Institute for health and Care Excellence (NICE) guidance. The trust also participated in the Sentinel Stroke National Audit Programme and had an Early Supported Discharge team to support stroke patients. There was a national plan for stroke which was currently being refreshed and practitioners within the Dorset System were inputting into this. The trust had service specifications for Early Supported Discharge, long term conditions therapy and were working on a stroke six-month review. Management of Parkinson’s Disease within the trust was directed by specific NICE guidelines. The trust also had a Parkinson’s Disease Nurse specialist service with a team that split the county into east and west. Management of Diabetes within the trust was directed by specific NICE guidelines. The team also used national guidelines written by Joint British Diabetes Societies. The Diabetes team were also undertaking a piece of work to put these guidelines into a trust policy and protocols format, to go through governance groups in the next month. Patients had clear, personalised outcome goals. In the notes we reviewed, we found patients had well written and comprehensive care plans with clear personalised goals the patient wished to achieve. They also included, where appropriate, the patient’s resuscitation decision. Care plans had been reviewed at every visit.

Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them. The trust monitored patient outcomes and undertook a range of audits to promote best practice and develop actions to improve. There was some internal audit work ongoing across the community adults service to look at the outcomes of care and treatment for patients and identify

Page 54 where improvements could be made to practice. The tissue viability team audited chronic wound assessment over a four-week period. They saw a 31% improvement over six months. The early supported discharge team for stroke submitted data for the Sentinel Stroke National Audit Programme and the Parkinson’s disease specialist nurse for the UK Parkinson’s audit, from which a service improvement plan was formulated, completed in March 2018. The service had participated in the 2018 national audit of intermediate care audit (NAIC). The NICA was a national benchmarking audit which covered different models of intermediate care. These included intermediate care which was home based, bed based, crisis response and reablement. This audit showed; • Intermediate care worked with more than 93% of service users to maintain or improve their level of independence, an improvement from 91% in 2017. • In 2018, 99% of people felt they had been treated with dignity and respect. Audits – changes to working practices The trust has participated in seven clinical audits in relation to this core service as part of their Clinical Audit Programme.

Audit name Area covered Key Successes Key actions Audit on assessment Bournemouth The number of patients not Discuss Policy for the and escalation within Intermediate Care escalated in line with Trust Prevention and Management Bournemouth policy has decreased since July of the Deteriorating Adult Intermediate Care 2017 from 14% to 5.5%. This is Patient at the Team meeting. January 2018 an improvement. UK Parkinson’s Audit Physiotherapy, A majority of patients surveyed Comprehensive action plan to Occupational Health, as part of the audit (35/43) felt address issues, with short Neurology, Speech this was a good service. 4 stated term. Medium term and long- and Language the service was improving. 3 felt term actions the service needed to improve and 1 did not answer Re-Audit of Keele Dorset The scores are being The compliance rate is to be STarT back tool Musculoskeletal appropriately assigned and the dropped to 70% for the next Outpatient patients are being placed on the audit round to allow for the Physiotherapy correct pathway. variants discussed and changes in how the data is captured, as the questionnaire is now to be sent out by the GP on referral to the Physiotherapists. Re-Audit on Bournemouth Improvement noted in the To continue to re-audit in assessment and Intermediate Care number of patients with a full set 2019, the monitoring of the escalation within of baseline observations, and all staffing levels will continue, Bournemouth patients who required it were and Team Leaders are aware. Intermediate Care escalated in line with Trust August 2018 Policy Sentinel Stroke ESD Our ESD SSNAP audit Annual detailed notes audit to National Audit compliance for transfer of explore quality of service Programme records remains 100%. provision within ESD time (Quarterly) At discharge from ESD the period. majority of patients demonstrate Use of extended questions an improvement in score, with within F+F questionnaire improvement in functional ability Ongoing involvement in CCG and dependency. and Acute Vanguard (Stroke Subset) review of pan-Dorset ESD provision including

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patient and carer participation forums Re-Audit of Stroke East Dorset, West The majority of standards had Where missing documentation Early Supported Dorset and North demonstrated an improvement was noted this is from Discharge (ESD) Dorset ESD Services since the audit in 2015. practitioners who provide ESD Clinical Records 2018 There was evidence of thorough on top of their normal and completed full assessments caseload, changes and by the Stroke Team training given to these practitioners. Audit of adult hearing Audiology Overall compliance levels are Implemented universal note aid fittings 2018 very high (100% compliance text templates for fittings and was achieved for 3 out of 5 so this hopefully will improve questions) and so it shows that compliance rates for this factor overall, we are verifying adult hearing aid fittings using validated verification measures as recommended by national Audiology governing bodies

(Source: Universal Routine Provider Information Request (RPIR) – Audits tab)

Competent staff Managers made sure they had staff with a range of skills needed to provide high quality care. Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff competencies within their area of expertise were appropriately assessed. Managers ensured staff completed relevant to role competencies to enable staff to do their job. Advanced core clinical skills were required by district nurses which included male and female catheterisation, changing supra-pubic (a urinary catheter inserted through the abdominal wall into the bladder) catheters, accessing central intravenous lines (to give medication straight into a vein), syringe driver training and feeding through a gastrostomy tube (a tube inserted into the stomach to feed patients). Staff had appropriate training to meet their learning needs to cover their scope of work. Support and rehabilitation workers in community teams completed nursing, occupational therapy and physiotherapy competencies for their role. This prepared them to provide care and treatment to patients within their limitations to patients during visits. This allowed qualified healthcare professionals to see more complex patients. Support and rehabilitation workers told us they knew their boundaries of competence and knew when to refer to a healthcare professional. Only therapists employed by the wheelchair service were allowed to prescribe specialised wheelchairs for patient use following a three-day intensive training course. There was a drive to increase skills of staff to provide effective care and treatment for patients. The trust was investing in further education and training to increase the skills of existing staff and to attract and retain new staff. For example, advanced nurse practitioner apprenticeships. This was to improve the patient experience and utilise current staff knowledge and experience. The speech and language therapists had established a dysphagia (swallowing difficulties) training team. They taught a wide variety of health professionals in the community, hospitals and care home. This ensured patients with swallowing difficulties were treated correctly according to the severity of their condition. Volunteers were recruited where required and trained and supported for the role they undertook. The trust has recently been awarded £75,000 by NHS England and a national charity to launch an

Page 56 initiative to enable local volunteers to work within end of life care. The trust was one of 12 out of 115 selected following a nationwide competition earlier this year. The project will be initially developed in the locality of Purbeck and they will work with local partners including primary care. It is hoped that the first cohort of volunteers will be recruited and trained by the end of June. Clinical Supervision

There were arrangements for supporting and managing staff to deliver effective care and treatment. The trust provided information about their clinical supervision process. The trust had a clinical supervision policy which outlined the requirements for all staff to receive and record a minimum of two formal clinical supervision sessions within each of the six-month periods from 1 April to 30 September and 1 October to 31 March: a minimum of four per year. The clinical supervision sessions were recorded by the supervisee on the electronic system, as per the trust policy. Learning and Development extracted reports from the electronic system which pulled compliance data. This fed into the triangulation reports and Board reports”. Staff showed us their supervision records on the electronic system, which were comprehensive. Supervision was undertaken bi-monthly for staff and monthly for team leaders. The community neurology team also had monthly supervision sessions with a psychologist.

(Source: CHS Routine Provider Information Request (RPIR) – Clin Supervision tab) Appraisal rates

The learning needs of staff were identified through appraisals (annual performance reviews) and staff across the community service were nearly all compliant with the trust’s target. From January 2018 to January 2019, 93% of required staff in community services for adults received an appraisal compared to the trust target of 95%.

The breakdown by staff group can be seen in the table below:

Community adults total 29 January 2018 – 29 January 2019 Staff who Staff group Eligible Completion Trust Met received an staff rate target (Yes/No) appraisal Healthcare Scientists 1 1 100% 95% Yes Allied Health Professionals 228 237 96% 95% Yes Estates and Ancillary 22 23 96% 95% Yes Administrative and Clerical 146 157 93% 95% No Nursing and Midwifery Registered 366 393 93% 95% No Additional Clinical Services 270 302 89% 95% No Additional Professional Scientific And 10 12 83% 95% No Technical Total 1043 1125 93% 95% No

Staff from four groups did not meet the trust target of 95% for appraisal. However, the overall rate was 93%

Medical staff by site / location Site or location 29 January 2018 – 29 January 2019

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Staff who Eligible Completion Trust Met received an staff rate target (Yes/No) appraisal Wimborne Community Hospital 1 1 100% 95% Yes

Nursing staff by site / location 29 January 2018 – 29 January 2019 Staff who Site or location Eligible Completion Trust Met received an staff rate target (Yes/No) appraisal 11 Shelley Road, Boscombe 7 7 100% 95% Yes 1a Moorland Parade 6 6 100% 95% Yes 55 High West Street 1 1 100% 95% Yes Abbotsbury Road Surgery 2 2 100% 95% Yes Acland Road, Dorchester 4 4 100% 95% Yes Alderney Hospital 15 15 100% 95% Yes Atrium Health Centre 3 3 100% 95% Yes Bridges Medical Centre 4 4 100% 95% Yes Bridport Medical Centre 10 10 100% 95% Yes Canford Health Clinic 1 1 100% 95% Yes Canford Heath Practice 4 4 100% 95% Yes Cerne Abbas Surgery 5 5 100% 95% Yes Christchurch Hospital 4 4 100% 95% Yes Christchurch Medical Centre 6 6 100% 95% Yes East Way Clinic 5 5 100% 95% Yes Evergreen Oak Surgery 5 5 100% 95% Yes Forston Clinic 2 2 100% 95% Yes Frederick Treves House 3 3 100% 95% Yes Hadleigh Lodge 5 5 100% 95% Yes Heatherview Medical Centre 3 3 100% 95% Yes Highcliffe Medical Centre 4 4 100% 95% Yes Juniper Lodge, Dorchester 3 3 100% 95% Yes Kinson Road Medical Centre 8 8 100% 95% Yes Lilliput Surgery 3 3 100% 95% Yes Littlemoor Health Centre DCHS 7 7 100% 95% Yes Longfleet House Surgery 3 3 100% 95% Yes Marine Surgery 3 3 100% 95% Yes Marnhull Surgery 2 2 100% 95% Yes Moordown Clinic 1 1 100% 95% Yes Moordown Medical Centre 6 6 100% 95% Yes Orchid House Surgery 1 1 100% 95% Yes Pelhams Clinic 3 3 100% 95% Yes Penny's Hill Practice 2 2 100% 95% Yes Poole Community Health Clinic 3 3 100% 95% Yes Poole Road Medical Centre 3 3 100% 95% Yes Queens Avenue Surgery 2 2 100% 95% Yes Rosemary Medical Centre 4 4 100% 95% Yes Royal Crescent Surgery 3 3 100% 95% Yes

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Rushmoor House 8 8 100% 95% Yes Shelley Manor Medical Centre 4 4 100% 95% Yes Sixpenny Handley Surgery 4 4 100% 95% Yes Southbourne Surgery 5 5 100% 95% Yes Sturminster Newton Medical Centre 6 6 100% 95% Yes Swanage Community Hospital ISC 9 9 100% 95% Yes Swanage Health Centre 4 4 100% 95% Yes The Adam Practice 1 1 100% 95% Yes The Grove Surgery, Christchurch 2 2 100% 95% Yes The Harvey Practice 6 6 100% 95% Yes Wareham Community Hospital 1 1 100% 95% Yes West Howe Clinic 16 16 100% 95% Yes Westminster Memorial Hospital 1 1 100% 95% Yes Whitecliff Mill St Practice 6 6 100% 95% Yes Kings Park Hospital 16 17 94% 95% No Quarter Jack Surgery 13 14 93% 95% No Parkstone Health Clinic 9 10 90% 95% No Wimborne Community Hospital 18 20 90% 95% No Barn Surgery 8 9 89% 95% No Wareham Health Centre ICS Purbeck 8 9 89% 95% No Westhaven Hospital ICSWP 8 9 89% 95% No Bridport Community Hospital IS 7 8 88% 95% No Blandford Community Hospital 6 7 86% 95% No St Leonards' Community Hospital 15 18 83% 95% No Wool Wellbridge Surgery, Ringwood 4 5 80% 95% No Weymouth Community Hospital IC 3 4 75% 95% No Yeatman Hospital ICSND 5 7 71% 95% No Acorn Buildings - St Leonards 4 6 67% 95% No Farmhouse Surgery Christchurch 2 3 67% 95% No Ferndown Health Clinic 6 9 67% 95% No Wallisdown Heights 2 3 67% 95% No Royal Manor Health Centre 1 2 50% 95% No Westbourne Medical Centre 2 4 50% 95% No

However, it should be noted that some percentages were skewed when there were few nursing staff in some locations and were not truly representative as overall, 93% of nursing staff had had an appraisal.

Allied health professionals by site / location 29 January 2018 – 29 January 2019 Staff who Site or location Eligible Completion Trust Met received an staff rate target (Yes/No) appraisal 11 Shelley Road, Boscombe (T) 19 19 100% 95% Yes Acorn Buildings - St Leonards 2 2 100% 95% Yes Alderney Hospital (T) 19 19 100% 95% Yes Atrium Health Centre 4 4 100% 95% Yes Bridges Medical Centre 1 1 100% 95% Yes Bridport Medical Centre 1 1 100% 95% Yes

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Buckland Centre, 9 Shelley Road 5 5 100% 95% Yes Christchurch Hospital 5 5 100% 95% Yes Coastal Lodge - 26 Knyverton Road 1 1 100% 95% Yes Ferndown Health Clinic 4 4 100% 95% Yes Frederick Treves House 1 1 100% 95% Yes Littlemoor Health Centre DCHS 2 2 100% 95% Yes Maiden Castle Road 2 2 100% 95% Yes Parkstone Health Clinic 7 7 100% 95% Yes Peacemarsh Surgery (T) 1 1 100% 95% Yes Pelhams Clinic 3 3 100% 95% Yes Poole Community Health Clinic 8 8 100% 95% Yes Poole Hospital 6 6 100% 95% Yes Poole NHS Healthcare Centre (B 1 1 100% 95% Yes Portland Hospital ICSWP 3 3 100% 95% Yes Royal Bournemouth Hospital 4 4 100% 95% Yes Unit F2 1 1 100% 95% Yes Westbourne Medical Centre 1 1 100% 95% Yes Westhaven Hospital ICSWP 5 5 100% 95% Yes Westminster Memorial Hospital 9 9 100% 95% Yes Weymouth Community Hospital IC 11 11 100% 95% Yes Winton Health Centre 1 1 100% 95% Yes Wyke Regis Health Centre 1 1 100% 95% Yes St Leonards' Community Hospital 20 21 95% 95% Yes Wareham Community Hospital (T) 18 19 95% 95% Yes Blandford Community Hospital I 14 15 93% 95% No Yeatman Hospital ICSND 11 12 92% 95% No Wimborne Community Hospital (T 10 11 91% 95% No Bridport Community Hospital IS 8 9 89% 95% No Kings Park Hospital (T) 7 8 88% 95% No Swanage Community Hospital ISC 7 8 88% 95% No Acland Road, Dorchester (T) 5 6 83% 95% No

It should be noted that some percentages were skewed when there were few allied health professional staff in some locations. Overall, 96% of allied health professional had had an appraisal which exceeded the trust target.

(Source: Universal Routine Provider Information Request (RPIR) – Appraisals tab)

Multidisciplinary working and coordinated care pathways The trust had a single point of access system. The single point of access (SPOA) service coordinated care and treatment for patients receiving care under the community adults service. The single point of access (SPOA) was based at St Leonards community hospital and went live in September 2018. The pathway for hub referrals had been finalised using the SPOA and had gone to the trust board to be approved and rolled out across the other developing hubs. Staff told us the hubs had created efficiencies as the patient was only triaged once. Information about referral criteria to community services was now clear. This was an improvement on the last inspection on October 2015.

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All health professionals could refer into the SPOA which had access to the community, local hospital, social services and mental health electronic systems. The SPOA had links with local authority and social services in order for all the services to work together and prevent duplication. Since the system went live it has managed 3,000 referrals. A referral made to the SPOA would be triaged by a clinician on duty who would send the referral to the most appropriate service to provide the care pathway for the patient. This meant that the patient had one assessment, were involved in planning their care and received care from most appropriate health clinician to utilise the full skill mix of the teams. Staff from different disciplines worked together as a team to benefit patients. The trust had two types of multidisciplinary teams, Community Intermediate Care Services (CICSs) Bournemouth and Poole) including Rapid Response, and Integrated Community Rehabilitation Teams (ICRTs) (Dorset). The aim was to enable patients to regain a maximum level of independence where possible and to live as independently as possible. The teams supported people to prevent an unplanned admission to hospital where possible, supported timely and early discharge from hospital, avoid admission into long term health care, provided rehabilitation and reduce dependency on long-term care packages. Staff told us that ‘teams worked together for seamless care for patients. Locality managers told us that their teams were working closely with care homes. They offered training in, for example, tissue viability, recognising the deteriorating patient and contractures. This is what the care homes wanted. Multidisciplinary working supported effective care planning and delivery for adults with long term conditions and complex needs. All CICSs, ICRTs, Rapid Response teams and district nursing, formed an important part of locality hubs. The multidisciplinary teams worked together to manage the proactive and reactive needs of people who were frail, elderly or had complex needs. The multidisciplinary team was made up of a number of teams and services such as; • GPs and Medical Consultant • District Nursing, • Community Matrons, • Allied Health Professional such as occupational and physiotherapy • Pharmacy, • Older Peoples Mental Health Team, • Social Care, • Voluntary sector. At this time the hubs only managed physical health with mental health input when required. The service was planning to fully include mental health teams in the same way as physical health teams. However, joint visits with physical and mental health teams were already happening. Staff gave us an example of how the integrated system worked. A district nurse visited a patient and their relative who had both fallen. The paramedic was still in attendance. The district nurse rang a hub and organised a community hospital bed for them both on the same ward. The couple both received rehabilitation and went home. This prevented the couple from attending the emergency department of the local acute trust, kept them together and discharged them home together. This demonstrated the hub arrangement worked effectively when patients’ needs suddenly increased.

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Each hub ran a ‘virtual’ ward, on the electronic system, for people who need intensive support, working with local GP practices to identify people with rising frailty and patients discharged from hospital as 24-48 hours post discharge was deemed a high risk for patients. Patients were identified by any health professional and placed on virtual ward. The multidisciplinary team met weekly to discuss the patients and their needs, which were recorded in their notes in real time and all services could access the notes. The ward round was led by health and social care coordinators and referrals to other services could be made immediately and tracked for follow up. Patients usually stayed on the virtual ward for one to two weeks. The medical consultant visited patients at home if required and could request the GPs if the patient required further medication. When the patient had improved they were then referred back to their previous community care or admitted to hospital if their clinical condition required. The community neurology team jointly managed and reviewed patients with neuro-muscular conditions every six months with a local acute trust. As the aim was to keep patients out of hospital, the service worked closely with speech a range of health professionals. For example, speech and language therapists to promote and maintain good oral health. Also, orthotics to provide bespoke and specialised equipment such as collars to maintain good neck control and braces to prevent foot drop. Staff worked closely with the local hospice and attended gold standard framework meetings regularly to discuss their joint patients. There were arrangements for working with social workers and social care providers to help plan and deliver care, treatment and other support to people in a holistic and joined up way. This was achieved through the use of the single point of access and contact with other social care teams. As this system was in its infancy, it was too early to measure its effectiveness.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff supported patients to make decisions on their care for themselves. They understood the trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly. Staff understood and explained the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005. They understood the importance of obtaining consent before providing care or treatment interventions and completed the associated documentation of consent before care and treatment was given. Staff knew about best interest decisions that had been made on behalf of a patient if they lacked the mental capacity to make a certain decision. We saw examples of the documentation which needed to be completed by staff when a patient lacked mental capacity. Staff gave us examples of what happened when patients did not have capacity to make decisions, including how they made best interest decisions.

Mental Capacity Act and Deprivation of Liberty training completion

The trust set a target of 95% for completion of Mental Capacity Act training.

From 29 January 2018 to 29 January 2019 the trust reported that Mental Capacity Act (MCA) training had been completed by 93% of staff within community health services for adults.

The trust did not provide data on Deprivation of Liberty training.

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A breakdown of compliance for MCA courses from 29 January 2018 to 29 January 2019 for medical staff in community services for adults is shown below:

Number of Number of staff eligible Completion Target Target met Training module name trained staff (%) (%) (Yes/No) (YTD) (YTD) Mental Capacity Act 6 7 86% 95% No

The trust did not meet the target for MCA training relevant for medical/dental staff. However, it should be noted that the percentage was skewed when there were few medical staff and were not truly representative as overall, six out of seven medical staff had completed the training.

A breakdown of compliance for MCA courses from 29 January 2018 to 29 January 2019 for nursing and midwifery staff in community services for adults is shown below:

Number of Number of staff eligible Completion Target Target met Training module name trained staff (%) (%) (Yes/No) (YTD) (YTD) Mental Capacity Act 407 433 94% 95% No

The trust did not meet the target for MCA training relevant to nursing and midwifery staff. However, it should be noted that the completion percentage was 94%.

A breakdown of compliance for MCA courses from 29 January 2018 to 29 January 2019 for allied health professionals in community services for adults is shown below:

Number of Number of staff eligible Completion Target Target met Training module name trained staff (%) (%) (Yes/No) (YTD) (YTD) Mental Capacity Act 233 259 90% 95% No

The trust did not meet the target for MCA training relevant to allied health professionals. However, it should be noted that the completion percentage was 90%.

(Source: Universal Routine Provider Information Request - Training tab)

Deprivation of Liberty Safeguards From 1 January 2018 to 31 December 2018 the trust reported that 278 standard and 275 urgent Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority. None of which were pertinent to community health services for adults.

The trust told us that across all services, 19 DoLS direct notifications were sent to CQC. However, CQC received 324 direct notifications from the trust between 1 January 2018 to 31 December 2018. These numbers do not match across the two sources. Under HSCA legislation, all DoLS applications should also be sent to the CQC in the form of a direct notification so this is important.

The number of DoLS applications made during this inspection was not comparable to the last inspection.

(Source: Universal Routine Provider Information Request (RPIR) – DoLS tab)

Staff understood the relevant requirements of legislation and guidance for Deprivation of Liberty. The staff we spoke to had not been involved in the deprivation of liberty for a patient, they

Page 63 understood and explained the process to us. They also showed us where to access trust guidance.

Is the service caring?

Compassionate care Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity and supported their individual needs. We saw staff interact with patients and relatives in a positive, respectful and compassionate manner. They introduced themselves to the patients in line with the NICE QS15 (Statement 1, patient experience in adult NHS services). We observed that staff recognised and respected patient’s personal, cultural, social and religious needs. We saw examples of caring for patients with kindness and compassion. For example, we witnessed a nurse make tea for a patient who was struggling to make one for themselves and help the patient organise their diary following the patient's confusion over appointment dates. Staff shared examples of where they treated patients with compassion and kindness. For example, at Alderney Hospital, staff had rearranged a ward, so an elderly couple admitted to the hospital could be placed in adjoining beds. Staff told us they wanted to make the couple's stay at the hospital as comfortable as possible. We spoke with patients and their relatives and all praised the staff and the care they received. Comments from patients and their relatives included: “The district nurses are great. They are very caring, and they attend to our needs. We are grateful for their help”, “They are always cheerful, and they always address our needs, we could not manage without them”, “The care can't get any better, we are very happy with the team”. The trust collected feedback from patients using the NHS Friends and Family Test. During April 2019, 94% of the 3,371 people who provided feedback on the community services said they would recommend the service to friends and family if they needed similar care or treatment. The Parkinson’s disease six-month review service completed a patient satisfaction questionnaire from May 2018 to April 2019. This showed 87.5% of patients surveyed were ‘extremely likely’ to recommend the service to friends and family. Positive comments included ‘I have always been treated with respect and having this care has enabled me to carry on a fairly normal life’, ‘I can’t fault the care I have been given’ and Always available for help is we need it’. Also, patients were asked if they felt involved as much as they wanted to be in decisions about their care to which 82.5% answered yes, definitely. When asked if staff were caring, 97.5% of patients answered yes. Staff took the time to interact with people who use services and those close to them in a respectful and considerate way. Staff showed an encouraging, sensitive and supportive attitude to people who use the service and those close to them. For example, on a home visit we observed a nurse listening and making suggestions to a patient who was frustrated about the impact their physical health was having on their life. On another home visit, we witnessed a nurse encourage and advising a new nursing mother who was struggling to find time to eat. We also observed a rehabilitation fitness group where we saw staff allowing participants time to complete exercises and praise patients for their efforts. Staff told us that at the end of the course patients received a certificate of achievement. Staff understood and respected the personal, cultural, social and religious needs of people and how these may relate to care needs, and they took these into account in the way they delivered services. For example, a nurse visited a patient with a health issue, who would not normally qualify

Page 64 for a home visit. The patient was geographically isolated and caring for two young babies but required a wound dressing and monitoring for infection. The patient was unable to get to the surgery and told us that they were “so grateful for the visits as I am unable to get out. It enables me to get through the day at present.” Services and staff made sure that patients’ privacy and dignity needs were understood and always respected, including during physical or intimate care and examinations. On home visits where we accompanied staff, staff always introduced themselves to the patient (and their carers or family where applicable) and sought consent for us to be present at the visit. We observed nurses treating patients with respect and dignity, including during physical examinations. Staff responded in a compassionate, timely and appropriate way when patients experienced physical pain, discomfort or emotional distress. We observed nurses listen and give advice to patients on pain management. A patient we spoke to told us that when they had experienced catheter pain, the district nurses visited them "straight away and sorted it out". We witnessed nurses frequently checking on patients to find out if they were in any pain. This included when nurses were applying compression bandaging (a form of dressing for legs) and taking blood from patients. When observing a focus fitness group session run by the Bournemouth and Pool Community Therapy Team, staff responded quickly and appropriately to a patient who became unwell. Staff helped the patient sit down, ensured they were hydrated and took their observations, as well as informing medical staff to review the patient. The trust ensured that patients receiving care in their own home were able to give valid feedback. The Bournemouth and Poole Community Therapy Team ran regular patient focus groups for recently discharged patients and their carers to discuss their experiences, the last one in March 2019. The team told us that they reported on the feedback from these meetings and developed an action plan on how the service could be improved. Staff in the team also said us they would soon be offering patients the opportunity to feedback in their homes during appointments with the team by completing a questionnaire on an electronic tablet. In the community neurology team, texts were sent to patients reminding them to complete a patient satisfaction survey. Using the electronic system ensured patients did not receive a survey invite from every service that visited them. Patients could also access a link by email or complete a paper copy of the survey as an alternative. This was performed not more than every six months. Staff told us the response rate was 35%, which exceeded their expectation of 8-12% and that initial feedback was very positive. Patients and those close to them were also able to share their experience by making suggestions, complaints or compliments on the trust’s website. This was easy to access by clicking the ‘Patients and Visitors’ tab at the top of the front page of the website. Staff showed an encouraging, sensitive and supportive attitude to people who used services and those close to them. On visits with district nurses, we found they treated the patients with dignity and compassion. The district nurses displayed a compassionate manner towards patients and relatives. They were caring and considerate to the needs of the patients. Explanations were given about procedures performed and pain levels were discussed. For example, the patient was experiencing pain for which Paracetamol was not working. The nurse suggested alternative pain relief and said she would discuss with the GP if the pain did not settle. Staff were committed to work in partnership with patients and their relatives, from care planning to care delivery. Patient’s individual preferences and needs were always reflected in how care was planned and delivered. For example, a patient had a leg wound dressed that had almost healed. The nurse discussed with the patient about her level of mobility and the patient decided she Page 65 wished to attend the surgery in future for dressing changes. The nurse said she would arrange this and asked if the patient had any further problems.

Emotional support Staff considered the emotional needs of the patient alongside their physical needs. Patients told us they felt supported emotionally by the community teams. We observed patients talking to community staff about emotional, personal issues and saw how staff dealt with these sensitively. Patients told us how they felt comfortable to talk to staff and felt they could raise any worries or concerns with them. People were given appropriate and timely support and information to cope emotionally with their care, treatment or condition. Staff said that where appropriate they referred or signposted patient's and relatives to other community services, including support groups and voluntary agencies, for emotional and mental health support with their care. Staff made suggestions about services and resources available to carers and family members. The trust website also had a page dedicated to carers, including family members. This included information on assessments for carers on how their caring responsibilities affected their lives physically, mentally and emotionally. The page also listed other resources and sources of help in the area, including local support groups. Staff understood the impact that patient care, treatment or condition had on their wellbeing and on those close to them, both emotionally and socially. Community nursing and intermediate care teams considered and asked about the welfare of patients and those close to patients during home visits. Nurses asked how they were managing and whether they could be of any further support. For example, on a patient visit, the district nurse dealt with the patient then asked the wife of a patient, who was also caring for their grown-up disabled daughter, what support they could offer the family including their daughter. This was evidence of true holistic and individualised care for the patient and their family. The service worked with voluntary agencies to support patients and families post diagnosis. The community neurology team holistically assessed their needs patients and relatives and signposted them to relevant voluntary groups for help and support. For example, Motor Neurone Disease Association. They also signposted patients to other forms of help such as exercise classes and accessible transport. The Bournemouth and Poole community rehabilitation team also told us that following holistic assessment of patients, they referred patients to several other services for example, advocacy, financial assistance or equipment.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. treatment. Staff involved patients and those close to them in decisions about their care and treatment. Staff also communicated with people so that they understood their care, treatment and condition and any advice given. We observed staff communicate effectively with patients to ensure that they had relevant information to make decisions about their care. Staff took the time to interact with patients and their relatives. The home visit appointments and rehabilitation fitness sessions we observed did not feel rushed. Staff took the time to talk with patients in a manner and language that suited their needs. Staff explained complicated medical information in simple terms to ensure patients and, where applicable, those close to them understood important information.

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This helped to reduce anxiety and concern for patients and those close to them. When patients asked questions, staff took the time to answer in a way which increased patients’ understanding. Staff communicated with people when their protected or other characteristics made this necessary to reduce or remove barriers. Staff appreciated the demographics of the county, including people for whom English was not their first language. Staff told us that the trust had a translation service to assist them in delivering informed care to all patients. Staff told us that leaflets produced by the trust for patients and those close to them, including leaflets explained the Community Support Worker Service and the Bournemouth and Poole Community Therapy Team, were available in additional languages and alternative formats so that they were accessible to as many people as possible. We also found that the trust’s website could be viewed in several different languages. Staff involved people who used services and those close to them in planning and making shared decisions about their care and treatment. We observed many examples of how staff included patients and those close to them in making decisions about their care. For example, staff made efforts to encourage the involvement of patients and those close to them in decisions about their care through personalised care planning. Staff said that it is about “what is important” to patients and about patients taking “ownership” of their care plan. We were shown care plans by staff at Alderney Hospital and the district nursing team based in Moordown Medical Centre. These care plans began with a statement of what was important to the patient, written in the first person, followed by a section on the views of the carer. The care plans also included the goals set by the patient. The Bournemouth and Poole Community Rehabilitation Team told us that all patients referred to the team were asked want they wanted from the service. The team explained that this focussed on the goals the patient wanted to achieve. Patients were active partners in their care. Staff made sure that people who used services and those close to them were able to find further information, including community and advocacy services, or ask questions about their care and treatment. At the Dorset Wheelchair Service, we saw posters for the trust’s Patient Advice and Liaison Service (PALS) throughout the premises. This was also the case in other services we visited. The leaflets provided to patient's and those close to them included information on seeking further information as well as contacting PALS. Service user’s carers, advocates and representatives including family members and friends identified, welcomed, and treated as important partners in the delivery of their care. The community neurology service’s steering group included patients, family members, carers. Feedback we received from patients, carers and family members supported our findings that they were identified, welcomed and treated as important partners in the delivery of care for patients. Comments from patients included: “They work with the family as a team”. This was in line with statements on the trust’s website that [carers’] “knowledge will be vital in helping us do our best” service users. Staff supported people to make and review choices about information sharing. On a home visit we witnessed a nurse ask a patient who was living with others whether the patient was happy for the nurse to leave a copy of their care plan with the patient. Staff also told us that they keep information in care plans to a minimum to give patient's as much control over the information they share with others.

Is the service responsive?

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Planning and delivering services which meet people’s needs People could access the service closest to their home when they needed it. Patients had access to timely care and treatment. The service worked well with other health and social care providers to meet the needs of patients. Intermediate care and rehabilitation teams (ICRT) were based in community hospitals such as Shaftesbury, Blandford and Bridport, and developed from community occupational and physiotherapy services. Their role was admission avoidance to acute hospitals, long term therapy for patients and supported discharges. Some teams only provided acute admission avoidance and supported discharges as, in some areas, there were long term therapy teams. Patients were referred to a ‘single point of access’ in the trust who triaged calls and passed them to the correct service. The calls were triaged by healthcare professionals. However, patients could refer also themselves directly to the ICRT. When patients required a wheelchair, staff visited them at home to look at the home environment, ask the patients about their needs and decide the type of wheelchair that would be most appropriate for the patient and their environment. Wheelchair repair and maintenance could be carried out in patient’s homes or the wheelchair picked up and delivered back, whichever was convenient for the patient. The community neurology team reviewed patients in their own home, when required when attending a clinic could be problematic. Community physiotherapists and assistants ran a stroke rehabilitation exercise group. This was a 12-week programme for patients that had been discharged home from a stroke unit. Each group had patients of similar levels of ability. We observed this class as part of our inspection. The patients were very positive in their feedback on this class. They felt they were improving their balance, mobility and strength. The service worked with other health and social care providers to meet the needs of people, particularly those with complex needs, long term conditions or life limiting conditions. Community teams managed complex patients and those with a life limiting illness in the community through use of a ‘virtual ward’. The aim of the virtual ward was to support frail patients at home with an enhanced package of healthcare and avoid admission to hospital. Patients were seen at home and medical support was provided by a medical consultant and advanced nurse practitioners. If a health professional visited a patient and had concerns, they would telephone a hub and the patient would be placed on the virtual ward for close monitoring. There was no fixed criteria and no limits to the number of patients on the virtual ward as it was based on clinical judgement. Each week at a multidisciplinary meeting, the patients progress would be discussed, and each team provided details of their input. This meeting was led by a health and social care coordinator. The virtual ward allowed community teams to manage complex patients in the community. It also provided continuity of care and therapy in the patient’s home. Staff were very proud of this service as it was driven by the needs of the patient. The trust had community therapy teams for rehabilitation of patient in their own homes. Patients were treated for short periods of time and could be re-referred if required. The team dealt with patients with long term conditions and shorter more acute rehabilitation requirements, for example stroke patients, fractures, patients who fall and Parkinson’s disease. When stroke patients finished their two-week episode being seen by the early supported discharge team (ESD), the long-term conditions team took over. Referral was made to the long-term conditions team at the same time as the ESD, therefore care was seamless for the patient. The team worked with patients to write achievable goals with timeframes, they told us it was ‘about empowering the patient to manage their own condition’.

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The service was accessible to all who needed it and took account of patients’ individual needs. Patients had access to timely care and treatment. Community health services for adults delivered care and treatment to patients across Dorset. Services were provided in health centres, community hospitals and patients homes. The trust had a ‘in reach’ liaison nurses who worked in the local acute hospitals. The nurse identified patients appropriate for early supported discharge and referred them to the ICRT. The ICRT also worked closely with local social services and their reablement team as part of integrated health and social care. This improved communication between health and social care and allowed the patient to have the correct level of care at home. This stopped inappropriate referrals and duplications of service. The joint strategic needs assessment (JSNA) was no longer used to develop the community adults service. The JSNA looked at the current and future health and care needs of local populations to inform and guide the planning and commissioning (buying) of health, wellbeing and social care services within a local authority area. However, the local JSNA was no longer produced as a written document. Those making enquiries were signposted to intelligence webpages of Public Health Dorset site and the Dorset Sustainability and Transformation Plan for local health and care. Facilities and premises were appropriate for the services being delivered. Nurses, physiotherapists, occupational therapists, rehabilitation assistants, health and social care coordinators, call handlers and healthcare assistants were all based at the clinical hubs. Staff sat within their teams and had access to a desk space, computers and telephones. Staff told us that multidisciplinary team working was much easier being based together. Communication about patients who were being seen by different healthcare professions across different teams was more effective. In the wheelchair service, staff had consulting rooms which had good access for wheelchair users and were spacious, uncluttered and tidy. Staff had access to translation services to help patients with communication. Staff told us how they could access translation services when required.

Meeting the needs of people in vulnerable circumstances Services were delivered, made accessible and coordinated to account for the needs of different people. We found healthcare professionals worked together to ensure the most appropriate staff provided care and treatment to patients with complex needs. This started at the triage stage when the call came into the single point of access. It was reviewed and sent to the most appropriate team and health care professional to manage the patient’s individual needs. This meant patients did not receive duplicate care visits and received personalised care and treatment. District nurses worked from 8 am till 8 pm with planned and reactive visits, seven days a week. The night nursing service started at 4 pm and worked until 8 am the next morning seven days a week. They completed any work from the day time and reacted to calls from patients, GPs, the single point of access and the 111 service. The integrated care and rehabilitation team worked from 8 am to 8 pm seven days a week. Between the hours of 8 am and 6 pm, a therapist or nurse was rostered to provide urgent response. After 6 pm the night nursing team supported the service to ensure patient safety. The trust set the rapid response team a target of 98% to respond and see patients within two hours of referral. In March 2019, the team achieved 100% and also achieved 100% on a cumulative three-month time span.

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The community neurology team supported and monitored patients with long term neurological cognitive and physical conditions, 40% of their caseload were patients with Multiple Sclerosis. Patients could be referred by any health professional through the trust electronic referral system. Patients on their caseload were never discharged. Patients categorised as ‘SOS’ patients had not been actively managed for five years but could contact the team at any time should the need arise. The team reviewed some patients in their own home, when required. This review identified what the patient and carer wanted and looked holistically at their needs. Physiotherapy was arranged for patients initially for one or two sessions. If more therapy was needed, the team would work closely with the intermediate community rehabilitation team with joint appointments if required. The community neurology team would also have joint appointments with the continence service and the patient. The community neurology team also made bespoke laminated posters of the patients themselves to ensure they used and wore their splints properly. Staff told us that patients liked to see themselves using their equipment properly. There was a template for the poster so that it could be personalised for each patient. Reasonable adjustments were made so that people with a disability, mental health or complex needs could access and use services on an equal basis to others. Community nursing teams and intermediate care and rehabilitation teams visited patients in their own homes. This meant people with disabilities could access the service on an equal basis to others. For example, a community matron took photographs of patient’s inhalers and put them on a laminated poster for the patient with timings for their administration. This was also completed for diabetic patients and included when to take their blood sugar level readings and their medication times. This meant patients had access to a personalised poster explaining when and how to take their medicines. Staff worked across services to coordinate people's involvement with families and carers, particularly for those with multiple long-term conditions. We observed staff involved with patients living with long term conditions and found they provided a holistic approach to patient care with a clear understanding of the patient’s needs. For example, the community neurology team completed a full holistic assessment on patients, in their own home or clinic, whichever was convenient for patients. Services were coordinated and delivered to ensure people who were approaching the end of their life. The trust did not have a palliative care team as palliative care was delivered by all staff. Staff told us they received training for palliative care from the trust and from a local hospice. Funding had been secured from the Integrated Community and Primary Care Services for rehabilitation assistants to provide ‘double handed’ care for end of life patients. Advance care planning for these patients was recorded on the electronic system which could be accessed and amended by all staff. Staff told us patients were given a paper copy of their care plan which was replaced when their needs changed.

Access to the right care at the right time Services provided reflected the needs of the population served and ensured flexibility, choice and continuity of care. The trust minimised the length of time people had to wait for care treatment or advice. The community health service for adults had a target of 80% for the percentage of urgent referrals contacted within four hours and 90% to be contacted within 24 hours. From January to December 2018 the trust achieved both targets.

Technology was used to support access to care and treatment. The trust provided ‘Telehealth’ for patients who wanted to manage their long-term condition themselves. This was run by an external company. Originally commissioned for heart failure and chronic obstructive pulmonary disease, it Page 70 was now open to any patient in Dorset. Patients had predetermined limits for their vital signs (pulse, blood pressure, respiratory rate, temperature and oxygen saturation). Clinicians were contacted if the patient’s observations were not within these limits. Relatives and carers could also input data if the patient was unable to. If the patients became ill, they were referred to a hub and a review of their condition was arranged. This system was not suitable for all patients as it may have caused unnecessary anxiety. This has now been extended to care homes on a pilot study. Initial results on whether this has resulted in fewer hospital admissions and 999 emergency calls is to be produced in May 2019.

Referrals

The trust did not report on days from referral to initial assessment or days from initial assessment to treatment. However, the trust has identified the below services in the table as measured on ‘referral to treatment’. The trust met the referral to treatment target in 26 out of the 28 targets listed. The number of days from referral to initial assessment and assessment to treatment during this inspection is not comparable to the last inspection.

