Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Trust Headquarters, Doncaster

St Catherine's House, Tickhill Road, Doncaster, Tel: 01302796400 DN4 8QN

Date of Inspections: 24 October 2013 Date of Publication: 23 October 2013 December 2013 22 October 2013 21 October 2013 16 October 2013 15 October 2013 14 October 2013

We inspected the following standards as part of a routine inspection. This is what we found:

Consent to care and treatment Met this standard

Care and welfare of people who use services Met this standard

Cooperating with other providers Met this standard

Safeguarding people who use services from Met this standard abuse

Staffing Met this standard

Supporting workers Met this standard

Assessing and monitoring the quality of service Met this standard provision

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 1 Details about this location

Registered Provider Rotherham Doncaster and South Humber NHS Foundation Trust

Registered Manager Mrs. Jacqueline Saczek

Overview of the Trust Headquarters, Doncaster is a service provided by service Rotherham Doncaster and South Humber NHS Foundation Trust. It provides inpatient and community mental health and learning disabilities services for the areas of Rotherham, Doncaster and North Lincolnshire. It also provides integrated community healthcare services in Doncaster.

Type of services Community healthcare service Domiciliary care service Community based services for people with a learning disability Long term conditions services Community based services for people with mental health needs Hospital services for people with mental health needs, learning disabilities and problems with substance misuse Prison Healthcare Services Rehabilitation services Supported living service Community based services for people who misuse substances

Regulated activities Accommodation for persons who require nursing or personal care Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Family planning Personal care Transport services, triage and medical advice provided remotely Treatment of disease, disorder or injury

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 2 Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page Summary of this inspection:

Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5

Our judgements for each standard inspected:

Consent to care and treatment 6 Care and welfare of people who use services 9 Cooperating with other providers 11 Safeguarding people who use services from abuse 13 Staffing 15 Supporting workers 17 Assessing and monitoring the quality of service provision 19

About CQC Inspections 23 How we define our judgements 24 Glossary of terms we use in this report 26 Contact us 28

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 3 Summary of this inspection

Why we carried out this inspection

This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 14 October 2013, 15 October 2013, 16 October 2013, 21 October 2013, 22 October 2013, 23 October 2013 and 24 October 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We spoke with one or more advocates for people who use services, talked with people who use the service, talked with carers and / or family members and talked with staff. We reviewed information given to us by the provider, took advice from our specialist advisors and were accompanied by a specialist advisor.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

What people told us and what we found

The focus of this inspection was the service provided by the Trust Headquarters, Doncaster location. The inspection team of 12 people consisted of inspectors, specialists and experts by experience. We spoke with 52 people who used the service and 13 relatives.

We found that before people received any care or treatment they were asked for their consent. If they did not have capacity to consent the provider acted in accordance with the law. People told us they were asked for their consent and their care and treatment was explained to them.

We found that care and treatment was planned and delivered in a way that ensured people's safety and welfare. Most people we spoke with told us they were happy with the care provided.

We found that the provider worked in co-operation with others. Organisations which co- operated with the trust told us they were satisfied with the way the trust worked with them.

We found that people who used the service were protected from the risk of abuse. People told us they felt safe.

We found there were enough qualified, skilled and experienced staff to meet people's needs. People told us they felt there were enough staff on duty.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 4 We found that staff were supported to deliver care and treatment safely. People told us they were satisfied that staff knew what they were doing.

We found there were effective systems in place to assess and monitor the quality of service. People told us they were asked for their opinions.

You can see our judgements on the front page of this report.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 5

Our judgements for each standard inspected

Consent to care and treatment Met this standard

Before people are given any examination, care, treatment or support, they should be asked if they agree to it

Our judgement

The provider was meeting this standard. Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Where people did not have the capacity to consent, the provider acted in accordance with legal requirements.

Reasons for our judgement

We found that the provider, Rotherham Doncaster and South Humber NHS Foundation Trust had a policy for consent to examination or treatment. We reviewed this policy and found it covered all relevant areas.

We visited the adult mental health inpatient services on Brodsworth and Cusworth Wards, Coral Lodge, and the Psychiatric Intensive Care Unit on Skelbrooke Ward. We spoke with people who used the service and staff, and reviewed people's care records. People who used the service told us that staff always asked for consent.