Name of Name of Service Type Days from referral to Comments, clarification hospital in-patient treatment site or ward or location unit

National / Actual

Local Target (median)

Days from referral to initial assessments Multiple Podiatric 92% within are not reported. Days from referral to Various 97.6% sites Surgery 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various General Surgery 92.0% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Urology 94.2% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple Trauma & 92% within are not reported. Days from referral to Various 94.5% sites Orthopaedic 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple Ear Nose & 92% within are not reported. Days from referral to Various 96.3% sites Throat 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Ophthalmology 83.5% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple General 92% within are not reported. Days from referral to Various 97.5% sites Medicine 18 weeks treatment are recorded, validated and reported

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Days from referral to initial assessments Multiple Gastroenterolog 92% within are not reported. Days from referral to Various 100.0% sites y 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Cardiology 99.4% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Rheumatology 98.2% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Elderly Medicine 100.0% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Oral Surgery 91.4% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Gynaecology 98.4% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Other 97.2% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Tissue Viability 97.0% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Dietetics 98.7% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple Continence - 92% within are not reported. Days from referral to Various 92.6% sites Clinic 18 weeks treatment are recorded, validated and reported Speech and Days from referral to initial assessments Language are not reported. Days from referral to Multiple 92% within Various Therapy (Adult 99.8% treatment are recorded, validated and sites 18 weeks Learning reported Disability) Days from referral to initial assessments Multiple Ear, Nose, 92% within are not reported. Days from referral to Various 99.5% sites Throat 18 weeks treatment are recorded, validated and reported Musculoskeletal Days from referral to initial assessments Multiple Service (MSK) 92% within are not reported. Days from referral to Various 98.6% sites (previously OMS 18 weeks treatment are recorded, validated and and DOTS) reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Podiatry 99.9% sites 18 weeks treatment are recorded, validated and reported

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Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Vasectomy 98.5% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Audiology 97.1% sites 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 92% within are not reported. Days from referral to Various Wheelchairs 94.3% sites 18 weeks treatment are recorded, validated and reported Physiotherapy Days from referral to initial assessments (Outpatients) are not reported. Days from referral to Multiple including 92% within treatment are recorded, validated and Various 97.5% sites Dermatology UV 18 weeks reported Light Therapy - Yeatman Days from referral to initial assessments Multiple Chronic Fatigue 92% within are not reported. Days from referral to Various 97.5% sites Service 18 weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 95% within 6 are not reported. Days from referral to Various Endoscopy 96.3% sites weeks treatment are recorded, validated and reported Days from referral to initial assessments Multiple 95% within are not reported. Days from referral to Various Dermatology 95.3% sites 18 weeks treatment are recorded, validated and reported (Source: CHS Routine Provider Information Request – Referrals tab)

Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. Patient’s complaints and concerns were listened to and used to improve the quality of care. The trust policy for complaints covered the procedure for managing complaints, roles and responsibilities of the staff and timescales for dealing with complaints. We reviewed four complaints, two concerning values and behaviour, one for communication and one for privacy, dignity and wellbeing. Complainants received a full written response from a manager. In each case the complaint was handled sensitively, lessons learned noted and actions planned to prevent recurrence. Patients were aware of how to report concerns about their care and treatment. We saw leaflets in patients notes and homes displaying how patients could make a complaint or who to contact if they wanted to do so. Patients and relatives reported they would feel confident in raising complaints or concerns if they had any. From 1 January 2018 to 31 December 2018 the trust received 83 complaints about community services for adults (21.7% of total complaints received by the trust). The trust took an average of 21 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be dealt with within 21 working days.

A breakdown of complaints by subject and site is shown below:

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Community Adults Total

Type of complaint Number of complaints Percentage of total Values and Behaviours 27 33% Access to Treatment or Drugs 18 22% Communications 10 12% Clinical Treatment 7 8% Patient Care 7 8% Appointments 6 7% Privacy, Dignity, Wellbeing 3 4% Trust Admin/Policies/Procedures 2 2% Admission/Discharge 1 1% Consent 1 1% Prescribing 1 1% Total 83 100%

Compliments The trust did not hold compliment letters centrally. Compliment letters and cards were held by individual teams. We saw letters and complimentary cards on display for each team/service we visited. From 1 January 2018 to 31 December 2018 the trust received 1762 compliments for community services for adults, which accounted for 43% of all compliments received by the trust as a whole (4077).

Team Number of compliments Wheelchair Service 201 Swanage Hospital - Outpatients 197 District Nursing - Mid Dorset 118 Wimborne Hospital - Endoscopy 104 Intermediate Care - Bridport ICRT 98 IAGP - Wimborne 80 Intermediate Care - Dorchester ICRT 61 District Nursing - North Dorset 57 Intermediate Care - East Dorset ICRT 56 Intermediate Care - Shaftesbury ICRT 52 Wimborne Hospital - Outpatients 48 Dorset Community Pain Service 45 Swanage Hospital - Theatres 45 Podiatry 37 Acquired Brain Injury Rehabilitation Service 34 Complex Leg Ulcer Service 29 Intermediate Care - Sherborne ICRT 29 Swanage Hospital - Radiography 29 Adult Chronic Fatigue Syndrome - ME Service 26 Dorset Bladder & Bowel Continence Service 25 Intermediate Care - Poole PICs 24 District Nursing - Bournemouth East 23 District Nursing - Bournemouth North 23 District Nursing - Christchurch 21 Intermediate Care - Blandford ICRT 20 District Nursing - West Dorset 19 Yeatman Hospital - Outpatients 19 District Nursing - Rosemary Road 18 District Nursing - West Moors/Verwood 18 Intermediate Care - Christchurch ICRT 17 District Nursing - Wimborne 14 Community Matrons - Bournemouth North 13 Bournemouth & Poole Community Therapy Team 12 Dermatology Service 12

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Community Neurology Service 11 Bridport Physiotherapy 10 Night Nursing Service 10 Intermediate Care - Weymouth ICRT 9 Physiotherapy - Swanage Hospital 9 Bridport Hospital - Outpatients 8 Wimborne Hospital - Day Surgery Unit 8 Yeatman Hospital - Physiotherapy 8 Community Matrons - Poole 7 Dorset Musculoskeletal Service (DMSK) 6 District Nursing - Poole Town Surgery/Evergreen Oak/ Carlisle 5 Anti-Coagulation 4 Community Matrons - Bournemouth Central 4 Intermediate Care - Bournemouth (BICS) 4 Intermediate Care - Purbeck ICRT 3 Vocational Services 3 Wimborne Hospital - Physiotherapy 3 Bridport Orthotics 2 Community Matrons - Bridport 2 Dietetics 2 Heart Failure Specialist Nurse 2 Poole Orthotics 2 Westminster Physiotherapy 2 Blandford Orthotics 1 Bridport Hospital - Theatres 1 Community Matrons - East Dorset 1 Diabetes Education Service 1 Diabetic Foot Service 1 District Nursing - Bournemouth Central 1 District Nursing - East Dorset 1 District Nursing - Longfleet Adams/Longfleet House 1 Dorset Musculoskeletal (MSK) - Podiatry Surgery 1 Heart Failure - Matron 1 IAGP - Swanage 1 Outpatients - Alderney 1 Stroke Six Month Review Service 1 Wimborne Hospital - Cardiology 1 Total 1762

(Source: Universal Routine Provider Information Request (RPIR) – Compliments tab) Is the service well-led?

Leadership Managers at all levels in the trust had the right skills and abilities to run a service providing high- quality sustainable care. The service had dedicated and experienced leaders within the clinical hubs. The senior managers and matrons had worked in various clinical and managerial roles before progressing into their senior roles. The senior management team comprised of staff who had completed additional qualifications in district nursing, non-medical prescribing, advanced practitioner and allied health professions. They also held, or were studying for, management qualifications and had community and primary care experience. The senior managers told us that there were also 'robust' leadership courses for the team leads they managed, and that team leads were also able and encouraged to undertaken 360-degree feedback. Senior managers understood the challenges to quality and sustainability, and they had identified actions to address these challenges. Senior managers told us that the main challenge to quality and sustainability they faced related to the workforce, specifically recruitment and retention. Senior

Page 75 managers referred to the geography of the county as one of the reasons why recruitment had been a challenge for some teams. For example, a senior leader gave the example of Weymouth and Portland, which forms the southernmost point of the county, as an area where recruitment has been a challenge because of the distance it took for people to travel to the area. Senior managers told us that another challenge to quality and sustainability was the need to move away from siloed working, both within the service and across the trust. They explained that siloed working affected the quality of care and treatment delivered to patients, as well as being an inefficient use of the trust's resources. Senior managers told us about the actions they had identified to address these challenges. For example, they explained that alongside efforts to recruit, they were placing emphasis on staff retention. One of the senior leaders told us "it's about looking at the staff we've got and helping them to develop and grow". Senior managers referred to various initiatives that had been launched to develop and make the most of the trust's existing workforce. For example, they referred to the training that has been delivered to healthcare assistants to specialise in complex care or to even qualify as nurses. However, senior managers acknowledged this was a challenge for them and that their efforts were still a work in progress. Service leaders were visible and approachable. Staff in the teams we spoke to during our inspection, including the district and night nursing teams, said service leaders were visible and approachable. Staff said that they would feel comfortable approaching leaders in the service. Managers were seen by staff as supportive and took on clinical duties when the service was short staffed. The rural community nursing teams felt isolated at times. However, they felt part of the wider trust and well supported by their nurse managers and area manager. They also felt senior managers were visible. Many of the staff we spoke with knew the chief executive officer (CEO) and some teams told us they had been visited by the CEO as well as the chairman of the board. The service had clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership. Senior leaders told us that there were leadership courses and development courses available for staff, in line with the service and wider trust's efforts to make the most of its existing workforce. Senior managers spoke in particular of a senior leadership development programme that they were currently undertaking. They explained that the board of directors were first to go through this programme and that it has been making its way down the management chain in the trust. Senior managers in the service told us that this programme involved a mixture of training, reflections on individual strengths and weaknesses, and discussions on how to improve the service. Senior leaders also said that they were encouraged to undertake 360-degree feedback to help identify their leadership strengths and development needs.

Vision and strategy The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups. The trust had a clear vision and a set of values, with quality and sustainability as top priorities. In 2015, the trust introduced a five- year strategy (2015-2020) to deliver on its purpose of providing integrated healthcare services to empower people to make the most of their lives. At the same time, the trust introduced its new values, as well as a set of behaviours to inform how it would manage its purpose. The trust’s

Page 76 values were working together for patients, respect and dignity, commitment to quality of care, compassion, improving lives, everyone counts and commitment to learning. The strategy was aligned to local plans in the wider health and social care economy, and services were planned to meet the needs of the relevant population. Senior managers in the service told us that their work, and the trust’s five-year strategy more generally, was informed by national and local plans in the wider health and social care economy. In particular, senior managers referred to NHS England’s Five Year Forward View as well as efforts to collaborate locally with health and care partners for the delivery of the Better Together vision and the Dorset clinical services review. The strategy was informed by needs of the local population including the relatively older age of the people living in the county. There were clear links between the vision and strategy for this service and the overall organisational strategy. Senior managers in the service explained that their work, including the development of integrated community hubs, was based on the trust’s five-year strategy. Senior managers told us that each of their localities has their own plans. In addition, they have plans called key features and functions for respective integrated community and primary services care model, which informed them where they needed to focus. There was a robust, realistic strategy for achieving the priorities and delivering good quality sustainable care. Progress against delivery of the strategy and local plans were monitored and reviewed. Senior managers explained they have an integrated community and primary services dashboard which showed trends and against which they are able to monitor and review their progress. However, they acknowledged that this was only provided part of the picture and that they were working to gather information to develop and monitor their progress. In future, it a template was planned for the whole county to use and collect this information in a more structured way. Staff knew and understood the vision, values and strategy of the service and their role in achieving them. Staff we spoke to across the service, including district nurses, were aware of the trust’s vision and values. Staff told us that the vision, values sand strategy of the service and the trust more broadly was well communicated across the organisation. The vision, values and strategy were developed using a structured planning process in collaboration with staff. Senior managers told us that the vision and strategy for the service reflected the trust-wide vision and strategy which was under review. They said their staff have been involved in workshops as part of the work to refresh the vision and strategy. Senior managers stressed that frontline staff were keenly involved in the development of the vision and strategy.

Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There was a clear patient-centred culture embedded across the community adults service. Staff we spoke to were passionate about the providing holistic care for patients. Patients were at the heart of the service in the way teams cared for them. Staff spoke of supporting patients to remain living independently in the community and this was reflected during the inspection. Leaders we spoke with reported the thing they were most proud of was the level of care staff provided. They also told us about how staff were focused on providing safe and quality patient care regardless of the stresses and challenges they had faced especially with the newer developing hubs.

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The trust had systems and processes to ensure staff met the duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. The trust did not provide training as duty of candour training was not formally monitored. Duty of candour was included in the trust's induction programme which ensured all new starters were provided with relevant information. Duty of candour has been integrated into the Root Cause Analysis and pressure ulcer training packages. An animated video explaining the importance of saying sorry and outlining the steps required to fulfil the requirements of the duty of candour has been produced and is available on the trust intranet to support staff. The Patient Safety team and Serious Incident team supported clinical staff by providing support, advice and guidance. This was an improvement from the last inspection in October 2015 when we found duty of candour training was lacking and there was no formal process for staff to follow. Staff felt positive and proud to work for the trust. Staff felt they were in a better position since the last inspection in October 2015. They were very proud of the relationship with primary care and they felt they now provided a ‘seamless’ service and were more were more resourceful in their working processes. Staff talked to us about the ‘can do’ attitude and the willingness of staff to change and adapt working systems driven by the needs of the patients. They felt they were ‘making a difference for patients. The intermediate care and rehabilitation teams met informally once a month to review what was going well and what needed changing. For example, how they were going to incorporate the plans for Lyme Regis into the existing work plan. Staff told us they felt part of decision-making processes about their work. Staff were also very proud of the individualised care they gave to patients. The trust was very proactive in supporting development opportunities for staff. Staff told us the trust was investing in further education and training to provide a career pathway. This would increase skills of existing staff and to attract and retain new staff. For example, advanced nurse practitioner (ANP) apprenticeships. This was a post graduate programme leading to a recognised ANP qualification which included non-medical prescribing. Staff could go on to complete the full masters programme. This was open to all band six and seven staff. There was a strong emphasis on the safety and well-being of staff. Measures were taken to protect staff who worked alone and as part of a dispersed team working in the community. The trust had a Lone Working policy which staff adhered to. All staff had a mobile phone provided by the trust. Staff called in to their respective teams at the end of their shift and district nurses also called in at 1 pm prior to handover. For the out of hours service, staff called into the district nurse liaison to report they were safe. Some patients had unpredictable behaviour patterns and staff in all community teams usually visited them in pairs for safety. Staff also had code words to report all was well or to raise an alert of danger. This would then be documented and shared with teams for future visits. Staff felt comfortable raising concerns with the leadership of the organisation. Staff were aware and knew how to access the trusts Freedom to Speak up, Raising Concerns and Whistleblowing policy. Staff we spoke to knew who the Freedom to Speak up Guardian was in the trust and how to contact them.

Governance

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There were structures, processes and systems of accountability to support the delivery of the strategy and good quality services. The service monitored waiting times for all services. The long- term conditions, community nursing, community matrons and community therapy teams all achieved performance targets; • people on the caseload with a long-term condition to have an individualised acre plan which was developed with the patient. The team achieved 98.6% against the target 95% • The percentage of urgent referrals contacted within four hours was 97% against the target of 80% • The referrals contacted within 24 hours and given an appointment time appropriate to their clinical need was 91.4% against the target of 90%. These were the latest figures for March 2019. There were clear lines of accountability to support good governance and management. This included clear responsibility for escalating information upwards to the senior leaders and the management team and cascading downwards to the clinicians and other staff. Staff we spoke with were clear about their roles and they understood what they were accountable for, and to whom. Within the service there were several meetings to discuss performance. The trust produced a performance assurance framework for the community adults’ team which was a combined report for all localities. The governance structure was simple and straightforward. Team meetings and leaders contributed to the community matrons, this then fed into locality management group who in turn reported to the integrated community services performance meeting, into the directorate governance meeting and on up to the board. The directorate governance meeting minutes showed which issues were to be escalated to the board. This system also worked from the board back down to the local teams. Staff at all levels were clear about their role, what they were accountable for and to whom they were accountable. Staff were clear about who they reported to in their teams and were clear about the roles and responsibilities of other senior managers. Staff told us they communicated with their team leaders for example, for advice or help with a complex case. Team leads were also available day-to-day in the office for staff to contact and in attendance at service meetings or conference calls to provide support and advice if required.

Management of risk, issues and performance The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust had a comprehensive winter management plan for community services. This was contained in the trust policy called ‘Dorset Healthcare Surge and Escalation Plan. This contained the winter operational plan and escalation requirements for the trust. This ensured older people and people in vulnerable circumstances would continue to receive safe care. Lessons learned from the previous year were incorporated into the current plan, which also included things that had gone well. There were arrangements for identifying, recording and managing risks, issues and mitigating actions. The trust had a risk register which covered the whole of the Community health services for adults. We saw evidence of risks being recorded on the risk registers which were regularly reviewed governance meetings. The risk register had evidence that each risk had been reviewed and rated, and actions were implemented to reduce the impact of the risk. Risks included staffing issues for all disciplines in the service, a breech in the contract to provide complex leg ulcers

Page 79 service and the increase in the number of patients referred to the heart failure nurse specialist. Managers knew their own particular risks on the risk register. The top risks were staffing and lone working. We saw evidence that risk registers were reviewed at directorate governance meetings and regularly updated. The risk register coordinator met with new starters to help them understand the risk register. There was a systematic programme of clinical and internal audit to monitor quality. We saw evidence the community health services for adults conducted clinical audits, including record keeping for community adult services. The service participated in seven clinical audits in relation to this core service as part of their clinical audit programme.

Engagement Public Engagement The trust engaged well with patients to plan and manage appropriate services and collaborated with partner organisations effectively. Patients were engaged, and the wider community, in the design and running of the community service. Cluster leaders and the community service managers attended regular meetings. We attended the steering group for community neurological service where staff, managers, medical consultant and patients discussed the results of the long- term condition survey, the text service to remind patients to complete the survey, transition from paediatric to adult services, the recent successful practice placement by a physiotherapy student and being a pilot site in physical health for reviews over Skype. The team has also developed, with their service users, a leaflet about the team and how it works. This will be available in GP surgery’s, the Multiple Sclerosis service in a local acute hospital and will be sent to patients when they are referred to the service.

Staff Engagement Staff were engaged so that their views were reflected in the planning and delivery of services. At the last inspection in October 2015, staff had felt that changes were made without consultation and without being made aware that changes were happening. At this inspection, staff were much more positive. Staff told us they were heavily involved in the design and set up of the hubs and they felt they had invested a lot of their time and were determined to make the hubs work. The 2018 staff survey was positive for staff as they felt two key measures had improved; ‘I am able to deliver the patient care I aspire to, and, I am able to do my job to a standard I am personally pleased with’. Staff (92%) felt that that the trust took positive action on staff health and wellbeing. Staff were sponsored by the trust to attend national conferences to share good practice. For example, the tissue viability nurse (TVN) was able to attend the Tissue Viability Society conference. The TVN devised a set of posters of the new standardised categories of pressure ulcers which were sent to locality managers to display for staff.

Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

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Staff in the wheelchair service had protected time, one day a week, to work on projects. For example, a wheelchair skills group for patients and also work on pressure relieving cushions and the setting up of a pressure clinic as a preventative measure for patients. The metal health teams were running a pilot to review patients through Skype. The community neurology team wanted to be the next pilot site within physical health to run this type of review. The development of the integrated hubs across the county was planned and acted upon by the teams themselves and was to be put forward for a national award. The tissue viability nurse presented a poster to share good practice at the Wounds UK conference in 2018. The campaign was called ‘Deal with Heels’. Staff had been issued with a card with a reflective surface to take on visits to patients. This made looking at the underside of heels easier and they identified and treated pressure areas earlier. This had resulted the trust achieving a 50% reduction in heel pressure ulcers. Accreditations NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. The table below shows which services within community services for adults have been awarded an accreditation together with the relevant dates of accreditation.

Accreditation scheme Service/Team accredited Services working towards accreditation by not yet awarded Joint Advisory Group on Victoria Hospital Wimborne (2014) N/A Endoscopy (JAG) Swanage Community Hospital (2014) Victoria Hospital Wimborne and Imaging Services Accreditation Swanage to apply February 2019. N/A Scheme (ISAS) Weymouth Community Hospital to apply March 2019. Dorset Healthcare Wheelchair Code of Practice for Disability Service works to these standards Equipment, Wheelchair and N/A but have not applied for Seating Services (CECOPS) accreditation Alderney Hospital, Westhaven Hospital, Bridport Hospital, Alderney Elder Friendly Quality Mark Swanage Hospital, Blandford Hospital Hospital, Yeatman Hospital (2018)

(Source: Universal Routine Provider Information Request (RPIR) – Accreditations tab)

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Urgent care

Facts and data about this service Dorset Healthcare University NHS Foundation Trust is the healthcare provider for community health services for adults serving a population of over 750,000 people and employing around 5,000 staff. The trust provides healthcare to the people in the county of Dorset including urgent care. This is an alternative to accident and emergency (A&E) for a range of minor injuries and urgent medical problems. It is a walk-in service for patients whose condition is urgent enough that they cannot wait for the next GP appointment (usually within 48 hours) but who do not need emergency treatment at an accident and emergency department. This service is available for all service users of all ages registered with an NHS Dorset GP practice and out of area visitors who require urgent care. Community urgent and emergency care are provided in seven minor injury units (MIUs) and one urgent treatment centre (UTC). Services provide walk-in appointments for patients who suffer minor injuries which can be treated outside of an emergency department (ED) by urgent care practitioners. A four hour standard is adhered to and patients can access x-ray, wound assessment, dressings, casts and prescription of basic medicines. Between April 2018 and March 2019, 61,307 patients over the age of 18 and 19,346 patients under 18 years old were seen across all eight sites.

Information about the sites and teams, which offer community urgent care services at this trust, is shown below: Location / Team/ward/satellite Services provided Address (if site name name applicable) Is a nurse led service, where Blandford Blandford Minor Injury registered clinicians are competent Milldown Road, Blandford Community Unit to assess and treat various minor Forum, Dorset Hospital injuries and ailments Is a nurse led service, where Bridport Community Bridport Bridport Hospital - registered clinicians are competent Hospital, Community Minor Injury Unit to assess and treat various minor Hospital Lane, Bridport Hospital injuries and ailments DT6 5DR Is a nurse led service, where Portland Portland Minor Injury registered clinicians are competent Castle Road, Castletown, Hospital Unit to assess and treat various minor Portland, Dorset injuries and ailments Is a nurse led service, where Swanage Swanage Community Swanage Hospital - registered clinicians are competent Community Hospital, Queens Road, Minor Injury Unit to assess and treat various minor Hospital Swanage, Dorset injuries and ailments Is a nurse led service, where Victoria Victoria - Wimborne registered clinicians are competent Victoria Hospital, Victoria Hospital, Hospital - Minor Injury to assess and treat various minor Road, Wimborne, Dorset Wimborne Unit injuries and ailments Is a nurse led service, where Westminster Westminster Hospital, Westminster Hospital registered clinicians are competent Memorial Abbey Walk, Shaftesbury, Minor injury Unit to assess and treat various minor Hospital Dorset injuries and ailments

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Weymouth Weymouth Urgent 3 Melcombe Avenue, Community Urgent Treatment Centre Treatment Centre Weymouth, Dorset Hospital Is a nurse led service, where Yeatman Hospital, Yeatman Yeatman Hospital - registered clinicians are competent Hospital Lane, Sherborne, Hospital Minor Injury Unit to assess and treat various minor Dorset injuries and ailments

(Source: Universal Routine Provider Information Request (RPIR) – P2 Sites tab)

Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. They had training on how to recognise and report abuse and knew how to apply it.

Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.

Paediatric patient information forms differed from adults and had specific questions related to school; social worker, parental responsibility and household members. The electronic patient record system had a national child protection sharing programme embedded which meant safeguarding alerts from elsewhere in the country could be seen by staff.

Staff understood their responsibilities in relation to safeguarding policies and procedures for adults and children. All staff we spoke with could describe examples of what may constitute a vulnerable person, including those at risk of neglect, financial abuse, child sexual exploitation, female genital mutilation, domestic violence and abuse. They told us they accessed safeguarding advisors for adults and children within the trust for additional advice and support when required.

Ten sets of patient notes were audited by the nurse in charge each month. We reviewed patient notes audits for January, February and March 2019 and in all cases, staff checked whether there was a safeguarding flag on the patient’s record to alert them to previous safeguarding concerns; and where appropriate, escalated any concerns in accordance with the trust safeguarding policy.

Staff described examples of safeguarding concerns in relation to children and adults and how they were escalated. We saw written safeguarding records which identified reasons for concern, escalation and immediate actions taken.

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One nurse retained their paediatric nurse registration and attended a monthly multidisciplinary safeguarding meeting chaired by police as well as representatives from the local authority and education. This meeting discussed information and updates about people and families of potential concern in the catchment area. Relevant information from this was shared with local MIUs which provided additional background information should any of the people discussed attend for treatment.

We observed two instances during inspection where consideration was given to the nature of the presenting injuries and whether there were any safeguarding concerns. The practitioners were thorough in their assessment; they justified their reasoning at every stage and reflected this in their notes.

The trust set a target of 95% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses from 29 January 2018 to 29 January 2019 at trust level for qualified nursing staff in community urgent care services is shown below:

29 January 2018 to 29 January 2019 Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No) Safeguarding Children Level 2 12 12 100% 95% Yes Safeguarding Adults Level 2 32 33 97% 95% Yes Safeguarding Children Level 3 17 21 81% 95% No

In community urgent care services, the 95% target was met for two of the three safeguarding training modules for which qualified nursing staff were eligible. (Source: Universal Routine Provider Information Request (RPIR) – Training tab)

We confirmed during inspection that all staff across the seven MIUs and one UTC were either up to date with their Safeguarding Children Level 3 or were booked to complete it in the weeks following inspection. In addition, at least three members of staff from each site attended a study day on domestic abuse in February 2017.

A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.

It was not possible for the trust to extract the actual numbers of safeguarding referrals made by staff from the current trust patient record system. We were told work was underway to collate safeguarding data specific to each core service.

Recruitment and training

The service provided mandatory training in key skills to all staff and made sure everyone completed it.

Training was provided by either e-learning or face-to-face, dependent on the subject. Staff told us they found access to the trusts mandatory training and support information both useful and easy to access. They demonstrated how access was available through electronic systems to support their practice. There were systems to monitor and remind staff when training was due; the unit lead Page 84

nurse or matron from the adjoining community hospital had oversight of mandatory training and sent emails to staff to remind them when training was due.

All MIU and UTC staff were trained to deliver immediate life support to both adults and children, this included anaphylaxis training for severe allergic reactions. Staff treating children under the age of 18 completed paediatric minor injury training to ensure they could provide safe care to those children.

Where there were reception staff, they were aware of “red flag” presenting complaints and the deteriorating patient. Each receptionist we spoke with showed us a list of conditions which required immediate attention and said they felt competent to escalate immediately to a clinician.

The trust set a target of 95% for completion of mandatory training. A breakdown of compliance for mandatory training courses from 29 January 2018 to 29 January 2019 at trust level for registered nursing staff in community urgent care services is shown below:

29 January 2018 to 29 January 2019 Training module name Staff Eligible Completi Trust Met trained staff on rate target (Yes/No) Equality and Diversity 33 33 100% 95% Yes Safeguarding Children Level 2 12 12 100% 95% Yes Basic Life Support - Taught 32 32 100% 95% Yes Immediate Life Support 31 31 100% 95% Yes Safeguarding Adults Level 2 32 33 97% 95% Yes Paediatric Immediate Life Support 30 31 97% 95% Yes Mental Capacity Act 31 33 94% 95% No Fire 30 33 91% 95% No Information Governance 30 33 91% 95% No Conflict Resolution 29 33 88% 95% No Infection Control - 3 Yearly 28 33 85% 95% No Safeguarding Children Level 3 17 21 81% 95% No Moving and Handling Practical Level 2/3 26 33 79% 95% No Medicines Management 0 35 0% 95% No

The trust submitted further evidence following inspection which confirmed there was full compliance with mandatory training. We queried the 0% for compliance with medicines management. The trust confirmed medicines training in the organisation was not mandatory, therefore there were no compliance figures available. General medicines management training was available through e-learning and was accessible to all staff. We were told the patient group direction (PGD) policy states the relevant clinical lead must ensure that any training needs in relation to the administration of medicines were identified and met. Individual clinicians had professional responsibility to ensure they were up to date with any changes to PGDs. These are written instructions for the administration of authorised medicines to patients. All MIU and UTC staff were trained to deliver immediate life support to both adults and children, this included anaphylaxis training for severe allergic reactions. Staff treating children under the age of 18 completed paediatric minor injury training to ensure they could provide safe care to those children. Where there were reception staff, they were aware of “red flag” presenting complaints and the deteriorating patient. Each receptionist we spoke with showed us a list of conditions which

Page 85 required immediate attention and said they felt competent to escalate immediately to a clinician. Staff did not have specific training on sepsis. There were resources and supportive information available on the intranet which staff told us were easily accessible. All units had a sepsis folder with age relevant flow charts to be used for patients suspected of having sepsis.

Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept equipment and the premises clean. They used control measures to prevent the spread of infection.

Under the Health and Social Care Act 2008, all trusts were required to have clear arrangements for the effective prevention, detection and control of healthcare associated infection, including the procedures to be taken in the event of an outbreak of infection. Infection control policies for many aspects of practice were available on the trust website and provided clear guidance on the measures required to prevent the spread of infection. There was guidance on hand hygiene, use of personal protective equipment such as gloves and aprons, and management of the spillage of body fluids. All the infection prevention and control standard operating procedures we reviewed were up to date and accessible by staff on the trust intranet.

Patients and relatives told us they found the waiting areas and treatment rooms to be clean. We found all areas across the MIUs and UTCs maintained to a good standard of cleanliness. There were ‘I am clean’ stickers on treatment trolleys, examination couches and equipment marked with the date the item was cleaned. Patients were treated in either cubicles or rooms; all disposable curtains were visibly clean and had replacement dates recorded on them.

Clinical waste management practices, including those for contaminated and hazardous waste, were safe and in line with national standards. There was a colour-coded system for disposal of waste, and clear segregation of clean and dirty equipment. The dirty utility room (used to store equipment, to reduce the risk of infection and cross-contamination) was generally tidy and clean.

Sharps bins were available in treatment areas where sharps may be used. This was in line with health and safety regulation 2013 (The sharps regulations, 5 (1) (d)). The regulation requires staff to place secure containers and instructions for safe disposal of medical sharps close to the work area.

There was ready access to personal protective equipment (PPE). This included aprons and gloves in all areas we inspected. Hand washing basins had a plentiful supply of soap and paper towels as well as hand gel dispensers and drying facilities. Services displayed signage prompting people to wash their hands and gave guidance on good hand washing practice.

Staff complied with local infection control policies. Nursing and support staff were ‘bare below the elbow’ and adhered to infection control precautions throughout our inspection. We were told that patients with a known or suspected infection would be isolated and treated in a designated room, which would be decommissioned until appropriately cleaned Hand hygiene audits seen on site during inspection showed 100% compliance between January and March 2019. The trust submitted an asepsis audit completed in December 2018 for all sites which showed there was almost 100% compliance with hand hygiene, appropriate preparation for procedure, segregation and disposal of clinical waste. There were two recorded occasions on one site where there was 98% compliance, where the clinician did not wear a disposable apron or non-sterile gloves to remove a dressing on two occasions. The action plan was to remind staff to always wear apron and gloves as part of the aseptic technique.

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Environment and equipment The service had suitable premises and equipment and looked after them well.

The design, maintenance and use of facilities and premises keep people safe There was adequate seating and space in waiting areas which were visibly tidy, clean and uncluttered. Weymouth UTC had a waiting area for children which was separated from the adult waiting area by a gate. The children’s waiting areas in MIUs was demarcated by low level seating and a play area. Patients were treated in individual rooms or in curtained cubicles. Some MIUs had a treatment room decorated in a child-friendly way and included a television, where paediatric patients were treated. Waiting rooms had CCTV coverage which enabled staff to observe patients from the treatment area. However, we found that there was poor visibility of patients on the CCTV monitors in Bridport MIU and Weymouth UTC. We discussed these issues with members of the senior leadership team during inspection and received a written reply following inspection. We were told a short life task and finish group was since established to review the concerns raised and initiate safety measures including improved visibility of waiting areas. All equipment we inspected had up to date safety checks and service stickers. There was wall supplied oxygen and suction in Weymouth UTC and portable oxygen and suction in the minor injury units. All cylinders available were safely secured or on portable trolleys. Spare consumables and other equipment were appropriately stored and labelled. Consumables including intravenous fluids and sterile water were in date and stored off the floor. We checked the contents of each resuscitation trolley in the minor injury units and urgent treatment centre. Six out of eight trollies had all required equipment, including appropriately sized equipment for smaller or paediatric patients and there were no gaps in daily checks. However, of the two remaining trollies, one was overstocked which had the potential to delay staff finding the appropriate equipment in an emergency. The second trolley had a community hospital resuscitation trolley checklist rather than a minor injury unit checklist. Staff used this to do daily checks for the whole of the month but did not recognise they were using the incorrect checklist. Since some items on the trolley were not listed on the checklist, staff would not have recognised whether an item or piece of equipment was missing or out of date.

Staffing The service usually had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

In general, the level of staffing was set and did not fluctuate as patient numbers varied. In response to staff concerns about capacity, there was a recent skill mix review. The outcome of this was agreement to recruit a healthcare assistant to cover peak times between 9am and 1pm in one minor injury unit (MIU). In another MIU, there was agreement that bank healthcare assistant hours could be accessed to increase capacity on planned busier days.

All registered nurses were senior, at band six or seven and had completed patient group direction (PGD) training to administer identified medicines to specific patient groups. Some staff had qualified as nurse prescribers and could prescribe the required medication for some illnesses and injuries.

Bank staff were former MIU members of staff and used when required; there was no use of agency staff.

Annual staffing metrics From 1 January 2018 to 31 December 2018, the comparison of staff groups in post WTE in core service is shown in the chart below. Page 87

Core service annual staffing metrics (1 January 2018 – 31 December 2018) Annual Annual Annual agency “unfilled” Annual Annual Annual Annual bank hours hours hours average vacancy turnover sickness (% of (% of (% of establishment rate rate rate available available available hours) Staff group hours) hours) All staff 48.9 12% 5% 3.0%

Qualified 30.8 2% 2% 3.4% 0 (0%) 0 (0%) 0 (0%) nurses Nursing 7.3 42% 0% 1.9% 0 (0%) 0 (0%) 0 (0%) assistants

Medical staff 0.0 N/A N/A N/A 1661(100%) 0 (0%) 0 (0%)

Allied Health N/A N/A 0% 0.0% Professionals

(Source: Universal Routine Provider Information Request (RPIR) Staffing data P16 – P21)

During the reporting period from January 2018 to December 2018, there were no reported cases where staff were either suspended or placed under supervision.

(Source: Universal Routine Provider Information Request (RPIR) – P23 Suspensions or Supervised)

The Trust submitted data following inspection which showed the current vacancy rate across all services for was 6.8%, where the trust standard was 8%. The current sickness rate was 5.2%, with a trust standard of 3%.

We saw two electronically recorded incidents where there were many patients, some with multiple complex healthcare needs, waiting to be seen by a lone practitioner. The practitioner called for additional clinical support from the adjoining community hospital inpatient unit. In this way, risk to patient safety was mitigated. MIU leads March monthly meeting noted there were large number of four hour breaches due to staffing and capacity issues in one MIU. This was also reflected in electronic incident reporting.

Staffing levels meant there were times when staff had concerns for patient safety. Some staff told us there were times when they were the sole practitioner on duty, which made them feel unsafe. We discussed this with members of the senior leadership team during inspection and received a written reply following inspection. We were told a short life task and finish group was since established to review the concerns raised and initiate safety measures including improved staffing levels.

Assessing and responding to patient risk Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

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The trust standard was for all patients to be seen and either assessed as ‘safe to wait’ or triaged within 15 minutes. Performance was monitored against this 15-minute standard which was consistently met on all sites.

All MIUs carried out a ‘safe to wait’ assessment which meant the nurse did a quick verbal check with the patient about their condition and level of discomfort. No formal observations were made or recorded at this stage. This happened once the patient was taken in to the clinical treatment room. Patients to Weymouth UTC were triaged. A series of observations were completed and recorded to create a baseline of condition and priority for care.

Receptionists booked in patients as they arrived at the department. This was done electronically and was visible to nurses on a screen in the treatment area. Receptionists had a list of ‘red flag’ conditions displayed which included chest pains, breathing difficulties, fitting and uncontrolled bleeding. They immediately alerted the staff on duty if a patient presented with any of these conditions. Receptionists went off duty at 5:30 pm at which point patient details were collected by the trained nurses on duty.

However, Bridport MIU did not have a receptionist to support the nurses on duty. There was a reception desk with two receptionists solely for the adjoining outpatient department, and they did not book MIU patients in. There were blue seats for MIU patients which were positioned behind the red seats for outpatients. There were signs to advise patients of this and asked them to ring a bell outside the treatment area which alerted staff to their arrival. The patient completed a personal information sheet and waited for a nurse to ‘eye-ball’ them to ensure they were ‘safe to wait’.

Nurses we spoke with in Bridport told us they mitigated risk to patients by checking on them in the waiting area every 10 minutes and continuously viewing the CCTV which was positioned above the nurse’s desk and trained on the waiting area. However, we noticed the view of the MIU patients was not very clear either on the CCTV or through the observation window. We also noted that due to the volume of patients on the day of our inspection, it was not possible for nurses to leave patients they were treating to review the CCTV or to check on those in the waiting area every 10 minutes. In addition, the lack of receptionist support meant that nurses had to book patients in which took time away from their clinical duties. This situation was eased when there was a healthcare assistant on duty 22 hours per week, Monday to Friday. We were told they monitored patients in the waiting area and booked them in.

We saw there were sepsis folders with current information on each site. They included age relevant flow charts for patients suspected of having sepsis. Weymouth Urgent Treatment Centre had a sepsis management kit which was audited weekly. Nurse told us where they suspected sepsis, the patient was transferred to the nearest acute hospital for treatment. Management meeting minutes from March noted agreement was reached to have a ‘Think Sepsis’ alert added to the electronic patient record system, though there was no identified date for this.

Quality of records Staff kept detailed records of patients’ care and treatment. All staff had access to an electronic records system that they could all update.

The trust used an electronic patient record system. Records identified if patients had any mental health or learning disability needs alongside their physical health needs. This ensured nurses were alerted to the patient’s additional needs and they would be prioritised to be seen quickly and additional support considered as appropriate. However, the current system did not support templates to record pain scores or consent.

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Ten patient records were randomly selected and audited each month on each site to monitor the content and quality of patient’s records. We noted that one MIU had 0% recording of pain for March and April 2019, and 75% for February. We spoke with the nurse on duty about this who told us whilst they were confident they always checked pain levels with patients, they did not always record it as there was no easy way to do so on the patient electronic system. We raised this with members of the senior leadership team who acknowledged this was indeed an issue with the system and was under review. Nevertheless, there was an expectation that pain should be recorded manually, and this would be reiterated to staff.

Medicines The service followed best practice when prescribing, giving, recording and storing medicines.

The trust medicines policy was available to support staff to manage medicines safely. This policy described who the responsible person for the safe keeping of medicines was, as well as storage and refrigeration. It also outlined the procedures that should be used when prescribing, supplying or administering a medicine.

There were no incidents relating to medicines and MIUs. Bespoke medicines training was offered where there was an identified need or specific request.

Some units had controlled drugs (CD) on site. We confirmed they were managed in accordance with NICE guideline [NG46] Controlled drugs: safe use and management. They were stored securely, checked regularly and access was by authorised staff.

Medicines, including refrigerated medicines were stored appropriately in locked cupboards or fridges. Fridge and room temperatures were regularly checked by staff and were within required parameters. Staff checked expiry dates and rotated stock accordingly. We reviewed an electronically recorded incident where the temperature in one MIU treatment room was above 30c on five consecutive days. Following advice from the pharmacist, all drugs in the cupboard were safely disposed of. This incident was discussed at the July 2018 MIU leads meeting, when the lead pharmacist was in attendance. They reiterated guidance on safe storage, temperature controls and rotation of medicines during the hot weather.

There was regular support from the pharmacy team who facilitated medicines checks and disposal. The lead pharmacist attended the bi-monthly MIU leads meeting and shared current information including updates to the national antimicrobial guidelines and information from Public Health England.

According to the patient group directions (PGD) policy, relevant clinical leads must ensure that all authorised practitioners under the previous PGD are aware of the changes and that any training needs have been identified and met. Individual clinicians retain professional responsibility to ensure that they are up to date with any changes to PGDs.

Patient group directions were completed, up to date and reviewed annually. PGD’s were written instructions for the administration of authorised medicines to patients. They are needed to ensure that medicines are only administered to patients by staff with the legal authority to do so.

Almost all sites had at least one member of staff qualified as a nurse prescriber to prescribe medicine for medical conditions. Medicine prescription pads (FP10) were kept securely and managed safely to ensure an audit trail of use.

There were clear disposal processes for wasted or out-of-date medicines. Facilities for the disposal of wasted medicines and destruction could be arranged through the pharmacy.

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There was an antimicrobial policy to enable staff to keep updated and aware of any changes in antibiotic stewardship.

Incident report, learning and improvement The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

There were 105 electronically recorded incidents across all sites between 01 April 2018 and 31 March 2019. Of these, 100 were rated low or no harm; four were rated moderate harm and one high. The incident rated as high related to a road traffic accident close to a MIU where a member of the public first notified staff there rather than immediately dialling 999.

One of the incidents rated as moderate referred to low staffing levels to meet the patient demand and another referred to the concerns of a sole practitioner on duty with reference to patient safety, and their personal safety.

We noted that just one MIU (Sherborne) electronically recorded whenever there was a sole practitioner on duty, which was the case on five occasions during this reporting period. During inspection, staff from other sites raised concerns about lone practitioner working; although these were not reflected on the electronic incident record. Members of the senior leadership team told us they encouraged staff to record unplanned incidents of lone practitioner working.

Incidents were discussed at the MIU leads meeting held every two months. Minutes from these meetings identified any learning considered and further action required. Staff said any learning from incidents from other minor injury units was shared in an e-mail, supervision and through general discussion. We saw plaster refresher training was set up for all staff as a result of learning from an incident. Another incident was raised where the electronic patient record system did not alert staff quickly enough when a potentially violent patient attended for treatment. Swanage MIU piloted an alert process, which was then rolled out to all sites and the risk was subsequently closed. Never Events Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From 1 January 2018 to 31 December 2018, the trust did not report any never events for community urgent care services.

(Source: Strategic Executive Information System (STEIS))

In accordance with the Serious Incident Framework 2015, the trust did not report any serious incidents (SIs) in community urgent care services, which met the reporting criteria set by NHS England from 1 January 2018 to 31 December 2018. (Source: Strategic Executive Information System (STEIS; Universal Routine Provider Information Request (RPIR) – P29 Serious Incidents)

The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners

Page 91 with the intention of learning lessons from the cause of death and preventing deaths. There were no such reports made for the minor injury units or urgent treatment centre. (Source: Prevention of Future Death Analysis)

Is the service effective?

Evidence-based care and treatment The service provided care and treatment based on national guidance.

The National Institute for Health and Care Excellence (NICE) provided national guidance and advice to improve outcomes for people using the NHS and other public health and social care services. The trust’s policies and services were developed to reflect best practice and evidence- based guidelines, including for patients with asthma. Other guidance used included British National Formulary, The Royal Pharmaceutical Society, and the Nursing and Midwifery Council code – Professional Standards Practice 2018.

However, no clinical audits were done to demonstrate that care and treatment was provided in line with evidence-based guidance, standards and recent best practice guidance. For example, the assessment and management of patients who presented with a suspected spinal injury (NICE guideline [NG41] Spinal injury: assessment and initial management); or with a suspected head injury (NICE Clinical guideline [CG176]: Head injury: assessment and early management).

There were care pathways in line with current NICE guidance. These included the referral pathway for orthopaedic and ophthalmology patients as well as a sepsis pathway for the transfer of patients with suspected sepsis to the nearest acute hospital for treatment.

Pain relief Staff assessed and monitored patients to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

We spoke with patients in waiting areas as well as in the cubicles who told us staff offered pain relief at regular intervals. We did not observe any patients left in pain and heard they were repeatedly asked whether they required any pain relief during their clinical examination.

There was a variety of pain scales in use appropriate to the patient, for example for those living with dementia or who had communication difficulties. There was also a pain score chart with a recognisable cartoon character to encourage children to indicate their level of pain.

However, nurses told us the current electronic patient record system allowed for one entry to document pain but did not support repeat recording of pain levels. We were told this was managed by recording repeat monitoring on paper and then transcribing it to the electronic record. However, some nurses told us whilst they were confident they regularly checked patient pain levels, they did not always have time to record it.

Patient outcomes The trust did not participate in national audit for minor injury units but reviewed the service they provided for effectiveness The minor injury units (MIU) and urgent treatment centre (UTC) did not participate in any clinical audits as part of the trust Clinical Audit Programme. The Royal College of Emergency Medicine

Page 92 audits are not relevant to community urgent and emergency care as they only collect data for patients attending type one emergency departments. Dashboards were used to monitor performance, planned and unplanned attendance and daily attendance rates. The data was reviewed during daily reporting, quality assurance visits and bi- monthly unit leads meetings. Each unit did a monthly audit of x-rays taken by individual practitioners to see whether their interpretations matched that of the radiographer. In this way, any consistent error in diagnosis was recognised and appropriate support and supervision offered to the member of staff. Audits showed there was between 93% and 100% correct interpretation by practitioners. Radiographers used the ‘Red-dot’ system on x-rays where they placed a red dot prominently on the image to draw the practitioner’s attention to the likelihood of an abnormality. Nurses told us radiographer reports were usually returned within 24 hours, but no later than 48 hours. Practitioners could request a ‘hot report’ where they wanted rapid confirmation of their initial interpretation. These reports were returned within hours. We saw this in one MIU, where the nurse wanted to allay a parent’s concerns about the nature of their child’s injury and requested a ‘hot report’. This was returned by the radiotherapist within three hours and the nurse telephoned the parent with the result.

Competent staff The service made sure staff were competent for their roles. Managers appraised staff work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

Staff told us the trust had good learning and development opportunities. They had access to e- learning and face-to-face training. In addition to mandatory training there was specialist training in minor injury. Nurses told us they were actively encouraged to undertake training relevant to their role, f example, nurse prescriber course and skills-masters modules. The trust confirmed that all nurses had completed their Ionising Radiation Medical Exposure Regulations (IRMER) training to enable them to read and report on x-rays.

All staff were encouraged and supported to attend a six day course run over three months on paediatric minor injury and illness. They spoke positively about the confidence it gave them when treating children. A paediatric trained nurse in one MIU accessed ‘Spotting the Sick Child’ NHS training and ensured it was available on the trust intranet. Minutes of MIU professional leads meeting noted all staff should be encouraged to complete this training.

There was a programme of staff visiting other sites as well as emergency departments in local hospitals to share skills.

Staff told us they had regular clinical supervision with their line manager. One staff member showed us a copy of their most recent supervision, which considered their learning and development, as well as any recent challenges in their clinical practice.

Staff appraisal was to support staff development and all members of staff had a current appraisal. Appraisals were used to identify learning needs, and a plan put to support staff to develop their practice.

The trust provided the following information about their appraisal process:

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From January 2018 to January 2019, 96% of permanent non-medical staff within the community urgent care services core service had received an appraisal compared to the trust target of 95%.

Community urgent care total

Sum of Target Number of staff Appraisal Trust Staffing group Individuals met appraised rate (%) target (%) required (Yes/No)

Additional clinical services 7 7 100% 95% Yes Allied health professionals 1 1 100% 95% Yes Nursing and midwifery 25 26 96% 95% Yes registered Administrative and clerical 10 11 91% 95% No All staff 43 45 96% 95% Yes

Nursing staff by site / location

Sum of Number of Appraisal Trust Target met Site or location Individuals staff appraised rate (%) target (%) (Yes/No) required

Blandford Community 1 1 100% 95% Yes Hospital Bridport Community Yes 3 3 100% 95% Hospital Swanage Community Yes 3 3 100% 95% Hospital Westminster Memorial Yes 3 3 100% 95% Hospital Weymouth Community Yes 11 11 100% 95% Hospital Yeatman Hospital 3 3 100% 95% Yes Wimborne Community No 2 1 50% 95% Hospital Grand Total 25 26 96% 95% Yes

Allied health professionals by site / location

Sum of Number of Appraisal Trust Target met Site or location Individuals staff appraised rate (%) target (%) (Yes/No) required

Bridport Community 1 1 100% 95% Yes Hospital Grand Total 1 1 100% 95% Yes

(Source: Universal Routine Provider Information Request (RPIR) – P39 Appraisals)

We confirmed during inspection that the one outstanding appraisal in Wimborne MIU was already

Page 94 completed.

Multidisciplinary working and coordinated care pathways Staff of different kinds worked together as a team to benefit patients.

Staff liaised with GPs, district nurses, school nurses and social workers where appropriate. This was to arrange any ongoing care or appropriate follow up for patients post-discharge.

A nurse told us of recent concerns they raised with a school nurse. Another told us how they worked with a social worker to encourage a patient, well known to the MIU, to accept support in their own home. This had positive benefits for the patient and reduced their MIU attendance.

Staff were encouraged to spend time shadowing in a hospital emergency department, as well as share skills and experience across MIUs and the urgent treatment centre.

Staff were able to refer to secondary healthcare, including hospitals and specialists as well as allied healthcare professionals such as physiotherapists, occupational therapists and speech and language therapists. There were orthopaedics and ophthalmology referral pathways.

Health promotion Staff were skilled in identifying those patients who may need extra support and contacting other agencies to implement action. They provided health promotion advice and directed patients to where further information and support could be found. This included other trust resources, social services and local support groups. Discharge advice was given to patients and carers on how to safely manage their condition at home as well as when to seek further advice if required. There was a GP letter embedded in the electronic patient record system which was automatically sent to notify them of treatment received by their patients. There were health and condition specific advice leaflets and posters available in all units. There were leaflets which explained about drugs and alcohol services as well as mental health, domestic violence and sexual abuse helplines. There was also information about being bitten by a bat or noticed a tick on their body. Noticeboards had information about local support groups, for example for drug and alcohol dependency, macular degeneration or social isolation.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.

Consent to treatment was undertaken by the nurse directly responsible for the person’s treatment and each patient was asked for their consent before treatment was provided. Staff followed trust policies to ensure a consistent and monitored approach.

The current patient electronic system did not support templates to prompt staff to record consent. We heard nursing staff ask patient’s permission whenever they undertook any examination or treatment.

There was a consent policy for children and young people accessible to staff. Staff confirmed that they used the Gillick competence to assess if a child could consent. Gillick competence is a term Page 95 originating in England and is used in medical law to decide whether a child (under 16 years of age) can consent to his or her own medical treatment, without the need for parental permission or knowledge.

Staff were also aware of Fraser guidelines, to decide if a child could consent to contraceptive or sexual health advice and treatment.

The trust set a target of 95% for completion of Mental Capacity Act training and there was 94% compliance amongst community urgent care staff.

A breakdown of compliance for MCA courses from 29 January 2018 to 29 January 2019 for nursing and midwifery staff in community urgent care services is shown below:

Number Number of of staff eligible trained staff Completion Target Target met Training module name (YTD) (YTD) (%) (%) (Yes/No) Mental Capacity Act 31 33 94% 95% No Total 31 33 94% 95% No

(Source: Universal Routine Provider Information Request - P38 Training)

Is the service caring?

Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

We saw staff interact with patients and relatives in a positive, respectful and compassionate manner. They introduced themselves to the patients in line with the NICE QS15 (Statement 1, patient experience in adult NHS services).

The trust collected feedback from patients using the NHS Friends and Family Test. Between October 2018 and March 2019, 97% of the people who provided feedback on the community urgent care service said they would recommend the service to friends and family if they needed similar care or treatment. between 95% and 99% would recommend each respective minor injury unit or the urgent treatment centre.

There were signs at the reception desk asking people to respect confidentiality and stand back from the desk when there was another patient in front of them. We saw patients were treated with dignity and compassion from the time they entered the unit. Reception staff offered information and assurance; for example, a patient arrived very distressed, the receptionist was able to discreetly establish the reason for their distress and communicate that to the nurse in charge who then came to see the patient in the waiting room. Treatment rooms had either doors or disposable curtains which ensured patient privacy. We saw staff knocked on the door or stood outside the curtain and asked if they could enter.

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Parents were involved in the assessment and treatment of their children and clear explanations were given to child and parent. Where the adult patient was accompanied by another adult, we heard staff ask the patient’s permission to include their companion in the discussion.

We observed several instances of staff being caring towards patients. For example, we saw a nurse accompanying a patient back to where their relative was in the waiting room. We spoke with six patients and four family members. Each patient spoke positively about the attitude of staff. Patients consistently reported good experiences with nursing staff during consultations. One told us, “I get the finest and the most loving care you could ever ask for” and another told us “I couldn’t wish for nicer people to treat me”.

Emotional support Staff provided emotional support to patients to minimise their distress.

We saw staff spent time with patients to explain their treatment options. They spent longer with anxious patients and provided assurance before commencing any treatment. Patients we spoke with said they felt involved and were aware of their plan of care. One young patient told us they felt they were spoken to in a calming way and “they reassured me that my injury was not serious.” Staff we spoke with were non-judgmental when talking about patients with mental health needs, learning disabilities, autism or dementia. They demonstrated insight and understanding into behaviours presented by these patient groups.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment.

We observed staff introduced themselves and communicated effectively with patients, to ensure that care and treatment were understood. They gave a concise explanation to the patient about the process and ensured patients fully understood their care and treatment by asking if there were further questions at the end of a treatment.

Staff had established processes to support patients with mental illness. They said when they had concerns about patient’s mental health wellbeing they would liaise with the patients GP. Where there were more immediate concerns, they would contact the trust acute mental health team. Staff in each unit told us they were familiar with most regular attendees, some of whose needs were social rather than medical. These patients were often signposted to other services or community support groups.

Whilst there were no electronic indicators to show waiting times, patients told us receptionists or nurses kept them updated on their expected waiting time. Staff made sure patients and relatives understood the assessments being done and the likely diagnosis and treatment plan. Is the service responsive?

Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people.

The MIUs and urgent treatment centre (UTC) provided minor injury care. Patients were treated for sprains and strains; broken bones; wound infections and insect and animal bites; as well as minor

Page 97 head injuries; minor eye injuries and injuries to the back, shoulder and chest. There were established pathways to refer patients to secondary care if required which included hospitals and specialists; as well as allied healthcare professionals.

The service was accessible to all who needed it and took account of patients’ individual needs. Patients had access to timely care and treatment. Opening times of each unit were clearly displayed. There were slight variations in the opening times of MIUs and UTC. All were open five days per week, and six were open at the weekend. There were x-ray facilities available at all sites Monday to Friday hours variable and for a limited period on Saturday and Sunday at Weymouth UTC. Staff told us they were aware of x-ray opening times across all sites and signposted patients to other units or to the local NHS x-ray department. Some units offered booked evening appointments as part of an integrated urgent care system.

The x-ray department at Swanage MIU was closed for refurbishment and equipment replacement at the time of inspection. This closure was well publicised on the trust website, as well as in other MIUs, with information on alternative departments to access.

Members of the senior leadership team told us there was ongoing consultation between Dorset HealthCare, Dorset clinical commissioning group and users of MIUs and the UTC. Patients completed a questionnaire on reasons for attending and their experience. These details were needed to inform the direction of service over the next five years. This consultation was in line with a national requirement from National Health Service England which identified that the current provision of service was confusing to the public.

Meeting people’s individual needs The service took account of patients’ individual needs.

Learning Disabilities and Mental Health Awareness training was not part of mandatory training for staff within minor injuries. We saw a copy of a presentation on disability awareness made by the trust learning disability at the MIU leads bi-monthly meeting. All members of staff we spoke with told us the presentation was shared with them. They also said they had access to the learning disability lead for advice and support or where there was an adjoining hospital, they contacted the community hospital champions.

The trust submitted current dementia training compliance for April 2019. There was no trust standard for this, but we noted that four units had 100% compliance whilst the remaining four varied between 41% and 75%.

Reasonable adjustments were made so that people with a disability, mental health or complex needs could access and use services on an equal basis to others. All areas of the MIU were accessible for patients with limited mobility or who used mobility aids. Accessible toilets were available for disabled patients and visitors. There was a flag on the electronic patient record system to indicate a known learning disability. Nurses told us they fast-tracked any patient identified as vulnerable or with a special need, to minimise their waiting time.

Each MIU and the UTC had a loop system to assist patients with hearing difficulties. Staff had access to translation services to help patients with communication where English was not their first language. Staff told us how they could access translation services when required. Information leaflets were available for patients for a variety of medical conditions.

For patients awaiting transfer to the acute hospital, staff remained with them and continued to observe and support until the ambulance arrived.

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Access and flow People could access the service when they needed it and received the right care in a timely way.

The Department of Health’s standard for emergency departments is that 95% of patients should be assessed and treated within four hours of arrival in the emergency department. This was achieved by all units between December 2018 and Mach 2019. The trust standard for time to initial assessment (15 minutes) was achieved between 93% and 97% during this same period.

December 2018 Total Time to Time to Time to Attendances attendance initial treatment treatment who left for the assessment (waited one (waited up before seen month (assessed hour or to four Trust within 15 less) No hours) standard minutes) trust target Trust 5% Trust standard standard 95% 95% Sherborne 370 97.3% 74.9% 100% 0.54% Blandford 377 97.6% 88.3% 100% 0.00% Shaftesbury 385 96.6% 93.0% 100% 0.52% Swanage 662 95.6% 95.5% 100% 0.15% Bridport 689 98.2% 98.8% 100% 0.00% Portland 230 93.5% 94.3% 100% 0.43% Weymouth 2779 98.4% 93.7% 100% 0.50% UTC Wimborne 500 83.3% 78.4% 100% 1.20% Overall 97.2% 91.7% 100% 0.43% performance

January 2019 Total Time to Time to Time to Attendances attendance initial treatment treatment who left for the assessment (waited one (waited up before seen month (assessed hour or to four Trust within 15 less) No hours) standard minutes) trust target Trust 5% Trust standard standard 95% 95% Sherborne 345 99.4% 79.4% 100% 0.0% Blandford 453 97.1% 85.0% 100% 0.0% Shaftesbury 371 97.8% 94.9% 100% 0.8% Swanage 641 96.9% 96.3% 100% 0.0% Bridport 708 94.2% 97.5% 100% 0.9% Portland 310 88.1% 89.0% 100% 0.0% Weymouth 2638 79.2% 93.6% 100% 0.4% UTC Wimborne 597 98.2% 64.7% 100% 1.2% Overall 93.9% 89.9% 100% 0.4% performance Page 99

February 2019 Total Time to Time to Time to Attendances attendance initial treatment treatment who left for the assessment (waited one (waited up before seen month (assessed hour or to four Trust within 15 less) No hours) standard minutes) trust target Trust 5% Trust standard standard 95% 95% Sherborne 346 99.1% 78.3% 100% 1.2% Blandford 388 96.7% 84.3% 100% 0.5% Shaftesbury 366 94.4% 92.3% 100% 0.0% Swanage 539 92.6% 93.1% 100% 0.9% Bridport 751 96.9% 96.5% 100% 0.4% Portland 243 97.9% 88.5% 100% 0.4% Weymouth 2,449 77.0% 92.4% 100% 0.2% UTC Wimborne 513 97.1% 60.4% 100% 2.3% Overall 94.8% 88.5% 100% 0.6% performance

March 2019 Total Time to Time to Time to Attendances attendance initial treatment treatment who left for the assessment (waited one (waited up before seen month (assessed hour or to four Trust within 15 less) No hours) standard minutes) trust target Trust 5% Trust standard standard 95% 95% Sherborne 374 94.7% 77.8% 100% 0.3% Blandford 431 94.0% 83.3% 100% 0.0% Shaftesbury 440 97.5% 95.9% 100% 0.2% Swanage 714 94.8% 92.2% 100% 1.0% Bridport 745 96.2% 94.4% 100% 0.3% Portland 266 94.7% 94.4% 100% 0.0% Weymouth 2926 73.1% 91.7% 100% 0.5% UTC Wimborne 606 98.2% 54.5% 98.7% 3.6% Overall 93.0% % 99.8% 0.7% performance

Where the data for time to initial assessment at Weymouth UTC records 77% and 73% in February and March, we confirmed that the average wait time was 16 minutes. The trust submitted data which showed there were 25 occasions when a minor injury unit or the urgent treatment centre closed to patients or diverted them to other services, for example, other

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MIU, GP surgery or local hospital accident and emergency department. Reasons for closure or diversion were mainly due to staff shortages or high patient activity. Wimborne had the largest number with 12 closures or diversions and Sherborne had seven. Nursing staff told us not all attendances who left before being seen were captured. It was dependant on the patient telling them they were leaving or noted by a receptionist where there was one. Access to the right care at the right time. Weymouth was re-designated an urgent treatment centre (UTC) in January 2018 in accordance with NHSE requirements. The hours changed to 8am to 8pm, in line with national UTC requirements. The trust told us this made better use of staffing resources as well as to offer bookable GP appointments via the NHS 111 service. Bookable appointments were also offered by all MIUs from 01 April 2019 as part of the NHS ‘improving access to general practice services’ (IAGPS) programme. These were available between 6pm and 8pm Monday to Friday and 10am to 12pm Saturday morning.

Learning from complaints and concerns It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.

Service leads managed complaints. There was evidence that learning points had been identified and lessons learned were shared with to prevent future occurrences. We saw examples of responses made to three complaints. They were clear and explained to the complainant the nature of the investigation carried out. Learning and improvement forms were completed in relation to each complaint. Minutes from MIU leads meetings recorded discussions on each complaint, with named persons allocated any resultant actions. Nurses on all sites were aware of complaints related to their service and where there were lessons to be learned from other sites, these were e- mailed to all staff and discussed at team meetings or in supervision.

From 1 January 2018 to 31 December 2018 the trust received 17 complaints about community urgent care services (4.4% of total complaints received by the trust). The trust took an average of 20 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be dealt with within 21 working days.

A breakdown of complaints by subject and site is shown below:

Community Urgent Care Services Total Type of complaint Number of complaints Percentage of total Values and behaviours 8 47% Clinical treatment 5 29% Access to treatment or drugs 1 6% Communications 1 6% Transport (ambulances) 1 6% Waiting times 1 6% Total 17 100%

Community Urgent Care Services – Bridport Community Hospital

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From 1 January 2018 to 31 December 2018 there was one complaint about community urgent care services at Bridport Community Hospital. The trust took an average of 15 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be dealt with within 21 working days. A breakdown of complaints by subject is shown below: Type of complaint Number of complaints Percentage of total Values and behaviour 1 100% Total 1 100%

Community Urgent Care Services – Portland Hospital From 1 January 2018 to 31 December 2018 there were two complaints about community urgent care services at Portland Hospital. The trust took an average of 15 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be dealt with within 21 working days. A breakdown of complaints by subject is shown below: Type of complaint Number of complaints Percentage of total Waiting times 1 50% Values and behaviour 1 50% Total 2 100%

Community Urgent Care Services – Swanage Community Hospital From 1 January 2018 to 31 December 2018 there was one complaint about community urgent care services at Swanage Community Hospital. The trust took an average of 43 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be dealt with within 21 working days. A breakdown of complaints by subject is shown below: Type of complaint Number of complaints Percentage of total Clinical treatment 1 100% Total 1 100%

Community Urgent Care Services – Westminster Memorial Hospital From 1 January 2018 to 31 December 2018 there was one complaint about community urgent care services at Westminster Memorial Hospital. The trust took an average of 8 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be dealt with within 21 working days. A breakdown of complaints by subject is shown below: Type of complaint Number of complaints Percentage of total Transport (ambulances) 1 100% Total 1 100%

Community Urgent Care Services – Weymouth Community Hospital From 1 January 2018 to 31 December 2018 there were ten complaints about community urgent care services at Weymouth Community Hospital. The trust took an average of 18 days to

Page 102 investigate and close complaints, this is in line with their complaints policy, which states complaints should be dealt with within 21 working days. A breakdown of complaints by subject is shown below: Type of complaint Number of complaints Percentage of total Values and behaviours 5 50% Clinical treatment 3 30% Access to treatment or drugs 1 10% Communications 1 10% Total 10 100%

Community Urgent Care Services – Wimborne Community Hospital From 1 January 2018 to 31 December 2018 there were two complaints about community urgent care services at Wimborne Community Hospital. The trust took an average of 34 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be dealt with within 21 working days. A breakdown of complaints by subject is shown below: Type of complaint Number of complaints Percentage of total Values and behaviour 1 50% Clinical treatment 1 50% Total 2 100%

(Source: Universal Routine Provider Information Request (RPIR) – Complaints tab)

From 1 January 2018 to 31 December 2018 the trust received 225 compliments for community urgent care services, which accounted for 6% of overall compliments received by the trust.

Team Number of compliments Blandford MIU 10 Bridport MIU 48 Portland MIU 1 Swanage MIU 25 Westminster MIU 7 Weymouth Urgent Care Centre 14 Wimborne MIU 81 Yeatman MIU 39 Total 225

Community Urgent Care Services – Blandford Community Hospital From 1 January 2018 to 31 December 2018 Blandford Community Hospital received 10 compliments.

Team Number of compliments Blandford MIU 10 Total 10

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Community Urgent Care Services – Bridport Community Hospital From 1 January 2018 to 31 December 2018 Bridport Community Hospital received 48 compliments.

Team Number of compliments Bridport MIU 48 Total 48

Community Urgent Care Services – Portland Hospital From 1 January 2018 to 31 December 2018 Portland Hospital received 1 compliment.

Team Number of compliments Portland MIU 1 Total 1

Community Urgent Care Services – Swanage Community Hospital From 1 January 2018 to 31 December 2018 Swanage Community Hospital received 25 compliments.

Team Number of compliments Swanage MIU 25 Total 25

Community Urgent Care Services – Westminster Memorial Hospital From 1 January 2018 to 31 December 2018 Westminster Memorial Hospital received 7 compliments.

Team Number of compliments Westminster MIU 7 Total 7

Community Urgent Care Services – Weymouth Hospital From 1 January 2018 to 31 December 2018 Weymouth Hospital received 14 compliments.

Team Number of compliments Weymouth Urgent Care Centre 14 Total 14

Community Urgent Care Services – Victoria Hospital From 1 January 2018 to 31 December 2018 Victoria Hospital received 81 compliments.

Team Number of compliments Wimborne MIU 81 Total 81

Community Urgent Care Services – Yeatman Hospital From 1 January 2018 to 31 December 2018 Yeatman Hospital received 39 compliments.

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Team Number of compliments Yeatman MIU 39 Total 39

(Source: Universal Routine Provider Information Request (RPIR) – Compliments tab)

Is the service well-led?

Leadership Managers had the right skills and abilities to run a service providing high-quality sustainable care. All members of the leadership team had previously worked in various clinical and managerial roles before progressing into their current roles. The senior management team comprised of two professional leads, a locality manager, two heads of integrated services and a service director. Most members were clinically qualified, two provided clinical supervision to MIU leads and one continued to practice as a part-time clinician; others held qualifications in management. This team presented as a cohesive working group with a good level of understanding of the challenges and differences within each unit. Service leaders were visible and approachable. Nursing staff told us they were familiar with members of the leadership team, all of whom were visible and approachable and said the service was well led. There was regular engagement by the leadership with staff to help them identify as one cohesive service rather than as eight individual services.

Staff know how to trigger escalation and told us members of the leadership team responded rapidly when, for example, patient capacity outstripped staffing levels. In these circumstances, staff were supported to either close the MIU or divert patients to an alternative MIU.

Staff told us they felt connected to the other sites within their service and to the organisation as a whole. They attributed this to the current leadership structure which facilitated good communication between sites by way of regular meetings as well as written updates on policies, incidents, learning and general developments within the trust.

Vision and strategy The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

The trust had a clear vision and a set of values, with quality and sustainability as top priorities. In 2015, the trust introduced a five-year strategy (2015-2020) to deliver on its purpose of providing integrated healthcare services to empower people to make the most of their lives. New values and behaviours were developed to deliver this. These included working together for patients, respect and dignity, commitment to quality of care, compassion, improving lives, everyone counts and commitment to learning.

Senior managers in the service told us that their work, and the trust’s five-year strategy more generally, was informed by national and local plans in the wider health and social care economy. This was part of NHS England’s Five Year Forward View as well as efforts to collaborate locally with health and care partners for the delivery of the Better Together vision and the Dorset clinical services review.

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The strategy was informed through consultation with other providers in the county as well as the local population to better understand the needs of the local population. Proposals would inform the strategy and direction of minor injury units over the next five years.

Staff we spoke with knew what the trust vision was and said they were updated on strategic developments. They felt positive and proud to work for the organisation which they believed was a progressive trust.

Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

The culture across the urgent and emergency community care service encouraged openness and honesty at all levels, including with people who used services, in response to incidents. The trust had systems and processes to ensure staff met the duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.

Managers told us they encouraged a culture of openness and honesty, which included application of the duty of candour (DoC). Staff told us they understood their responsibility with regards to DoC. We did not speak with anyone who had been engaged in applying it; however, all those whom we spoke with considered it was a priority to be honest and open with patients and relatives when something went wrong with their treatment and caused or had the potential to cause, harm or distress.

Staff worked collaboratively and responsibly to ensure high quality patient safety and care was maintained. They told us the patient was at the heart of all they did and was their motivation to be the best they could be. They told us they felt supported and listened to, and there was a collective desire to drive quality and improvement. They said they were actively encouraged to raise any concerns and learning from incidents was a positive part of the culture.

Governance The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

There was an established clinical governance structure. Members of the senior leadership team said they worked hard to develop a governance structure which did not have too many layers, and which met the needs of the service. There was a ‘ward to board’ route which they believed was effective and uncomplicated.

Governance arrangements included analysing and responding to patient, public and staff experience feedback, incidents and risks, key performance indicators, quality metrics and audit results.

The bi-monthly minor injury unit leads meetings reviewed governance for the service. The agenda was aligned with Care Quality Commission domains of safe, effective, caring, responsive and well- led. These meetings were well attended and where a lead was unable to attend, a representative went instead. All electronically recorded incidents, as well as any outstanding actions and risk registers were reviewed.

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The professional leads made regular quality assurance visits and attended the minor injury unit leads meetings; in this way, they maintained clinical oversight of each site. The locality manager regularly met with the clinical leads and took information from these meetings to locality managers meetings and from there to the trust management group. Matters could be escalated as necessary to board level at this point.

Management of risk, issues and performance The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

There were separately held risk registers for each MIU and the UTC. These were reviewed and updated when the locality manager met with the professional leads; they were also reviewed at the minor injury unit leads meetings. There were two risks specific to MIUs and the UTC on the trust wide risk register; demand and capacity within the MIU which was rated as low and entered on the risk register on April 2019. The other risk was delay in transfer of care from MIU's to acute care facilities by an emergency ambulance which was rated as low and entered on the risk register on March 2017. Staff were aware of these risks which were also on local risk registers.

However, we identified risks which were not on the trust risk register; for example, the occasions when there was a sole practitioner on duty. This was identified on one local risk register, although it was an occurrence in other units. We raised this formally with the senior leadership team who said the risk was mitigated by ensuring there was a receptionist on during the same hours. This was initiated in response to findings in the CQC inspection 2015.

Whilst this contributed to improved personal safety for staff, patient safety remained of concern. Nurses told of us of times where there was a deteriorating patient in the unit at the same time as they were treating other patients; or where a patient presented with mental health needs who had to be redirected to other services. CQC acknowledged that some sites, but not all, had an adjoining community hospital and the sole practitioner could call for additional assistance in an emergency.

Another risk identified by inspectors which was not on either trust or any local risk registers was the restricted visibility of patients in both Weymouth and Bridport waiting areas. Inspectors raised this formally with the trust at the time of the inspection. There was CCTV in both units; in the case of Weymouth, not all parts of the waiting area were visible on the viewing monitor. There was a reception area which had privacy screening on the glass, which further restricted patient observation. The CCTV in Bridport was positioned in such a way that it was difficult to observe MIU patients seated on chairs behind patients waiting to attend the outpatient department. There was a window in the treatment area, but the positioning did not give a clear view of patients. Staff on both sites told us they did their best to review patients in the waiting area every 10 minutes. They acknowledged that this was not always achievable at busy times.

Following inspection, the trust told CQC a short life task and finish group was since established to review the concerns raised and initiate safety measures which included improved staffing and visibility of waiting areas.

There was a systematic programme of internal audit to monitor quality. There were regular audits of patient records; hand hygiene; infection prevention and control; equipment and x-ray quality. We saw action plans where areas of improvement were identified.

Information management The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

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Staff told us they were able to access the information they needed to provide safe and effective care. The intranet was available to all staff and contained links to current guidelines, policies and procedures. All staff we spoke with knew how to access the intranet and information relevant to their role. They accessed their work email and we saw they received regular organisational information including updates and changes to policy and procedures.

Engagement The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.

The MIU leads meetings were held on the same day each month and there was a bi-monthly meeting which did roster planning. Draft agendas are sent out approximately three weeks before each meeting and staff were invited to submit agenda items. Not all units had a regular team meeting where the team was small. In response to this, the lead nurse sent regular email updates which kept staff informed of matters and related actions relevant to the unit, as well as clinical matters and information. The Friends and Family test was used to assess patients’ overall experience and was routinely reported to the board. Key findings were collated and discussed at the MIU leads meetings for review and were displayed around each unit. Professional Leads regularly liaised with emergency department leads at nearby NHS trust hospitals to share experiences and discuss matters including patient transfer. Public engagement was led by the clinical commissioning group, the focus of which was to shape the future of the community urgent care service.

Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

Managers met with staff to hear their concerns. Staff told us they felt confident to raise concerns with managers who listened and acted as appropriate. In response to concerns about capacity at certain times of the day, a review of patient attendance times was undertaken, and additional healthcare assistant hours were introduced during those peak times.

Learning was shared across the organisation including with bank staff. We saw examples of emails sent to all staff to highlight learning from incidents with an outline of how the trust would address this to prevent a recurrence. This included additional training in some instances and in others, a revision of working patterns.

The provider initiated innovative practice. Staff in Weymouth urgent treatment centre told us how they adapted an innovative practice which meant some patients were discharged without the need for prescribed medicines. Point of care blood testing was available and nurses checked if there was inflammation present and whether antibiotics were required. Prior to this, a blood test would be sent off to a pathology laboratory to test for inflammation and the patient was automatically discharged with antibiotics pending results which took a number of days to be returned. In a similar way, a specific blood test was done to detect possible deep vein thrombosis which determined whether daily anti-clotting injections were required.

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Mental health services

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

Facts and data about this service

Location site name Ward name Number of beds Patient group (male, female, mixed) St Ann's Hospital AAU (Seaview Ward) 14 Mixed Chine Ward (was St Ann's Hospital 17 Female Dudsbury) St Ann's Hospital Harbour Ward 16 Male

St Ann's Hospital Haven Ward, PICU 12 Mixed Linden Community Support Linden Inpatient 15 Mixed Unit Nursing ECT and Forston Clinic N/A Mixed Physical Health Waterston, Acute Forston Clinic Assessment 18 Mixed Treatment Unit

The methodology of CQC provider information requests has changed, so some data from different time periods is not always comparable. We only compare data where information has been recorded consistently.

Is the service safe?

Safe and clean care environments Safety of the ward layout At the time of the inspection, the wards complied with Department of Health national guidance on same sex accommodation. Linden Unit had policies in place for changing the ward layout to adhere to same sex accommodation guidance. Most of the spaces in the wards had been fitted with anti-ligature equipment and furnishings (including toilets, bathrooms, and communal areas). Ward managers told us the trust will be trialling door alarms which would go off if anyone tried to ligature over the top of doors. Environmental risk assessments were undertaken monthly and included fire checks, mattresses, windows and furniture. On Haven Ward, an annual ligature audit was conducted and peer reviewed. During our previous inspection we identified many ligature risks across the wards which had not been identified or mitigated effectively. We also identified the courtyard on Waterston had a

Page 110 number of ligature risks such as unboxed drain pipe, missing panels in the smoking shelter which exposed the frame creating ligature points. However, during this inspection there was no unboxed drainpipe on Waterstone ward. The larger garden was labelled as ‘yellow’ which meant patients had to ask to go outside due to the increased risks. There were no obvious fencing, cabling or drainpipe issues creating ligature anchor points. The smoking shelter remained but had been re- purposed as patients could no longer smoke on site. There was no Perspex side panel missing. Staff on Chine ward completed robust risk assessments on admission to make sure they were suitable for shared rooms and if they were not, single bedrooms were offered. Chine Ward, being a listed building, had imposed limitations on the number of alterations that can be made to the building. Patient accommodation composed of three single bedrooms and seven double bedrooms. As some of the bedroom doors did not have self-locking mechanisms, this posed a ligature risk as patients could access other patients’ bedrooms and ligature using un-fixed items. However, staff always used relational security to manage risk of patients on the ward and knew the clients well therefore could increase the level of observations if they felt the patient was at any risk of self- harm. We found significant improvements had been made to address ligature risks in the communal areas of the wards. The ward also made use of a Red Amber Green (RAG) colour code door system, where each door had a RAG coded sticker to mark the level of patient supervision needed inside the room. Staff told us that they felt the system had helped to improve safety on the wards. We identified a number of blind spots across Chine, Seaview, Linden and Harbour ward, however this was mitigated by increased staff presence in those areas. Where appropriate the wards made use of a convex mirror for areas that were harder to observe. The ward managers assured us that additional convex mirrors had been ordered to ensure all areas of the wards were observable. For example, additional mirrors had been ordered for the courtyard at Seaview ward. Staff had access to emergency alarms allocated at the start of the shift. The alarms allowed staff to call for assistance in the event of a risk situation or emergency. There was a daily security nurse identified with a bleep linked to the alarm system, and a site wide response team for emergency responses. Over the 12-month period from 1 January 2018 to 31 December 2018 there were two mixed sex accommodation breaches within this service. The number of same sex accommodation breaches reported in this inspection was the same as the two reported at the time of the last inspection. There were ligature risks on seven wards within this service. All wards had a ligature risk assessment in the last 12 months, except Nursing ECT.

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Briefly describe High Ward / risk - one level of unit Summary of actions taken sentence risk? name preferred Yes/ No Waterston Risk of ligaturing No Staff use an individualised approach to manage people with Unit from an attached increased risk through clinical intervention i.e. observation high-level anchor level. All patients who have either a history of or currently point. display risk behaviours (specifically ligaturing) will have a co- produced safety plan / behavioural support plan as appropriate. When working with patients who are high risk staff will consider the patients access to means i.e. belts, cords shoe laces and remove where clinically indicated. Ligature cabling works to reduce the accessible length and placing other cables into conduit. Ward has just had Capital works to increase bed capacity by 4 rooms. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Linden Risk of ligaturing No Each patient has a clinical risk assessment to identify risk of Unit from an attached self-harm/ suicide and accidents. Continuing to manage via high-level anchor clinical practice. Ligature risk radiators and works to bedrooms point. progressed. Ligature cabling works to reduce the accessible length and placing other loose cables into conduit completed. Cabling on gym equipment cannot be shortened and is therefore determined through a clinical risk assessment or supervised area. Bespoke bookcase/TV cabinet sourced through Capital works. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Chine Risk of ligaturing No Staff will use an individualised approach to manage people with Ward from an attached increased risk through clinical intervention i.e. observation high-level anchor level. All patients who have either a history of or currently point. display risk behaviours (specifically ligaturing) will have a co- produced safety plan / behavioural support plan as appropriate. Room 0091 now has different style taps and boxing (Reflected on LMP) Room 0093c & 0095 – gaps in new shower casing. The change in type of bin has been reflected on respective ward management plans (LMP & LMS). Main dining room – Addition of bookcase reflected on LMS & LMP and requested for securing to wall and seal. Additional review identified ceiling mounted items accessible in bedrooms that require anti-pick sealant to be applied. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Harbour Risk of ligaturing No Clinical Risk assessment. Safety planning with the patient Ward from an attached which may include the removal of ligature items. Increasing high-level anchor staffing levels. Staff present in communal areas at all times. All point. areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Anti- climbing works have been undertaken in the courtyard to prevent patients from climbing up the external window frame to gain access to roof / sun canopy. Fitting off anti climb coving extended. Anti-pick sealant being applied to ceiling mounted items.

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Briefly describe High Ward / risk - one level of unit Summary of actions taken sentence risk? name preferred Yes/ No Seaview Risk of ligaturing No Patients have individual clinical risk assessments that will Ward from an attached strongly consider the likelihood of self-harm by ligaturing from a (AAU) high-level anchor fixed anchor point and is documented as part of the patient’s point. individual care plan. Changes have occurred within the environment; Telephone Kiosk has had a new telephone phone fitted. An anti-ligature cabinet has been fitted over the wall mounted TV in the dayroom. Review undertaken in August to identify ceiling mounted items accessible items in bedrooms that require anti-pick sealant. External courtyard has had high level fixings either removed or amended to prevent gaining high level access. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Haven Risk of ligaturing No The ligature points identified do not indicate as high risk due to Ward from an attached the process of continued observation of patients & (Male) high-level anchor individualised risk assessments relating to care delivery. All point. patients on Haven ward are checked (whereabouts) every 15 minutes and this is captured & documented. The courtyard when accessed by patients is monitored at all times by two members of staff. The courtyard area has some unboxed lighting cables, a netball hoop, fire call point, Pinpoint, lighting and a Ping Pong table. Access to this area is restricted (locked). When access to the courtyard is granted patients are monitored at all times by two members of staff. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Review undertaken in August to identify ceiling mounted items accessible items in bedrooms that require anti-pick sealant. Haven Risk of ligaturing No The ligature points identified do not indicate as high risk due to Ward from an attached the process of continued observation of patients & (Female) high-level anchor individualised risk assessments relating to care delivery. All point. patients are checked (whereabouts) every 15 minutes and this is captured & documented. Capital planning working with the manufacturer to identify a more robust design to TV screens fitted in cabinets to prevent smashing and accessing to cabling. Review undertaken to identify ceiling mounted items accessible items in bedrooms that require anti-pick sealant to be applied. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access.

Maintenance, cleanliness and infection control The wards were clean and tidy, with bright and airy communal areas. Cleaners had a list of daily cleaning tasks and more focused cleaning for intermittent periods. The furnishings were well- maintained.

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Staff adhered to infection control practices. We saw wall-mounted hand sanitisers and gels on the wards. There were handwashing signs in the toilets and the kitchen. For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018), two of the locations scored higher than similar trusts for cleanliness and one scored lower than similar trusts. The three locations all scored lower than similar trusts for condition, appearance and maintenance.

Site name Core service(s) Cleanliness Condition appearance and maintenance MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems St Ann's MH – Mental health crisis services and 97.9% 91.5% Hospital health-based places of safety MH – Secure wards/Forensic inpatient Other MH – Specialist community mental health services for children and young people MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems Forston Clinic MH – Mental health crisis services and 98.7% 90.1% health-based places of safety MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older people CHS – Adults community MH - Acute wards for adults of working Linden age and psychiatric intensive care 98.7% 86.3% units Trust overall 98.1% 92.6% England average (Mental 98.4% 95.4% health and learning disabilities)

Seclusion room Only Haven ward had a seclusion room. This was used for seclusion and de-escalation, and generally fit for purpose with the right furniture and layout. It was fitted with two cameras linked to the office, which offered good observation. However, communication between staff and patient was through the door. This was not in line with guidance of Mental Health Act Code of Practice

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(2015). We highlighted this to the manager at the time of the inspection. We were told that the trust had already identified this and had plan to fit a two-way intercom in the seclusion suite to facilitate conversation. The ward manager could not give a completion date for this at the time of this inspection. Chine, Harbour, Waterston and Linden Unit used quiet or de-escalation rooms for managing aggression and violence in a safe way. However, the de-escalation room on Linden ward had a large beanbag which could present a possible suffocation risk to patients if they were to access it unsupervised. Accordingly, this room was rated as amber meaning patients were only to access the space under staff supervision.

Clinic room and equipment Staff ensured all the wards had clean, tidy and well-equipped clinic rooms. Staff kept medicines stored in locked cupboards and checked the medicines fridge and clinic room temperature readings daily.

The equipment staff used to monitor the health of patients, such as blood pressure monitors, was clean and well-maintained. There were records which showed that staff ensured equipment was in good working order including stickers on equipment showing the date the equipment had been checked.

Each ward had access to emergency resuscitation equipment including a defibrillator and oxygen supply as well as emergency medicines supplies. Although staff told us the emergency trolleys were checked weekly and audited during whilst doing the checks in the clinic room we found that emergency drugs were not always audited and checked appropriately. During this inspection we found there were missing checks of emergency medications. For example, we found that the anaphylaxis kit at the Waterston clinic contained two out of date ampoules of adrenaline. On Seaview ward a patient with an identified nut allergy was prescribed an Epipen, this had been ordered from the pharmacy but was not in stock. This was also raised during our inspection and nurse contacted the pharmacy to chase the order. This was raised during this inspection, the out of date ampoules were removed from Waterston ward. Each ward also had a range of equipment for monitoring patients’ physical health including blood pressure machines, thermometers, weighing scales, blood sugar level machines and pulse oximeters.