We spoke with four members of staff who told us when and how they obtained consent. They told us that consent was constantly sought due to fluctuations in people's capacity. They explained this was also the case with people who were detained under the Mental Health Act 1983. They also described how people's capacity was assessed on admission and throughout their stay.

Our review of people's care records showed evidence of consent being obtained. We also found that the appropriate forms had been completed under the Mental Capacity Act 2005. The Act and the associated Deprivation of Liberty Safeguards are designed to protect people who can't make decisions for themselves.

We visited Amber Lodge, a low secure unit which was part of the learning disability forensic service. In this unit people were detained under the Mental Health Act 1983. We reviewed care records and spoke with people who used the service and staff.

The staff we spoke with told us that people who used the service were reminded of their rights under the Mental Health Act on a regular basis and this was confirmed in the

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 6 records we reviewed. They were also able to explain to us how consent was obtained in the case of a person who was detained.

We saw evidence in care records and through talking with people who used the service that people were involved in developing their care plans. We reviewed three care records, where we found from the notes of meetings that people were involved and consulted about their care plans, risk assessments and treatments. These discussions showed evidence that people agreed to their care and treatment. People we spoke with confirmed they attended their review meetings and that medical and nursing staff talked with them about their progress and treatment. They also told us that they had their rights explained to them on a regular basis.

However, we found one care record where a number of care plans and treatments had not been consented to. We brought this to the attention of a senior manager who ensured consent was obtained. We also spoke with two people who told us that although they were aware they had a care plan they didn't know how to access it. The provider may wish to note that not all the people who used the service had signed their care plans, or knew how to access them.

People told us they had access to independent advocacy services and advocates often attended review meetings. There were brochures about the local advocacy services on display on the ward. We found there was a telephone available on the ward which people used to make calls in private to their advocates and solicitors. We also spoke to an advocate who worked with people in Amber Lodge, and described how they helped people at reviews and meetings about their care.

We visited Sapphire Lodge, an assessment and treatment unit for people with learning disabilities. At the time of the visit the unit was caring for a young person, under the age of 18. The unit was not designed for people under the age of 18 and only admitted them when no appropriate beds were available in a specialist unit elsewhere. We reviewed this person's care records which showed that their parents were involved in, and in agreement with their care and treatment.

We also spoke with staff who told us how they ensured best interest meetings were held in the case of people who lacked capacity to make decisions. This was confirmed by a review of people's records, which showed that mental capacity assessments and best interest meetings had been used to help determine how best to meet people's needs.

We spoke with five people who attended the Talking Shop drop-in centre in Doncaster. The Talking Shop is a drop-in advice and psychological therapy centre which gives people the opportunity to browse information on mental health issues and gain information about the therapies offered by the trust. At the time of the inspection psychological therapies were being offered. They confirmed to us they had consented to the care and treatment provided. They also told us they had been given a full explanation of the services offered to them.

We visited Howarth House in Rotherham, a community based service for older people. On the day of our visit staff offered cognitive stimulation therapy in the morning, and help with coordination and limb flexibility in the afternoon. We observed that staff involved people in their care, and encouraged them to make decisions about the care and support being offered to them. People who used the service we spoke with told us that staff always asked if they were happy for them to proceed with any care or treatment.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 7 Staff we spoke with were knowledgeable about the Mental Capacity Act and the Deprivation of Liberty Safeguards. However, we observed the door to the day services' unit was locked and people, once they were inside the unit, could not get outside without asking staff to open the door. We discussed this with the manager who explained it was to stop people entering the unit, rather than to stop them leaving it. He told us that he had not considered it a restriction as people could access the garden. There was no evidence that a formal risk assessment had been undertaken. The provider may find it useful to note that locking the day service unit door is liable to unnecessarily restrict people's movements.

We spoke by telephone to six people who accessed community mental health services in the North Lincolnshire area. They told us they were always asked for their consent and given an explanation of the care staff wished to provide.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 8 Care and welfare of people who use services Met this standard

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement

The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

When we visited the adult inpatient wards people who used the service told us they were satisfied with the overall standard of care they received. One person on Brodsworth Ward told us they had recently had a meeting with ward staff and a community psychiatric nurse where they discussed where they would be going when they left the ward. This showed coordination between inpatient and community services. Another person told us that staff knew what they were doing and had looked after them well when they were very ill.

Staff explained that people were often admitted to the ward through their GP or the accident and emergency (A&E) department. Before they got on the ward the crisis team did an assessment at people's homes or in A&E. The information from this assessment was reviewed by staff on the wards before the person was admitted. Once on the ward the person would be assessed by the medical team.

Although there were systems in place to protect people who used services staff told us there were blind spots in Brodsworth Ward which were not covered by the CCTV system. They explained they managed this by doing regular physical checks of these blind spots. There was also no CCTV coverage of people's bedrooms and shower areas so as to not to invade their privacy.

There were also anti ligature door alarms throughout the mental health inpatient wards. However, the ones on Skelbrooke Ward were not working at the time of our visit. Senior managers informed us that the supplier had been alerted in order to repair the alarms.

On Coral Lodge we reviewed care records and found they contained appropriate information about the areas people needed support with and any risks associated with their care. People we spoke with told us they were aware of their assessed needs and the contents of their care plan. One person told us; "It is the best ward I have been on, the staff are lovely and help me improve."

We spoke with staff who told us that the liaison with the teams who worked in the community had recently improved and they considered that it worked well. We also spoke with the service director for community services who described work which had been

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 9 undertaken on care pathways between community services and the inpatient services. We reviewed care pathways which showed that improvements had been made in this area.

We visited Amber Lodge, a low secure unit which was part of the learning disability forensic service. In this low secure unit people were detained under the Mental Health Act 1983. We reviewed care records and spoke with people who used the service and staff.

People who used the service told us they could usually have access to their bedrooms during the daytime. They told us they always had access to cold drinks and could usually make hot drinks. The ward kitchen was locked and people told us they didn't have access to it. A senior manager told us this was because the kitchen was awaiting refurbishment.

We found that access to fresh air was restricted. People said there were restrictions on times they could go outside, for fresh air or to smoke. We noted there was no outside space that people could gain access to easily. To get to the secure outside area where there was a smoking shelter staff had to accompany people through two locked doors. The manager said this was due to there being no fencing to the required height in other areas of the garden. One person said, "It's better than it was, but it feels like a medium secure ward, there's still a lot of restrictions."

We put these issues to the chief executive following our inspection who told us that they had a plan to refurbish the unit so as to provide a less restrictive and more accessible environment. We also discussed the management of Amber Lodge with the clinical director and senior managers responsible for Forensic Services, who were responsible for the unit. They told us that they were in the process of changing the practices on the unit. This was in order to make it a less restrictive and more person friendly unit than it had been previously.

We visited Sapphire Lodge, an assessment and treatment unit for people with learning disabilities. At the time of the visit the unit was caring for a young person, under the age of 18. The unit was not designed for people under the age of 18 and only admitted them when no appropriate beds were available in a specialist unit elsewhere. However, they had been provided with a separate area within the ward. This included a bedroom with en-suite facilities and access to a garden. There was a de-escalation and seclusion suite in this area of the ward. The provider had ensured they had been assessed by a child and adolescent mental health service (CAMHS) specialist. We asked for and received assurances that all efforts were being made to transfer the young person to a more age appropriate setting.

We found that published research and guidance was referenced as part of the records of the regular multi-disciplinary team and care programme approach meetings. These records also included evidence of co-ordination of care between inpatient and community services, and between different geographical areas.

The senior manager told us that Sapphire Lodge operated the Green Light Project. This project is a toolkit for improving mental health support services for people with learning disabilities. It paints a picture of what good mental health support services for people with learning disabilities look like, and gives a way of assessing how well local services measure up to this.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 10 Cooperating with other providers Met this standard

People should get safe and coordinated care when they move between different services

Our judgement

The provider was meeting this standard. People's health, safety and welfare was protected when more than one provider was involved in their care and treatment. This was because the provider worked in co-operation with others.

Reasons for our judgement

We spoke with staff from the provider, Rotherham Doncaster and South Humber NHS Foundation Trust ('the trust'), about how they cooperated with other providers. We also contacted senior representatives of the organisations who worked with the trust to enquire as to their view of the quality and effectiveness of that cooperation. We also reviewed meeting minutes and other documents that provided supporting evidence of this cooperation.