Safe staffing Nursing staff The trust specified the minimum number of registered and non-registered nurses required on each ward to ensure patient and staff safety. The service had enough staff with the right skills and qualifications to keep patients safe from avoidable harm. The trust reported for this service an overall vacancy rate of 11% for registered nurses and an overall vacancy rate of 17% for non- registered nurses as at 31 December 2018. We found that the staffing situation had improved since December 2018. For example, on Linden ward, there were six registered nurse vacancies and no non-registered nurse vacancy out of an overall establishment of twenty staff. On Waterston ward, there were four nurse vacancies, and one non-registered nurse vacancies. On Harbour ward, there were five nurse vacancies, and four non-registered nurse post vacancies. However, the manager told us that these posts have now been filled and the staff were due to start soon. To address vacancies and sicknesses, the managers block booked agency staff to ensure

Page 115 consistency for patients. The trust had carried out local recruitment drives, many nursing were staff due to start work in the forthcoming month. This core service has reported a vacancy rate for all staff of -13% (indicating an over establishment) as of 31 December 2018. This was lower than to the 20% rate reported at the last inspection (30 June 2017). This core service reported an overall vacancy rate of -11% (indicating an over establishment) for registered nurses at 31 December 2018. The vacancy rate for registered nurses was lower than the 21% reported at the last inspection. This core service reported an overall vacancy rate of -17% (indicating an over establishment) for nursing assistants. The vacancy rate for nursing assistants was not comparable to the last inspection.

Registered nurses Health care assistants Overall staff figures

Location Ward/Tea

m

(%) (%) (%)

Vacancies Vacancies Vacancies

Vacancy rate rate Vacancy rate Vacancy rate Vacancy

Establishment Establishment Establishment Forston Nursing 0.1 2.9 4% 0.0 0.4 0% 0.5 3.7 14% Clinic ECT Ward Inpatient St Ann’s Harbour -1.0 8.6 -12% 0.7 13.9 5% -0.2 23.4 -1% Hospital Ward Linden Communit Inpatient Linden 2.2 10.5 21% -4.2 9.5 -44% -1.8 22.0 -8% y Support Unit Unit Inpatient St Ann’s Chine -1.8 10.8 -17% -0.5 15.1 -3% -2.7 26.8 -10% Hospital Ward (was Dudsbury) Inpatient Forston Waterston -0.3 14.7 -2% -3.1 12.3 -25% -3.2 28.9 -11% Clinic (AAU) Inpatient St Ann’s Seaview -2.9 14.7 -20% -1.5 10.9 -14% -4.2 26.6 -16% Hospital Ward (AAU) Inpatient St Ann’s Haven -4.4 15.3 -28% -5.8 25.0 -23% -10.2 41.4 -25% Hospital Ward (PICU) Core service total -8.2 77.5 -11% -14.4 87.1 -17% -21.8 172.9 -13% Trust total 96.4 1424.4 7% -12.0 1055.7 -1% 156.3 3761.0 4% NB: All figures displayed are whole-time equivalents

Between 1 January 2018 and 31 December 2018, of the (120228) total working hours available, 10% were filled by bank staff to cover sickness, absence or vacancy for registered nurses.

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The main reason for bank and agency usage for the wards/teams was vacancies. In the same period, agency staff covered 6% of available hours for registered nurses and 1% of available hours were unable to be filled by either bank or agency staff.

Wards Total hours Bank Usage Agency Usage NOT filled by bank available or agency Hrs % Hrs % Hrs % Chine 18660 1094 6% 62 <1% 47 <1% Harbour 14472 596 4% 68 <1% 126 1% Haven 27852 4717 17% 1404 5% 296 1% AAU Seaview 22500 829 4% 29 <1% 158 1% Waterston AAU 18420 1609 9% 227 1% 185 1% Linden Unit 18324 3093 17% 5350 29% 68 <1% Core service 120228 11938 10% 7140 6% 880 1% total Trust Total 510921 74437 15% 32421 6% 4747 1%

Between 1 January 2018 and 31 December 2018, of the (178332) total working hours available, 35% were filled by bank staff to cover sickness, absence or vacancy for nursing assistants. The main reasons for bank and agency usage for the wards/teams were vacancies and Level 3 observations. In the same period, agency staff covered 5% of available hours and 3% of available hours were unable to be filled by either bank or agency staff. Wards Total hours available Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Chine 28560 12925 45% 86 <1% 1022 4% Harbour 22884 10208 45% 1056 5% 466 2% Haven 54132 17395 32% 6002 11% 2106 4% AAU Seaview 21132 6565 31% 1028 5% 596 3% Waterston AAU 35148 5733 16% 150 <1% 1203 3% Linden Unit 16476 9666 59% 99 1% 7 <1% Core service 178332 62492 35% 8421 5% 5400 3% total Trust Total 727272 194080 27% 25351 3% 16663 2%

This core service had 18.2 (9%) staff leavers between 1 January 2018 and 31 December 2018. This was higher than the 4% reported at the last inspection (1 July 2016 to 30 June 2017).

Location Ward/Team Substantive Substantive staff Average % staff leavers staff (at latest Leavers over the over the last 12 months month) last 12 months Nursing ECT Forston Clinic 3.2 0.7 25% Ward Linden Community Linden Unit 23.6 4.0 18% Support Unit

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Location Ward/Team Substantive Substantive staff Average % staff leavers staff (at latest Leavers over the over the last 12 months month) last 12 months St Ann’s Haven Ward 51.2 6.0 12% Hospital (PICU) St Ann’s Chine Ward 29.6 2.2 8% Hospital (was Dudsbury) Waterston Forston Clinic 32.5 1.9 6% (AAU) St Ann’s Seaview Ward 30.9 2.0 6% Hospital (AAU) St Ann’s Harbour Ward 24.6 1.4 5% Hospital Core service total 195.5 18.2 9% Trust Total 3623.9 364.5 10%

The sickness rate for this core service was 4.8% between 1 January 2018 and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 4.9%. This was lower than the sickness rate of 6% reported at the last inspection (30 June 2017).

Location Ward/Team Total % staff sickness Ave % permanent staff sickness (1 (December 2018) January 2018 – 31 December 2018) Linden Community Linden Unit 11.1% 10.7% Support Unit Haven Ward St Ann’s Hospital 6.1% 5.2% (PICU)

St Ann’s Hospital Harbour Ward 8.5% 5.0%

Seaview Ward St Ann’s Hospital 2.5% 4.2% (AAU) Waterston Forston Clinic 2.3% 2.7% (AAU) Chine Ward St Ann’s Hospital 1.1% 2.7% (was Dudsbury) Nursing ECT Forston Clinic 0.0% 0.0% Ward Core service total 4.9% 4.8% Trust Total 5.4% 4.9%

The below table covers staff fill rates for registered nurses and care staff during September 2018, October 2018 and November 2018. Waterson AAU had below 90% of the planned care staff for day shifts across all three months and below 90% of the planned nurses for night shifts across all three months. Chine Ward and Linden Unit had above 125% of the planned care staff for all night shifts. Linden Ward also had above 125% of the planned care staff for all shifts and Chine Ward had above 125% of the planned care staff for two of the three months. AAU Seaview and Haven Ward also had above

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125% of the planned care staff for night shifts. Chine Ward also had below 90% of the planned nurses for day shifts across two of the months. Key:

> 125% < 90%

Day Night Day Night Day Night Care Nurs Care Nurs Care Nurs Care Nurs Care Nurs Care Nurses staff es staff es staff es staff es staff es staff (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) September 2018 October 2018 November 2018 Waterston AAU 114 83 72 124 115 83 89 107 113 87 68 127 AAU Seaview 81 128 100 160 95 105 100 155 91 100 113 145 Chine Ward 73 127 100 126 80 149 100 186 93 123 110 157

Harbour Ward 91 137 100 102 90 100 100 103 89 119 100 128 Linden Unit 121 177 92 161 131 176 101 148 125 168 100 153 Haven Ward 103 158 102 157 105 115 100 134 117 106 102 147

Safe staffing levels were maintained on the wards. The trust mainly used bank staff to cover vacancies, leave, absence and sickness. These were staff with current or previous experience of working on the acute wards who wanted to work additional hours. Consequently, bank staff were usually familiar with the ward they were working on and knew the patients. New agency and bank staff undertook an induction to the ward, which provided them with essential information about the service. This included reading the ligature risk assessments and training in management of violence and aggression.

Staff told us there were contingency plans if they immediately required extra staff due to unforeseen circumstances. They told senior staff and staff from other wards assisted them to ensure the safety of staff and patients. Staff said that ward managers arranged additional staff for the night shift when the ward was unsettled or new admissions were planned. However, some staff on Harbour ward felt that due to high acuity at times it would be beneficial to have above established staff numbers at night.

Ward managers adjusted staffing levels to safely meet the needs of patients. They booked additional staff if there was more than one patient requiring close observation. During the inspection, we saw that additional staff were booked to escort patients to appointments and to enable the safe supervision of patients when some staff were in ward rounds and other meetings.

We observed that staff were mainly in communal parts of the wards interacting with patients and ensuring they were safe. Ward managers told us they emphasised the importance of this with staff and gave staff protected time to interact with patients. Most patients told us that staff spent time getting to know them and they were offered daily one to one time with a member of staff.

Staff teams could safely carry out physical interventions. Training in physical interventions took place regularly and was part of induction for new staff. Staff told us that training was effective and included simulation exercises, which prepared them to deal with difficult situations on the wards.

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There were arrangements to reduce the risk of patients being unable to take planned escorted leave due to staffing issues. For example, staff held a morning meeting with patients to discuss escorted leave arrangements. This helped to ensure arrangements were as fair as possible. Ward managers were monitoring escorted leave arrangements. Escorted leave was sometimes postponed because the wards were busy but then rearranged for later the same day.

Medical staff Between 1 January 2018 and 31 December 2018, the trust did not submit any data for this service regarding the use of bank and agency staff to cover medical locum. There was sufficient medical cover, which meant a doctor could attend the wards in an emergency.

Mandatory training The service provided mandatory training in key skills to all staff and made sure everyone completed it. Ward managers held data on staff completion of mandatory training, which showed a high level of compliance of over 92.89% as of the time of this inspection. Staff could easily access mandatory training and were clear on which courses they were required to complete for their work role. They were reminded of the training they needed to complete. Courses included basic and advanced life support, infection control and child and adult safeguarding. During this inspection we questioned the poor compliance of medicine management training reported at 23% and immediate life support training at 20% (table below), which were below the target national figure of 75%. The ward managers told us that this training was not mandatory.

The compliance for mandatory and statutory training courses at 29 January 2019 was 89%. Of the training courses listed 11 failed to achieve the trust target and of those, two failed to score above 75%. The trust set a target of 95% for completion of mandatory and statutory training. The trust’s training completion data is based on a rolling basis depending on training repeat requirement. The training compliance reported for this core service during this inspection was not comparable to the previous year. Key: Not met trust Met trust target Below CQC 75% target ✓ 

Training Module Number Number YTD Trust of of staff Compliance Target eligible trained (%) Met staff Safeguarding Adults Level 1 7 7 100% ✓ Safeguarding Children Level 1 7 7 100% ✓

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Training Module Number Number YTD Trust of of staff Compliance Target eligible trained (%) Met staff Equality and Diversity 180 179 99% ✓ Moving and Handling Theory Level 1 180 179 99% ✓ Prevention and Management of Violence and Aggression 174 170 98% ✓ Infection Control - 3 Yearly 180 171 95% ✓ Information Governance 180 170 94%  Basic Life Support - Taught 174 163 94%  Safeguarding Adults Level 2 173 158 91%  Safeguarding Children Level 2 97 87 90%  Mental Capacity Act 76 66 87%  Enhanced Life Support 76 66 87%  Fire 180 153 85%  Mental Health Act 83 67 81%  Safeguarding Children Level 3 76 60 79%  Medicines Management 88 20 23%  Immediate Life Support 5 1 20%  Total 1936 1724 89% 

Assessing and managing risk to patients and staff Assessment of patient risk Chine, Harbour, Haven and Seaview wards were part of the acute and Psychiatric Intensive Care Unit (PICU) pathway at St Anne’s Hospital. Seaview ward functioned as the assessment unit where patients were assessed and transferred to the appropriate treatment ward (Chine, Harbour and Haven). Staff at the treatment wards went to meet prospective patients on Seaview Ward to ensure a continuity of care, and to make patients feel comfortable about the transition. Staff thoroughly assessed each patient on admission to the service and then regularly reviewed and updated risk assessments. The admitting doctor and nurse followed protocols in terms of the blood tests, screening tools and risk assessments, which should be completed within the first 72 hours of the patient’s admission. This included full assessment of the patient’s physical and mental health risks. Standardised tools, such as a falls risk assessment were used.

We looked at 45 patient records across the six wards. Overall, risks were assessed appropriately at the point of admission and then reviewed each weekday by the multidisciplinary team.

The trust had introduced the ‘Safewards’ model to improve the safety of patients and staff. Staff on the wards had a good understanding of the model. We saw how staff put the model into practice to reduce levels of physical and verbal aggression on the wards. For example, staff and patients had together developed clear standards of behaviour for both staff and patients.

The trust had standardised risk assessment documentation, which included information about the patient’s history, risks to self and others and physical and mental health risks.

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Management of patient risk Staff completed risk assessments for each patient on admission. We saw evidence of risk assessments being completed and updated weekly or in the event of a change in the level of risk. The trust utilised a risk assessment tool built in to the RIO electronic notes system. No specialised risk assessments were used. Registered nurses did use specialist tools for the monitoring and assessing of risk relating to physical concerns. These included Waterlow for tissue viability and National Early Warning Score (NEWS) for physical health monitoring We saw the use of blanket restrictions on the wards such as access to mobile phone chargers, chargers to e-cigarettes. However, the patients we spoke with felt these blanket restrictions were fair. Patients were asked not to bring some prohibited items such as alcohol, ropes, cans, cameras, matches and lighters onto the ward with them. Staff were trained in searching patients and their belongings were searched and logged when they were admitted All the wards demonstrated an ability to use supportive observations in response to change in risk. Staff and patients told us that de-escalation techniques were used as a stepped approach to the management of risk. We saw evidence that the safe wards principles were being used, there were posters on the wall in the corridors with staff details on, discharge trees were available for people to attach their recovery stories and calm boxes were also in use. Use of restrictive interventions This service had 744 incidences of restraint (213 different service users) and 87 incidences of seclusion between 1 January 2018 and 31 December 2018. The below table focuses on the last 12 months’ worth of data: 1 January 2018 to 31 December 2018.

Ward name Seclusions Restraints Patients Of restraints, Of restraints, restrained incidents of prone incidences of restraint rapid tranquilisation AAU (Seaview 6 91 56 22 (24%) 33 (36%) Ward) Chine Ward 2 159 34 20 (13%) 38 (24%) Harbour 4 58 19 13 (22%) 4 (7%) Ward Haven Unit 75 331 71 119 (36%) 96 (29%) (PICU) Linden - AMH – 0 27 12 4 (15%) 7 (26%) Inpatient Waterston 0 78 21 2 (3%) 17 (22%) AAU Core service 87 744 213 180 (24%) 195 (26%) total

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There were 180 incidences of prone restraint, which accounted for 24% of the restraint incidents. Over the 12 months, incidences of restraint ranged from 30 to 91 per month. The number of incidences of restraint (744) had increased from the previous 12-month period (518). There were 195 incidences of rapid tranquilisation over the reporting period. Incidences resulting in rapid tranquilisation for this service ranged from three to 26 per month over the year (1 January 2018 to 31 December 2018). The number of incidences (195) had increased from the previous 12- month period (169). In the six seclusion records we looked at, staff had monitored vital signs and completed physical observations where safe to do so. In these records we also saw staff had updated the patient`s risk assessment and care plans following the use of seclusion or rapid tranquilisation. There have been zero instances of mechanical restraint over the reporting period. The number of incidences (0) was the same as the number of incidences from the previous 12-month period (0). The number of restraint incidences reported during this inspection was higher than the 287 reported at the time of the last inspection. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff told us that their training in preventing violence and aggression emphasised working in a patient-centred way and using de- escalation techniques. The ward staff participated in the provider’s restrictive interventions reduction programme. The ‘Safewards’ model was also used to predict potential ‘flashpoints’ for patients, for example, when patients were told they could not do something they wanted to do, and plan how staff should respond to behaviour which challenged them, in a compassionate way. Staff used multi- disciplinary meetings and handovers to discuss any circumstances that may cause patients distress and planned how to support the patient in the least restrictive way. Staff told us that restraint was a last resort and they always recorded it on the trust’s incident reporting system. They said often the same patient was restrained several times for brief periods before they were transferred to a psychiatric intensive care unit. Staff kept records, which showed how they had attempted to avoid the use of restraint and how the restraint had been carried out. Incident reports included information on how long the patient was restrained. There have been 87 instances of seclusion over the reporting period. Over the 12 months, incidences of seclusion ranged from three to 10 per month. The number of incidences (87) had decreased from the previous 12-month period (96). The number of seclusion incidences reported during this inspection was higher than the 48 reported at the time of the last inspection.

There have been zero instances of long-term segregation over the 12-month reporting period. The number of incidences (0) was the same as the previous 12-month period (0).

The number of segregation incidences reported during this inspection was the same as the zero reported at the time of the last inspection.

Safeguarding A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.

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Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This core service made 41 safeguarding referrals between 1 January 2018 and 1 January 2019, of which 41 concerned adults and zero concerned children. The number of safeguarding referrals reported during this inspection was not comparable to the last inspection. Number of referrals Core service Adults Children Total referrals MH – Acute wards for adults of working age 41 N/A 41 and psychiatric intensive care units

The number of adult safeguarding referrals in month ranged from one to seven (as shown below). The trust did not provide data on safeguarding referrals for children.

Total referrals (1 January 2018 to 1 January 2019)

7 6 7 5 5 4 2 2 0 1 1 1 Adult Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Staff understood multi-agency procedures to protect patients from abuse and the service worked well with other agencies. Wards had local safeguarding leads and there were trust leads for adult and child safeguarding who were available for advice. Staff understood their responsibilities to ensure that patients were protected from bullying and harassment whilst on the ward. Patients told us they felt safe on the wards and confident that staff would act to prevent any bullying or harassment. Staff could give us examples of how they had made sure that patients with protected characteristics felt comfortable on the wards. Staff received appropriate training on safeguarding children. Children could not come onto the wards but there were designated visiting areas for the wards at St Ann`s Hospital. On Linden ward the female lounge was used to facilitate visits. The trust had a safeguarding lead. This meant staff had a person they could ask for advice and guidance if they were concerned about a patient’s safety. The trust has not submitted details of any serious case reviews commenced or published in the last 12 months (1 February 2018 and 31 January 2019) that relate to this service. Page 124

Staff access to essential information Staff kept appropriate records of patients’ care and treatment. Records were clear and up-to-date. Staff used an electronic database. The trust used the same system throughout all services and it was easy for staff to access the information needed when patients moved between services. Staff said they could access and record information when they needed to.

Medicines management The service prescribed, gave and stored medicines well. However, we saw many gaps where medicines were given by were not signed for by staff. Patients told us they received the right medicines at the right dose at the right time. Staff told us they followed trust procedures in relation to the safe management of medicines and these complied with National Institute for Health and Care Excellence guidance.

On each ward, a registered nurse kept the keys to the clinic rooms, medicines cupboards, trolleys and controlled drugs cabinets. Pharmacists visited the wards at least once a week to advise the multidisciplinary team on the safe and effective use of medicines. Stocks of medicines were monitored and there were monthly medicines audits to check the storage and dispensing of medicines. However, during this inspection, we also found gaps on medication charts that were not signed for and there were gap in the auditing process of controlled drugs on Haven ward. Staff told us they had weekly audits on medicine management but we found that these audits did not identify signature gaps on medicine charts and out of date emergency medicines. There was no oversight from managers ensuring these checks were completed. At the last inspection in November 2017, we found that the trust should ensure that all ‘as required’ medicines (PRN) prescribed for patients were not reviewed regularly. However, we saw improvement during this inspection. There was clear information from the prescriber about the circumstances in which they should offer the patient the ‘as required’ medicine. In most cases, the prescriber had appropriately reviewed the use of ‘as required’ medicines. During our last inspection we also found that in the cases of High Dose Antipsychotic Therapy (HDAT), a HDAT care plan was not always in place. During this inspection we saw appropriate care plan for patient who were on high dose antipsychotic medicine, these included physical health monitoring, side effects profile in accordance with National Institute for Health and Care Excellence guidelines. There were the appropriate records of authorised medicines for patients who were detained under the Mental Health Act. The trust had procedures in place, which ensured staff arranged for patients to have the appropriate blood tests and health checks when they were prescribed antipsychotic medicines.

Track record on safety The ward managers attended a monthly Data Analysis Review Team (DART) meeting where they looked at an analysis of incidents related to violence and aggression. The meeting focused on the top ten patient incidents, with an aim to look for patterns and reduce risk trends. All serious incidents went through a root cause analysis, which was scrutinised by the patient safety team and the serious adverse incident panel. A summary was created and the patient

Page 125 safety team liaised with the wards to look at the results and prevention techniques. The staff were able to give an example where learning from a serious incident led to change. Between 1 January 2018 and 31 December 2018 there were 10 serious incidents reported by this service. Of the total number of incidents reported, the most common type of incident was ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’ with four. There were no unexpected deaths in this service. We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with 10 reported. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This service did not report any never events during this reporting period. The number of serious incidents reported during this inspection was higher than the seven reported at the last inspection. Number of incidents reported

Type of Slips/trip Disruptive/ag Apparent/actual/ Failure to Accident Total incident s/falls gressive/viole suspected self- obtain e.g. reported meeting nt behaviour inflicted harm appropriat collision/sca (SIRI) SI criteria meeting SI meeting e bed for ld (not criteria child who slip/trip/fall) needed it meeting SI criteria AAU (Seaview 0 1 2 1 1 5 Ward) Chine Ward 0 0 1 0 0 1 Harbour Ward 0 0 1 0 0 1 Haven Unit 1 1 0 0 0 2 (PICU) Waterston 1 0 0 0 0 1 AAU Total 2 2 4 1 1 10

Reporting incidents and learning from when things go wrong The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there have been two ‘prevention of future death’ reports sent to Dorset Healthcare University NHS FT. None of these related to this service. The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned through a “lesson learnt” document with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

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Staff could explain to us what incidents should be reported and knew how to make a report. Ward managers had clear information on what incidents had occurred on their ward and how they were being followed up.

Staff told us they could learn from incidents, which occurred locally and across the trust. Team meetings and clinical governance meeting notes over the previous two months included some information on incidents and the lessons learnt. Staff also said they received information on lessons learnt through team meetings, emails and briefing meetings for staff.

Staff told us that learning from past incidents across the trust had led to new initiatives such as physical health clinics for patients. Another example following a self-harming incident on Linden ward the observation policy had changed to reflect that when staff carry out checks on patients they need to also ensure they are engaging with patients at the same time. Staff knew the changes and recommendations that the trust had implemented.

Staff understood the duty of candour. Duty of candour is a legal requirement, which means providers must be open and transparent with clients about their care and treatment. This includes a duty to be honest with clients when something goes wrong. Staff told us about how they communicated with patients and what they would do in the event something went wrong.

Staff provided debrief sessions to patients involved in or witnessing incidents on the wards. Staff told us that the trust had provided them with immediate support and longer-term assistance after adverse incidents. Staff said managers, including senior managers, had been responsive and caring when incidents occurred.

Is the service effective?

Assessment of needs and planning of care Staff assessed patients’ mental and physical health care needs on admission. We looked at 45 care and treatment records across the three locations. Staff received assessment information from trust colleagues prior to the patient’s admission to the ward. On admission to the ward, a doctor carried out a mental and physical health examination of the patient, including blood pressure, heart rate, body mass index, electrocardiograms (ECGs) and routine blood tests. The doctor then put in place an interim care plan until a more detailed care plan was developed. Staff understood the importance of addressing physical health issues. Wards had a physical health lead nurse. Staff followed protocols in relation to making observations of patients’ vital signs on admission and during their stay. The frequency of observations was kept under review and was varied according to the physical health care needs of the patients. Some wards offered a weekly clinic to patients where they received a range of health checks and could ask for advice about their health conditions and their medicines. Staff used the national early warning score two (NEWS) system to record patients’ physical health observations. Records showed that staff completed these observations daily and escalated any high scores to clinicians. This reduced the risk of patients’ physical health deteriorating rapidly unnoticed. Staff developed personalised recovery-orientated care plans together with patients and ensured they were updated regularly. Care plans covered: mental health, physical health, medication, risks, rights, activities, religious/spiritual needs, social situation and family. Most patients told us that

Page 127 they were aware of the content of their care plan and had been involved in their development and review. Patients could request a copy of their care plan. Care plans varied in quality and some care plans lacked detail due to patient`s ability in be involved. Ward managers told us that care plans were an ongoing area for improvement. The trust had initiatives to support staff to develop effective holistic care plans. The trust had recently introduced the “my wellbeing plan” which encompasses crisis plans, risk management plans and care plans to help uniformity of care plans across the trust. Staff planned patients’ care in a personalised and holistic way. This included activity for daily living assessments completed by the occupational therapist, to identify a suitable placement for discharge. Patients were supported to address substance misuse and linked to a local drug and alcohol service. Each patient had a named nurse and had regular one-to-one key worker sessions as part of their care plan.

Best practice in treatment and care The service provided care and treatment based on national guidance for adult mental health patients such as short-term management of violence and aggression in adults and admission and stay in an inpatient mental health service. Staff teams provided a wide range of personalised interventions, which included medicines, psychological therapy and a wide range of therapeutic and rehabilitation activities. However, on Harbour ward we found a number of patients were prescribed regular and ‘as required’ haloperidol, which is an antipsychotic used to treat symptoms of psychosis and schizophrenia. As Haloperidol causes very unpleasant side effects its use as a first line medication is now not considered best practice.

Psychological treatments recommended by the National Institute for Health and Care Excellence were available for patients. Patients could access group therapies, such as cognitive behavioural therapy, mindfulness and meditation, with more limited access to individual therapies. At St Ann`s hospital there was an inpatient psychology team which provided interventions to inpatients including complex assessment, psychological formulation and brief, crisis focused psychological interventions. In addition, the clinical psychologists provided team formulation and reflective practice for inpatient staff, bespoke teaching and training for staff, consultation and supervision. The clinical psychologist provided teaching session to staff which included providing training to staff in understanding personality disorder and complex trauma, using compassion focused therapy ideas for self-care and promoting compassionate care. A cognitive behavioural therapist had recently provided bespoke training in understanding substance misuse and using cognitive behavioural therapy (CBT) to understand and work with people with psychosis. The dialectical behaviour therapy (DBT) consultant at St Ann’s Hospital had ran sessions which were well attended by staff from each ward. This provided supervision for staff working with patients with a personality disorder. Staff adapted this model to their ward in different ways including using it in assessment, formulation, running DBT skills classes/groups, and informing 1:1 nursing work. Seven staff recently received intensive training in DBT and were working to improve this service further. This was the way inpatient psychologists work with colleagues and the wider service to promote psychological thinking and provided supervision to others, which enabled staff to deliver

Page 128 psychological interventions. This model allowed for more patients to benefit from psychological interventions than if they were delivered only by the psychologists themselves. This initiative had received positive feedback from patients and other staff. Occupational therapists (OTs) facilitated groups providing support to patients such as activities of daily living, for example cooking, shopping budgeting. OT staff also supported patients with access to educations, voluntary work, community-based activities. Patients had good access to physical healthcare, which included access to specialists when needed. Patients told us they could ask to see a doctor if they felt physically unwell. Staff escorted patients to the local acute hospital when they required specialist care. Some wards held weekly health and well-being clinics. Registered nurses ensured that there were appropriate physical health assessments and investigations recorded for each patient. They talked with patients and clarified any substance misuse issues with regular input from a local drug and alcohol support service. Routine health screens were carried out and standardised risk assessments were completed for example on blood sugar, diet and nutrition, and falls. Staff supported patients to live healthier lives. For example, smoking was not permitted at any of the hospitals. A nicotine replacement therapy was provided on each ward. E-cigarettes were allowed in the grounds. Patients told us staff supported them to be physically active and they had access to the gym, walking groups and other opportunities for exercise. At St Ann`s hospital, the trust employed an active life instructor who also facilitated exercise groups and sessions. Staff participated in a range of clinical audits including restrictive interventions, Mental Health Act, multi-disciplinary template, MUST (malnutrition universal screening tool) and ECG completion audits. The service monitored the effectiveness of care and treatment and used the findings to improve care and treatment. The service used health of the nation outcome measures (a standard outcome measure used across hospitals) to gauge efficiency of the service. This service participated in six clinical audits as part of their clinical audit programme 2018 – 2019.

Audit Audit Date Key actions following Audit name Core service scope type completed the audit Refresher training will be delivered to all MHA MH - Acute wards for administrators who Mental Health Mental adults of working age accept and scrutinise Act Programme Health Clinical 30/01/2018 and psychiatric detention papers and - Section 4 Services intensive care units will be recommended for some 201 bleep holders Amendment of HIV and BBV admission protocols to screening in MH - Acute wards for included addition of HIV acute Waterston adults of working age and Hep B/C screening psychiatry Clinical 12/03/2018 tests to routine AAU and psychiatric inpatient cohort admission bloods. intensive care units at Waterston Educate ward staff on AAU indications for HIV and Hep B/C screening Prescribing The 20% of patients MH - Acute wards for High Dose and identified all had regular adults of working age Combined Linden Unit Clinical 27/12/2018 side effect monitoring and psychiatric and physical health Antipsychotics intensive care units checks, the aim is to on Adult reduce the dosage

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Audit Audit Date Key actions following Audit name Core service scope type completed the audit Psychiatric down to within BNF Inpatient Ward guidance RE-AUDIT of POMH-UK 1g & 3d Prescribing MH - Acute wards for High Dose and adults of working age None required Linden Unit Clinical 27/12/2018 Combined and psychiatric Antipsychotics intensive care units on Adult Psychiatric Inpatient Ward Time taken to Cover for secretaries MH - Acute wards for complete Linden Unit when on leave/ sick. adults of working age This allows work to be discharge Medical Clinical 23/01/2019 and psychiatric prioritised and avoids a summaries Re- Staff intensive care units backlog. Audit

Skilled staff to deliver care On each ward in the service, staff from a full range of mental health disciplines provided input to the planning and delivery of patient care and treatment. This included consultant psychiatrists, doctors, nurses, nursing assistants, occupational therapists, clinical psychologists, social workers and pharmacists. Patients could request to see the pharmacists on a one-to-one basis to discuss their medicines. Patients also had access to a dietitian. We spoke with 33 staff, including those from each mental health disciplines during the inspection. Some of the staff we interviewed had worked within the service for several years, whereas others were newly appointed. Staff said the trust supported them to develop their skills through formal training courses and ward-based learning events. Specialist training provided included learning disability and suicide prevention e-learning for nurses and non-registered nurses and dialectical behavioural therapy training. New staff, working on a ward for the first time, had an induction to the ward. Staff followed a checklist to ensure new staff were given all appropriate information about the ward, the patients and key procedures. The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 April 2017 to 31 March 2018), the overall appraisal rate for non-medical staff within this service was 92%. So far in this financial year, the overall appraisal rate was 83% (as at 28 January 2019). The wards with the lowest appraisal rate at 28 January 2018 were Harbour Ward with an appraisal rate of 69%, Haven Unit (PICU) with an appraisal rate of 70% and Waterston AAU at 71%. The rate of appraisal compliance for non-medical staff reported during this inspection was higher than the 76% reported at the last inspection.

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Ward name Total Total % % number of number of appraisals appraisals permanent permanent (as at 28 (previous non- non- January year 1 medical medical 2019) April staff staff who 2017-31 requiring have had March an an 2018) appraisal appraisal AAU (Seaview Ward) 26 26 100% 100% ECT 4 4 100% 100% Chine Ward 19 18 95% 100% Linden Inpatient 17 16 94% 95% Waterston AAU 31 22 71% 88% Haven Unit (PICU) 33 23 70% 87% Harbour Ward 13 9 69% 86% Core service total 143 118 83% 92% Trust wide 4197 3827 91% 95%

The trust did not provide appraisal data for medical staff in this service. The trust’s target of clinical supervision for non-medical staff is 95% of the sessions required. Between 1 April 2017 and 31 March 2018, the average rate across all seven teams in this service was 69%. The rate of clinical supervision reported during this inspection was lower than the 81% reported at the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%)

ECT 7 7 100%

AAU (Seaview Ward) 27 22 81%

Chine Ward 21 17 81%

Waterston AAU 22 16 73%

Harbour Ward 22 15 68%

Linden - AMH - Inpatient 15 10 67%

Haven Unit (PICU) 25 9 36% Core service total 139 96 69%

Trust Total 1568 1236 79%

Managers provided staff with supervision. Our evidence above recorded for the service was 69% between 1 April 2017 and 31 March 2018. This figure was out of date at the time of this inspection. Staff told us they received supervision; management supervision, clinical supervision and peer

Page 131 supervision regularly. When supervisions happened, they discussed current staff performance, aspirations and training requirements. The ward managers showed us the supervision records and evidence that supervisions were happening. However, there were many gaps in supervision records across the wards. Reflective practice was demonstrated across the wards and learning from incidents took place during supervision. Appraisals occurred annually. At the time of this inspection the trust provided figures of 93.22% of staff who were appraised for the service. These focussed on staff development, both professionally and personally. There were opportunities for staff to develop their clinical skills. For example, support workers were encouraged to join nurse training programs. Managers identified the learning needs of staff during supervisions and appraisals. Managers provided staff with opportunities to develop their skills and knowledge. This was across all staff groups and provided there was a clinical justification for specialist training, staff could access this easily. For example, the aspiring leaders course, venepuncture, ECG and physical observations training. Managers ensured staff had access to regular team meetings. Meeting minutes were recorded comprehensively and disseminated to staff. Managers dealt with poor staff performance promptly and effectively. Managers gave staff the opportunity to improve and identified improvement needs early on before problems arose. Managers were quick to refer staff to occupational health and wellbeing if they felt that staff may drop in performance due to stress or non-work-related issues. The trust did not provide clinical supervision data for medical staff in this service.

Multidisciplinary and interagency team work On all the wards doctors, nurses and other healthcare professionals worked effectively together to plan and provide personalised care and treatment. Staff described good teamwork, with the views of all disciplines considered. For example, a non-registered nurse on Linden ward, said that the consultant psychiatrist would always check with the staff team when making a significant decision about a patient’s care and treatment. All wards had daily (Monday to Friday) short multi-disciplinary meetings which were attended by all staff disciplines. We observed seven such meetings. Meetings were well conducted and effective. All wards also held at least weekly multi-disciplinary meeting (ward rounds), whereby patient care was discussed and reviewed by the multi-disciplinary team. Named nurses gathered feedback, concerns, suggestions and requests from the patient ahead of the meeting and shared these in the multi-disciplinary meeting. Feedback from the minutes were then shared by the consultant psychiatrist. On Haven ward we saw the whole multi-disciplinary team went to the patient`s room to discuss the patient`s care and review. The ward manager told us that this helped patients of not feeling intimidated in a room full of professionals. External teams also attended ward round meetings to exchange information and plan for discharge. There was representation from community mental health teams and home treatment teams. The teams had effective working relationships with teams outside the organisation to support patients holistically. Staff had a good working relationship with the local police. They worked closely with the local drugs and alcohol rehabilitation service. There were effective handovers between outgoing and incoming nursing staff three times each day. In the handover meetings we observed staff sharing key information. This included risk information and an update on each patient’s current mental and physical health. Staff also shared Page 132 information about any meetings or appointments in relation to housing or welfare benefits. Staff told us handover meetings were very useful and enabled them to start their shift with a clear picture of the priorities for their work with patients. Staff attended fortnightly reflective practice sessions to promote personal development and optimum care for patients.

Adherence to the Mental Health Act and the Mental Health Act Code of Practice As of 29 January 2019, 81% of the workforce in this service had received training in the Mental Health Act. The trust stated that this training is mandatory for all services for inpatient and all community staff (role-specific) and renewed every three years. The training compliance reported during this inspection was not comparable with the last inspection. Staff were trained in and had a good understanding of the Mental Health Act (MHA), the Code of Practice and the guiding principles. Staff had easy access to local MHA policies and procedures and the Code of Practice through the trust’s intranet. Staff had easy access to the administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who the MHA administrators were and how to contact them. MHA detention papers received by ward staff were checked by the MHA office staff who also organised Mental Health Tribunals and hospital managers’ hearings. MHA office staff visited wards to complete monthly audits and to provide advice. Staff stored copies of patients’ detention papers and associated records appropriately so that they were available to all staff that needed to access them. The MHA documents were uploaded to patients’ records so they were accessible to all staff. They were also available centrally for the trust to monitor. Staff explained and recorded patient rights under the MHA in a way they could understand, and repeated as needed. Records showed this happened regularly. Detained patients told us that ward staff encouraged them to take their authorised section 17 leave when this had been granted. Clinicians clearly recorded the start and end date of patients’ leave and updated this in their care records. Staff authorised and administered medicines for detained patients in line with the MHA code of practice. For example, patients had their consent to treatment forms completed accurately and kept with their medicines charts for staff to access. Copies of consent to treatment were also available on the electronic system. Staff requested an opinion from a second opinion appointed doctor when necessary. Patients had easy access to information about independent mental health advocates (IMHAs). The wards displayed posters with the contact details of the local advocacy service. An IMHA visited the wards to support patients. There was information about how to contact the IMHA available for patients. However, there were no notices near the exit doors of the wards explaining the right of informal patients to leave the ward.

Good practice in applying the Mental Capacity Act

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As of 29 January 2019, 87% of the workforce in this service had received training in the Mental Capacity Act. The trust stated that this training is mandatory for all services for inpatient and all community staff (role-specific) and renewed every three years. The training compliance reported during this inspection was higher than the 64% reported at the last inspection. Staff understanding of the Mental Capacity Act and the principles were variable between registered and non-registered nurses. The ward managers told us that Mental Capacity Act training was a mandatory training for all registered nurses but not unregistered staff. Managers identified this as a shortfall and told us this was something that the trust were considering as mandatory for all staff. Staff did not demonstrate good practice in recording the Mental Capacity Act. Capacity and consent were discussed in MDT meetings but were not always recorded in the notes. There was not consistent recording of how capacity assessments were conducted. From the review of records, it was not always possible to determine how capacity assessments were conducted. In many cases there was only a line stating the patient did not have capacity to consent or agree to something, such as treatment, but there was no rationale or assessment process described that led staff to this conclusion. There were also no specific capacity assessments for differing aspects of patient care. For example, there were rarely separate capacity assessments to determine if a patient could consent to personal care, or to manage their finances, or to accept treatment. Often there was one description that the patient lacked capacity, and this was applied to all the various aspects of patient care. This took away the assumption that a person can have the capacity to decide on differing aspects of their life. The trust told us that one standard and one urgent Deprivation of Liberty Safeguard (DoLS) application was made to the Local Authority for this service between 1 January 2018 to 31 December 2018. The greatest number of DoLS applications were made in May 2018 with one standard and one urgent application made. The trust told us that across all services, 19 DoLS direct notifications were sent to CQC. However, CQC received 324 direct notifications from the trust between 1 January 2018 to 31 December 20182. These numbers do not match across the two sources. Under HSCA legislation, all DoLS applications should also be sent to the CQC in the form of a direct notification so this is important. The number of DoLS applications made during this inspection was not comparable to the last inspection.

Number of ‘Standard’ DoLS applications made by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 18 18 18 18 18 18 18 18 18 18 18 18 Standard applications made 0 0 0 0 1 0 0 0 0 0 0 0 1 Standard applications approved 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of ‘Urgent’ DoLS applications made by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 18 18 18 18 18 18 18 18 18 18 18 18 Standard applications 0 0 0 0 1 0 0 0 0 0 0 0 1 made

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Number of ‘Urgent’ DoLS applications made by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 18 18 18 18 18 18 18 18 18 18 18 18 Standard applications 0 0 0 0 1 0 0 0 0 0 0 0 1 approved Is the service caring?

Kindness, privacy, dignity, respect, compassion and support We spoke with 13 patients across the six wards. Patients said they felt staff were kind and treated them with dignity and respect. Most patients told us that staff asked them how they were feeling and took the time to explain their care and treatment to them. Patients said that staff always tried to understand their point of view and gave them the support and encouragement they needed to recover and move on from the wards. Most patients commented on the fact that staff supported them well even though they were always busy due to the demands of the wards. Most patients felt that restrictions on their wards were fair, and that they understood the reason for them. Two patients said that they had experienced disrespectful care from some individual staff. We raised this the respective ward manager at the time who told us they will approach these patients and encourage them to make a complaint. We observed staff treating patients with a high level of compassion and kindness and using de- escalation techniques effectively. Staff understood the importance of communicating with patients in a friendly, polite and open way to convey their respect for patients. We observed that staff had good interpersonal skills and demonstrated their interest in what patients were saying through their body language and the way they spoke with patients. Staff took the opportunity to greet patients and ask them how they were when making routine ward checks. Staff were respectful and friendly when talking to and interacting with patients and were consistently patient and calm. Staff were always mindful of confidentiality and ensured they did not speak about patients in communal areas. There was a high turnover rate of patients, and the named nurse system was used effectively to ensure staff spent time talking and getting to know patients. Ward managers arranged ‘protected time’ for staff to interact with patients. Staff showed a person-centred and supportive manner towards patients. For example, we observed the morning community meetings on three different wards. Staff ensured that all patients were included and had the opportunity to contribute their views. Staff checked that each patient knew who their primary nurse was and had been offered a copy of their care plan. On Chine and Haven ward staff members had put together ‘pamper boxes’ (includes necessary toiletry products) which they gave to patients upon their admission to the ward. Patients spoke positively about these initiatives. On these wards staff also ran a hand massage group for patients. On Linden ward, for example, a patient had written a very positive and complimentary poem about their positive experience on the ward. Most patients told us that they felt able to report concerns, and we observed patients raising concerns about the ward environments during community meetings. Staff reported that they felt confident to report any disrespectful or discriminatory attitudes towards patients. However, when patients were moved to the seclusion suite on Haven ward from the other wards at St Ann`s hospital, they are escorted through the female corridor on Haven ward. This meant that that the escorting patient`s privacy and dignity were compromised.