We spoke with the clinical director for older people's mental health services who told us how they provided services to the local acute hospital, Doncaster Royal Infirmary (DRI). This took the form of a ten person hospital liaison team comprising of a consultant, nursing staff and a physiotherapist. As well as undertaking a clinical service they provided training in dementia to health care assistants and other staff at the hospital.

We also reviewed the minutes of meetings, held between July and September 2013, between the trust and the clinical commissioning groups in Doncaster and Rotherham. These showed how they cooperated with the commissioners in the development of older people's mental health, and dementia services.

We spoke with the assistant director and clinical director for adult mental health services who described their work with the accident and emergency departments (A&E) in Doncaster and Rotherham. They told us they had an access team working in the A&E at Doncaster 24 hours a day throughout the year. This service was augmented by a team of children's and adolescent mental health service specialists who could be called on when required. During an earlier inspection of Doncaster Royal Infirmary in September 2013 we saw this team seeing people who used the service in a designated room. They told us that although they did not have an access team on-site at Rotherham A&E they would respond to calls for assistance.

They told us how they worked with the police to care for people with suspected mental health conditions. This included having staff based in the police cells in Doncaster every morning during the working week. At other times this was covered by the access team. We

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 11 also reviewed the minutes of a meeting held in July 2013 with the police where proposed joint projects in Doncaster and Rotherham were discussed. These projects were aimed at looking at the best ways of assessing people with suspected acute mental illness and ensuring they accessed the most appropriate service. This showed evidence of cooperation with the police to ensure people got the most appropriate care as soon as possible.

We contacted the mental health liaison officer for South Yorkshire Police who provided further information about the joint work being undertaken with the trust. This included training in mental health issues being provided to police officers by staff from the trust. He told us that, "Clear lines of communication and professional relationships have been developed." He also said that the trust were, "More than willing to engage in active discussions" in order to provide a better service for vulnerable people.

We reviewed the minutes of commissioning meetings held in 2013 with the early intervention partnership board in Manchester. These discussed the development of the early intervention in psychosis community service which the trust provided in Manchester. Further information was provided by a member of the commissioning team in Manchester who described an open and transparent relationship with the trust. This showed cooperation in the development of services.

We reviewed the minutes of meetings between trust executives and senior managers, with the senior teams from other organisations. These included with the chief officers group in Doncaster, and the chief executive officers group in Rotherham. These showed cooperation at a senior level that complemented the joint work being done at a more local level.

This cooperation was corroborated by information provided by the chief executives of Doncaster and Bassetlaw hospitals, and Doncaster Metropolitan Borough Council. They described themselves as being satisfied with the quality and effectiveness of their relationships with the trust. This message was also conveyed by the chief officers responsible for the clinical commissioning groups in Doncaster, Rotherham and North Lincolnshire. In order for cooperation between different organisations to be effective there have to be good working relationships at the strategic as well as the managerial level.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 12 Safeguarding people who use services from abuse Met this standard

People should be protected from abuse and staff should respect their human rights

Our judgement

The provider was meeting this standard. People who used the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Reasons for our judgement

We found that the provider, Rotherham Doncaster and South Humber NHS Foundation Trust ('the trust') had policies for the safeguarding of children and adults. We reviewed these policies and found they covered all relevant areas.

We spoke with the executive lead, and the senior manager responsible for safeguarding. They told us that the trust investigated safeguarding incidents within their services with oversight from the local safeguarding boards. They explained that the investigators would be from a different part of the trust from that where the incident occurred. This showed that management arrangements were in place to ensure safeguarding incidents were appropriately investigated.

They also told us they had the responsibility to investigate safeguarding incidents at two independent sector mental health hospitals in Doncaster. Their involvement ensured that those investigating alerts at these hospitals were fully independent as well as having mental health experience.

We found the trust had processes for auditing and assuring themselves that their safeguarding processes were robust. The governance process involved safeguarding being discussed at the clinical governance group, a sub-group of the board of directors. The trust is also represented on the adult and children's safeguarding boards in Doncaster, Rotherham and North Lincolnshire. The managers responsible for these safeguarding boards informed us that the trust was represented as part of their structures and took an active role in their meetings.

We also spoke with the manager responsible for the Doncaster safeguarding board who told us there were differences in the way the threshold for safeguarding alerts were managed between the trust and the local authority. They felt that in some instances incidents were being investigated as clinical incidents rather than safeguarding alerts. However, the trust told us that all incidents of suspected safeguarding were investigated appropriately. In order to manage safeguarding appropriately it is important that the trust and safeguarding board agree on the most appropriate way to manage the process. The

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 13 provider may find it useful to note that the Doncaster safeguarding board felt there were differences in approach between the way they investigated safeguarding, and the way safeguarding was investigated by the local authority.

We spoke with a nurse on Sapphire Lodge, a learning disabilities unit, about their understanding of their role in safeguarding people from abuse. They told us they were confident in their role and that all staff on the ward were very aware of their responsibilities safeguarding vulnerable people. They said they had received safeguarding training organised jointly with the local authority and had annual updates. They said all the trust's procedures were available on the trust's web site and could be easily accessed by staff. They were very clear of their role and confident about the action they should take if they suspected, saw or heard about anything that concerned them. They said safeguarding was taken very seriously and was a part of their regular supervision. This was confirmed by the pro-forma for staff supervision that we saw.

We interviewed three staff at the Solar Centre about their understanding of their role in safeguarding people from abuse. The Solar Centre is a day service for people with learning disabilities. They told us there were very clear policies and procedures in place for staff. They said they had received good quality training in safeguarding and also had regular updates via e-learning. They were very clear of their role and confident about the action they should take if they suspected, saw or heard about anything that concerned them. They said safeguarding was a part of their regular supervision.

One person we spoke with on Amber Lodge, the forensic unit for people with learning disabilities, alleged they had recently experienced abuse. This was reported by the inspection team to the hospital managers and a safeguarding investigation was initiated. The ward manager told us that additional safeguards had been put in place so the person could remain on the ward while a safeguarding investigation was undertaken. The trust later informed us that the person withdrew their allegation whilst being interviewed. This provided evidence which tended to show that the trust investigated safeguarding alerts in a timely manner.

On Amber Lodge we spoke with five people who told us they felt safe on the ward. They said there were people to talk to if they felt bullied or abused by other people who used the service or staff. They said they would speak with the manager, the lead nurse or an independent advocate. Several other people we met briefly, as we were shown around the ward, made positive comments about the way they were treated on the ward and about the staff.

Another person, whose relative was on the forensic rehabilitation unit of Jubilee Close, told us they felt they were safe there. We also spoke with a young person at a children and adolescent mental health clinic in Doncaster who said they felt safe and secure.

We also spoke with a person who accessed community services in Rotherham. They told us that safeguarding advice from staff had stopped the abuse of their benefit payments by a friend. A person who accessed community mental health services in Scunthorpe also told us they felt safe.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 14 Staffing Met this standard

There should be enough members of staff to keep people safe and meet their health and welfare needs

Our judgement

The provider was meeting this standard. There were enough qualified, skilled and experienced staff to meet people's needs.

Reasons for our judgement

We spoke with staff on the wards that comprised the adult mental health inpatient service. On Cusworth Ward a member of staff told us that if they needed extra staff because the dependency level of a person who used the service had changed they might get someone from another ward. Because of this they did not feel safe with the staffing levels on the ward. Whilst on Skelbrooke Ward which contained the Psychiatric Intensive Care Unit a member of the nursing staff told us that they felt staffing levels were not adequate. They said they relied on the other two adjacent wards to provide extra staff.

We discussed the concerns of staff with trust senior managers. They told us that as part of a staffing review minimum staffing levels had been drawn up for qualified and unqualified nursing staff for inpatient services. We reviewed the paper which contained these numbers, which had been presented to the board of directors in September 2013. It explained that further work would be undertaken on staffing levels for community based staff. In addition a predictive model was being developed which would allow them to develop staffing based on dependency levels, and to plan for peaks in demand and emergency situations. There was presently no available national model for mental health services. This showed the trust were making reasonable efforts to ensure staffing levels were based on the best available evidence.