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The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at all three service locations scored lower than similar organisations.

Site name Core service(s) provided Privacy, dignity and wellbeing MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems St Ann's Hospital MH – Mental health crisis services and 89.3% health-based places of safety MH – Secure wards/Forensic inpatient Other MH – Specialist community mental health services for children and young people MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems MH – Mental health crisis services and Forston Clinic 82.6% health-based places of safety MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older people CHS – Adults community MH - Acute wards for adults of working age Linden 89.3% and psychiatric intensive care units Trust overall 85.3% England average (mental health and learning 91.0% disabilities)

Involvement in care Involvement of patients The staff teams on each ward supported patients to understand their stay in hospital, their mental and physical health needs and how to manage their own care and treatment. Patients received a welcome pack on admission, which helped introduce them to the ward. This included information about the multidisciplinary team, ward rounds, community meetings and the roles of different staff members. Staff on Linden ward also held a weekly “mutual expectation meeting” where patient would be briefed on the ward expectation and patient could suggest any alternative approach to their care and treatment. The rules, routines and activities were explained. There was information on meals, behaviour towards others and visitors. Patients told us staff involved them in the assessment of risks and in care planning. They said they were invited to discuss and plan their care and treatment by their named nurse before the multi- disciplinary meetings. They said that staff spoke with them clearly and made sure they understood

Page 136 what was being said. We observed a ward round and saw that staff were careful to use plain language and to provide answers to any questions raised by the patient. Patients told us they could bring family members or an advocate to multi-disciplinary meetings and other meetings. Care plans were variable in terms of record keeping by staff about the level of collaboration between the member of staff and the patient. The patient’s views were sometimes clearly recorded. Staff told us that some patients did not wish to work with them on their care plans or were too unwell to fully participate. Staff offered each patient a copy of their care plan and this was recorded on the notes. The trust involved patients in giving feedback and planning improvements to the service. The trust gave patients a questionnaire to report their views on the quality of the service when they were discharged. On Linden, Haven and Chine ward, on a wall in the communal area was a ‘Tree of Hope’ where patients could leave messages about positive experiences of the ward and their recovery as a way of encouraging patients to feel they too could recover and move on from the ward. Patients on all the wards said that they found daily community meetings helpful and interesting. These meetings were recorded, and actions were noted for follow-up. On all wards, patients told us that changes had been made to the food and activities on offer because of their feedback. Advocates attended the wards on request and contact details for advocates were on display on the wards. All wards displayed information about the staff team with photographs. They also included a wide range of information for patients including information about medicines, staff allocated on each shift, Mental Health Act information, and information about different diagnoses and psychological therapies available. The wards had a ‘you told us, so we did’ board, which highlighted any requests or suggestions that patients had made and what actions had been completed.

Involvement of families and carers All staff undertook carer awareness training and signed up to the “triangle of care” initiative. Carer contact sheet were completed on admission. Carers were given information packs with contact details of specialist peer carers, who are two volunteers who have lived experience of caring. On Haven Ward, the friends and family test were filled out at the point of discharge, and a monthly summary was displayed on the noticeboard in the corridor.

Is the service responsive?

Access and discharge Seaview acted as the admission ward for the acute and PICU care pathway. The admission ward worked closely with the crisis and hospital liaison team to prioritise referrals and was monitored by bed managers to ensure effective use of the beds available. If Seaview Ward was full, they would consider an out-of-area bed or see who could be discharged safely or transferred to a treatment bed. Seaview Ward also worked closely with the crisis team to support people transition back into the community. Managers told us they dealt with emergency referrals promptly. Following the care pathway, the patients were transferred to the treatment units of Chine, Harbour or Haven wards. Page 137

Staff on Harbour ward told us when patients go on leave their bed will be given away if the plan was for them to be discharged if their leave went well. These staff also told us that they had more acutely unwell patients on the acute ward and this was due to no bed available on the psychiatric intensive care unit (PICU). This meant that patient who required psychiatric intensive care were not always admitted in the appropriate environment. Bed management The trust provided information regarding average bed occupancies for seven wards in this service between 1 January 2018 to 31 December 2018. Seven of the wards within this service reported average bed occupancies ranging above the minimum benchmark of 85% over this period. Ward name Average bed occupancy range (1 January 2018 – 31 December 2018) (current inspection) AAU - Seaview 93%-98% Chine 97%-100% Harbour 98%-100% Linden 96%-100% PICU - Female 90%-100% PICU - Male 85%-100% Waterston 95%-100%

The trust provided information for average length of stay for the period 1 January 2018 to 31 December 2018. Ward name Average length of stay range (1 January 2018 – 31 December 2018) (current inspection) AAU - Seaview 9-33 days Chine 25-137 days Harbour 55-322 days Linden 34-121 days PICU - Female 2-150 days PICU - Male 4-140 days Waterston 19-88 days

The trust did not provide data on out of area placements in a format that was suitable for analysis by core service. This service reported 35 readmissions within 28 days between 1 January 2018 to 31 December 2018. Twenty-one readmissions (60%) were readmissions to the same ward as discharge. The average of days between discharge and readmission was 12 days. There was one instance whereby a patient was readmitted on the same day as being discharged but there were three where patients were readmitted the day after being discharged. At the time of the last inspection, for the period July 2016 to June 2017, there were a total of 27 readmissions within 28 days. Of these, 12 were readmissions to the same ward (44%) and the average days between discharge and readmission was 27 days. Therefore, the number of readmissions within 28 days has increased between the two periods and the average time between discharge and readmission has decreased.

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Ward name Number of Number of % Range of Average days readmissions readmissions readmissions days between (to any ward) (to the same to the same between discharge within 28 ward) within ward discharge and days 28 days and readmission readmission AAU Seaview 10 10 100% 0-24 14 Chine Ward 5 2 40% 2-28 17 Harbour Ward 4 2 50% 4-22 13 Linden Unit 4 2 50% 7-17 11 Psychiatric Intensive 5 2 40% 0-20 7 Care Unit – Female Psychiatric Intensive 2 1 50% 1-14 8 Care Unit - Male Waterston Acute 5 2 40% 1-14 7 Assessment Unit

Some of the staff we spoke with on Harbour ward told us that some patients went through accelerated discharges and these patients then unfortunately had to come back into hospital quickly. Staff also told us that these patients who had experienced “accelerated discharge”, usually did not always go through a proper discharge planning process whereby family and care coordinators were part a discharge planning meeting. These also told us that they had more acutely unwell patients on the acute wards and this was due to no bed available on the psychiatric intensive care unit (PICU). The ward manager told us the trust had plans to create more beds to address this.

Discharge and transfers of care Between 1 January 2018 to 31 December 2018 there were 784 discharges within this service. This amounts to 20% of the total discharges from the trust overall (3886). In this service the trust reported 77 delayed discharges. Across the 12-month period, delayed discharges ranged from four to nine per month. The proportion of delayed discharges reported during this inspection was not comparable to the last inspection.

Facilities that promote comfort, dignity and privacy The wards had a full range of rooms and equipment to support the treatment and care of patients. We witnessed good use of the activities and therapies rooms while on site. There were family rooms and quiet rooms available for patients to meet their friends, family and other visitors. Patients were able to make phone calls in private. Patients had access to their own mobile phone and the wards provided access to computers with internet facilities. On all wards, people had access to outside space. On some wards, previous smoking areas had been converted into indoor conservatories or therapeutic spaces and these provided bright, airy spaces with canvas or landscape prints on the walls. On Linden Ward, the garden acted as a therapeutic space where patients could do some gardening. The flowers and vegetables grown were used for floral decorations, and cooking. There was also a garden swing which patients

Page 139 found soothing. The manager on Linden Ward had enlisted the help of a local artist to make a mosaic in the courtyard with the patients. Patients were involved in the planning, drawing and painting of the mosaic in the garden and expressed a sense of ownership of it. The courtyard had then become a recreational, therapeutic space. Similarly, on Haven Ward patients had access to a secure outside space, with good use of murals featuring local landmarks. The wards also had access to gym facilities for the physical well-being of patients, and all wards encouraged their patients to use them. There was a good range of activities on most of the wards, and these were happening daily. Patients enjoyed visits to the shops and beach walks, arts and crafts and baking. The lack of an occupational therapist on Harbour Ward meant that patients were lacking continuous engagement and therefore had long spans of time with not much to do. Staff on the ward had tried to keep the activities going daily but did not always have the resources or staff to ensure this happened. Patients also responded that they felt bored most of the time and that they often had nothing to do. Three of the staff we spoke with on Harbour ward told us when patients were moved to the seclusion suite on Haven ward from the other wards at St Ann`s hospital, they were escorted through the female corridor on Haven ward. This could potentially compromise the escorting patient`s privacy and dignity at times. This was due to the layout of the ward and no alternative access were available. When we spoke to the ward manager on Haven ward, she told us that escorting patient through the female corridor were planned interventions and staff made sure that female patients were moved to their bedroom or lounge so the escorting patient`s dignity were not compromise. The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at the three locations scored higher than similar trusts. Site name Core service(s) provided Ward food

MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems St Ann's Hospital MH – Mental health crisis services and health- 94.5% based places of safety MH – Secure wards/Forensic inpatient Other MH – Specialist community mental health services for children and young people MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems MH – Mental health crisis services and health- Forston Clinic 93.2% based places of safety MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older people CHS – Adults community

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Site name Core service(s) provided Ward food

MH - Acute wards for adults of working age Linden 99.0% and psychiatric intensive care units Trust overall 94.3% England average (mental health and learning 92.2% disabilities)

Patients’ engagement with the wider community The trust encouraged the use of peer specialists. These are people who have previously been through the acute or PICU care pathway as patients and have carried out training to help support people currently in the pathway. The peer specialists had been involved in planning handovers to help make them more patient-centred. They also delivered training to current patients around reflection and developing skills for rehabilitation back into the community. All the wards made extensive use of the peer specialists and involved them in patient review meetings, outings and activities around the wards.

Meeting the needs of all people who use the service The wards had a good display of information leaflets for patients and carers, including information on physical and mental well-being, nutrition, advocacy support, complaints procedures and help lines. Food was well-liked by patients and we observed staff sitting with patients during lunchtimes. Some patients told us they thought that the food was of good standard. Patients had access to drink making facilities and snacks during the day. For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018) Linden scored lower than similar trusts for being dementia friendly. All three locations scored lower than similar trusts for the environment supporting those with disabilities.

Site name Core service(s) provided Dementia Disability friendly MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems St Ann's Hospital MH – Mental health crisis services and health- N/A 81.6% based places of safety MH – Secure wards/Forensic inpatient Other MH – Specialist community mental health services for children and young people MH - Acute wards for adults of working age and psychiatric intensive care units Forston Clinic MH – Other Specialist Services N/A 73.2% MH – Wards for older people with mental health problems

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MH – Mental health crisis services and health- based places of safety MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older people CHS – Adults community MH - Acute wards for adults of working age Linden 80.1% 81.4% and psychiatric intensive care units Trust overall 83.2% 84.1% England average (Mental health 88.3% 87.7% and learning disabilities)

Patients had their own bedrooms on Linden, Seaview, Harbour, Forston and Haven ward. On Chine ward only three patients had access to single bedrooms and ten other patient had access to shared rooms. There were dividers in these rooms to offer a degree of privacy to the patients. Staff risk assessed each patient prior to admitting them into a shared room on Chine ward. If staff felt the risks were high, staff would offer the patient a single room. If this was not possible staff increased observation levels and remained with a patient in the shared room, to protect the patient or other patients depending on the reason for higher risk. There had been a clinical review of the use of shared accommodation and was decided to retain the shared beds, however in the long term the trust will be planning to remove all shared accommodation. On all the wards female patient had access to a female only lounge or quiet area. All patients had lockable cupboards and stored personal items in locked storage room Patients’ were able to personalise their bedrooms. Staff and patients generally had access to the full range of rooms and equipment to support treatment and care. This included therapy rooms, examination rooms, lounges, dining rooms and outside space. All the wards had outside space that patients could use. However, on Haven ward staff and patient told us there was a lack of private therapy space where patients were able to have private sessions. Staff told us that if they were to have a quiet one to one meeting this would have to take place in the patients’ bedroom. The food was of good quality in all the wards. Menus were varied, with healthy and vegetarian, vegan options. Patients’ commented to us during the inspection that the food was good. Hot and cold drinks, as well as snacks, were available to patients at any time during the day. On Linden ward we saw the occupational therapist performing kitchen assessments with patients that allowed the patients to cook meals for themselves as part of their recovery.

Listening to and learning from concerns and complaints Patients knew how to make complaints and provide feedback about the service provided. They felt comfortable doing so. Most patients tended to contact the ward manager directly to express their concerns. On Chine Ward, the manager had an ‘availability board’ outside her office which told patients whether she was busy, or available for a chat.

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Patients could also provide feedback through the ‘post-boxes’ which were operated in each of the wards. Patients were able to write down their concerns or feedback and post it anonymously in the post-box. This is checked on a daily basis. Staff were able to provide examples of where patient feedback and concerns had led to a change in practice. This service received 24 complaints between 1 January 2017 to 31 December 2018. Four of these were upheld, 11 were partially upheld and three were not upheld. No complaints were referred to the Ombudsman.

Ward

name

Other

Under Under

Referred to to Referred

Withdrawn

Not upheld Not

Fully upheld Fully

Ombudsman

Investigation

Partially upheld Partially Total Complaints Total Waterston 6 0 5 0 0 1 0 0 AAU Haven Unit 5 1 2 1 0 1 0 0 (PICU) AAU (Seaview 4 1 0 1 2 0 0 0 Ward) Chine 4 1 1 0 0 2 0 0 Ward Harbour 3 0 2 1 0 0 0 0 Ward Linden 2 1 1 0 0 0 0 0 Inpatient

This service received 70 compliments during the last 12 months from 1 January 2017 to 31 December 2018 which accounted for 2% of all compliments received by the trust (4077).

Is the service well-led?

Leadership Staff reported that the managers of the wards were highly approachable and that they felt well- supported and listened to. Staff told us that the managers listened to their concerns and ensured that these were responded to. Managers held a regular meeting for acute wards at which they discussed incidents, new developments or other matters relevant to the core service, and shared learning. All the managers we spoke to were supportive of their staff’s personal development and training. Staff gave examples of non-mandatory training such as Dialectical behaviour therapy (DBT) training that they had attended. Vision and strategy Staff knew and understood the trust’s vision and values and how they were applied in the work of their team. During staff interviews they could describe the vision and values and demonstrate this Page 143 in the way they worked. Patients described the care they received as being in line with the trust’s vision and values. The ward manager team had successfully communicated the trust’s vision and values to the ward staff. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. For example, we were told about managers using a staff member’s strengths during a refurbishment to give advice on how the service should look. Staff could explain how they were working to deliver high quality care within the budgets available.

Culture Staff felt respected, supported and valued. Staff told us how they were all treated with support by each other and senior staff. We saw this during meetings such as multi-disciplinary meetings and handovers. Staff treated each other with respect and listened to each other. Managers valued staff feedback. Staff felt positive and proud about working for the trust and on the wards with their teams. We saw this in the interactions between the staff and staff commented on this when we spoke to them. During inspection we were told that morale can fluctuate, especially during busy periods when patients had high acuity, however staff said that the teams supported each other. During times of stress and lower morale staff could access psychological support and occupational health. Staff were able to raise concerns without fear of retribution. They were aware of the trust’s whistle- blowing process. Not all staff were aware of the Speak Up Guardian, but there were posters and leaflets on the ward. The Speak Up Guardian had visited the wards previously. Managers dealt with poor staff performance when needed. Managers could describe the process for performance management process and gave examples of when they have had to use this process. Managers told us about times they had addressed staff short-comings before they required performance management, taking an active approach in staff performance. The managers sought support from human resources and the senior managers as needed. Staff appraisals included conversations about career development and how staff could be supported. This included specialist training and leadership opportunities. Managers and staff were proactive in facilitating their professional development. Staff had access to support their own physical and emotional health needs though an occupational health service. Managers encouraged staff to seek support when needed. The wards had access to psychological support for staff. Staff were able to approach managers if they needed to. There was a health and wellbeing policy in place to ensure staff are looked after.

Governance Ward managers completed a Quality Effectiveness Safety Trigger Tool (QUEST) audit each month, which included sickness absence, complaints, supervision, hand hygiene and incidents. The monthly summary went to all managers and was seen by the board of the trust. There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Team meetings occurred regularly, and from reviewing meeting minutes the teams discussed a range of issues, patient risks, safeguarding and incidents. There were monthly managers meetings between the ward managers and modern matron Page 144

Staff undertook local clinical audits. However, not all the audits were sufficient to provide assurance. Staff did not always act on the results when needed. There were examples of emergency drug audits, and mental capacity assessment and consent audits that were not used effectively. We were told that these audits occurred weekly and were actioned. However, we saw evidence that the audits were not being done regularly with the missing signatures on medicine charts and emergency medicines. There were also actions from the consent audit that had not been completed. Managers did not always have oversight of these audits as they were unaware of the missing checks. Staff understood the arrangements for working with other teams, both within the trust and external, to meet the needs of the patient. There was good liaison with social services, clinical commissioning groups and carer representatives.

Management of risk, issues and performance Staff maintained and had access to the risk register at ward level. Staff at ward level could escalate concerns when required although staff told us they would escalate this to the ward manager in the first instance. Staff were aware of the risks on the ward. The service had plans for emergencies. This included fire emergencies, outbreaks of diseases such as flu. The wards conducted fire assessments to ensure readiness for the emergency. Staff were aware of emergency procedures.

Information management The service used systems to collect data from wards and directorates. These were mostly based through their internal computer systems. However, wards also collected their own data. For example, Haven ward collected data on therapeutic intervention and the effect on staff sickness and patient restraint. Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure worked well and helped improve the quality of care. Managers could access learning and development reports to keep track of staff training figures. The information technology infrastructure allowed managers to know which bank staff were coming onto the ward, to ensure that they had the required skills and experience. This was set up in a way that bank staff could not apply to shifts if they did not have the required training for that ward. Information governance systems included confidentiality of patient records. These were secured by password protection and encryption to ensure there was no inappropriate access. Staff made notifications to external bodies as needed. This included statutory notifications to CQC and any referrals to the local authority.

Engagement Staff, patients and carers had access to up-to-date information about the work of the wards. This was done through staff and patient community meetings, leaflets and one to one sessions.

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Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. This could be done through formal feedback such as the patient liaison service or through one to one meetings with staff or ward managers. Managers and staff had access to the feedback from patients, carers and staff. This was used to make improvements to the service.

Learning, continuous improvement and innovation NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. The trust did not report any accreditations associated with this service. Staff were given the time and support to consider opportunities for improvements and innovation. This led to changes. For example, managers, were supported to visit other NHS trusts to share learning regarding managing violence and aggression and seclusion. Staff used quality improvement methods and knew how to apply them. For example, the staff on Haven ward were supported by an external Quality Improvement (QI) team to produce research into therapeutic activity on the reduction of violence and aggression.

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Long stay/rehabilitation mental health wards for working age adults

Facts and data about this service

Location site name Ward name Number of beds Patient group (male, female, mixed) 30 Maiden Castle Road Glendinning 9 Mixed

49 Alumhurst Road Nightingale Court 13 Mixed

49 Alumhurst Road Nightingale House 16 Mixed

The methodology of CQC provider information requests has changed, so some data from different time periods is not always comparable. We only compare data where information has been recorded consistently.

Is the service safe?

Safe and clean environment Safety of the ward layout Staff carried out regular risk assessments of the care environment. All areas of the wards were colour coded with a red, amber, green (RAG) warning system to highlight potential safety risks. Patients also had individual risk assessments to determine their access to, and support needed within different areas of the buildings. The wards had a number of potential ligature anchor points (which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation). Staff were aware of these points and had mitigated the risks adequately. The provider had installed reflective mirrors to mitigate the risks associated with blind spots on the ward. Staff carried out regular checks of all patients to mitigate risks. The service only accepted patients who were considered at low risk of self-harm. If a patient became higher risk, staff would provide additional monitoring while assessing whether their needs could continue to be met on the ward, or if they needed to move to an acute ward. Over the 12-month period from 1 January 2018 to 31 December 2018 there were no mixed sex accommodation breaches within this service. At the previous inspection we issued a requirement notice to Nightingale Court for not complying with mixed sex accommodation regulations. The service had ensured that female patients had access to a female only lounge. The bedrooms on the upstairs floor that required women to walk through male occupied areas to access bathroom facilities had been changed to male only rooms to ensure the ward complied with the regulations. There were ligature risks on three wards within this service.

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Ward / unit Briefly describe risk - one High level of risk? Summary of actions taken name sentence preferred Yes/ No Nightingale Court Risk of ligaturing from an No Patients are referred to attached high-level anchor Nightingale Court for potential point. inpatient status, they are assessed by at least 2 clinicians to ascertain, besides other issues that they present low risk level regarding suicide, self-harm, absconding or violence and aggression towards others. Capital programme has converted a previous meeting room (locked non-patient area) to form a new small female lounge & smaller meeting room (locked non-patient). The ligature anchor points of the new female lounge are not scoring as high risk. Ligature cabling works to reduce the accessible length and placing other cables into conduit. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Nightingale Risk of ligaturing from an No Clinical assessments to identify House attached high-level anchor patients at risk of ligature. This point. includes increased observation levels, locking off rooms/restricting access if necessary, receiving pre-existing patient history or if this is not known 1:1 observations. All belongings checked on return from leave. Staff located in corridor at night to listen out for noise of concerns. Works in progress to fix 20 wardrobes to the wall using corner bases and Trust approved anti tamper screws. All to be sealed with Everbuild 109 white anti pick mastic. Ligature cabling works to reduce the accessible length and placing other cables into conduit. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access.

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Ward / unit Briefly describe risk - one High level of risk? Summary of actions taken name sentence preferred Yes/ No Glendenning Unit Risk of ligaturing from an No Each patient has a clinical risk attached high-level anchor assessment to identify risk of point. self-harm/ suicide and accidents. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access.

Staff had easy access to alarms, and patients had access to staff call systems.

Maintenance, cleanliness and infection control All ward areas were clean, had good furnishings and were well-maintained. For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018), the location scored lower than similar trusts for cleanliness and for condition, appearance and maintenance.

Site name Core service(s) Cleanliness Condition appearance and maintenance 49 Alumhurst MH - Long 96.3% 91.7 Road stay/rehabilitation mental health wards for working age adults MH - Child and adolescent mental health wards MH - Other Specialist Services MH - Specialist community mental health services for children and young people Trust overall 98.1% 92.6% England 98.4% 95.4% average (Mental health and learning disabilities)

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Staff completed monthly audits of cleanliness on the ward. Staff adhered to infection control principles, including handwashing.

Clinic room and equipment

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Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. A pharmacist visited the three wards on a weekly basis and carried out additional stock checks.

Safe staffing Nursing staff Managers had calculated the number and grade of nurses and healthcare assistants required for each of the three wards. The staffing levels varied across the wards and generally reflected the number and complexity of patients on the ward. Glendinning ward had one allocated nurse and one healthcare assistant for the day shifts to cover the nine patients on the ward. An occupational therapist and occupational therapy assistant joined this team during the day to provide activities and additional support. The ward clerk could also double up as an additional support worker as needed and was also trained in phlebotomy. Nightingale House had two registered nurses and three support workers during the day with additional occupational therapy support. Nightingale Court had one registered nurse and two support workers. The manager on Nightingale Court had recently completed a business case to request an additional Band 6 registered nurse in addition to the current staffing level of one registered nurse per day. This would free up nursing staff for more professional development and to enable them to have an admin day each week. The ward managers could adjust staffing levels as needed to take account of the needs on the ward. On Nightingale Court an additional registered nurse was brought in on ward rounds and meeting days to ensure there were sufficient staff to meet the patients’ needs. When necessary, managers used agency (on rare occasions) and bank staff to maintain safe staffing levels. When using agency or bank staff, managers booked staff who were familiar with the ward where possible. Bank and agency staff received an induction. They also had the opportunity to attend clinical supervision sessions on the wards. New staff told us they felt supported by more experienced staff. A registered nurse was present on the ward at all times. Staffing levels allowed patients to have regular one-to-one time with staff. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. There were enough staff to carry out patient observations as needed. This core service reported a vacancy rate for all staff of 3% as of 31 December 2018. This was lower than the 8% reported at the last inspection (between 1 August 2016 and 31 July 2017). This core service reported an overall vacancy rate of 6% for registered nurses at 31 December 2018. This core service reported an overall vacancy rate of 1% for nursing assistants at 31 December 2018.

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Registered nurses Health care assistants Overall staff figures

Ward/Team

(%) (%) (%)

Vacancies Vacancies Vacancies

Vacancy rate rate Vacancy rate Vacancy rate Vacancy

Establishment Establishment Establishment Nightingale 0.8 6.4 12% 1.8 8.8 20% 2.5 16.1 16% Court Nightingale 1.1 8.6 13% 0.5 13.4 4% 1.6 25.0 6% House Nightingale -0.3 0.3 -114% 0.0 4.2 0% -0.3 7.8 -4% Joint Glendinning -0.2 5.8 -4% -1.8 4.8 -39% -2.1 11.5 -18% Core 1.3 21.0 6% 0.4 31.1 1% 1.7 60.5 3% service total Trust total 96.4 1424.4 7% -12.0 1055.7 -1% 156.3 3761.0 4%

NB: All figures displayed are whole-time equivalents

Between 1 January 2018 and 31 December 2018, of the (31896) total working hours available, 25% were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. The main reason for bank and agency usage for the wards/teams was vacancies. In the same period, agency staff covered 2% of available hours for qualified nurses and 1% of available hours were unable to be filled by either bank or agency staff.

Wards Total hours Bank Usage Agency Usage NOT filled by bank available or agency Hrs % Hrs % Hrs % Nightingale House 13308 2193 16% 10 <1% 0 0% Nightingale Court 9924 3841 39% 271 3% 97 1% Glendinning unit 8664 1887 22% 235 3% 145 2% Core service 31896 7921 25% 516 2% 242 1% total Trust Total 510921 74437 15% 32421 6% 4747 1%

Between 1 January 2018 and 31 December 2018, of the (50088) total working hours available, 17% were filled by bank staff to cover sickness, absence or vacancy for nursing assistants. The main reasons for bank and agency usage for the wards/teams was vacancies. In the same period, agency staff covered less than 1% of available hours and less than 1% of available hours were unable to be filled by either bank or agency staff.

Wards Total hours available Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Nightingale House 27444 5372 20% 0 0% 0 0%

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Wards Total hours available Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Nightingale Court 14172 2139 15% 10 <1% 177 1% Glendinning unit 8472 1132 13% 118 1% 0 0% Core service 50088 8643 17% 128 <1% 177 <1% total Trust Total 727272 194080 27% 25351 3% 16663 2%

This core service had 3.0 (5%) staff leavers between 1 January 2018 and 31 December 2018. This was lower than the 7% reported at the last inspection (from 1 August 2016 to 31 July 2017).

Ward/Team Substantive staff Substantive staff Average % staff leavers over (at latest month) Leavers over the last the last 12 months 12 months Nightingale Court 13.6 2.0 13% Nightingale House 23.4 1.0 4% Glendinning 14.6 0.0 0%

Nightingale Joint 8.1 0.0 0% Core service total 59.7 3.0 5% Trust Total 3623.9 364.5 10%

The sickness rate for this core service was 3.6% between 1 January 2018 and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 1.6%. This was higher than the sickness rate of 2.5% reported at the last inspection (from 1 August 2016 to 31 July 2017). Ward/Team Total % staff sickness Ave % permanent staff sickness (1 January (December 2018) 2018 to 31 December 2018) Nightingale Joint 9.9% 8.0%

Nightingale Court 0.0% 5.5%

Glendinning 1.1% 2.8%

Nightingale House 0.0% 1.3%

Core service total 1.6% 3.6%

Trust Total 5.4% 4.9%

The below table covers staff fill rates for registered nurses and care staff during September, October and November 2018.

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Nightingale House had below 90% of the planned registered nurses for all day shifts in September and October 2018 and below 90% of the planned care staff for day shifts in September, October and November 2018. Nightingale Court had over 125% of the planned registered nurses for day shifts in October 2018. Key:

> 125% < 90%

Day Night Day Night Day Night Care Nurs Care Nurs Care Nurs Care Nurs Care Nurs Care Nurse staff es staff es staff es staff es staff es staff s (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) September 2018 October 2018 November 2018 Nightingale 89 80 100 100 89 80 100 100 96 79 100 100 House Glendinning 107 90 111 102 108 106 110 103 99 101 107 107 Unit Nightingale 109 108 100 100 135 111 96 107 124 96 100 100 Court

Medical staff Between 1 January 2018 and 31 December 2018, there was no recorded use of medical locums for this service. There was adequate medical cover day and night. Each of the wards had a consultant, and a specialist doctor or advanced nurse practitioner to support them. Junior doctors provided out of hours cover. A doctor could attend the wards in an emergency. If they were busy with another emergency and could not attend quickly, emergency services would be contacted as a back-up. Glendinning ward was in the middle of a one-year pilot for the advanced nurse practitioner role. This meant that the advanced nurse practitioner could focus more on physical health needs and health promotion with patients. This would free up the consultant to focus more on supporting patients with their mental health needs.

Mandatory training The compliance for mandatory and statutory training courses at 29 January 2019 was 91%. Of the training courses listed five failed to achieve the trust target and of those, two failed to score above 75%. The trust set a target of 95% for completion of mandatory and statutory training. However, ward managers were not confident with the reliability of the recording system for staff training. On Glendinning ward staff were recorded as having completed mandatory training on one part of the training system, but not on another. The team had established a training spreadsheet separate to the Trust recording system to monitor training compliance. Releasing staff to complete training was a challenge on Glendinning ward due to the low establishment staffing levels. Staff worked rotating day and night shifts, and there was an expectation that staff would be in a better position to complete online learning training during night

Page 153 shifts. The ward clerk on Glendinning would remind staff when they were due for training and ensured this was recorded in the ward spreadsheet. Key:

Met trust target Not met trust target Below CQC 75% ✓ 

Training Module Number Number YTD Trust of of staff Compliance Target eligible trained (%) Met staff Equality and Diversity 51 51 100% ✓ Mental Capacity Act 22 22 100% ✓ Moving and Handling Theory Level 1 51 51 100% ✓ Safeguarding Adults Level 1 3 3 100% ✓ Safeguarding Children Level 1 3 3 100% ✓ Infection Control - 3 Yearly 51 50 98% ✓ Information Governance 51 50 98% ✓ Safeguarding Adults Level 2 48 47 98% ✓ Safeguarding Children Level 2 28 27 96% ✓ Basic Life Support – Taught 48 46 96% ✓ Safeguarding Children Level 3 20 19 95% ✓ Moving and Handling Practical Level 2/3 22 21 95% ✓ Prevention and Management of Violence and Aggression 48 45 94%  Enhanced Life Support 22 20 91%  Fire 51 42 82%  Mental Health Act 22 15 68%  Medicines Management 22 2 9%  Total 563 514 91% 

Assessing and managing risk to patients and staff Assessment of patient risk We looked at 16 patient records across the three wards. We found a consistent, detailed and clear approach to risk assessment. Staff did a risk assessment of every patient on or before admission and updated this regularly, including after any incident or change in circumstances. Staff used the Trust risk assessment tool.

Management of patient risk Staff were aware of and dealt with any specific risk issues, such as deteriorating mobility or substance misuse. Staff identified and responded to changing risks to, or posed by patients. Staff followed good policies and procedures for use of observation, including to minimise risk from potential ligature points, and for searching patients or their bedrooms. Staff applied blanket restrictions on patients’ freedom only when justified. For example, on Glendinning (an unlocked

Page 154 unit), doors were locked between the hours of midnight and 6am for overnight patient safety and security. Staff carried out risk assessments and had a protocol in place for all patients working towards self- administration of medication. Staff adhered to best practice in implementing a smoke-free policy. All sites were smoke-free. Informal patients could leave at will and knew that. Not all wards had posters explaining this to patients, but all informal patients were notified of this on admission and were given information leaflets detailing their rights as informal patients.

Use of restrictive interventions This service had one incidence of restraint (one service user) and no incidences of seclusion between 1 January 2018 to 31 December 2018. If restraint were needed on an ongoing basis, a transfer to an acute ward would be arranged.

The below table focuses on the last 12 months’ worth of data: 1 January 2018 to 31 December 2018.

Ward name Seclusions Restraints Patients Of restraints, Of restraints, restrained incidents of prone incidences of restraint rapid tranquilisation Nightingale 0 0 0 0 0 Court Nightingale 0 1 1 0 0 House Core 0 1 1 0 (0%) 0 (0%) service total

There were no incidences of prone restraint. The number of incidences (0) was the same as the previous 12-month period (1 January 2017 to 31 December 2017). There were no incidences of rapid tranquilisation over the reporting period. The number of incidences (0) was the same as the previous 12-month period (0). There have been no instances of mechanical restraint over the reporting period. The number of incidences (0) was the same as the number of incidences from the previous 12-month period (0). Staff used restraint very rarely. Staff did not admit patients at high risk of aggression to the wards. Staff used verbal de-escalation, and would only use restraint after this had failed. Staff were trained in prevention and management of violence and aggression (PMVA). This included training on de-escalation skills and breakaway techniques. There have been no instances of seclusion over the reporting period. The number of incidences (0) was the same as the previous 12-month period (0).

There have been no instances of long-term segregation over the 12-month reporting period. The number of incidences (0) was the same as the previous 12-month period (0).

Safeguarding

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A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern was raised regarding a child or vulnerable adult, the organisation would work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This service made no safeguarding referrals between 1 January 2018 and 1 January 2019. However, ward managers were able to confirm that they had made safeguarding referrals to the local authority directly and gave examples of when it would be appropriate to make referrals, as well as occasions when they had done this. Staff were trained in safeguarding, knew how to make a safeguarding referral, and did so when appropriate. Staff knew how to identify adults and children at risk of or experiencing significant harm. This included working in partnership with other agencies. Safeguarding was an ongoing topic of discussion in the teams and managers were confident in their staff’s abilities to keep people safe from abuse. Staff followed safe procedures for children visiting the ward. They risk assessed each visit on an individual basis and ensured any safety measures were in place as needed. The trust has submitted details of no serious case reviews commenced or published in the last 12 months (1 February 2018 and 31 January 2018) that relate to this service.

Staff access to essential information All patient records were stored electronically. All information needed to deliver patient care was available to all relevant staff (including bank or agency staff) when they needed it and was in an accessible form. This included when patients moved between wards or teams. Bank and agency staff had access to records as needed. However, this was not the case on Glendinning ward, where the manager was looking into a system to enable temporary access to computer records for bank or agency staff. At the time of the inspection temporary staff received a handover from staff, but did not have full access to the computerised records.

Medicines management Staff followed good practice in medicines management (transport, storage, dispensing, administration, medicines reconciliation, recording, disposal), and did this in line with national guidance. There were however some minor issues. We found a discrepancy in the recording of pregabalin (rescheduled by NHS England from 1 April 2019 as a controlled drug). NHS England guidance identifies pregabalin as exempt from safe custody regulations and storage in the controlled drugs cabinet. On Glendinning ward, staff had stored pregabalin in the controlled drugs cabinet and recorded this in the controlled drugs book. Following guidance from the team pharmacist, staff were no longer recording in this way (in line with national guidance). However, when medicines had been removed from the cabinet, staff had not updated the controlled drugs book to reflect that this had been administered, or to reflect that pregabalin was no longer being

Page 156 recorded in the book. As such this gave the incorrect impression that medicines were unaccounted for. The pharmacist rectified this recording error during the inspection and ensured staff were aware of correct recording procedures. We also found some out-of-date medication in the fridge in Nightingale House. Staff were no longer dispensing this, but had not disposed of the medication and had not picked this up within medicines audits. The pharmacist acted upon this immediately to dispose of the medicine and to investigate why this had not been identified during audits. At Nightingale House, one patient was administered medicine that had not been agreed on their T3 (consent to treatment under the Mental Health Act) form. On identifying this, the consultant immediately rectified the error and updated the paperwork to reflect the current medicines prescribed and administered. On Glendinning ward, the temperature in the clinic room was over 25 degrees Celsius on six days in the previous month. The ward manager was aware of the issues with the temperature, and had submitted a request for a roof vent to be installed to rectify this. Staff reviewed the effects of medicines on patients’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance.

Track record on safety Between 1 January 2018 and 31 December 2018 there were no serious incidents reported by this service. We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with none reported.

Reporting incidents and learning from when things go wrong The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there have been two ‘prevention of future death’ reports sent to Dorset Healthcare University NHS Trust. None of these related to this service. Staff knew what incidents to report and how to report them. Staff reported all incidents they should report. Staff understood the duty of candour. They were open and transparent, and gave patients a full explanation if things went wrong. Staff received feedback from the investigation of incidents. This was generally done during staff meetings. We saw evidence of individual meetings held to review incidents. These meetings looked at what worked well and what could have been improved, to ensure a team approach to improving practice and lessons learnt. There was evidence that changes had been made as a result of these meetings. For example, following an error in medicines management, all medicines sheets were taken into handover. This was to ensure the nurse taking over shift audited the sheets at the start of each shift, to identify any errors and make sure that all information was handed over in an organised way.

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Staff also completed incident reflection forms to support these changes and improvements in practice. These supported both staff and patients to reflect on incidents, causes and consequences of behaviour, and how to learn from this in the future. These were stored in patient records. Is the service effective?

Assessment of needs and planning of care We looked at 16 care records across the three sites. Each of the records included a holistic, person centred approach to assessment of needs and care planning, with clear evidence of patient involvement. This was particularly the case when patients had a “My Wellbeing” care plan. Staff were in the process of completing these plans for all patients following a successful trial of the plans within the service. Staff completed a comprehensive mental health assessment of the patient in a timely manner at, or soon after admission. Patients were generally transferred from other wards within the Trust, and so were already known to the service before admission. Staff assessed patients’ physical health needs in a timely manner after admission. Staff carried out physical observations fortnightly (or more often if needed), during a physical health clinic. Staff recorded these observations and any other relevant health issues on a physical health care plan. Staff used recognised assessment tools such as the brief psychiatric rating scale (BPRS), social functioning questionnaire and the model of human occupation, the Montreal cognitive assessment (MoCA) and the assessment of comprehension and expression (ACE). Staff developed care plans that met the needs identified during assessment. Care plans were personalised, holistic and recovery-orientated. Patient voice was particularly evident throughout the “My Wellbeing” care plans. Staff updated care plans when necessary.

Best practice in treatment and care Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence. These included physical health care, psychological therapies, activities, training and work opportunities intended to help patients acquire daily living skills. The wards had a dedicated psychologist for 3.5 days per week between them. Patients could access a range of therapeutic activities to develop their daily living skills and support independence and reintegration back into the community. These included activities on site and within the community. The service offered patients the chance to become involved in the “horse course”, equine therapy in the community. Staff also supported patients to access voluntary work and education opportunities in the community, as well as joining community groups. Patients could access art rooms, creative expressions groups, music group, shabby chic (furniture restoration), cinema group and bowling amongst other activities. Staff tailored activities to support the individual patients’ aims and objectives. Not all patients felt there were enough activities in place, particularly at the weekend. Staff ensured that patients had good access to physical healthcare, including access to specialists when needed.

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Staff assessed and met patients’ needs for food and drink and supported patients to lead healthier lives. Staff encouraged patients to develop healthy eating habits as part of daily living skills development. The physical health lead on Nightingale House delivered health promotion sessions including nutritional advice. Patients were given smoking cessation advice and support, and had access to gym equipment at Glendinning ward. Staff used recognised rating scales to assess and record severity and outcomes, such as the Health of the Nation Outcome Scales (HoNOS) and Glasgow antipsychotic side effect scale (GASS). Staff participated in clinical audit, benchmarking and quality improvement initiatives. Nightingale Court and Glendinning Unit had completed a research paper on improving inpatient wards for patients with cognitive impairment. Staff were involved in a training programme on cognitive impairment. Staff made changes to the ward environments to make them more suited to patients with cognitive impairment (in line with learning disability and dementia services within the Trust). The wards also implemented a cognitive screening programme to identify patients with cognitive impairment on admission. The research indicated that staff had increased confidence and knowledge about cognitive impairment as a result of this programme. This service participated in one clinical audit as part of their clinical audit programme 2018 – 2019. Audit name Audit scope Core service Audit type Date Key actions completed following the audit Clozapine St Ann’s MH - Long Clinical 25/01/2018 Review of Clozapine monitoring of Hospital, all stay/rehabilitation policy to bring it up to in adult wards mental health date with current inpatients at evidence-based administering wards for St Ann’s practice and Hospital clozapine, working age incorporation of the adult in- adults Linden Unit patients Guidelines to capture cases of asymptomatic myocarditis. Develop a protocol to follow in the event of raised troponin. Develop a single document for recording all parameters required for monitoring clozapine. One for titration and one for maintenance

Skilled staff to deliver care The team included the full range of specialists required to meet the needs of patients on the wards. As well as medical and nursing staff, the wards had access to a clinical psychologist, occupational therapists and occupational therapy assistants, support workers, and peer support workers. Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group. Managers provided new staff (including any bank or agency staff) with appropriate and comprehensive induction.

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The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 April 2017 and 31 March 2018), the overall appraisal rate for non-medical staff within this service was 94%. This year so far, the overall appraisal rate was 71% (as at 28 January 2019). Ward name Total Total % % number of number of appraisals appraisals permanent permanent (as at 28 (previous non- non- January year 1 medical medical 2019) April 2017 staff staff who – 31 requiring have had March an an 2018) appraisal appraisal Glendinning Unit AMH 13 12 92% 100% Nightingale Court 14 12 86% 100% Nightingale House 22 11 50% 85% Core service total 49 35 71% 94% Trust wide 4197 3827 91% 95%

There was no data provided for medical staff appraisal rates for this service. The trust’s target of clinical supervision is 95% of the sessions required. Between 1 April 2017 and 31 March 2018, the average rate across all three teams in this service was 50%. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%)

Nightingale Court 12 10 83%

Nightingale House 18 7 39%

Glendinning Unit AMH 14 5 36% Core service total 44 22 50% Trust Total 1568 1236 79%

While supervision rates across the service were below the Trust expected standard of 95%, clinical supervision was recorded in such a way that this only reflected supervision delivered during a particular quarter. As such, if figures were obtained at the start of that quarter, supervision rates would be lower than expected. This did not reflect a true picture of supervision delivered within that quarter until the end of that time period. As such the clinical supervision rates provided did not fully reflect the situation on the wards. We saw evidence on site of managers providing staff with regular clinical and managerial supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development). Staff were satisfied with the quality and amount of supervision. Managers were providing staff with annual appraisals of their work performance. Managers ensured staff had access to regular team meetings.

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Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers ensured that staff received the necessary specialist training for their roles. Managers were supportive of staff accessing additional training where this was relevant to their role. Managers also arranged bespoke training for staff to assist them with their roles. The psychologist for the service also delivered additional training on specialist subjects, such as personality disorder. Managers dealt with poor staff performance promptly and effectively. Any issues of concern were generally followed up in supervision following the Trust staff performance policy. The wards had volunteer peer support workers who had previously been through rehabilitation, delivering groups to patients. These groups were well received by patients who gave very positive feedback. The peer support workers were trained and supported by the Trust in carrying out this role.

Multidisciplinary and interagency team work Staff held regular and effective multidisciplinary meetings. Staff shared information about patients at effective handover meetings within the teams. The ward teams had effective working relationships, including good handovers, with other relevant teams within the organisation. For example, when patients were transferred from acute wards, staff would have a handover from the acute team and would often visit the patients on the acute ward as part of the transfer. The ward teams had effective working relationships with teams outside the organisation, including the local authority safeguarding teams, GPs and local charities.

Adherence to the Mental Health Act and the Mental Health Act Code of Practice As of 29 January 2019, 68% of the workforce in this service had received training in the Mental Health Act. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed every three years. However, there were some discrepancies on the recording of training within the teams, and not all completed training had been accurately recorded on the training matrix. The team manager on Nightingale Court held bespoke training sessions for staff on the ward in addition to mandatory training. These sessions included topics such as Section 132 rights (informing detained patients of their legal rights) and Section 17 leave (the right to leave the hospital for an agreed period while detained), and were tailored to meet staff identified needs. Staff had a good understanding of the principles of the Mental Health Act 1983, the Code of Practice and the guiding principles. Team managers were confident staff had sufficient knowledge to carry out their roles effectively. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act 1983 and its Code of Practice. The provider had relevant policies and procedures that reflected the most recent guidance. Staff had easy access to local Mental Health Act 1983 policies and procedures and to the Code of Practice.

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Patients had easy access to information about independent mental health advocacy. Staff explained to patients their rights under the Mental Health Act 1983 in a way they could understand, repeated it as required and recorded that they had done it. Staff ensured that patients could take Section 17 leave (permission for patients to leave hospital) when this had been granted. Staff requested an opinion from a second opinion appointed doctor when necessary. Staff stored copies of patients’ detention papers and associated records (for example Section 17 leave forms) correctly and so that they were available to all staff that needed access to them. Not all wards displayed a notice telling informal patients that they could leave the ward freely. However, this information was included in the induction information pack that Nightingale House gave to all patients on admission. Staff also told all informal patients they were free to leave, and reminded them of this. Staff did regular audits to ensure that the Mental Health Act 1983 was being applied correctly.

Good practice in applying the Mental Capacity Act As of 29 January 2019, 100% of the workforce in this service had received training in the Mental Capacity Act. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed every three years. Staff had a good understanding of the Mental Capacity Act 2005, in particular the five statutory principles. Team managers were confident that staff had sufficient knowledge and understanding to enable them to carry out their roles effectively. The manager at Nightingale Court had arranged and carried out additional bespoke Mental Capacity Act 2005 training for staff to strengthen this understanding. The trust told us that one standard and one urgent Deprivation of Liberty Safeguards (DoLS) application was made to the Local Authority for this service between 1 January 2018 to 31 December 2018. The greatest number of DoLS applications were made in January 2018 with one. The trust told us that across all services, 19 DoLS direct notifications were sent to CQC. However, CQC received 324 direct notifications from the trust between 1 January 2018 to 31 December 20183. These numbers do not match across the two sources. Under HSCA legislation, all DoLS applications should also be sent to the CQC in the form of a direct notification so this is important.

Number of ‘Standard’ DoLS applications made by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Tot 18 18 18 18 18 18 18 18 18 18 18 18 al Standard 1 0 0 0 0 0 0 0 0 0 0 0 1 applications made Standard 0 0 0 0 0 0 0 0 0 0 0 0 0 applications approved

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Number of ‘Urgent’ DoLS applications made by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Tot 18 18 18 18 18 18 18 18 18 18 18 18 al Urgent 1 0 0 0 0 0 0 0 0 0 0 0 1 applications made Urgent 1 0 0 0 0 0 0 0 0 0 0 0 1 applications approved

The provider had a policy on the Mental Capacity Act 2005, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the provider regarding the Mental Capacity Act 2005, including Deprivation of Liberty Safeguards. Staff gave patients every possible assistance to make a specific decision for themselves before they assumed that the patient lacked the mental capacity to make it. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. While there was good evidence of time and decision specific capacity assessments, not all staff were clear on this and spoke about generalised, rather than decision specific, capacity assessments. When patients lacked capacity to make a specific decision, staff made decisions in their best interests, recognising the importance and significance of the person’s wishes, feelings, culture and history. Staff made Deprivation of Liberty Safeguards applications when appropriate. Although this did not happen on a regular basis, managers were either familiar with their responsibilities, or knew where to go for any advice they needed.

Is the service caring?

Kindness, privacy, dignity, respect, compassion and support Staff attitudes and behaviours when interacting with their patients showed that they were discreet, respectful and responsive, providing patients with help, emotional support and advice at the time they needed it. Staff supported patients to understand and manage their care, treatment or condition. Staff directed patients to other services when appropriate, and if required, supported them to access those services. Patients said staff treated them well and behaved appropriately towards them. They felt safe on the ward. A member of staff at Nightingale House had approached a local cosmetics and toiletries firm to request donations to the ward. As a result, patients benefitted from regular deliveries of donated luxury toiletries to the ward. Staff understood the individual needs of patients, including their personal, cultural, social and religious needs. Staff knew their patients well. Staff could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards patients without fear of the consequences.

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Staff maintained confidentiality of information about patients. The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at this location scored lower than similar organisations. Site name Core service(s) provided Privacy, dignity and wellbeing 49 Alumhurst Road MH - Long stay/rehabilitation mental health 84.3% wards for working age adults MH - Child and adolescent mental health wards MH - Other Specialist Services MH - Specialist community mental health services for children and young people Trust overall 85.3%

England average (mental 91.0% health and learning disabilities)

Involvement in care Involvement of patients Staff used the admission process to inform and orient patients to the ward and service. Staff would visit patients as part of this process, and invited them to the wards where possible before admission. Patients were given information pre-admission about their legal rights, the ward routine and therapeutic activities, as well as having the opportunity to look around the ward. Nightingale House gave all patients a welcome pack on arrival, including information about the ward, their rights, routine etc, and a range of toiletries and home comforts such as slippers or fluffy socks to welcome them to the ward. Staff involved patients in care planning and risk assessment. This was particularly evident in the “My Wellbeing” care plans, which were written from the patient’s perspective and included their wishes, views and preferred goals and outcomes. Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Patients were involved in regular discussions about their medication and treatment. Patients were also able to tell us about their discharge plans which they were involved in shaping. Staff involved patients when appropriate in decisions about the service. For example, patients and their families/carers were invited to contribute to discussions as part of the formal review of the service that was ongoing at the time of the inspection. Patients were also invited to identify which additional activities they wanted to take place on a Sunday. Staff invited patients to attend multidisciplinary meetings each fortnight. Staff enabled patients to give feedback on the service they received, and encouraged this through community meetings and feedback forms. Following feedback from patients Glendenning ward had put a board in place that was updated daily with patients and staff to highlight any issues of the day and planned activities for the following day. This created a further outlet for working with and involving patients, as well as giving protected 1:1 time to discuss any issues with staff. Staff ensured that patients could access advocacy.

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Involvement of families and carers Staff informed and involved families and carers appropriately and gave them support when needed. This contact continued throughout the admission. Staff contacted carers to update them when patients were first admitted to the ward, and invited them to meet with staff. Staff enabled families and carers to give feedback on the service they received. Carers were also invited to feedback evenings to discuss the future service development as part of the service review. The service had a lead for the triangle of care (a scheme promoting joint work between carers, patients and professionals). If carers needed an assessment this was generally identified by the care co-ordinator, but staff would provide carers with this information if this had not already been done. The service completed a quarterly self-assessment of carer involvement, which led to an improvement action plan. As a result of this staff received carers training. Glendinning were also in the process of putting together a carers information pack and had a carers information board on the ward.

Is the service responsive?

Access and discharge Bed management The trust provided information regarding average bed occupancies for three wards in this service between 1 January 2018 to 31 December 2018. All three wards within this service reported average bed occupancies ranging above the minimum benchmark of 85% over this period. Ward name Average bed occupancy range (1 January 2018 – 31 December 2018) (current inspection) Glendinning 94% - 100% Nightingale Court 91% - 100% Nightingale House 95% - 100%

The trust provided information for average length of stay for the period 1 January 2018 to 31 December 2018. Ward name Average length of stay range (1 January 2018 – 31 December 2018) (current inspection) Glendinning 260 977 Nightingale Court 128 790 Nightingale House 268 1452

The service offered a long term complex care service for people with enduring and complex mental health needs. Their aims were to promote independence and reintegration into the community. Nightingale House was a locked ward, and Glendinning and Nightingale Court were unlocked wards. Patients who were considered high risk of violence or aggression, or self-harm or

Page 165 suicidal ideation, were not admitted to the service. Patients admitted to the service would generally be expected to have some level of Section 17 leave to enable them to access community activities. Managers acknowledged the average length of stay was longer than they would have hoped. The wards had a philosophy of continuing to work with the patients until they no longer felt there was further potential for rehabilitation. Part of the ongoing service review into the delivery model was considering how to reduce length of stay within the service. This included consideration of a community rehab to support and promote earlier discharges into the community. The trust had not provided out of area placements data at core service level. Patients who used the service predominantly lived in the county of Dorset, but patients from outside the locality could also be admitted to the service. Beds were available when needed for patients living in the “catchment area”. There was always a bed available when patients returned from leave. Patients were not moved between wards during an admission episode unless it was justified on clinical grounds and was in the interests of the patient. When patients were moved or discharged, this happened at an appropriate time of the day. A bed was always available in a psychiatric intensive care unit (PICU) if a patient required more intensive care and this was sufficiently close for the person to maintain contact with family and friends. This service reported no readmissions within 28 days between 1 January 2018 and 31 December 2018. The team clinical psychologist had completed some research into discharge outcomes over the period 2013-2015, looking at the three-year period before admission, and what happened in the three years post rehabilitation. While this was only a small sample of 14 patients, the results of this research showed a considerable reduction in number and length of admissions post rehabilitation, a reduction of 97.2% in the length of time in hospital.

Discharge and transfers of care Between 1 January 2018 to 31 December 2018 there were 23 discharges within this service. This amounts to less than 1% of the total discharges from the trust overall (3886). Delayed discharges (11) across the 12-month period ranged from none to three per month. Any delayed discharges were generally attributed to shortage of resources, both to complete assessment of need for discharge, and arrangement of suitable accommodation for discharge. Staff planned for patients’ discharge, including good liaison with care co-ordinators. Staff supported patients during referrals and transfers between services.

Facilities that promote comfort, dignity and privacy Most patients had their own bedrooms, however, there were some shared rooms. Staff asked patients if they were happy to share, and if not, staff would arrange a single room. Patients could personalise bedrooms. Patients had somewhere secure to store their possessions. Staff and patients had access to the full range of rooms and equipment to support treatment and care. Access to rooms was risk assessed on an individual basis and support provided as needed. However, there was limited space available in Nightingale Court particularly as this was a small unit. There were quiet areas on the wards, and places where patients could meet visitors. Patients could make a phone call in private, either using their own mobile phones or one of the ward phones. Patients had access to outside space. Page 166

Patients could make hot drinks and snacks, with support if needed. The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at this location scored lower than similar trusts. Site name Core service(s) provided Ward food

49 Alumhurst Road MH - Long stay/rehabilitation mental health 77.5% wards for working age adults MH - Child and adolescent mental health wards MH - Other Specialist Services MH - Specialist community mental health services for children and young people Trust overall 94.3%

England average (mental 92.2% health and learning disabilities)

Patients’ engagement with the wider community When appropriate, staff ensured that patients had access to work and education opportunities. Staff supported patients to maintain contact with their families and carers. Staff encouraged patients to develop and maintain relationships with people that mattered to them, both within the services and the wider community. Staff supported patients to access community support groups, including those for the lesbian, gay, bisexual and transsexual (LGBT) community.

Meeting the needs of all people who use the service For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018) the location scored lower than similar trusts for the environment supporting those with disabilities. The score for the environment being dementia friendly was not available.

Site name Core service(s) provided Dementia Disability friendly 49 Alumhurst Road MH - Long stay/rehabilitation mental health wards - 77.0% for working age adults MH - Child and adolescent mental health wards MH - Other Specialist Services MH - Specialist community mental health services for children and young people Trust overall 83.2% 84.1% England average 88.3% 87.7% (Mental health and learning disabilities)

The service made adjustments for disabled patients, for example, by ensuring disabled people could access the premises, and by meeting patients’ specific communication needs. However,

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Nightingale House was unable to admit patients with mobility needs due to the design of the building. All bedrooms were on the first floor, accessed via stairs only. If patients had mobility needs they would be admitted to Nightingale Court or Glendinning. Staff ensured that patients could obtain information on treatments, local services, patients’ rights, and how to complain, for example. The information provided was in a form accessible to the patient group. Staff made information leaflets available in languages spoken by patients as needed. Managers ensured that staff and patients had access to interpreters and/or signers. Patients had a choice of food, and the menu could be tailored to meet a range of dietary requirements such as vegan and halal options. Staff ensured that patients had access to appropriate spiritual support, including a range of religious texts on the ward, and supporting patients to access places of worship in the community.

Listening to and learning from concerns and complaints This service received two complaints between 1 January 2018 to 31 December 2018. Both of these were not upheld and none were referred to the Ombudsman.

Ward

name

Total Total

Other

Under Under

Referred to to Referred

Withdrawn

Not upheld Not

Complaints

Fully upheld Fully

Ombudsman

Investigation Partially upheld Partially Glendinning 2 0 0 2 0 0 0 0 Unit AMH

Patients knew how to complain or raise concerns. When patients complained or raised concerns, they received feedback. Staff protected patients who raised concerns or complaints from discrimination and harassment. Staff knew how to handle complaints appropriately. Staff received feedback on the outcome of investigation of complaints and acted on the findings. Following an investigation into a complaint, the manager completed a learning and improvement form, looking at any good practice, and any improvements to be made. Any lessons learnt from complaints were shared with staff through team meetings. This service received 20 compliments during the last 12 months from 1 January 2018 to 31 December 2018 which accounted for less than 1% of all compliments received by the trust.

Is the service well-led?

Leadership Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Leaders were visible in the service and approachable to patients and staff.

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Leadership development opportunities were available, including opportunities for staff below team manager level. The Trust ran an aspiring leaders course, that staff could access either in full or selecting relevant development opportunities within the provided modules.

Vision and strategy Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s visions and values to the frontline staff in this service. The teams had recently had away days, where some of them looked at the visions and values and what they meant to the team. Nightingale Court had a unit vision statement. This included their ethos of working alongside individuals to promote their independence. This statement was reviewed annually, and was discussed in staff meetings to ensure they were in agreement with the statement. This was then taken to patient community meetings to ensure patients were also in agreement with this. Staff had the opportunity to contribute to discussions about the strategy for the service, especially with the ongoing service review at the time of the inspection.

Culture Staff felt respected, supported and valued and had faith in the ward managers. Staff felt positive and proud to work for the provider and their team. Staff felt able to raise concerns without fear of retribution. Staff knew how to use the whistle-blowing process and about the role of the Speak Up Guardian (to give independent support and advice to staff who want to raise concerns). Managers dealt with poor performance when needed. Teams worked well together, and when there were difficulties managers dealt with them appropriately. Staff appraisals included conversations about career development and how it could be supported. The service’s staff sickness and absence rates were lower than the average for the Trust. Staff had access to support for their own physical and emotional health needs through an occupational health service. The service also had a staff wellbeing group and offered mindfulness sessions to staff.

Governance The service had systems and procedures in place to ensure the wards were safe and clean and that there were enough staff who were trained and supervised. Patients were assessed and treated well and the ward adhered to the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff managed beds and planned discharges effectively. Staff reported incidents, these were investigated and lessons learnt from these to improve practice. There was a clear framework of what must be discussed at a ward level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Staff had implemented recommendations from investigations into incidents and complaints and safeguarding alerts at the service level.

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Staff undertook or participated in local clinical audits. The audits were sufficient to provide reassurance and staff acted on the results when needed. Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients.

Management of risk, issues and performance Staff maintained and had access to the risk register at ward level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register.

Information management The service used systems to collect data from the wards that were not over-burdensome for frontline staff. Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure worked well and helped to improve the quality of care. Information governance systems included confidentiality of patient records. Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. However, there were some issues with the recording of staff training and supervision across the service. The system used did not appear to accurately reflect the training completed or supervision delivered. Information was in an accessible format, and was timely, accurate and identified areas for improvement. Staff made notifications to external bodies as needed.

Engagement Staff, patients and carers had access to up-to-date information about the work of the provider and the services they used. Patients and carers had opportunities (and were actively encouraged) to give feedback on the service they received in a manner that reflected their individual needs. The service used a range of methods to gather feedback, including feedback questionnaires, meetings with carers and 1:1 discussions with staff. Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. The “My Wellbeing” plans were developed following this feedback. Patients and carers were involved in decision-making about changes to the service as part of the service review. Patients and staff could meet with members of the provider’s senior leadership team to give feedback.

Learning, continuous improvement and innovation Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes within the service. Staff had opportunities to participate in research. Page 170

Innovations were taking place in the service. The ward manager for Nightingale Court was leading a steering group reviewing the admission and discharge pathway to look at improvements that could be made to this process. NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. There were no accreditations awarded to this service. However, the managers were keen to consider applying for accreditation in the future but felt this was not appropriate at a time when the service was under review and considerable changes would be made as a result.

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Wards for older people with mental health problems

Facts and data about this service

Location site name Ward name Number of beds Patient group (male, female, mixed) St Ann's Hospital Alumhurst Ward 20 Mixed Herm Ward, OPMH Organic Inpatient Alderney Hospital 23 Mixed Alderney Forston Clinic Melstock House, Forston 12 Mixed St Brelades, OPMH Organic Inpatient Alderney Hospital 17 Male Alderney

The methodology of CQC provider information requests has changed, so some data from different time periods is not always comparable. We only compare data where information has been recorded consistently.

Is the service safe?

Safe and clean environment Safety of the ward layout Over the 12-month period from 1 January 2018 to 31 December 2018 there was one mixed sex accommodation breach within this service. The number of same sex accommodation breaches reported in this inspection was not comparable to the last inspection (published September 2016). There were ligature risks on four wards within this service. All wards had a ligature risk assessment in the last 12 months. Ward / unit Briefly describe risk - High level of Summary of actions taken name one sentence preferred risk? Yes/ No Each patient has a clinical risk assessment to identify risk of self-harm/ suicide and accidents. Application of Trust Observation Policy for all assessed as at risk. Reviewed if patient group changes or in event of emergency use of bed Risk of ligaturing from an Herm Ward attached high-level anchor No for functional patient. Ligature cabling works to point. reduce the accessible length and placing other cables into conduit. All areas now have colour coded doors using a RAG process to determine the level of escorted /unescorted access.

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Ward / unit Briefly describe risk - High level of Summary of actions taken name one sentence preferred risk? Yes/ No Each patient has a clinical risk assessment to identify risk of self-harm/ suicide and accidents. Application of Trust Observation Policy for all assessed as at risk. Review if patient group changes or in event of emergency use of bed for functional patient. Following recent changes Risk of ligaturing from an St Brelade’s within the ward, additional areas included in the attached high-level anchor No Ward Ligature Management Plan as these are now point. accessible to patients: x2 Bedrooms (One was previously a Quiet Lounge & one was previously the MDT room). All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Each patient has a clinical risk assessment to identify risk of self-harm/ suicide and accidents. Using clinical judgement. Increasing Risk of ligaturing from an observations for high risk patients. Ligature Melstock attached high-level anchor No cabling works to reduce the accessible length House point. and placing other cables into conduit. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access. Risks are assessed and identified on admission. Patients are risk assessed in accordance with the Trust Observation policy. Where risks are identified, observation levels are increased up to potentially 2:1 Hourly ‘rounding’ checks. 1 bedroom has been converted into a Female Only Lounge which is Risk of ligaturing from an Alumhurst fobbed locked with patient’s being allowed attached high-level anchor No Ward access as appropriate following clinical risk point. assessments. Ceiling mounted items required anti-pick sealant to be applied. The review also identified gaps between the bedroom TV cabinets and walls. All areas now have colour coded doors using a RAG process to determine the level of escorted / unescorted access.

Staff did regular risk assessments of the care environment. This included outside areas. The garden at Herm and St Brelades wards was not dementia friendly as there were uneven pavements, thorny bushes and an unstable pagoda. This was unsafe due to the high risk of falls and accidental injury. Staff were aware of this and evidenced how they had requested urgent action. The female-only lounge at Herm ward was not fit for purpose due to damage to the floor boards, however we were shown plans to have this fixed. As a temporary measure the conservatory had been turned into the female-only lounge.

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The layout of the wards allowed staff to observe patients from all parts of the ward. There were convex mirrors that allowed staff to see into blind spots, for example around corners. There were ongoing discussions on how to resolve some blind spots that remained on Melstock ward and staff mitigated the risk through staff presence and patient risk management. There were potential ligature points. A ligature point can be defined as anything which can be used to attach a cord, rope or other material for the purpose of hanging or strangulation. These were identified by staff using the annual ligature audit. Mitigating measures were put in place to reduce the risk of these ligature points. These measures included staff presence for higher risk patients. However, not all staff were aware of the ligature audit report. Agency staff were not routinely shown the ligature report or ligature points during their ward induction. The service did not always comply with Department of Health same-sex guidance. There was a female-only lounge on Herm ward, but occasionally male patients entered this lounge. However, this was due to their clinical presentation and staff were able to show us how they mitigated the risk. Their clinical justification for not removing male patients from the female only lounge was due to the patient’s potential confusion and removal would increase patient anxiety. There was always staff presence, and staff would encourage male patients out of the female only lounge. There was a communal area in the centre of the building with activity space and dining space and two mixed lounges, one of which the trust has since assured us will be designated as female-only. Staff had easy access to alarms and were given one at the start of each shift. There were alarms in patient rooms to enable them to call staff if needed and patients knew how to use them. On the dementia wards these had contrasting colours to allow patients with dementia to find them more easily.

Maintenance, cleanliness and infection control For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018), two of the locations scored lower than similar trusts for cleanliness and one scored higher. All three locations scored lower than similar trusts for condition, appearance and maintenance.

Site name Core service(s) Cleanliness Condition appearance and maintenance Alderney CHS – Adults Community 95.3% 90.4% Hospital CHS – Community Inpatients MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older people MH – Wards for older people with mental health problems Other St Ann’s MH - Acute wards for adults of working age 97.9% 91.5% Hospital and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems MH – Mental health crisis services and health-based places of safety

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Site name Core service(s) Cleanliness Condition appearance and maintenance MH – Secure wards/Forensic inpatient Other MH – Specialist community mental health services for children and young people Forston Clinic MH - Acute wards for adults of working age 98.7% 90.1% and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems MH – Mental health crisis services and health-based places of safety MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older people CHS – Adults community Trust overall 98.1% 92.6% England 98.4% 95.4% average (Mental health and learning disabilities)

The wards were clean with the exception of the female lounge on Herm ward. The managers assured us that this had been referred to estates and would be rectified as soon as physically possible. The wards had good furnishings and were well-maintained, with furniture suitable for older people. This included pressure reducing beds and chairs to reduce the incidence of pressure sores. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Staff adhered to infection control principles. This included hand washing, with posters in bathrooms and hand sanitiser around the wards.

Clinic room and equipment Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs. However, there were nine occasions we noted where the monthly and weekly checks were not completed. This was noted on each ward. This was raised with managers who assured us they were rectifying the problem and addressing it with staff during supervision. Emergency trolleys were not always audited and checked appropriately. For example, we found trolleys that did not have security tags or a list of medications. There was no checklist to confirm that the contents of the trolley were present and in date. Staff did not always maintain equipment well. There were clean stickers to indicate the condition and date cleaned, and these were clearly visible. However, some electrical equipment had not been tested within the recommended dates. Managers were aware of this and had requested estates to test the electrical equipment as soon as possible.

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Safe staffing Nursing staff This core service has reported a vacancy rate for all staff of -7% (over establishment) as of 31 December 2018. This was not comparable to the rate reported at the last inspection (published September 2016). This core service reported an overall vacancy rate of -2% (over establishment) for registered nurses at 31 December 2018. The vacancy rate for registered nurses was not comparable to the last inspection. This core service reported an overall vacancy rate of -13% (over establishment) for nursing assistants. The vacancy rate for nursing assistants was not comparable to the last inspection.

Registered nurses Health care assistants Overall staff figures

Location Ward/Team

(%) (%) (%)

Vacancies Vacancies Vacancies

Vacancy rate rate Vacancy rate Vacancy rate Vacancy

Establishment Establishment Establishment Alderney Herm Ward 0.4 14.1 3% -2.0 33.1 -6% -0.6 51.2 -1% Hospital Alderney St Brelade’s 0.4 14.1 3% -5.2 29.8 -17% -3.8 46.9 -8% Hospital Ward Forston Melstock -0.3 8.6 -3% -0.8 10.6 -8% -1.0 20.2 -5% Clinic House St Ann’s Alumhurst -1.6 11.5 -14% -3.4 13.2 -26% -5.0 25.7 -19% Hospital Ward Core service total -1.1 48.3 -2% -11.4 86.6 -13% -10.4 144.0 -7% Trust total 96.4 1424.4 7% -12.0 1055.7 -1% 156.3 3761.0 4% NB: All figures displayed are whole-time equivalents

Between 1 January 2018 and 31 December 2018, of the (79800) total working hours available, 12% were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. The main reason for bank and agency usage for the wards/teams was vacancies. In the same period, agency staff covered 4% of available hours for qualified nurses and 1% of available hours were unable to be filled by either bank or agency staff.

Wards Total hours Bank Usage Agency Usage NOT filled by bank available or agency Hrs % Hrs % Hrs % Alumhurst 18696 2365 13% 1329 7% 143 1% Herm 23292 3327 14% 413 2% 89 <1% St Brelade’s 23112 1547 7% 1192 5% 333 1% Melstock House 14700 2173 15% 103 1% 54 <1% Core service 79800 9412 12% 3037 4% 619 1% total Trust Total 510921 74437 15% 32421 6% 4747 1%

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Between 1 January 2018 and 31 December 2018, of the (168432) total working hours available, 23% were filled by bank staff to cover sickness, absence or vacancy for nursing assistants. The main reasons for bank and agency usage for the wards/teams were vacancies, level 2 observations, and level 3 observations. In the same period, agency staff covered 3% of available hours and 1% of available hours were unable to be filled by either bank or agency staff. Wards Total hours Bank Usage Agency Usage NOT filled by available bank or agency Hrs % Hrs % Hrs % Alumhurst 28440 16710 59% 921 3% 111 <1% Herm 63780 8713 14% 1479 2% 168 <1% St Brelade’s 57372 8340 15% 2599 5% 1118 2% Melstock House 18840 5153 27% 189 1% 362 2% Core service 168432 38916 23% 5188 3% 1759 1% total Trust Total 727272 194080 27% 25351 3% 16663 2%

This core service had 9.4 (6%) staff leavers between 1 January 2018 and 31 December 2018. This was not comparable to the last inspection (published September 2016).

Location Ward/Team Substantive Substantive staff Average % staff leavers staff (at latest Leavers over the over the last 12 months month) last 12 months Alderney Herm Ward 51.9 5.8 11% Hospital Alderney St Brelade’s 50.7 2.8 6% Hospital Ward St Ann’s Alumhurst Ward 30.7 0.8 3% Hospital Forston Clinic Melstock House 21.1 0.0 0% Core service total 154.4 9.4 6% Trust Total 3623.9 364.5 10%

The sickness rate for this core service was 7.0% between 1 January 2018 and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 7.9%. This was not comparable to the last inspection (published September 2016).

Location Ward/Team Total % staff sickness Ave % permanent staff sickness (1 (December 2018) January 2018 – 31 December 2018) St Brelade’s Alderney Hospital 8.0% 8.1% Ward

Alderney Hospital Herm Ward 6.9% 7.2%

St Ann’s Hospital Alumhurst Ward 7.2% 5.8%

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Location Ward/Team Total % staff sickness Ave % permanent staff sickness (1 (December 2018) January 2018 – 31 December 2018)

Forston Clinic Melstock House 11.0% 5.6%

Core service total 7.9% 7.0% Trust Total 5.4% 4.9%

The below table covers staff fill rates for registered nurses and care staff during September 2018, October 2018 and November 2018. Alumhurst Ward had above 125% of the planned care staff for all night shifts and below 90% of the planned registered nurses for night shifts. St Brelade’s Ward and Herm Ward had below 90% of the planned registered nurses for day and night shifts across all three months. Key:

> 125% < 90%

Day Night Day Night Day Night Care Care Care Care Care Care Nurses Nurse Nurse Nurse Nurse Nurse staff staff staff staff staff staff (%) s (%) s (%) s (%) s (%) s (%) (%) (%) (%) (%) (%) (%) September 2018 October 2018 November 2018 Alumhurst Ward 90 136 70 304 97 117 75 317 107 109 89 156 Melstock House 98 100 100 102 98 102 100 102 103 96 100 100

Herm Ward 81 100 74 109 85 98 73 111 80 94 67 111 St Brelade’s 87 113 64 114 78 111 70 110 81 105 59 113 Ward

Managers had calculated the number and grade of nurses and healthcare assistants required for the ward. This was based on the ward being fully occupied. However, what these numbers did not consider was if the ward was not fully occupied, or if there was higher acuity on the ward and therefore more staff needed for observation levels. This is the reason for the contradictory evidence above. Although established figures were adequate, often extra staff were needed to cover the level of observations required to ensure safety on the ward. The managers had autonomy to bring in extra bank and agency staff to ensure safe staffing numbers. The managers also gave permission to the nurse in charge to increase staffing numbers, providing there was clear clinical reasoning and justification. Bank and agency usage were high for this reason. There were problems with registered nurses in particular, with vacancies and established figures not matching required figures. We were told that nurse staffing numbers were not always met, for example, the required two nurses for night shifts was not met on certain wards with only one nurse on duty. This affected the skill mix of the staff and meant that certain duties had to be postponed. Bank and agency staff were not always regular. Managers were able to block book bank/agency staff, but this was not a frequent occurrence. Bank and agency staff were inducted and given a permanent staff member as a buddy for their first shift. This ensured the bank/agency staff were never without a regular member of staff on the ward.

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A registered nurse was always present on the ward. Staff shortages occasionally resulted in activities being cancelled. Patient care was prioritised, and activities would be cancelled to maintain patient care. There was always enough staff to carry out physical interventions safely. Staff were trained in appropriate physical intervention strategies. If managers were block booking agency staff, they were able to provide them with appropriate training to ensure that they could carry out the required physical interventions.

Medical staff Between 1 January 2018 and 31 December 2018, the trust did not submit any data for this service regarding the use of bank and agency staff to cover medical locum. There was not always robust medical cover both day and night. A doctor could attend most of the wards quickly in the event of an emergency, however it was noted on Melstock ward that medical cover was challenged and that in some situations a doctor could not access the ward in a reasonable time. There were occasional issues with not having a doctor available to make admission decisions, and this had led to inappropriate admissions due to there being no clinical lead for admissions and especially over weekends.

Mandatory training The compliance for mandatory and statutory training courses at 29 January 2019 was 94%. Of the training courses listed five failed to achieve the trust target and of those, one failed to score above 75%. The trust set a target of 95% for completion of mandatory and statutory training. The trust’s training completion data is based on a rolling basis depending on training repeat requirement. The training compliance reported for this core service during this inspection was not comparable to the previous year. Key:

Below CQC 75% Met trust target ✓ Not met trust target 

Training Module Number Number YTD Trust of of staff Compliance Target eligible trained (%) Met staff Equality and Diversity 144 144 100% ✓ Moving and Handling Theory Level 1 144 144 100% ✓ Safeguarding Adults Level 1 4 4 100% ✓ Safeguarding Children Level 1 4 4 100% ✓ Safeguarding Adults Level 2 140 138 99% ✓ Safeguarding Children Level 2 98 97 99% ✓ Prevention and Management of Violence and Aggression 141 140 99% ✓

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Training Module Number Number YTD Trust of of staff Compliance Target eligible trained (%) Met staff Mental Capacity Act 43 42 98% ✓ Infection Control - 3 Yearly 144 140 97% ✓ Information Governance 144 140 97% ✓ Basic Life Support – Taught 141 137 97% ✓ Moving and Handling Practical Level 2/3 111 107 96% ✓ Fire 144 133 92%  Safeguarding Children Level 3 42 38 90%  Enhanced Life Support 44 38 86%  Mental Health Act 46 36 78%  Medicines Management 49 5 10%  Total 1583 1487 94% 

Although the evidence above says that medicines management training was not meeting the appropriate targets, this is incorrect as medicines management is not a mandatory training requirement. However, managers said that they would address medicines management through supervision and appraisal, giving staff the opportunity to update their training as needed. If there were medication errors, they gave staff the opportunity to update their medicines management training to prevent further errors being made. All mandatory training was above recommended compliance targets.

Assessing and managing risk to patients and staff Assessment of patient risk We reviewed 21 care records during the inspection. Staff did a risk assessment of every patient on admission and updated it regularly, or as required, for example after an incident. There were several different risk assessments used to reflect individual issues, such as falls risk and aggression risk. Staff used recognised risk assessment tools.

Management of patient risk Staff were aware of and dealt with any specific risk issues, such as falls or pressure ulcers. There was evidence of these specific risks in their risk assessments and subsequent care plans. Staff identified and responded to changing risks. This included risks posed by patients, and risks posed to patients. These risks had corresponding management plans that had patient-led directives. Staff followed good policies and procedures for use of observation. These were always clinically justified, and least restrictive practices used. For example, staff took positive risks by reducing observations levels in the morning and then returning to level three in the evening. This was because patients’ anxiety tended to increase in evening. Staff did not put patients on blanket observations but would treat each patient individually.

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There were no blanket restrictions as any restriction was individually assessed and justified. Staff adhered to best practice in implementing smoke-free policy. Informal patients could leave at will and these rights were made clear to them. There were posters detailing this visible on the ward.

Use of restrictive interventions This service had 235 incidences of restraint (62 different service users) and five incidences of seclusion between 1 January 2018 to 31 December 2018. The below table focuses on the last 12 months’ worth of data: 1 January 2018 to 31 December 2018.

Ward name Seclusions Restraints Patients Of restraints, Of restraints, restrained incidents of prone incidences of restraint rapid tranquilisation Alumhurst 0 19 10 0 (0%) 10 (53%) Ward Herm Ward 4 62 16 0 (0%) 16 (26%) Melstock 0 11 6 0 (0%) 1 (9%) House St Brelade's 1 143 30 1 (0.7%) 5 (3%) Ward Core service 5 235 62 1 (<1%) 32 (14%) total

There was one incidence of prone restraint, which accounted for <1% of the restraint incidents. Over the 12 months, incidences of restraint ranged from one to 40. The number of incidences (235) had increased from the previous 12-month period (92). There were 32 incidences of rapid tranquilisation over the reporting period. Incidences resulting in rapid tranquilisation for this service ranged from zero to eight per month over the 12-month reporting period (1 January 2018 to 31 December 2018). The number of incidences (32) had increased from the previous 12-month period (17). There have been zero instances of mechanical restraint over the reporting period. The number of incidences (0) was the same as the number of incidences from the previous 12-month period (0). The number of restraint incidences reported during this inspection was not comparable to the last inspection. The wards participated in the restrictive interventions reduction program. We saw current evidence of least restrictive practice being used by staff. For example, patients who had PRN (medication prescribed when needed) medications for challenging behaviour rarely had them given because of the success of de-escalation. Staff only used physical intervention when verbal de-escalation had failed. Staff were trained in and used the correct techniques to physically restraint patients. Staff followed best practice with respect to rapid tranquilisation, according to National Institute for Health and Care Excellence (NICE) guidance. On Alumhurst ward there was a de-escalation room with a bean bag for patient comfort during restraint or rapid tranquilisation.

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There have been five instances of seclusion over the reporting period. Over the 12 months, incidences of seclusion ranged from zero to two. The number of incidences (5) had increased from the previous 12-month period (2). The number of seclusion incidences reported during this inspection was not comparable to the last inspection. There was no seclusion room present on the wards. However, there were instances when staff had to separate a patient from other patients for their or the other patients’ safety. This was done through encouraging the patient into a quiet area of the ward. The patient was never alone, had staff with them and other patients were not routinely removed from the area. However, staff recorded this as seclusion. We saw this was appropriately recorded and care planned. There have been zero instances of long-term segregation over the 12-month reporting period. The number of incidences (0) was the same as the previous 12-month period (0).

The number of segregation incidences reported during this inspection was not comparable to the last inspection.

Safeguarding A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This core service made 16 safeguarding referrals between 1 January 2018 and 1 January 2019, of which 16 concerned adults and none concerned children. The number of safeguarding referrals reported during this inspection was not comparable to the last inspection. Number of referrals Core service Adults Children Total referrals MH – Wards for older people with mental health 16 0 16 problems

The number of adult safeguarding referrals in each month ranged from zero to four (as shown below). There were no child safeguarding referrals in this service.

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Total referrals (1 January 2018 to 1 January 2019)

4 3 2 3 2 0 1 0 0 0 1 0

Adult Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

*No safeguarding data was provided in January, May and December 2018.

Staff were trained in safeguarding, knew how to make a safeguarding alert and did so when appropriate. As part of recruitment interviews managers posed a potential safeguard scenario to staff and assessed their knowledge. Staff were confident to raise safeguarding concerns and knew how to raise them directly to the local authority, managers and modern matron. Incident forms were all screened by the trusts internal safeguarding team to identify patterns and trends, even if these did not meet the safeguarding threshold for the local authority. Staff performed clinical risk reviews for patients with possible safeguarding concerns. Staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. The safeguarding team gave training sessions and talks to staff on the ward. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies, such as social care workers. Healthcare assistants were trained in level two adults and children safeguarding, and qualified staff were trained in level three adults and children safeguarding. The trust had not submitted details of any serious case reviews commenced or published in the last 12 months (1 February 2018 to 31 January 2019) that relate to this service.

Staff access to essential information Staff used a combination of electronic and paper records. Prescription charts and certain legal documents were in paper form, and care plans and risk assessments were electronic. Both systems were easy to use, and staff could clearly explain the processes. All information needed to deliver patient care was available to all relevant staff and was in an accessible form. There were daily handovers that staff kept paper copies of. This was helpful for agency and bank staff as this included patient initials, current diagnosis, risks and behaviours, as well as presentation over last 24 hours.

Medicines management Staff did not always follow good practice and national guidance around checks of the medications and controlled drugs. There were weekly audits however these were not always fully effective. For

Page 183 example, on one occasion they did not pick up that medication had not been checked for three weeks. However, there were also some good examples of medication management. Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance. There were physical health leads and several staff had specialised physical health training, such as electro-cardiogram (ECG) and venepuncture training. The wards at Herm and St Brelades also had an exchange scheme with the physical health nurses on site, where they would do shifts on the mental health wards and the nurses from the mental health wards would do shifts on the physical health wards. This allowed both sets of nurses to gain experience in the respective fields and therefore be able to apply this on their own wards. NICE guidance used included the reduction of anti-psychotics and hypnotics. Full physical screening occurred prior to commencing any medication. The trust also used safe reduction plans. We saw good practice in the use of trans-dermal patches on Herm and St Brelades. This included the rotation of patches and how this was recorded to avoid the risk of accidental overdose. Staff followed NICE guidance and the nursing and midwifery council (NMC) guidance on maintaining health in inpatient facilities. The pharmacist on Herm and St Brelades demonstrated good practice by advising staff on how covert medications are best to be given.

Track record on safety Between 1 January 2018 and 31 December 2018 there were eight serious incidents reported by this service. Of the total number of incidents reported, the most common type of incident was ‘Slips/trips/falls meeting SI criteria’ with five. There were no unexpected deaths in this service. We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with eight reported. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This service reported zero never events during this reporting period. The number of serious incidents reported during this inspection was not comparable to the last inspection. Number of incidents reported

Type of incident Slips/trips/falls Apparent/actual/sus Pending review Total reported (SIRI) meeting SI criteria pected self-inflicted harm meeting SI criteria St Brelade’s Ward 1 0 2 3 Herm Ward 3 0 0 3 Alumhurst Ward 1 1 0 2 Total 5 1 2 8

Reporting incidents and learning from when things go wrong

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The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there have been two ‘prevention of future death’ reports sent to Dorset Healthcare University NHS FT. None of these related to this service. All staff knew what incidents to report and how to report them. This was done electronically through the incident reporting system. Staff reported all incidents that they should report. Staff understood the duty of candour and were open and transparent when things went wrong. They gave patients and families/carers a full explanation if things went wrong. Managers and staff gave us scenarios where the duty of candour had to be used, and how they used it. Staff received feedback from investigations of incidents, both internal and external to the service. Staff met to discuss the feedback. This was done through team meetings, or one to one during supervision and appraisal. There was evidence that changes had been made because of feedback. For example, the findings from an incident when a patient suffered a fracture from a fall found that their bone health was not adequate. The wards now screen for bone health in patients with high falls risk. Staff were debriefed and received support after a serious incident. There was a dedicated psychologist on the team that staff can access for support. The manager also referred staff to occupational health and well-being if appropriate. Staff on Melstock commented that there was not always a private space in which to have a debrief due to the physical environment.

Is the service effective?