We found that on occasions extra staff were required at short notice. This was often because of the emergency admission of a person with high dependency levels, or when a person needed to be supported on leave outside the ward. Senior managers told us that when extra staff were requested in such situations, or because of sickness or for other reasons, they were provided without question. They told us they were obtained from the staff bank, a staffing resource comprised of staff who make themselves available to work extra hours, or through overtime. They said that it was safer to use their own staff than to go out to staffing agencies. We saw documentary evidence of the shifts covered on Skelbrooke Ward in October 2013. This showed that the trust were making reasonable efforts to ensure there were sufficient staff to meet people's needs.

We spoke with 14 staff within the learning disability and forensic service inpatient wards. On Sapphire Lodge and Amber Lodge staff and managers told us there were sufficient staff employed to meet people's needs. This included enough staff to provide the levels of

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 15 individual observation required and to be available to provide support to other people, cover for activities, escorted leave and meetings. Staff spoke with confidence about the staffing numbers. They told us they felt the wards were appropriately staffed and if there were any shortfalls it was easy to find cover.

On Sapphire Lodge some people had two-to-one or one-to-one observation. Two senior managers told us that, in the case of one person who had very complex needs, they had arranged extra management and staff cover so that time spent in liaison with other professionals did not take staff away from the person.

The three people who used the service we spoke with on Amber Lodge told us there were enough staff to meet their needs. They said that they had not experienced leave from the ward being cancelled due to inadequate staffing levels. We observed that there where staff in sufficient numbers to observe, interact with people and respond to people's requests for support. The manager said the staff had time to do activities with people on the ward, and occupational therapists also provided timetabled activities with people.

We found there were systems in place to respond to unexpected circumstances, such as staff sickness and emergencies. In addition the trust employed ancillary staff, including housekeeping and catering staff.

The staff we spoke with at the Solar Centre, a day centre for people with learning disabilities, told us there were enough staff to meet people's needs.

We also observed staffing levels at a community clinic at Howarth House, Rotherham. Here we found there were enough qualified, skilled and experienced staff to meet people's needs.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 16 Supporting workers Met this standard

Staff should be properly trained and supervised, and have the chance to develop and improve their skills

Our judgement

The provider was meeting this standard. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

Reasons for our judgement

Staff received appropriate professional development. We spoke with staff on the wards which comprised the adult mental health inpatient unit. Nursing staff on Cusworth Ward told us; "Training is very good and there is plenty of it". They told us there were opportunities to undertake specialist training, as well as the mandatory training which they were expected to undertake. They also said there was time for reading and research, although the relevant journals were not always available.

Staff on Brodsworth Ward and the Psychiatric Intensive Care Unit, located on Skelbrooke Ward, told us they had appropriate training. We were told by a senior member of the nursing team that all staff on Skelbrooke Ward were trained in safeguarding. They said they were trained up to level 3 and had been booked on a level 4 safeguarding course. Safeguarding courses are available at different levels, with levels 3 and 4 being the higher level of course.

Staff on Coral Lodge told us they had completed their mandatory training, which they thought was very good. They also told us they were able to access any specialist training which would allow them to do their job more effectively. A review of staff files also provided evidence of regular supervision.

Staff throughout the adult mental health inpatient service told us that supervision was readily available, as well as yearly personal development reviews. They told us that supervision was monthly although it could be brought forward. They said it was undertaken on an open basis and staff could contribute freely. They felt personal development reviews were always held when they were meant to and were robust.

We spoke with one of the qualified nurses on Sapphire Lodge, an assessment and treatment unit for people with learning disabilities. They told us they had monthly supervision sessions with their line manager and an annual appraisal that reviewed their personal development and training needs. The senior manager on Sapphire Lodge explained that staff supervision included elements of clinical and general management. They said that group supervision was part of the support system for staff.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 17 We visited the Solar Centre, a learning disabilities day centre, where incidents of abuse had occurred in 2007. In response to an investigation, which had found unacceptable levels of management supervision and support, the trust had developed an improvement plan. During this inspection we interviewed three staff members about the support they received to help them do their jobs. They said they worked well as a team and supported each other. They told us they had regular supervision sessions organised by a manager whom they found supportive.

They also told us they had received their mandatory training in subjects such as health and safety, moving and handling, and infection control. They also told us they received more specialised training, relevant to the needs of the people who used the service. This included epilepsy and Makaton training. Makaton is a way of using signs and symbols to help people communicate.

We reviewed staff files at Howarth House, a community based service for older people with mental health needs. These showed records of regular supervision and personal development reviews. Staff we spoke with told us they felt supported, which enabled them to do their jobs well and meet the needs of people who used the service. They also told us they could access both mandatory and specialist training.

We reviewed electronic evidence of training provided by the trust's Organisational Management Learning system. Although it gave a breakdown of training the trust informed us it was not accurate and could not provide assurance as to staff attendance at training courses. However, we also reviewed training records held by business divisions. When all sources were combined it showed that the trust was providing a sufficient level of training to its staff in order to allow them to meet people's needs. The provider may find it useful to note that the Organisational Management Learning system was unable to provide an accurate up-to-date picture of training completed by staff.

People who used the service told us they thought staff knew what they were doing. A person who used the trust's community services in Rotherham told us that staff treated people in an inclusive way, and appeared competent and confident in their roles.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 18 Assessing and monitoring the quality of service Met this standard provision

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care

Our judgement

The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of service that people received.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

Reasons for our judgement

We found there was evidence that learning from incidents and investigations took place and appropriate changes were made. We spoke about the process for the management of incidents with the head of patient safety and experience. They told us that untoward incident reports are reviewed by the risk management sub-group and the clinical governance committee, a sub-group of the trust board of directors. Incidents were also discussed on a monthly basis during the closed session of the board meeting.

We met with the assistant director and clinical director responsible for mental health community services. They told us about the improvements made in response to the recommendations of an enquiry held following a homicide in 2012. The recommendations were made following both a trust investigation and an independent multi-agency review in November 2012. These recommendations had included calls for improvements in supervision and management oversight. They told us there was now increased management capacity to ensure sufficient oversight and supervision of staff. In response to the review training had been undertaken to improve knowledge of services for people with complex needs whose primary diagnosis was not mental illness. The action plan and discussions with executives, and senior managers showed that these recommendations had been completed.

The external review had also called for adult mental health services to move to an electronic patient record that was shared with community mental health services. Although this particular concern had been resolved there were still concerns in that there were two electronic patient records within the trust, which could lead to confusion. The director of business assurance told us the risk was that information held on one system might not be available to a clinician who used another system. They explained that they were examining software solutions that would enable staff to view both systems.

Following incidents of abuse in 2007 at the Solar Centre, a day care centre for people with

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 19 learning disabilities, a report from the trust highlighted supervision of staff as an area for improvement. When we visited the centre staff told us they were satisfied with the supervision and support which was provided to them. This showed that changes made following the trust investigation into these incidents had been embedded into day to day practice.

Another cause of concern to the trust was the admission of people under the age of 18 to adult mental health and learning disability inpatient services. The trust did not have an inpatient service for children and young people. Despite this admissions occurred because there were no suitable beds elsewhere. Following investigations into these incidents the trust produced a business case for the creation of an inpatient unit. As part of this improvement work the trust leadership met with the consultant psychiatrists who managed the care of young people in the trust. A representative of these consultants explained to us there were differences between them and the trust on this issue. They felt there were not enough consultants to ensure the proposed unit would be effective and safe. The chief executive told us they were in discussions with the consultants in order to resolve the issue. This showed that although there were differences of opinion the trust leadership sought the views of clinical leaders and took their opinions into account.

We found that staff were asked their view of the service and their views were acted on. The chair of the consultant's committee told us they met regularly with the trust leadership and felt their views were valued. We also spoke with representatives of the staff trade unions who told us they also met regularly with the trust leadership, and although they did not always agree told us their views were listened to. We reviewed the minutes of the meetings of these committees which showed discussion of relevant issues.

Nurses and care workers we spoke with told us they learned the lessons of complaints and incidents at daily ward meetings, staff meetings, supervision and through a weekly newsletter. All staff had an e-mail address and information was sent by this method. They said the chief executive communicated with them through a weekly blog and encouraged staff to respond individually.