Assessment of needs and planning of care During the inspection we reviewed 21 care records. Staff completed a comprehensive mental health assessment of the patient in a timely manner at, or soon after, admission. Staff would aim to have assessments completed within 24 hours if the patient was unable to take part in more comprehensive assessments. Staff assessed patients’ physical health needs in a timely manner after admission. This was also aimed to be completed within 24 hours depending on the patients’ presentation. The wards had dedicated physical health leads that ensured patients’ physical health care needs were met. Numerous assessments were performed, including pressure ulcer assessments, falls assessments, height and weight, and diabetic assessments. The wards had also recently been approved to purchase bladder scanners to allow more easy assessment of the patients’ bladder in case of urinary tract infections. This saved time and helped reduce patient anxiety by not having to go to hospital for tests. Staff developed care plans that met the needs identified during assessment. Care plans were easy to navigate and comprehensive. The care plans were structured in different sections and included physical health, mental health, discharge planning and other. The St Brelades and Herm wards had another section for the gold standard framework. The wards were moving to the 'my wellbeing plan’ approach, which would allow even more holistic and patient involvement than the current care plans. Page 185

Care plans were personalised, holistic and recovery-orientated. Recently the manager at Melstock brought in recovery specialists to a team away day to help educate the staff on recovery orientated models of care. Staff updated care plans when necessary. This could be in line with patients’ wishes, changes in presentation or after regular reviews and updates.

Best practice in treatment and care The trust did not report that this service participated in any clinical audits as part of their clinical audit programme 2018 – 2019.

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE). These included medical, therapy work and activities.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. There were physical health leads on each ward who took an active approach to ensuring that physical health was looked after. This included attending training on physical healthcare in mental health settings. Wards had access to general nurses who specialised in physical healthcare, for example at Herm and St Brelades they did rotations with physical health nurses and mental health nurses working on each other’s wards. This allowed sharing and transferring of skills.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. There were charts available for staff describing the diet and hydration needs of each patient. This was kept out of sight of communal areas but allowed staff to ensure that they were providing the right hydration and nutrition to the right patient, for example thickened fluids. The wards had access to dieticians if needed. Staff had access to good support aids for self-feeding and this allowed patients with higher nutrition needs to retain as much independence as possible.

Staff supported patients to live healthier lives. For example, patients were supported with smoking cessation. There were healthy meal choices available. On Alumhurst Ward they had a board with health topic of the month, with this month relating to bowel cancer and giving information about it. This included signposting information for patients that may be concerned.

Staff used technology to support patients effectively. This included in house testing, such as blood testing and the new bladder scanners, but also recreationally with games consoles that facilitated safe movement using motion capture cameras to play the game. This encouraged physical activity in a safe manner. Alumhurst Ward used wireless headphones to allow all patients to interact in activities, for example if listening to music.

Staff participated in clinical audits, benchmarking and quality improvement initiatives. There were many examples of these across the wards. Clinical audits included scanning for vitamin D deficiency and other bone health markers, as this was an important consideration for high falls risk patients who are consequently at risk of fractures. Quality improvement schemes included creating templates for progress notes to make them easier to read and use.

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As part of the aspiring leaders program on Herm and St Brelades, nurses were asked to complete a quality improvement (QI) project, with one example being using colour charts to track behaviour changes. Herm Ward had published a report on using therapeutic activity on violence and aggression, with results showing that patient violence and aggression decreased, but so too did staff sickness and the use of as and when required medication. This was done in conjunction with the University of Wessex.

Skilled staff to deliver care The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 April 2017 to 31 March 2018), the overall appraisal rate for non-medical staff within this service was 100%. So far in this financial year, the overall appraisal rate for this core service was 98% (as at 28 January 2019). The wards with the lowest appraisal rate at 28 January 2019 were Alumhurst Ward with an appraisal rate of 96% and Herm Ward with an appraisal rate of 98%. The rate of appraisal compliance for non-medical staff reported during this inspection was not comparable to the last inspection. Ward name Total number of Total number of % appraisals % appraisals permanent non- permanent non- (as at 28 January (previous year 1 medical staff medical staff 2019) April 2017 – 31 requiring an who have had an March 2018) appraisal appraisal

Melstock House 16 16 100% 100% St Brelade's Ward 39 39 100% 100% Herm Ward 48 47 98% 100% Alumhurst Ward 24 23 96% 100% Core service total 127 125 98% 100% Trust wide 4197 3827 91% 95%

The trust did not provide appraisal data for medical staff in this service. The trust’s target of clinical supervision for non-medical staff is 95% of the sessions required. Between 1 April 2017 and 31 March 2018, the average rate across all four teams in this service was 80%. The rate of clinical supervision reported during this inspection was not comparable to the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) Herm Ward 25 25 100%

St Brelade's Ward 20 20 100%

Melstock House 19 16 84%

Alumhurst Ward 22 8 36%

Core service total 86 69 80%

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Team name Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) Trust Total 1568 1236 79%

The trust did not provide clinical supervision data for medical staff in this service. The team included or had access to a full range of specialists required to meet the needs of patients on the ward. Although a full range of specialists were available, staff told us that this availability was limited for some specialities. For example, physiotherapy and occupational therapist was limited on some wards, the occupational therapist and physiotherapist being either part-time or covering other services as well. There was good access to psychological input on all wards, for both patients and staff. The trust recruited volunteer peer support workers, who attended the wards and took part in activities, such as playing musical instruments. Although staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group, there were sometimes shortages of the right skill mix for every shift. Managers on Herm and St Brelades informed us that it was sometimes difficult to get a full staff skill mix, with shortages in registered nurses. Managers mitigated the effects of this by having additional support workers, and therefore safety was never compromised. Managers provided new staff with an appropriate induction. This was described in detail by managers and staff and prepared staff well for the nature of the ward. The induction covered all the necessary skills, and for healthcare assistants used the care certificate as standard. The induction process included both a trust (corporate) induction and a ward induction. During the ward induction new staff were given a buddy to shadow. Agency and bank staff received a ward induction to make sure that they were aware of the ward layout and structure. Agency staff would be buddied with a permanent staff member. Managers provided staff with supervision. Our evidence above recorded Alumhurst as achieving only 36% supervision rate, however this information was due to a recording error and the numbers of staff supervised was not reflected on the trust internal systems. The ward manager showed us the supervision records and evidence that supervisions were happening more regularly than this, however there were still gaps in supervision received across the wards. Staff told us that they felt supervision was not done enough or regularly. When supervisions happened, they discussed current staff performance, aspirations and training requirements. Reflective practice was demonstrated across the wards and learning from incidents took place during supervision. Appraisals occurred yearly. These focussed on staff development, both professionally and personally. There were opportunities for staff to develop their clinical skills. For example, support workers were encouraged to join nurse training programs. Managers identified the learning needs of staff during supervisions and appraisals. Managers provided staff with opportunities to develop their skills and knowledge. This was across all staff groups and provided there was a clinical justification for specialist training, staff could access this easily. For example, the aspiring leaders course, catheterisation, venepuncture, ECG and physical observations training. Managers told us that staff had complained about the physical intervention training that was available to them, as this was inappropriate for the ward due to the patient group and was causing anxiety to the staff. Managers fed this back to the learning and development department who addressed the issue by creating two separate levels of physical restraint training.

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Managers ensured staff had access to regular team meetings. Meeting minutes were recorded comprehensively and disseminated to staff. Managers dealt with poor staff performance promptly and effectively. Managers described this process that always sought to develop and improve staff that needed performance management before seeking dismissal. Managers gave staff the opportunity to improve and identified improvement needs early on before problems arose. Managers were quick to refer staff to occupational health and wellbeing if they felt that staff may drop in performance due to stress or non-work-related issues. Volunteers were recruited to work on the wards. These were often former patient carers. These volunteers assisted with ward activities such as helping with meal times.

Multidisciplinary and interagency team work Staff held regular and effective multidisciplinary team meetings. These did vary in quality between the wards. Some meetings discussed patients in depth, while others discussed patients to an acceptable level. For example, at the more in-depth discussion there was a pharmacist who went into detail about how covert medication should be given, discussed best prescribing practice and checked medical records. At the better MDT risk levels were discussed and capacity and consent were discussed for each patient. At the other MDT meeting risk levels of patients were not discussed and capacity and consent were not discussed consistently. This MDT did not record the meeting on the electronic system effectively. There was no dedicated note taker, with professionals only taking notes useful to themselves, without an overall record of the MDT being taken and recorded. This meant some parts of the discussion such as capacity and consent may have been missed. Staff shared information about patients at effective handover meetings within the team, for example at the change of shifts. This occurred across all wards and gave staff a detailed overview of the patients, their current risk level, observation level, behaviour state and behaviour over the last 24 hours. This was detailed enough to allow agency/bank staff new to the ward to care for the patients. The ward teams had effective working relationships with other relevant teams both internal and external to the trust. This included other services within the trust, and also the general hospitals and local authorities, as well as community teams and care coordinators. The Integrated Care Service for Dementia (ICSD) provided support for patients in the community and have reduced the need for admittance. The ICSD and the wards work closely together, especially prior to and immediately after discharge to ensure the patient is able to remain in the community.

Adherence to the Mental Health Act and the Mental Health Act Code of Practice As of 29 January 2019, 78% of the workforce in this service had received training in the Mental Health Act. The trust stated that this training is mandatory for all services for inpatient and all community staff (role-specific) and renewed every three years. The training compliance reported during this inspection was not comparable to the last inspection. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its code of practice. Staff knew who their mental health act administrators were. Staff were also able to demonstrate good knowledge and understanding of the mental health act Page 189 and the code of practice. This was included in their mandatory training and managers could address this during supervision. Patients had easy access to information about independent mental health advocacy. There were posters and information leaflets on the ward. The wards had good relationships with the mental health advocates and invited them into the ward if they felt that patients would benefit from a visit. Staff explained to patients their rights under the Mental Health Act in a way that they could understand. Patients would have their rights repeated to them as required. Staff made sure to record this appropriately. During the inspection we saw evidence of this discussed in MDT meetings, and saw that reading of patients’ rights was recorded in patient notes. Staff ensured that patients could take Section 17 leave when this had been granted. This is leave granted to patients detained under the Mental Health Act. We saw grounds leave as part of activities timetables, and staff said that leave was prioritised. Staff requested an opinion from a second opinion appointed doctor when necessary. This was evidenced in the patients documented paperwork that we saw during the inspection. The wards displayed notices for informal patients telling them of their freedom to leave the ward. Staff completed regular audits to ensure Mental Health Act was being applied correctly and there was evidence of learning from these audits. For example, one audit showed that there were discrepancies between treatment orders and prescription charts on one ward. This was revealed in the audit, actioned and corrected. Learning was put forward, and reflected in team meetings an minutes, to ensure that this was not repeated.

Good practice in applying the Mental Capacity Act As of 29 January 2019, 98% of the workforce in this service had received training in the Mental Capacity Act. The trust stated that this training is mandatory for all services for inpatient and all community staff (role-specific) and renewed every three years. The training compliance reported during this inspection was not comparable to the last inspection. The trust told us that 64 standard and 63 urgent Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority for this service between 1 January 2018 to 31 December 2018. The greatest number of standard DoLS applications were made in January 2018 with 13. The trust told us that across all services, 19 DoLS direct notifications were sent to CQC. However, CQC received 324 direct notifications from the trust between 1 January 2018 to 31 December 20184. These numbers do not match across the two sources. Under HSCA legislation, all DoLS applications should also be sent to the CQC in the form of a direct notification so this is important. The number of DoLS applications made during this inspection was not comparable to the last inspection.

Number of ‘Standard’ DoLS applications made by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 18 18 18 18 18 18 18 18 18 18 18 18 Standard applications made 13 3 6 8 3 3 6 7 7 1 3 4 64 Standard applications approved 0 0 1 0 1 1 0 0 0 0 0 0 3

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Number of ‘Urgent’ DoLS applications made by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 18 18 18 18 18 18 18 18 18 18 18 18 Urgent applications 13 3 6 8 2 3 6 7 7 1 3 4 63 made Urgent applications 3 6 8 2 3 6 7 7 1 3 4 63 approved 13

Staff had a good understanding of the Mental Capacity Act and the principals involved. However, they did not always demonstrate good practice in recording the mental capacity act. Capacity and consent were discussed in MDT meetings but were not always recorded in notes. There was not consistent recording of how capacity assessments were conducted. From the review of records, it was not always possible to determine how capacity assessments were conducted. In many cases there was only a line stating the patient did not have capacity to consent or agree to something, such as treatment, but there was no rationale or assessment process described that led staff to this conclusion. There were also no specific capacity assessments for differing aspects of patient care. For example, there were rarely separate capacity assessments to determine if a patient could consent to personal care, or to manage their finances, or to accept treatment. When a patient was considered to lack capacity and placed on a deprivation of liberty safeguard (DoLS) they would have best interest decisions put in place. For example, to have certain medications would be in their best interest but they could not consent. These best interest decisions were discussed during MDT meetings, but were not clearly recorded in a patient notes. Often in notes there would be a single line stating that a best interest decision was made, but without discussing the rationale or justification. The only instance were this justification and rationale was clearly described in a best interest form, with appropriate capacity assessment form attached, was in the case of covert medication. We found a do not attempt resuscitation (DNAR) form not completed in the case of a patient under a DoLS. We saw an example where a patient was assumed to lack capacity for the DNAR but in the patient’s progress notes stated they had fluctuating capacity and staff had not recorded that they had attempted to further assess capacity. There was no capacity assessment attached to the DNAR. We raised this with the trust immediately and they provided assurance this would be rectified. The provider had a policy on the mental capacity act, including DoLS. Staff were aware of it and had access to it. This formed part of the induction and mandatory training. Staff knew where to get advice from within the trust regarding the mental capacity act, including DoLS. This included external bodies that the staff could seek support and advice from. This was noted in the patient notes. The staff made DoLS applications when required and monitored the progress of applications to supervisory bodies. These applications were noted in progress notes of the patient. Staff could make urgent applications if necessary. There was evidence of contact with the relevant body to update on the application.

Is the service caring?

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Kindness, privacy, dignity, respect, compassion and support The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at all three service locations scored lower than similar organisations. Site name Core service(s) provided Privacy, dignity and wellbeing Alderney Hospital CHS – Adults Community CHS – Community Inpatients MH – Community-based mental health services for adults of working age MH – Community-based mental health 86.9% services for older people MH – Wards for older people with mental health problems Other St Ann’s Hospital MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems MH – Mental health crisis services and 89.3% health-based places of safety MH – Secure wards/Forensic inpatient Other MH – Specialist community mental health services for children and young people Forston Clinic MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems MH – Mental health crisis services and 82.6% health-based places of safety MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older people CHS – Adults community Trust overall 85.3%

England average (mental 91.0% health and learning disabilities) During the inspection we saw that staff attitudes and behaviours when interacting with patients were discreet, respectful and responsive. Staff demonstrated that they provided patients with help, emotional support and advice at the time that the patient needed it. Staff supported patients to understand and manage their care and treatment. This was often difficult due patients’ presentations and diagnosis; however it was evident that staff supported the patients to a high standard.

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Staff directed patients to other services when appropriate, and if required, supported them to access those services. This included advocacy services or therapy services such as OT and psychology. There were leaflets describing medications and their side effects on the wards. Patients we spoke with praised staff highly. We were told about and saw examples of staff treating patients well and behaving appropriately and professionally. We saw staff encourage patients to be involved in activities and engaged well with those more complex patients that struggled to take part. Staff demonstrated patient-centred care on the ward, and there was always good staff presence. Staff understood the individual needs of patients. This included the personal, cultural, social and religious needs of the patients. This was documented in patients care plans, but also in the interaction of staff and patients. Patients could choose their dietary needs based on cultural or religious needs. The wards were furnished appropriately to reflect the patient group and was clear that staff had considered their needs, for example, one of the lounges on St Brelades was decorated like a pub and the staff were planning pub quiz nights and mocktails. There were retrospective signs decorating the wards to aid reminiscence and provide comfortable surroundings. Staff said they could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards patients. Staff told us that they could raise concerns without fear of consequences. Managers gave us examples of when staff had done this. Staff maintained the confidentiality of information about patients. This was done through locked offices and password protected computers. Staff did not discuss confidential information in communal areas. Both Herm and St Brelades Wards were awarded the Gold Standard Framework. This made these wards the first older people mental health wards in the country to earn this accreditation. The gold standard framework is a leading training provider in end of life care and commended the wards on the difference they made to patients’ lives. The accreditation panel found that patients received care how and where they wanted it, and that relatives had peace of mind.

Involvement in care Involvement of patients Staff used the admission process to inform and orient patients to the wards and the service, as far as possible considering the patients presentation on admittance. Patients were shown the ward by staff on first arrival and made to feel comfortable. On admission patients received a welcome pack that was a personalised resource package. As the patient progressed this would include personalised care plans, support information, medication information and their programme of therapeutic activities, as well as any legal information. However, staff could not guarantee that patients would be aware of the shared accommodation prior to arriving on the ward. Staff involved patients, as much as possible, in care planning and risk assessment. This was evidenced by the support workers and nursing staff joining the MDTs to aid in voicing the patients interests and choices. The move to the wellbeing care plans will further improve the patient involvement in care planning. Staff communicated with patients so that they understood their care and treatment. Staff were aware of ways to communicate with patients who struggled with communication. This included interpreters, written information and easy read format.

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Staff enabled patients to give feedback on the service they received. This was in the form of community meetings held weekly, informal one to one meetings with staff and through written feedback. There were ‘you said, we did’ boards and newsletters on the wards showing what patients had wanted changing and how staff had managed to address these concerns. Patients were able to give input into the decorations on the ward, for example flower arranging in dining rooms. Staff also ensured patients could make complaints about the service in a safe way. This was through speaking to staff, or through the patient advice liaison service. Staff enabled patients to make advance decisions about their care and treatment. This was reflected in care records. Patients described the wards positively, stating that the staff encourage their independence. Patients told us that staff were always approachable. Patients were offered copies of their care plans and any other documentation.

Involvement of families and carers Staff informed and involved families and carers appropriately and provided them with support when needed. Carers contacted during the inspection were highly praising of the staff and the care their loved ones were receiving. Carers told us that the wards communicated well with them and kept them up to date. Any changes to treatment were communicated if appropriate and consent to share was established. The psychologists for the wards were running carers support sessions. in some cases the psychologist had run individual sessions due to the complex nature of the cases. Carers could give feedback on decisions made, for example decisions around care and attending MDTs. Staff enabled families and carers to give feedback on the service they received. This was mostly done through informal means, with families and carers being able to speak directly with staff or through email/post. There were also formal ways for carers to give feedback and complain. Carers could send cards of thanks to the staff. Managers told us of the numerous donations the wards had received and how they had used these donations to purchase items beneficial to the ward and patients, such as a games console designed for dementia patients. Staff provided carers with information about how to access a carer’s assessment. This was primarily done through social services, but the wards could signpost carers. The wards were part of the triangle of care approach. This seeks to involve carers more and monitor the trust in the way that carers are engaged.

Is the service responsive?

Access and discharge Bed management The trust provided information regarding average bed occupancies for four wards in this service between 1 January 2018 to 31 December 2018. Four of the wards within this service reported average bed occupancies ranging above the minimum benchmark of 85% over this period.

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Ward name Average bed occupancy range (1 January 2018 – 31 December 2018) (current inspection) Alumhurst Ward 99%-100% Herm Ward 49%-88% Melstock House 95%-100% St Brelade's Ward 78%-99%

The trust provided information for average length of stay for the period 1 January 2018 to 31 December 2018. Ward name Average length of stay range (1 January 2018 – 31 December 2018) (current inspection) Alumhurst Ward 53-163 days Herm Ward 78-190 days Melstock House 37-137 days St Brelade's Ward 33-143 days

The trust did not provide data on out of area placements in a format that was suitable for analysis by core service. This service reported six readmissions within 28 days between 1 January 2018 to 31 December 2018. Three readmissions (50%) were readmissions to the same ward as discharge. The average of days between discharge and readmission was eight days. There was one instance whereby patients were readmitted on the same day as being discharged and there was one where patients were readmitted the day after being discharged. The number of readmissions within 28 days was not comparable to the last inspection.

Ward name Number of Number of % Range of Average days readmissions readmissions readmissions days between between (to any ward) (to the same to the same discharge discharge within 28 ward) within ward and and days 28 days readmission readmission Alumhurst Ward 3 1 33% 1-17 days 8 days Melstock House 1 0 0% 1 day 1 day Herm Ward 2 2 100% 5-18 days 12 days

Managers informed us that there was not always a bed for a patient if they left the ward, for example if they had to be admitted to general hospital. The managers told us that they would put forward rationale for keeping the bed for the patient, but ultimately it was the bed management team who made the decision. We saw examples of some clinically inappropriate placements when reviewing care records. Staff told us that sometimes patients with poor physical health were admitted to the ward inappropriately because the wards had effective physical healthcare. We were informed the medical director would be addressing the issues of inappropriate placements across the wards. Patients were not moved between wards during an admission episode unless it was justified on clinical grounds and was in the best interests of the patient.

Discharge and transfers of care Between 1 January 2018 to 31 December 2018 there were 734 discharges within this service. This amounts to 19% of the total discharges from the trust (3916).

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There was a total of 210 delayed discharges in this service and delayed discharges across the 12- month period ranged from 14 to 22 each month. The proportion of delayed discharges reported during this inspection was not comparable to the last inspection. Staff planned for patient discharge. This was evident from the discharge care plans and discussions during MDT. There were examples of good liaison with community services, social workers and care coordinators, with these external agencies being invited to MDTs and discharge planning meetings. There were monthly delayed discharge meetings involving the local authority, clinical commissioning groups and clinical team leaders from the wards, as well as the hospital discharge coordinator. These meetings looked at individual cases as well as the wider trust discharge concerns. When discharge was delayed this was mostly due to lack of placement for the patient. This could be in another facility or if in the patient’s own home, the delay could be due to not receiving a package of care in a timely manner. However, the staff managed the patients appropriately, keeping them informed of any changes. The integrated care service for dementia and Dorset community health teams were active in liaising with the care homes that offer placements. Their aim was to educate the care homes in dementia to better equip them to take dementia patients, with the hope of speeding up discharges. Staff supported patients during referrals and transfers between services. Staff included transfers or discharges as part of the patients’ care planning and, if possible, would ask the patient or carer their views on what would help with the transfer/discharge process.

Facilities that promote comfort, dignity and privacy The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at all three locations scored higher than similar trusts. Site name Core service(s) provided Ward food

Alderney Hospital MH – Wards for older people with mental health problems 97.5% Other St Ann’s Hospital MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems 94.5% MH – Mental health crisis services and health- based places of safety MH – Secure wards/Forensic inpatient Other Forston Clinic MH - Acute wards for adults of working age and psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental 93.2% health problems MH – Mental health crisis services and health- based places of safety Trust overall 94.3%

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Site name Core service(s) provided Ward food

England average (mental 92.2% health and learning disabilities)

Patients had their own bedrooms on Melstock and St Brelades. On Herm Ward there was shared rooms for two females. On Alumhurst there were female shared rooms, where four patients shared a room. There were curtains in the rooms to offer a degree of privacy to the patients. The patients all had lockable cupboards and stored personal items in locked offices. Staff assessed each patient carefully for risk and privacy prior to admitting them into a shared room. There had been a clinical review of the use of shared accommodation and was decided to retain the current facilities, however in the long term the trust plan to remove all shared accommodation. Patients’ could personalise their bedrooms to a degree. The shared accommodation in some areas made this limited because the space was shared and consideration needed to be given for all patients sharing the room. There was access to a full range of rooms and equipment to support treatment and care. This included therapy rooms, examination rooms, lounges, dining rooms and outside space. All the wards had outside space that patients could use. The outside space at Herm and St Brelades was not currently fit for purpose, with non-dementia friendly walk ways and a decrepit pagoda. During the inspection we were assured this had been reported to estates and that there was an action plan in place. This was confirmed by the trust. On Melstock Ward there was a central garden and activities area in the ward. This allowed patients to access activities such as gardening within the ward. There was pet therapy on the wards. However, on Melstock Ward there was a lack of private therapy space where patients could have private sessions. There were rooms on Herm and St Brelades that were designed for patients at high risk of falls and at high risk of injury from falls. These rooms were designed to reduce the impact of the fall, with cushioned floors and round edged furniture. There were not always quiet areas or rooms on the wards for patients to meet with visitors or staff. On Melstock there was no room available. Staff told us that if they were to have a quiet one to one meeting this would have to take place in the patients’ bedroom. This was due to the building Melstock was in not having enough space. Staff reported that if they needed a large meeting space, for example for team meetings, they would have to use the patients lounge and request patients to leave the lounge. MDT sessions occurred in the manager’s office. The matron and manager were aware of the impact this had on patients and staff. There were plans for an extension to be built, although this was subject to approval. The food was of good quality in all the wards. Menus were varied, with healthy and vegetarian, vegan options. Patients told us that the food was good. Hot and cold drinks, as well as snacks, were available to patients at any time during the day. Where possible staff encourage patients to make their own, for example on Alumhurst there were two kitchenette areas on the ward that patients could access. On Melstock the OTs performed kitchen assessments with patients that allowed the patients to cook meals for themselves as part of their recovery.

Patients’ engagement with the wider community

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When appropriate staff supported patients to access work and education opportunities. For example, referral to the recovery college on Alumhurst Ward. Courses were available on anxiety management and mindfulness. Staff supported patient contact with families and carers. We saw visitors on the wards, and it was recorded in progress notes. Patients could use phones, tablets and computers also to maintain contact. There were dedicated visiting areas at each site, however, not necessarily on each ward. For example, at Melstock Ward the family room was in the neighbouring building.

Meeting the needs of all people who use the service For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018) Alderney Hospital scored lower than similar trusts for the environment being dementia friendly. One location scored higher than similar trusts for the environment supporting those with disabilities and two locations scored lower.

Site name Core service(s) provided Dementia friendly Disability Alderney CHS – Adults Community Hospital CHS – Community Inpatients MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older 85.3% 89.5% people MH – Wards for older people with mental health problems Other St Ann’s MH - Acute wards for adults of working age and Hospital psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems MH – Mental health crisis services and health-based N/A 81.6% places of safety MH – Secure wards/Forensic inpatient Other MH – Specialist community mental health services for children and young people Forston MH - Acute wards for adults of working age and Clinic psychiatric intensive care units MH – Other Specialist Services MH – Wards for older people with mental health problems MH – Mental health crisis services and health-based N/A 73.2% places of safety MH – Community-based mental health services for adults of working age MH – Community-based mental health services for older people CHS – Adults community Trust 83.2% 84.1% overall

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England average (Mental health 88.3% 87.7% and learning disabilitie s)

The service made adjustments for disabled patients. This was achieved through disabled access, such as lifts and ramps, as well as shower and toilet facilities with the necessary fittings for disabled use. All staff received training to use specialist equipment for disabled or immobile patients. For example, on Alumhurst the ward had purchased specialised fitness equipment for disabled patients. The physiotherapist trained staff to use so that all patients could access the equipment at any time. Staff ensured that patients could obtain all necessary information. This included information regarding treatments, therapies, local services, patients’ rights and how to complain. We saw leaflets and posters on each ward with this information. The wards produced welcome packs with relevant information. During patient one to one time staff would provide information relevant to that patient. We saw examples of these discussions documented in patients’ notes. This information was always provided in an accessible format, dependant on the patients needs, including different languages and easy read. Managers knew how to access interpreters and signers if needed. They had to ensure that the interpreters understood the legality of what they were translating, for example when patients detained under the mental health act had their rights read. Patients had a choice of food to meet dietary requirements of a religious or cultural nature. Staff said they could request specific foods as required. During the admission process it was documented that staff asked about the spiritual life of the patients, either from them or their carers. A chaplain was available to visit the wards.

Listening to and learning from concerns and complaints This service received five complaints between 1 January 2018 to 31 December 2018. Two of these were upheld, none were partially upheld and two were not upheld. None were referred to the Ombudsman.

Ward name

Other

Under Under

Referred to to Referred

Withdrawn

Not upheld Not

Fully upheld Fully

Ombudsman

Investigation

Partially upheld Partially Total Complaints Total Alumhurst Ward 3 2 0 1 0 0 0 0 Melstock House 2 0 0 1 0 1 0 0

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This service received 60 compliments during the last 12 months from 1 January 2018 to 31 December 2018 which accounted for 1% of all compliments received by the trust as a whole (4077).

Patients knew how to complain or raise concerns. There were posters and leaflets explaining the complaints process. Managers told us of example where patients had made complaints and could show us the process taken to resolve it. Patients had weekly community meetings where they could voice their opinions about the service.

When patients complained or raised concerns they always received feedback. This was often from the manager of the ward. For example, the patients on one ward had complained about the food temperature. The manager and staff could describe the process taken to resolve this and how they explained to the patients what had gone wrong and how the staff have corrected it. Staff protected patients who raised concerns or complaints from discrimination and harassment. Patients could raise concerns anonymously using the patient advice liaison service, and staff had told us of occasions when they had referred patients to this service.

Staff knew how to handle complaints appropriately. Staff received feedback on the outcome of investigations and acted on findings.

Is the service well-led?

Leadership Leaders had the skills, knowledge and experience to perform their roles. Leaders attended courses on leadership. Some managers had been in post for several years on the same wards. Where managers were new in post, they demonstrated the necessary knowledge and skills to manage the ward. Periods without a manager on Melstock resulted in a drop in staff morale and a lack of structure, resulting in some staff leavers. This was partly due to no effective handover from old to new managers. The new manager was innovative and brought about positive change. Although changes took time to embed, and are still being embedded in the staff team, the managers monitored morale and how the changes were affecting staff. Managers received feedback and altered changes accordingly. The manager was proud of the changes and the staff teams attitude and culture. The new manager was able to spend time on the other wards to learn from them. Leaders generally had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. The matron had good oversight of the four wards, and through the monthly mangers meetings the leadership group was kept aware of what was happening in each ward. However, managers did not always have clear oversight of audits and ensured actions took place, such as the medication check audits. Leaders were visible on the ward and were approachable for both patients and staff. We saw evidence that patients knew who the leaders were, and staff were generally praising of the leaders. Managers could describe the activities on the ward and knew the current patients. Once a month the matron would do a nursing shift on one of the wards. However, senior leaders such as board members were reportedly distant, and staff felt that they often felt they were not informed what was happening at a trust-wide level.

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Leadership development opportunities were available, including opportunities for staff below team manager level. For example, on Alumhurst Ward the manager demonstrated how she created away days for staff to help develop their leadership skills. There were also aspiring leadership courses that staff below manager level could attend. These staff attended supervision courses, this allowed them to supervise others.

Vision and strategy Staff knew and understood the trust’s vision and values and how they were applied. During staff interviews they could describe the vision and values and demonstrate this in the way they worked. Patients described the care they received as being in line with the trust’s vision and values. The wards manager team had successfully communicated the trust’s vision and values to the ward staff. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. For example, we were told about managers using a staff members strength during a refurbishment to give advice on how the service should look. Staff could explain how they were working to deliver high quality care within the budgets available.

Culture Staff felt respected, supported and valued. Staff told us how they were all treated with support by each other and senior staff. We saw this during meetings such as MDT and handovers. Staff treated each other with respect and listened to each other. Managers valued staff feedback, for example the creation of separate restraint training because of staff feedback. Staff felt positive and proud about working for the trust and on the wards with their teams. We saw this in the interactions between the staff and staff commented on this when we spoke to them. During inspection we were told that morale can fluctuate, especially during busy periods when patients had high acuity, however staff said that the teams supported each other. During times of stress and lower morale staff could access psychological support and occupational health. Staff were able to raise concerns without fear of retribution. They were aware of the trust’s whistle- blowing process. Not all staff were aware of the Speak Up Guardian, but there were posters and leaflets on the ward. The Speak Up Guardian had visited the wards previously. Managers dealt with poor staff performance when needed. Managers could describe the process for performance management process and gave examples of when they have had to use this process. Managers told us about times they have addressed staff short-comings before they required performance management, taking an active approach in staff performance. The managers would get human resources and the modern matron as needed. All managers described support given to them during staff performance management, if needed. Teams worked well together and where there were difficulties managers dealt with them appropriately. Both staff and the managers could describe changes in the wards that led to difficulties in the team and decreased morale, and how the managers addressed these. The way managers addressed these difficulties resulted in an increase in staff morale and team work. Staff appraisals included conversations about career development and how it could be supported. This included specialist training and leadership opportunities. Managers and staff were proactive in facilitating their professional development.

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The service’s staff sickness and absence were slightly higher than the trust targets. Managers could cover sickness with bank staff, and regular staff were flexible in covering shifts. Staff had access to support their own physical and emotional health needs though an occupational health service. Managers were quick to refer staff to this if they suspected a need. The wards had access to psychological support for staff. Staff could approach managers if they needed to. There was a health and wellbeing policy in place to ensure staff are looked after.

Governance There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Team meetings occurred regularly, and from reviewing meeting minutes the teams discussed a range of issues, patient risks, safeguarding and incidents. Staff gave us examples of times where there had been an incident, and this had been discussed at team meetings. There were monthly managers meetings between the ward managers and modern matron, as well as a monthly meeting with all older people service managers. However, it was not clear that learning was shared or adopted from these meetings. Some of the wards had innovative approaches to care and others did not. For example, the MDT sessions on some wards was innovative and in depth, whereas others were not. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Staff undertook local clinical audits. Not all the audits were sufficient to provide assurance. Staff did not always act on the results when needed. There were examples emergency and controlled drug audits, and mental capacity assessment and consent audits that were not used effectively. Although we were told that these audits occurred weekly and were actioned, we saw evidence that the audits were not being done regularly with the controlled drugs and emergency medications. There were also actions from the consent audit that had not been completed. Managers did not always have oversight of these audits as they were unaware of the missing checks. Staff understood the arrangements for working with other teams, both within the trust and external, to meet the needs of the patient. There was good liaison with social services, clinical commissioning groups and carer representatives. During the clinical review of the shared accommodation these external agencies were consulted. However, there was a lack of sharing across the wards.

Management of risk, issues and performance Staff maintained and had access to the risk register at ward level. Staff at ward level could escalate concerns when required. Staff were aware of the risks on the ward. Staff concerns did not always match those on the risk register. For example, there was nothing on the risk register at Melstock, despite having challenges around the environment. The service had plans for emergencies. This included fire emergencies, outbreaks of diseases such as flu. The wards conducted fire assessments to ensure readiness for the emergency. Staff were aware of emergency procedures.

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Information management The service used systems to collect data from wards and directorates that were not over- burdensome for frontline staff. These were mostly based through their internal computer systems; however, wards also collected their own data. For example, Herm Ward collected data on therapeutic intervention and the effect on staff sickness and patient restraint. Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure worked well and helped improve the quality of care. The new bladder scanners purchased will improve patient care through them not having to be transferred to general hospital for assessment. Managers could access learning and development reports to keep track of staff training figures. The information technology infrastructure allowed managers to know which bank staff were coming onto the ward, to ensure that they had the required skills and experience. This was set up in a way that bank staff could not apply to shifts if they did not have the required training for that ward. Information governance systems included confidentiality of patient records. These were secured by password protection and encryption to ensure there was no inappropriate access. Team managers did not always have access to information to support them with their management role. Managers described not having a full picture of the performance of the ward when they first came into post, such as staff supervision. The manager had subsequently put in place measures to correct these shortcomings and staff performance and morale has since increased. Staff made notifications to external bodies as needed. This included statutory notifications to CQC and any referrals to the local authority.

Engagement Staff, patients and carers had access to up-to-date information about the work of the wards. This was done through staff and patient community meetings, leaflets and one to one sessions. The activities coordinator on Alumhurst Ward produced a monthly newsletter that was given to each patient with the months highlighted activities. Staff however, felt that they were not always kept up to date with changes in the trust. Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. This could be done through formal feedback such as the patient liaison service or through one to one meetings with staff. Care plans were written with the patients view on how to provide feedback to staff. Managers and staff had access to the feedback from patients, carers and staff. This was used to make improvements to the service.

Learning, continuous improvement and innovation NHS trusts can participate in several accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.

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Staff were given the time and support to consider opportunities for improvements and innovation. This led to changes. For example, managers, falls risk lead of the wards and medical devices lead were supported to visit other NHS trusts to share learning. This led to the development of the high risk falls rooms on Herm and St Brelades. Other NHS trusts had also attended Alumhurst to learn from what Alumhurst was doing right. Staff had the opportunities to participate in research. For example, the investigation into the use of therapeutic activity on the reduction of restraints on Herm Ward was conducted in partnership with Wessex University. Innovations were taking place in the service. Herm and St Brelades were the first mental health inpatient facilities to be awarded the Gold Standard Framework. This involves training in end of life care and is a certificate of excellence. The wards have also commenced in accreditation for the Quality Networks for Older Adults Mental Health Services through the Royal College of Psychiatry. Staff used quality improvement methods and knew how to apply them. For example, the staff on Herm Ward were supported by an external QI team to produce the research into therapeutic activity on the reduction of violence and aggression. There was a mindfulness practitioner on the ward at Alumhurst.

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Mental health crisis services and health-based places of safety

Facts and data about this service

Location site name Team name Number of clinics Patient group (male, female, mixed) Sentinel House 24 Hour Crisis N/A Mixed N/A - do not run set St Ann's Hospital Crisis Service East Mixed clinics Crisis Service West - Home N/A - do not run set Forston Clinic Mixed Treatment clinics Sentinel House Retreat East (Pilot) N/A Mixed N/A - do not run set Sentinel House Street Triage (county wide) Mixed clinics

The methodology of CQC provider information requests has changed, so some data from different time periods is not always comparable. We only compare data where information has been recorded consistently.

Is the service safe?

Safe and clean environment Mental health crisis services The crisis teams saw most patients in their own homes. Staff arranged to see patients at local centres owned by the trust, if patients preferred not to be seen at home. Staff did not leave patients alone in rooms to ensure they remained safe. Both teams had large, clean offices with access to computers. Staff from both crisis teams had access to an automated external defibrillator (AED) located on premises.

Health Based Place of Safety The trust had one designated place of safety which was clean, tidy and appropriately furnished. When the place of safety was in use, the staff used the family room and multi-faith room to accommodate subsequent people brought into the place of safety. The furniture in these rooms was appropriate and any non-fixed furniture was removed from these rooms when being used by a detained patient. Ligature assessments were appropriate and up to date for all rooms used as places of safety, which included action plans and outcome information. There were clear procedures in place for observation and engagement and mitigation of risk from harm. Patients remained on eyesight observation throughout their detention within the place of safety. Patients under the age of 18 always had a member of staff with them. Staff had access to alarms to alert colleagues where required. Staff from wards adjoining the

Page 205 place of safety responded immediately if the alarm was activated. Staff were always present to observe patients. When appropriate, the viewing panel in the door was used for observation, to minimise intrusion. The door to the place of safety was fob controlled to enter and exit, ensuring the safety of patients whilst they were using the facility. The place of safety had access to emergency equipment located on the closest ward. The staff confirmed that they were able to meet the Royal College of Psychiatry guidelines to meet the three-minute response time at all places of safety in the event of an emergency. The trust was in the process of opening a second place of safety, situated next to the current one in St Ann’s Hospital. This was due to open in the weeks following the inspection.

Safe staffing Nursing staff This core service has reported a vacancy rate for all staff of 12% as of 31 December 2018. This was lower than the 17% rate reported at the last inspection (30 June 2017). This core service reported an overall vacancy rate of 17% for registered nurses at 31 December 2018. The vacancy rate for registered nurses was lower than the 22% reported at the last inspection. This core service reported an overall vacancy rate of 11% for nursing assistants. The vacancy rate for nursing assistants was not comparable to the last inspection.

Registered nurses Health care assistants Overall staff figures

Location Ward/Team

(%) (%) (%)

Vacancies Vacancies Vacancies

Vacancy rate rate Vacancy rate Vacancy rate Vacancy

Establishment Establishment Establishment Sentinel 24 Hour 0.6 1.8 33% N/A N/A N/A 0.6 1.8 33% House Crisis Sentinel Retreat -0.8 3.0 -27% 3.4 3.4 100% 2.4 7.8 30% House East St Ann’s Crisis Hospital Services 8.3 23.0 36% -1.3 7.0 -18% 6.5 32.4 20% East Forston Crisis Clinic Services -1.0 15.2 -6% -0.2 7.7 -3% -1.4 23.6 -6% West Core service 7.1 42.9 17% 2.0 18.0 11% 8.1 65.6 12% total Trust total 96.4 1424.4 7% -12.0 1055.7 -1% 156.3 3761.0 4% NB: All figures displayed are whole-time equivalents Between 1 January 2018 and 31 December 2018, the trust did not report the use of any bank or agency staff to cover sickness, absence or vacancy for qualified nurses in this service.

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Between 1 January 2018 and 31 December 2018, the trust did not report the use of any bank or agency staff to cover sickness, absence or vacancy for nursing assistants in this service. This core service had 7.0 (12%) staff leavers between 1 January 2018 and 31 December 2018. This was higher than the 5% reported at the last inspection (1 July 2016-30 June 2017).

Location Ward/ Substantive Substantive staff Leavers Average % staff leavers Team staff (at latest over the last 12 months over the last 12 months month) Crisis Forston Services 25.0 4.6 18% Clinic West Crisis St Ann’s Services 25.9 2.4 9% Hospital East Sentinel 24 Hour 1.2 0.0 0% House Crisis Sentinel Retreat 5.5 0.0 0% House East Core service total 57.6 7.0 12% Trust Total 3623.9 364.5 10%

The sickness rate for this core service was 8.6% between 1 January 2018 and 31 December 2018. The most recent month’s data (31 December 2018) showed a sickness rate of 6.8%. This was higher than the sickness rate of 3% reported at the last inspection (30 June 2017).

Location Ward/Team Total % staff sickness Ave % permanent staff sickness (1 (at December 2018) January 2018 – 31 December 2018) St Ann’s Hospital Crisis Services 10.9% 12.3% East Forston Clinic Crisis Services 2.4% 5.7% West Sentinel House Retreat East 8.2% 3.7%

Sentinel House 24 Hour Crisis 0.0% 1.4% Core service total 6.8% 8.6% Trust Total 5.4% 4.9%

Mental health crisis services Both crisis teams operated 24 hours a day, 7 days per week. Vacancies within the West crisis team were low. Caseloads ranged between 12 - 15 in the West team to 24 - 30 at St Ann’s Hospital, in the East. Leaders told us the higher caseloads in the East team were due a higher population density in the East of Dorset. The East crisis team had more staff resource to manage the caseload numbers. Caseloads were managed by a team approach to support continuity of care because of shift patterns. Managers could increase staffing numbers by using regular bank staff who knew the patients and the service well. None of the teams used agency staff.