We also spoke with the trust chair and a non-executive director who told us the board of directors were fully involved in the work of the trust. The chairperson told us that part of their role was to challenge the executive team and assure themselves as to the safe operation of the trust. They told us how they were represented on finance, governance and performance groups which fed into the board. They felt there was a full system of information exchange between the ward and board levels. Both they and the executive team told us they would regularly make unannounced visits to wards and departments and talk with staff. However, when we spoke with staff in the areas we visited some of them told us they did not know who the executive directors or the chairperson were, and had not seen them in their wards. The provider might find it useful to note that not all staff we spoke with had experience of visits from the chairperson or executive directors.

Following an invitation from the chairperson we attended a council of governors' information and discussion group. Represented at the meeting were people who used the service, their relatives, local people and staff representatives. There was a full discussion of relevant issues with people being given the freedom to give their views, which were openly debated. In addition we reviewed the minutes of formal council of governor's meetings, which were also attended by the trust executive and non-executive leadership. These minutes showed that the council was an integral part of the trust's governance systems.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 20 We found that people who used the service and their relatives were asked their views of the service and they were acted on. People who used the service we spoke with told us they attended meetings concerning the service and their views were listened to. We reviewed the minutes of community meetings on Amber Lodge with people being cared for within this forensic services unit. We also saw the minutes of a meeting between people with a learning disability and staff on Sapphire Lodge. This meeting discussed people's treatment plans and was produced in an easy read format.

We discussed the community meetings which occurred within the forensics service with the assistant director for that service. They told us that concerns raised by people who used the service at these meetings were used to lever change within the service. However, they told us they had not had any formal complaints from people within the service in the last twelve months. They felt this was because all issues were raised within the community meetings.

We found that the comments of people who used the forensic service, the results of inspections by Mental Health Act commissioners, and the views of staff had been used in improvement work being undertaken in this division. Mental Health Act commissioners have the authority to make unannounced inspections of services where people are detained under the Mental Health Act 1983. Their inspections had led to criticisms of the practices within Amber Lodge being too restrictive. The leadership team in forensic services told us how work was being undertaken to modernise the service and make it more responsive to people's needs. We found evidence of change on the unit as people who used the service and staff told us that practices had improved.

We also found evidence of the involvement of people who used services and their relatives in service improvement. Following the introduction of an action plan for change within the children and young person's service a questionnaire was sent out which sought people's views. These views were then collated in a report which was used as part of the change programme.

We found that the trust undertook regular audits to ensure their clinical and management practices were safe and effective, and reflected the most recent professional guidance. We reviewed audits including ones concerned with care records, supervision, rapid tranquilisation, resuscitation, and clinical risk assessment. All these audits were thorough and professional. We also saw an audit undertaken in the trust by the prescribing observatory for public health. This was an audit which benchmarked all specialist mental health services in the use of medication in people with a personality disorder.

We spoke with a consultant in learning disabilities who told us of his involvement in research projects in collaboration with local universities. One of which was a study aimed at improving the oral health of people with a learning disability, done in collaboration with the institute of mental health at the University of Nottingham. This showed involvement in an academic study which had clear benefits for people who used the service. Following the visit we discussed research with the chief executive who told us the trust had organised a research conference. We reviewed the conference schedule and a paper introducing the trust's research strategy. The conference was attended by the trust executive and non-executive leadership team, as well as nursing, psychiatric consultants and other professional staff. This showed that the trust had made efforts to develop research within the organisation, in order to improve outcomes for people.

We found that at the time of the inspection the trust was running a learning programme for

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 21 staff with management responsibilities called 'Fit for the Future'. We reviewed positive feedback from staff who had attended this programme. This improvement programme showed evidence of a culture of change within the organisation.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 22 About CQC inspections

We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re- inspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 23 How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement If the breach of the regulation was more serious, or there action taken have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 24 How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.

Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 25 Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 26 Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 27 Contact us

Phone: 03000 616161

Email: [email protected]

Write to us Care Quality Commission at: Citygate Gallowgate Newcastle upon Tyne NE1 4PA

Website: www.cqc.org.uk

Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

| Inspection Report | Trust Headquarters, Doncaster | December 2013 www.cqc.org.uk 28