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Each team had access to a dedicated consultant psychiatrist, supported by other doctors including specialist registrars, and junior doctors. Psychiatrists were able to see patients at home. Patients seen by the West team were all seen by a psychiatrist for a medical overview within 72 hours of being referred into the service. Patients covered by the East crisis team were visited by a psychiatrist if a medical need had been identified at the initial assessment. Street triage also provided cover between 7pm and 3am, 7 days per week. The level of support provided by the street triage team had been based on the needs of the local demographic. A mental health walk in centre was also available, called The Retreat. This was open daily, from 4.30pm to midnight. Staff from both crisis teams and the place of safety gave patients the details for The Retreat. This service was staffed with at least one nurse, front of house worker and two peer support workers per shift. During inspection we saw this was well-attended and the staff spoke highly of the opportunities the service provided. A duty rota was in place for the shift coordinator, with access to a range of information and resources. The shift coordinator was responsible for triaging calls, prioritising assessments and home treatment activities, and monitoring whereabouts of staff. Health-based place of safety There was no dedicated staffing for the place of safety, although there was an allocated support worker from the adjoining ward, who was supernumerary to ward staffing numbers. Staff told us police officers would call ahead of bringing someone into the place of safety, allowing time for the bed manager to arrange the approved mental health professional (AMHP), doctor, and staff member to attend the place of safety. The role of the AMHP is to coordinate the assessment of people who are being considered for assessment under the Mental Health Act (MHA). Police officers would remain with the detained person until the staff accepted them into the facility. The support worker was responsible for completing observations. Staff were only left alone in the unit if the patient was considered low risk. The trust had developed a place of safety introduction booklet for staff which was given to all staff at the start of their shift. This included information on fire exits and emergency equipment. The management confirmed that there were plans to recruit dedicated staff for the place of safety, subject to trust approval. The leadership acknowledged that the current system was not optimising the delivery of high-quality care.

Medical staff Between 1 January 2018 and 31 December 2018, of the (7560) total working hours available, 0% were filled by bank staff to cover sickness, absence or vacancy for medical locums. The main reason for bank and agency usage for the wards/teams was vacancies. In the same period, agency staff covered 11% of available hours and 0% of available hours were unable to be filled by either bank or agency staff. Ward/Team Total hours available Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Crisis Service East 7560 0 0% 848 11% 0 0% Core service 7560 0 0% 848 11% 0 0% total Trust Total 58592 2961 5% 10922 19% 1163 2%

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Mandatory training The compliance for mandatory and statutory training courses at 29 January 2019 was 87%. Of the training courses listed eight failed to achieve the trust target and of those, two failed to score above 75%. During this inspection we saw this had improved to 93% compliance across the two crisis teams. The trust set a target of 95% for completion of mandatory and statutory training. Staff were expected to complete mandatory training. Training data provided from the trust showed that training compliance was generally good. The trust used an electronic record to monitor training and staff were sent emails when training was due or overdue. Team leaders could look at and monitor staff training records to discuss during supervision. The trust’s training completion data is on a rolling basis depending on the training repeat requirements. The training compliance reported for this core service during this inspection was not comparable to the previous year. Key:

Below CQC 75% Met trust target ✓ Not met trust target 

Training Module Number of Number of YTD Trust eligible staff staff trained Compliance (%) Target Met

Equality and Diversity 60 60 100% ✓ Safeguarding Adults Level 1 6 6 100% ✓ Safeguarding Children Level 1 6 6 100% ✓ Safeguarding Children Level 2 16 16 100% ✓ Conflict Resolution 53 52 98% ✓ Moving and Handling Theory Level 1 60 59 98% ✓ Information Governance 60 58 97% ✓ Safeguarding Adults Level 2 54 50 93%  Safeguarding Children Level 3 38 35 92%  Infection Control - 3 Yearly 60 53 88%  Mental Capacity Act 38 33 87%  Fire 60 50 83%  Basic Life Support – eLearning 53 44 83%  Mental Health Act 38 24 63%  Medicines Management 34 5 15%  Total 636 551 87% 

Assessing and managing risk to patients and staff Assessment of patient risk Mental health crisis services The 18 risk assessments we reviewed across both crisis teams were comprehensive and well

Page 209 detailed. Staff completed an initial risk assessment as part of the triage process, and a more detailed risk assessment during a home visit. Staff used the red, amber, green (RAG) risk assessment tool to identify level of risk. RAG status was reviewed and updated on the whiteboard in team offices during handover and clinical review meetings. Staff saw all patients at least once daily for the first three days and then reviewed frequency of visits. We saw evidence that staff saw patients twice a day where risk was considered high. Staff made home visits in pairs if required. Street triage teams worked with the police across the trust. The teams consisted of mental health professionals who provided support to people in distress. Workers had access to the trust’s electronic records, local authority and police systems and they could upload notes to all these systems. Health-based place of safety We reviewed eight care records of patients who had been detained at the place of safety. All contained detailed risk assessments and included any risk assessments completed jointly by the police officer and bed manager. Staff who had carried out the assessment had considered risks when making recommendations about the patients’ ongoing care and treatment. However, staff were not recording observations of patients after their initial presentation. In all the records we reviewed, there were no records of patient monitoring after the initial recording when they arrived at the facility. Staff aimed to include care coordinators and community psychiatrists in Mental Health Act assessments. Care coordinators knew the person which led to a better assessment and more appropriate decision-making. Staff gave us an example of a person who was detained out of county and brought back to Dorset. With support from their care coordinator at their assessment, a less restrictive option was reached.

Management of patient risk Mental health crisis services Staff responded to sudden deterioration of patient’s health. Any deterioration was recognised through patients’ presentation, home visits and communication from patients, carers or professionals. We saw examples of staff responding to risk which included increasing the number of visits. All staff we spoke with had a good understanding of patients’ risk. We observed comprehensive and focussed discussions during the daily handovers. Discussions included risk, level of support and consideration of family and other agency involvement. We saw that staff had a good knowledge of their patients. Meetings were attended by a range of disciplines and demonstrated good multi-disciplinary working. Information from handover meetings was recorded on patients’ electronic records. Staff adhered to the lone working policy which ensured their safety during visits. Staff recorded visits on the office whiteboard. The shift co-ordinator was responsible for monitoring staff whereabouts. Staff telephoned the shift co-ordinator before and after home visits. Whilst off the premises, staff wore neck-worn fob alarms with a button which dialled through to a response centre, when pressed. The alarms also had a Global Positioning System (GPS) tracking device installed for staff to be easily located in the event they could not be contacted.

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Health-based place of safety Staff completed a place of safety risk plan at the point of admission with the police service. The police service completed specific documentation as part of the handover process. Police searched patients before leaving which staff recorded on the patient’s electronic care record. Staffing numbers were determined during the initial assessment. Staff reviewed and monitored risk through observation, talking to the patient and monitoring their presentation. Patients remained on eyesight observations while they were in the place of safety. Staff completed prevention and management of violence and aggression training. The use of restraint was low in the place of safety. There were six recorded instances of mechanical restraint in January and seven instances in February 2019. Each restraint was recorded with narrative on rationale and decision-making.

Safeguarding A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This core service made one safeguarding referral (December 2018) between 1 January 2018 and 1 January 2019 which concerned adults and no safeguarding referrals which concerned children. The number of safeguarding referrals reported during this inspection was higher than the zero which were reported at the last inspection. Mental health crisis services Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff completed mandatory safeguarding training. Staff we spoke with were able to give examples of when a safeguarding alert should be raised. Team leaders were confident in staff knowledge of safeguarding and when to raise concerns.

Safeguarding concerns were discussed during handovers and clinical team meetings.

Health Based Places of safety Staff knew how to identify abuse and when a safeguarding referral would be appropriate.

We saw evidence of staff following the trust’s safeguarding procedure when reviewing care records at the place of safety. An appropriate safeguarding referral was made in a timely manner.

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Number of referrals Core service Adults Children Total referrals MH – Mental health crisis services and 1 0 1 health-based places of safety

The trust did not submit details of any serious case reviews published in the last 12 months (1 February 2018 to 31 January 2019) that relate to this service.

Staff access to essential information Mental health crisis services Staff recorded assessments during home visits on paper and transferred these on to the electronic patient record. Paper records were then appropriately disposed of.

Staff had access to patients’ GP records. This meant that information could be shared between the GP and crisis teams in a timely manner. We saw examples of this where patients had needed an electrocardiogram (ECG) at their GP surgery prior to Clozapine titration, staff at the crisis team were able to access the results almost immediately. Clozapine is an antipsychotic drug which should be slowly increased in dosage to reduce the risk of adverse events, such as seizures.

Health Based Place of Safety Staff had access to the patient electronic records. Staff completed paperwork specific to the place of safety during the initial assessment which they subsequently uploaded to the patient’s electronic care record.

Medicines management

Mental health crisis service When a patient had been accepted by the crisis team, and for the during of their admission, their responsible clinician was the consultant psychiatrist. This removed the risk of a patient being prescribed medication by a doctor in the community in addition to their prescription from the crisis team psychiatrist. Medicines taken away from patients to be dispensed by staff were kept in a locked cupboard. Staff assessed if medication could safely be left at a patient’s home and removed any medication when appropriate. Staff kept a record of medication held on behalf of patients and kept a log of medication to be returned to the pharmacy for destruction. Neither crisis team stored stock medication. Registered nurses completed medicines management training. We saw staff had supported patients to get their medication from a local pharmacy where required. Health-based place of safety Staff checked patient’s current medication and that a patient was medically fit during their initial presentation to the place of safety. Staff had access to GP records for people registered with a GP in Dorset. This meant that staff could access up-to-date information on a patient’s medical history and current medication. Staff ensured patients had access to their regular medication whilst detained at the facility. When

Page 212 a person had been accepted at the facility, the psychiatrist from the adjoining ward would become their responsible clinician for that person and assume responsibility for all their medication during their admission.

Track record on safety Between 1 January 2018 and 31 December 2018 there were two serious incidents reported by this service. These two incidents were both incidences of ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria.’ There were no unexpected deaths in this service. We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with two reported. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This service reported no never events during this reporting period. The number of serious incidents reported during this inspection was the same as the two reported at the last inspection. Number of incidents reported

Type of incident reported (SIRI) Apparent/actual/suspected Total self-inflicted harm meeting SI criteria Crisis Service East 2 2 Total 2 2

Reporting incidents and learning from when things go wrong

Mental health crisis services All staff had access to an electronic incident reporting tool. Staff were able to give examples of what incidents should be reported. Details of each incident was sent to the health and safety team and team manager for review and action.

Incidents were discussed during team meetings. Staff we spoke with gave examples of local incidents and the learning from these. The trust sent a bulletin to all staff with information about recent incidents and any learning identified. Staff had access to debrief sessions after serious incidents that were facilitated by senior managers and psychologists.

We reviewed a serious incident for the St Ann’s Hospital team and saw that appropriate investigations had taken place and learning was disseminated to staff.

The trust had a duty of candour policy and staff were aware of their responsibilities. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify people (or other relevant persons) of ‘certain notifiable safety incidents’ and provide reasonable support to that person. We saw examples of senior managers having spoken directly to families when an incident had taken place.

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Health-based place of safety Staff used the online incident reporting tool to record incidents. The clinical lead reported all incidents.

Staff discussed incidents and documented outcomes. Staff received a debrief following an incident. Incidents were discussed during the monthly steering group meeting.

Staff were aware of their responsibilities under the trust’s duty of candour policy.

However, there was no evidence of learning being disseminated to staff. The lack of a dedicated staff team meant that staff were not aware of learning from previous incidents and there was a risk of recurring incidents of the same nature. The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there have been two ‘prevention of future death’ reports sent to Dorset Healthcare university NHS FT. One of these related to this service, details of which can be found below. Date of report: 19 April 2018 A woman died as a result of a combination of multiple drugs (Codeine, Zopiclone, Amitriptyline and Mirtazapine) and ethanol intake. The Coroner’s concerns were: • She suffered with her mental health and had been engaging with Dorset Healthcare University NHS Foundation Trust (DHC) since 2009. On the 25th August 2017 she was admitted to Royal Bournemouth Hospital having taken an overdose of medication. She was assessed by the Psychiatric Liaison Team who are part of DHC and was discharged to the Crisis team within DHC. • She was seen daily by the Crisis team and during the visits they decided to change her medication regime so that the administration of this was supervised by the Crisis team staff. This decision was made in relation to the medication for her mental health. She was however also prescribed medication for her physical health. On the 3rd September she sadly died from an overdose of the prescribed medication. • Evidence was given that although the GP is written to when there is a change in regime regarding the mental health medication, there is no action taken in relation to the physical health medication. This may be a matter for the GP to resolve but if a patient’s access to medication is to be immediately changed by DHC employees, this should be addressed in relation to all medication not just mental health medication. • I heard evidence from the Psychiatric Liaison Team Lead and the Crisis Team Lead that there does not appear to be a policy in place at the Trust to deal with the communication of the supervision of physical health medication. If there is such a policy, they advised me that they are not aware of it. The following learning / recommendations were given: (include where applicable) • Once the access to medication has been identified as a risk to a patient and there is a need for the taking of it to be supervised, access to, and the taking of, all medication, not just mental health medication should be supervised. Page 214

• There are concerns that there is no policy in place in relation to the supervision of prescribed physical health medication when a decision has been made to supervise the administration of prescribed mental health medication. I would therefore request that DHC review their policies regarding the supervision of all medication a patient is prescribed and when and how to alert GP, or other treating practitioners, regarding changes to medication regimes and supervision. If there is already such a policy in place to deal with both physical health and mental health medication, then I would request that refresher training is undertaken to ensure all staff are made aware of the policy and the procedures to be adapted in such circumstances.

Is the service effective?

Assessment of needs and planning of care

Mental health crisis services We reviewed 10 care records across the two crisis teams. Care records were good quality, personalised, holistic and recovery orientated. They demonstrated robust initial assessments with evidence of multiagency working and joint working with care co-ordinators where appropriate. We saw that staff completed physical health monitoring at the initial assessment and liaised with doctors as appropriate. All 10 records showed that staff had gained patient consent and considered patients’ mental capacity. However, in nine of these records, staff recorded mental capacity as ‘yes’ or ‘no’ with no detail of a specific question and lacked narrative around how the decision was reached. Staff used ‘My Wellbeing plans’ which were concise, recovery focussed, person-centred and promoted self-management. This was a live document that all staff involved in the persons care could input into. Staff reviewed care plans with patients regularly and electronic records were updated in a timely manner. All staff were expected to update the electronic patient record transfer before the end of their shift. This meant that staff within the team and staff across the trust involved in the patient’s care could access up-to-date information. Staff told us of some instances where a hospital admission had been recommended following a Mental Health Act assessment, and an inpatient bed was not available. We reviewed one of these instances and were assured that staff managed the risk of the patient in the community until a bed became available.

Health-based place of safety All staff had access to the trust’s electronic care record system. Staff said that assessments may be delayed if the patient was asleep or refused to engage. Staff completed an initial screening which included physical observations. Assessments included information about a patient’s previous history. Staff completed physical health checks and raised any concerns with a doctor. We reviewed eight care records of patients that had been detained at the place of safety. Staff

Page 215 had clearly recorded patient arrival times, approved mental health professional (AMHP) and section 12 doctor arrival and second doctor arrival if required. This meant that the staff could accurately calculate the time from arrival to completion of assessment. A section 12 approved doctor is trained and qualified in the use of the Mental Health Act. The Mental Health Act Code of Practice section 16.47 says that a doctor and approved mental health professional should attend within three hours where there are no clinical grounds to delay an assessment. We saw that staff had recorded the reason for delay when a patient had not been seen within the recommended three hours.

Best practice in treatment and care

Mental health crisis services Staff followed the National Institute for Health and Care Excellence (NICE) guidelines. This included involvement of patients in care planning, crisis care planning, assessment and supporting clients to identify triggers to violent and aggressive behaviours. Staff also followed guidance for involvement and support of carers and family. We saw evidence of staff considering a range of care and treatment interventions for patients during handovers and team meetings. Staff considered least restrictive practice when discussing patient needs. We saw staff considering resources available in the community, including The Retreat and recovery bed service during a handover meeting. The trust had a six recovery beds at a unit in the community for patients to access for brief periods of intense crisis, to prevent a hospital admission. However, staff did not appear to have links or consider potential support available for patients to access education or training courses. Patients had access to psychological therapy through staff who were trained in therapies such as Dialectical Behaviour Therapy (DBT) and Behavioural Family Intervention (BFI), however there was a long waiting list to access a clinical psychologist. Both crisis teams had a nurse prescriber. This meant that they could prescribe medicines to patients to streamline a patient’s treatment journey. Staff discussed patients’ physical health during handover meetings. We saw evidence of staff completing a physical health screening tool and observations during the initial assessment. The crisis teams used the Health of the Nation Outcome Scales (HONOS). HONOS is used to measure the health and social functioning of people with severe mental illness.

Health-based place of safety. The trust was committed to reduce the number of people that were detained under a section 136. Since the Retreat opened in July 2018, there have been 166 occasions where police took someone to The Retreat, and nursing staff assessed that detention under section 136 of the Mental Health Act was not appropriate. Staff at The Retreat had provided guidance and appropriate support as needed.

This service participated in three clinical audits as part of their clinical audit programme 2018 – 2019.

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Audit name Audit Core Audit Date Key actions following the audit scope service type completed Further discussion with team MH – managers to be undertaken regarding admission proforma. Medical staff and Mental management team have to pursue health crisis providing additional support and Consent to Dorset services training around the importance of share East Crisis Clinical 05/02/2018 and health- consent to share information, information Team based assessment of capacity and places of importance of documentation of the same. Medical staff to provide safety information of training dates to the Crisis Team staff. Compliance with DVLA requirements MH – Review new guidance. Continue to of the Mental provide Re-think Driving and Mental patients with Crisis health crisis Illness leaflet and leaflets Dorset Mind acute Team, St services ‘fitness to drive’ information for Clinical 16/05/2018 psychotic Ann's and health- relevant patients. Include in the initial disorder in Hospital based assessment template comments on the care of places of driving and a leaflet to be left with the the safety patient. Psychiatric Crisis Team MH – Re-Audit Mental Further educational interventions Compliance Crisis health crisis could be considered along with with DVLA Team, St services consideration with the team for standards in Clinical 01/11/2018 Ann's and health- understanding reasons why it is that patient’s Hospital based DVLA advice may at times not have under Crisis places of been given. services safety

Skilled staff to deliver care

Mental health crisis services There was a range of disciplines in the crisis teams which included doctors, nurses and social workers. All staff we spoke with were appropriately experienced and qualified to meet the needs of patients. New staff received an induction to the trust and within their local team. New staff spent time shadowing staff, orientation to the service and receiving log in details to allow them to complete their role. There was an induction checklist for all new staff. We saw evidence of discussions regarding training in all the four supervision records reviewed. Staff could access specialist training including venepuncture and exposure therapy. The lead for immigration and homelessness had attended specific training to fulfil this role. Leadership training was available for team leaders and managers.

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Health Based Place of Safety There were suitably skilled staff to ensure people were kept safe. Additional staff could be requested from wards if required. Staff had access to a range of other professionals including consultants, mental health professionals and the police. However, the lack of dedicated staff meant that police officers were expected to stay with the person until the staff at the place of safety had accepted the person. Staff completed training relevant to their role on the ward. This included: risk assessment and management, observational skills, and prevention and management of violence and aggression. However, we saw no evidence of staff being trained in section 136 policy or any support provided to staff specifically for their role at the place of safety. The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 April 2017 to 31 March 2018), the overall appraisal rate for non-medical staff within this service was 98%. This year so far, the overall appraisal rates was 93% (as at 28 January 2019). The team with the lowest appraisal rate at 28 January 2018 was Crisis Service East with an appraisal rate of 83%. The rate of appraisal compliance for non-medical staff reported during this inspection was higher than the 91% reported at the last inspection. Ward name Total Total % % number of number of appraisals appraisals permanent permanent (as at 28 (previous non- non- January year 1 medical medical 2019) April staff staff who 2017-31 requiring have had March an an 2018) appraisal appraisal Retreat East 3 3 100% 100% Crisis Service West – Home Treatment 23 23 100% 100% Crisis Service East 18 15 83% 96% Core service total 44 41 93% 98% Trust wide 4197 3827 91% 95%

The trust did not provide appraisal data for medical staff within this service. Staff in both crisis teams were receiving regular supervision in line with the trust policy. We reviewed the supervision records of four members of staff at Forston Clinic and saw that supervision sessions were person specific and were detailed, covering personal development, wellbeing and reflective practice. Supervision sessions were recorded on an electronic dashboard, which allowed team leaders to monitor when their staff had received and or were due their next session. Staff who covered shifts at the place of safety were not receiving supervision specific to their role at the place of safety. We saw a rota which showed that the trust had some regular staff supporting the place of safety to ensure some continuity. Staff were receiving supervision for their roles on the ward, but we did not see any evidence of them receiving supervision specifically for their role at the place of safety. We raised this at the time of inspection and the trust implemented a monthly peer supervision session as from 5th June 2019, open to all staff covering shifts at the place of safety, including bank staff.

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The trust’s target of clinical supervision for non-medical staff was 95% of the sessions required. Between 1 April 2017 and 31 March 2018, the average rate across the two crisis teams in this service was 56%. During the inspection we saw this had improved to 67% compliance. The rate of clinical supervision reported during this inspection was not comparable to the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) Crisis Service West 30 21 70%

Crisis Service East 38 17 45% Core service total 68 38 56%

Trust Total 1568 1236 79%

The trust did not provide clinical supervision data for medical staff within this service.

Multi-disciplinary and interagency team work

Mental health crisis services A range of disciplines including doctors, nurses, social workers and managers attended the daily handovers where possible. We observed staff sharing appropriate information and risks during the meeting. Discussions were patient-centred and demonstrated knowledge of patients’ needs. All staff were engaged with the meetings, all views were valued and there was clear evidence of strong teamwork. The crisis teams had multidisciplinary handovers to discuss patients daily. Staff had detailed handovers twice a day in the Crisis West team and once a day in the Crisis East team. Staff discussed patient risks, presentation, plan and safeguarding concerns. Staff recorded the meeting content on the electronic system, which community mental health staff also had access to. This meant care coordinators could access up-to-date information on a patient’s progress.

Staff held Multi-Agency Risk Meetings (MARM) for individual patients for a variety of reasons, including regular crisis or frequent presentation at the place of safety. These meetings included social workers, care coordinators, support time recovery workers, psychiatrists, crisis team leaders and the police, as required. We saw these meetings were very detailed and covered history, assessments and risk, followed by a collective decision on a plan and date for review.

Staff worked closely with the psychiatric liaison team who were based at the general hospital. Staff supported the psychiatric liaison service to complete mental health assessments for people presenting at the Accident and Emergency department overnight.

The crisis teams worked closely with the community mental health teams, street triage, Assertive Outreach Team (AOT), The Retreat, psychiatric liaison and in-patient teams within the trust. We saw evidence of good collaborative working with the AOT to provide support for a patient over the

Page 219 weekend whilst an in-patient bed was identified.

Health-based place of safety Staff discussed patients during handover meetings.

The places of safety had a clear and comprehensive standard joint operational policy with other agencies including the police and the local authority. There were local and trust operational protocols for joint working involving the police, the trust and community teams. Regular multi agency meetings ensured effective information sharing and good working relationships.

There was a bi-monthly meeting with the police, psychiatric liaison, inpatient managers, ambulance service and local authorities. These meetings had a set agenda for discussion and reviewed reports for the place of safety, street triage and Dorset criminal justice liaison and diversity. Staff said they found the meetings effective and a good way of bringing operational procedures and differences together.

Staff worked closely with the police, approved mental health professionals and street triage.

There was a street triage service whereby an experienced mental health worker would be available to provide support to the police service between 7pm and 3am, when the police were more likely to apply Section 136. The mental health worker would look for alternatives to Section 136 being applied, such as referral to a local mental health service, or de-escalating the patients’ crisis, whilst at the same time releasing the police officer to resume their usual policing duties. Staff from street triage and the police service told us they had strong working relationships with the crisis teams and place of safety staff, and The Retreat had been well received.

Adherence to the Mental Health Act and the Mental Health Act Code of Practice

As of 29 January 2019, 63% of the workforce in this service had received training in the Mental Health Act. The trust stated that this training was mandatory for all services for inpatient and all community staff (role-specific) and renewed every three years. Mental health crisis services The trust had a Mental Health Act administration team, which staff could access easily for guidance. Staff could also refer to the Mental Health Act policy on the intranet. Social workers were integrated in both crisis teams inspected. When staff felt that a Mental Health Act assessment may be required, an approved mental health professional (AMHP) attended visits with the doctor who was section 12 approved. A section 12 doctor is a doctor who is trained and qualified in the use of the Mental Health Act 1983. Social workers provided patients with information about advocacy services.

Health Based Place of Safety The place of safety kept clear and concise records of all people brought into the place of safety in accordance with the Mental Health Act Code of Practice.

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Case notes included an initial report from the approved mental health practitioner (AMHP) and a set of section 136 documentation. Care records showed that patients had their rights under the Mental Health Act explained to them. Contact with the nearest relative was recorded in the patients care record.

Good practice in applying the Mental Capacity Act As of 29 January 2019, 87% of the workforce in this service had received training in the Mental Capacity Act. The trust stated that this training was mandatory for all services for inpatient and all community staff (role-specific) and renewed every three years. Staff completed annual mandatory online training. Staff could refer to the trust’s Mental Capacity Act policy on the intranet. We saw evidence of staff considering patient’s capacity in the electronic care records. However, in 17 out of the 18 records we reviewed, mental capacity assessments were not decision specific, and there was no evidence of staff following the five principles of the Mental Capacity Act.

Is the service caring?

Kindness, privacy, dignity, respect, compassion and support

Involvement in care Involvement of patients Mental health crisis services Staff provided patients with information about the service during assessments. Patients were given information leaflets which included key information. We observed staff treating patients with kindness, dignity, respect and compassion during home visits and telephone conversations. We observed staff sensitively discussing care and treatment and ensuring patient understanding. Care plans demonstrated patients were fully involved in their care. Staff had carefully considered patients’ holistic needs and completed detailed care plans in collaboration with the patients. Staff were passionate about positive patient outcomes and worked with internal and external colleagues to achieve this. We saw an example in the Crisis East team, where staff had supported a patient who was out of county, to return to Dorset and source permanent accommodation. Staff provided patients with information leaflets and signposted them to other relevant services and support. This included advocacy and support for individual concerns, such as gambling or alcoholism. Patients we spoke with were very complimentary of staff. Patients told us that staff were respectful, considerate and understanding. Patients had the opportunity to join the Mental Health Forum and become peer support workers. Peer support workers had been heavily involved in the development of the service. Staff told us

Page 221 peer support workers were involved in staff recruitment and had simplified information on the patient consent forms. Peer support workers we spoke with told us they were involved in the consultation prior to the remodelling of the crisis pathway. Peer support workers accompanied staff on home visits to enable patients to have contact with someone with lived experience. Peer support workers also visited wards, The Retreat and recovery houses which provided continuity for patients. Peer support workers were given the opportunity to deliver training. This included mental health awareness and psychosis training sessions within the trust, as part of the joint working with the Mental Health forum. Peer support workers had opportunities for paid employment. Peer support staff we spoke with at The Retreat were permanent staff, paid by the trust. Staff we spoke with told us that people who attended The Retreat liked talking to people who had lived experience of the recovery journey. The introduction of ‘The Retreat’ had encouraged social inclusion and patient-led crisis management. We saw people socially interacting with one another, enjoying the facilities on offer and patients having 1:1 sessions with staff and peer support workers. Patients were able to provide feedback using the friends and family survey and a recently introduced text message feedback service. However, although all patients we spoke with were offered the opportunity to provide feedback, they were not given information on how to make a complaint whilst using the service. Health Based Places of Safety Staff provided patients with information about helplines and additional support available, including advocacy and solicitors. However, there was a poster with out-of-date advocacy information displayed on the notice board. Staff removed this when brought to their attention by the inspection team. Care records demonstrated that staff asked patients if they could contact their nearest relative when they were in the place of safety.

Involvement of families and carers We saw evidence of consideration of carers during handovers, reviewing of care records and home visits. Staff sought the carer perspective during home visits and involved carers with difficult to engage clients where consent had been provided. Staff gave carers emergency contact information at initial assessment. Staff referred patients to the local authority for carer assessments and signposted carers to various resources within the community. Patients we spoke with told us that staff had involved their family in their assessment and care planning, with patient consent. Patients also told us their family were offered carers assessments to explore support for them as a carer. Carers could provide feedback using the friends and family survey. The survey could be completed electronically, or paper copies of the survey were available.

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Is the service responsive? Access and waiting times Mental health crisis services Crisis teams were available 24 hours a day, 7 days per week. The teams had capacity to visit patients between the hours of 9am and 9pm. The frequency of visits was based on risk and twice daily visits could be accommodated when required. We observed discussions that showed staff had a flexible approach and prioritised patient’s needs. Referrals to the service were from professionals including GP’s, approved mental health professionals, accident and emergency departments, primary care services and older persons mental health services. Self-referrals were not accepted, as people were expected to go to their GP initially. The crisis teams did not hold a waiting list. Each team had a qualified staff member on duty who would screen referrals and capture the immediate risks and purpose of the referral. Patients would either be accepted or signposted to alternative services/ support. Staff used initial assessments to prioritise home visits and most patients who had been accepted as urgent referrals received a home visit within 24 hours. Staff from psychiatric liaison were able to add people to the crisis teams’ caseload without further triage from the team. If staff from the liaison team identified urgent support for a patient, they completed a screening tool and initial risk assessment for the crisis team to follow up. Staff also completed a safety plan with the patient. If an appropriate referral was received, staff used the screening tool to follow up the patient, rather than reassess, to reduce the number of assessments and improve the patient experience. Staff followed the crisis team guidelines for discharging patients. Staff invited the care coordinator for a face to face meeting when a patient was discharged to the community mental health team. Crisis teams were responsible for ‘gatekeeping’ inpatient beds. During each shift there was an allocated bed manager on duty who ensured other alternatives to inpatient care had been fully considered. The bed manager worked closely with the crisis teams, community teams and ward managers to promote least restrictive options and maintain flow of bed availability. A mental health helpline was available for anybody needing help, whether or not they were already receiving mental health care. However, at the time of inspection this was only available for residents in the East of Dorset, covering Bournemouth, Poole and Christchurch. Helpline staff had access to the trust’s electronic record system to update records. There were plans for this to be rolled out to the rest of the County by the end of July 2019. Staff discussed hard to engage patients during handovers. They actively tried to engage patients who did not attend appointments or found it difficult to engage with the service. Engagement strategies used included telephone contact, carer involvement, making a home visit and placing a note through the door if unanswered, requesting a police welfare check and linking in with street triage. Staff were flexible with appointments, including medical reviews, to accommodate patient needs. Appointments were sometimes cancelled due to the volume of appointments, although we were told this was rare. Staff followed the trust policy for patients commencing clozapine treatment in the community. Clozapine is an antipsychotic medicine which requires strict monitoring of people’s physical health in the first two weeks. The referring doctor completed pre-screening checks prior to

Page 223 treatment starting. Staff arranged for patients to have an electro cardio gram (ECG) with their GP, as a preliminary indication for clozapine titration. Staff supported patients transferring to another service, for example the community mental health team, by arranging joint appointments where possible. We saw evidence of staff working closely with other teams and providers to ensure that the needs of the patients were met, for example the local authority safeguarding team.

Staff completed 7-day follow up visits to patients, post discharge where the patient was referred back to their GP.

The crisis service offered an ‘elective admission’ for patients with Emotionally Unstable Personality Disorder (EUPD). This meant patients could access the crisis service for a period of up to 72 hours, to promote the least restrictive option for them. We saw examples of this being part of patients care planning, for example ‘up to two elective admissions to crisis service per month’.

The trust was due to implement a redesign of the care pathway for crisis and home treatment. Intended to take effect in July 2019, the service will consist of two home treatment teams (9am – 10pm), a 24-hour mental health telephone-support line, two retreat centres, two recovery houses, community front rooms and psychiatric liaison. The reason for change is to reduce variation in the quality of care across the entire crisis pathway. However, some staff we spoke with were anxious about the changes affecting their roles and responsibilities.

Health-based place of safety. The place of safety was open 24 hours a day, seven days a week. Patients who were intoxicated or lacked capacity were not excluded. In these circumstances staff would delay assessments until the patient was able to engage with the process. There had been an increase in the number of assessments taking longer than the approved 3- hour timescale. In January 2019, 59% of patients waited longer than 3 hours before a Mental Health Act assessment was completed, which increased to 61% within the month of February. The unavailability of a doctor and/or AMPH accounted for 11 out of 26 cases in January and 28 cases out of 33 cases in February 2019. This was not in keeping with the trend of September, October, November and December 2018, where the number of assessments completed outside 3 hours had been under 50%. Although assessments were being completed in a timely manner during the day, they were being delayed at night whilst waiting for a second Section 12-approved doctor. Though this is not a requirement under the MHA, it is a local agreement between the trust and the local authority. There were protocols in place when the place of safety was occupied, such as using the family room and multi-faith room. Staff arranged Mental Health Act assessments where appropriate. Staff said that there was sometimes a delay in accessing approved mental health practitioners (AMHPs) or Section 12 approved doctors during the night. These issues were monitored and discussed during the monthly multi agency meetings. Staff reported improvements in patient treatment journeys because of The Retreat and street triage service. The Retreat had provided the police service an alternative to taking people to the place of safety, when safe and appropriate. Between November 2018 and February 2019, police Page 224 officers had used The Retreat as a triage and alternative, on 86 occasions. This meant that the police service was only taking people to the place of safety if necessary.

The facilities promote comfort, dignity and privacy Mental health crisis services. Staff saw most patients in their own home. Staff arranged to see patients at local centres if patients preferred to be seen away from home, and ensured the room was wheelchair accessible where required. Two recovery bed units were due to be opened. Each unit will have four beds to offer an alternative to inpatient admission, where appropriate. The visitor toilet was functional but in need of renovation. Staff told us the trust had plans to refurbish the visitor toilet within the 12 months following this inspection. Health-based place of safety Food and drink were available for patients using the place of safety. There were facilities to make hot drinks within the place of safety and food was arranged through the hospital catering staff. Patients entered the place of safety using a discreet entrance so that they did not have to walk through a ward. Outside windows in all the rooms being used as a place of safety were obscured by a film covering the window. Internal windows had vistamatic windows which allowed privacy and dignity when the rooms were in use. An easy-read version of section 136 rights was available for patients. Patients had access to an inflatable mattress, soft furniture and showering facilities. The suite also had a television, reading material and a notice board with relevant information. The place of safety due to open in May 2019 has an ensuite showering facility.

Patients’ engagement with the wider community Mental health crisis services Staff discussed patients’ engagement with the wider community during home visits. We saw staff explored patient’s hobbies and supported them to identify places in the community to access.

Staff supported patients to maintain positive relationships with their families through care planning.

Staff had access to a database on the trust intranet, which provided a vast amount of signposting information that staff could share with patients to access support. This included support available locally and nationwide. For example, there was information on how to access support for bereavement, pregnancy, eating disorders, asylum and hoarding.

Listening to and learning from concerns and complaints

The trust had evaluated the quality of feedback they received for the crisis teams and place of safety. Leadership had recently introduced a text messaging feedback service to encourage patients to provide feedback, when they were well enough to do so. A text message would be sent

Page 225 to patients a week after they were discharged from the service, unless the patient had asked not to be contacted for feedback. Staff told us that this was a new initiative but were positive that it would increase the quantity and quality of feedback. This service received seven complaints between 1 January 2018 to 31 December 2018. Two of these were upheld, one was partially upheld and three were not upheld. None were referred to the Ombudsman. We saw learning from complaints, and leadership were open to feedback from people who use the service. An ex-patient who had made a complaint about their experience at the place of safety had been invited to meet leadership and be involved in governance meetings to explore ways patient experience could be improved.

Ward name

Other

Withdrawn

Not upheld Not

Fully upheld Fully

Partially upheld Partially

Total Complaints Total

Under Investigation Under Referred to Ombudsman to Referred

Crisis Service East 4 1 1 2 0 0 0 0 Crisis Service West 2 0 0 1 1 0 0 0 Retreat East 1 1 0 0 0 0 0 0

This service received 13 compliments during the last 12 months from 1 January 2018 to 31 December 2018 which accounted for <1% of all compliments received by the trust (4077).

Is the service well-led?

Leadership

The managers and team leaders demonstrated the skills, knowledge and experience to perform their roles. All leaders showed a good understanding of the service and could clearly explain how to provide high quality care. Leaders were visible, accessible and approachable in all the teams inspected. We saw that leaders were supportive of the team and competent and professional within their role. All leaders we spoke with were able to clearly communicate how teams were working to provide high quality care. Leadership training was available for managers and team leaders we spoke with had completed this training. Vision and strategy

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Staff and peer support workers, we spoke with felt very positive about the changes to the acute care pathway and told us it was the right direction for delivering high quality care. Staff felt that the patient experience would be much better, and staff expected a reduction in the frequency of crises as a result of the planned changes. The trust was in the process of redesigning the crisis and home treatment care pathway. At the time of inspection, the consultation period had finished, and the new design was set to be implemented from the 1st July 2019. Peer support workers, staff of all grades and disciplines, police service, street triage and psychiatric liaison were all involved in the consultation process. However, some staff we spoke with were anxious about the changes affecting their roles and responsibilities. The trust had assured staff the redesign would incorporate a redistribution of resource and no jobs would be lost. Culture We observed a person-centred culture within the teams. Staff worked together to ensure the best patient outcomes.

Staff told us they felt the trust and leadership were very inclusive of all staff and patients with protected characteristics. Staff also told us they were given training opportunities and were well supported from peers through to senior management.

Leadership had protocols in place to manage higher caseloads and staff were aware of these. We saw part-time staff had taken on extra shifts when caseloads were higher or more complex to provide extra support to the team and patients.

Staff were aware of the whistleblowing process and felt able to raise concerns without fear of victimisation.

Staff were aware of the Freedom to Speak-Up Guardian and knew how to contact them. Freedom to Speak-Up Guardians encourage and enable staff to speak up safely within their own workplaces.

Governance There were regular governance meetings in both crisis teams. These meetings were well attended and had a clear framework of what must be discussed at a team or directorate level to ensure that essential information, such as learning from incidents, was shared. These meetings also kept staff involved and updated with the remodelling of the service.

There were twice daily multidisciplinary review meetings to discuss all patients on the caseload.

Team leaders met regularly with service managers to discuss individual team performance and the quality of service delivery across the teams.

Leadership held governance meetings for the place of safety, four times per year. These were attended by inpatient managers, Mental Health Legislation Manager, an assurance facilitator, patient experience facilitator and clinical governance facilitator. However, we did not see evidence of support staff attending these meetings, or the content of these meetings being shared with staff who regularly covered shifts at the place of safety.

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There was a clear framework of what must be discussed at a team or directorate level to ensure that essential information, such as learning from incidents, was shared and discussed.

We saw evidence of regular auditing, and meaningful use of the outcomes to improve practice. For example, the quality of patients’ records had improved following regular audits.

The trust had an intranet dashboard which allowed leaders to monitor, identify and address various performance indicators such as training, supervision and treatment times. This allowed data to be analysed and gaps to be identified and addressed in a timely manner.

We observed administrators during our inspection who were competent and knowledgeable and able to locate information and data requested during the inspection.

Health Based Places of Safety There was a regular strategy meeting that reviewed input from local area services. Staff were invited to give feedback and share issues and good practice during the meetings.

Staff were given a place of safety induction checklist at the start of their shift.

Management of risk, issues and performance Staff discussed risk during team meetings and handovers. Staff showed a good understanding of risk and were aware of how to escalate risk to managers.

The trust had a severe weather policy. There was a protocol for managing client contact in an emergency. Crisis services referred to the severe weather policy in the first instance for emergencies. The policy outlined how teams would continue to support patients if they were unable to physically visit them at home.

Team leaders reviewed performance using data provided by the trust. The trust provided clear procedures for managers to support staff if there were concerns about their performance. Managers were aware of the policy and felt supported by the trust’s human resources department.

Information management The electronic recording system allowed staff to access and input data as required. Staff were trained in using the electronic system during their induction. Staff from the mental health helpline and street triage team had access to the system and could update records if contacted by patients in the service.

Staff had individual log in detail to access electronic records. This ensured that information remained confidential. Information governance was part of the mandatory training for the trust. Staff recorded patient consent to share information. Although staff had considered mental capacity in all 18 records we reviewed, only one record had detailed how this decision was reached.

Staff accessed their training through an electronic system. This meant managers could monitor

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The service followed policy regarding notifiable incidents to external agencies such as the local authority, NHS bodies and the Care Quality Commission.

Health Based Places of Safety All staff had access to the electronic recording system. This meant that they could access information entered by other services that the patient may have been in contact with, for example the crisis team or community mental health teams.

Engagement The trust had an informative website which clearly detailed the services they provided and how people could access them. Staff could access information such as policies and bulletins via the trust’s intranet.

Patients and carers were invited to provide feedback about the service by completing the friends and family survey. The teams were starting to introduce a text message feedback service, which allowed people to feedback when they felt comfortable. Feedback was discussed during team meetings and used to improve the service where possible.

The service had empowered peer support workers to engage in service delivery. For example; sitting on interview panels, involvement in redesigning the care pathway and providing paid employment at ‘The Retreat’.

Learning, continuous improvement and innovation NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. The trust did not report any accreditations associated with this service. One of the consultant psychiatrists initiated a two-week pilot at the place of safety to improve the times people waited for a Mental Health Act assessment during working hours. This pilot was used to demonstrate that the place of safety would benefit from a pool of consultants on rota at St Ann’s Hospital who would be temporarily relieved of their ward duties when a person needed a Mental Health Act assessment. The trust acknowledged the waiting time was reduced significantly for people, and practice changed from using consultants countywide to using consultants only based at St Ann’s hospital. The trust had introduced a ‘Retreat’ and ‘Recovery house’ located in the East and the West of Dorset to ensure patients from the whole county could access these services. Two staff members from the West crisis team were on an apprenticeship scheme to become qualified nurses.

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