Surrey and Borders Partnership NHS Foundation Trust...lead the Frimley Health and Care integrated care system. The trust has an equality strategy with the following priorities: Post-inspection

Post-inspection evidence appendix Surrey and Borders Partnership NHS Foundation Trust RXX Page 1

Surrey and Borders Partnership NHS

Foundation Trust

Evidence appendix 18 Mole Business Park Randalls Road Leatherhead Surrey KT22 7AD

Tel: 0300 5555222

www.sabp.nhs.uk

Date of inspection visit:

11 December 2018 to 17 January

2019

Date of publication:

12 April 2019

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 18 locations registered with the CQC (on October 2018).

Registered location Code Local authority

Ashmount RXXFR Surrey

Courthill House RXXEH Surrey

Deacon Unit RXX18 Surrey

Derby House RXXFT Surrey

Farnham Road Hospital RXX22 Surrey

Hillcroft RXX17 Surrey

Jasmine at Primrose RXXZ2 Surrey

Kingscroft RXXX2 Surrey

Larkfield RXXHL Surrey

Margaret Laurie House RXXHE Surrey

Oakwood RXXY4 Surrey

Ramsay House RXX2T Surrey

Redstone House RXXGR Surrey

Rosewood RXXHM West Sussex

Shielings RXX18 Surrey

http://www.sabp.nhs.uk/


Registered location Code Local authority

St Peters site RXXW1 Surrey

Trust HQ, 18 Mole Business Park, Randalls Road, Leatherhead, Surrey, KT22 7AD

RXXHQ Surrey

West Park - The Meadows RXX2T Surrey

The trust had 196 inpatient beds across 12 wards, none of which were children’s mental health

beds. The number of acute outpatient clinics, community mental health clinics and community

physical health clinics per week were not supplied.

Total number of inpatient beds 196

Total number of inpatient wards 12

Total number of day case beds Not supplied

Total number of children's beds (MH setting) N/A

Total number of children's beds (CHS setting) N/A

Total number of acute outpatient clinics per week Not supplied

Total number of community mental health clinics per week Not supplied

Total number of community physical health clinics per week Not supplied

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. The trust provides the following mental health core services:

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

• Wards for older people with mental health problems

• Long stay/rehabilitation mental health wards for working age adults

• Wards for people with learning disabilities or autism

• Mental health crisis services and health-based places of safety

• Community-based mental health services for adults of working age

• Community-based mental health services for older people

• Community mental health services for people with a learning disability or autism

• Specialist community mental health services for children and young people

• Substance misuse services. The trust also provides 12 care homes providing residential care for people with a learning disability. At this inspection, we inspected the well-led key question for the trust overall and four of the 10 core services delivered by the trust between 11 December 2018 and 17 January 2019.

Is this organisation 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 trust board consisted of the Chair, the Chief Executive, six non-


executive directors and five executive directors. The Chief Executive was appointed in 2005 and

the chair has been in post since 2017.

The board had been strengthened by the appointment of new executive and non-executive

members since our last inspection. The trust had recruited a new Director of Nursing and had

created a new Chief Operating Officer role. The trust had appointed non-executive directors with

previous experience of senior leadership roles in mental health organisations. Board meetings had

become more rigorous and the non-executive directors were able to challenge the executive

directors and debate reports presented to the board in an informed and confident manner.

The trust published meeting papers for the trust’s public board meeting and for the trust’s council of

governors meeting on its website. Papers for board meetings and other committees were of a good

standard.

Evidence provided prior to the inspection through the provider information request confirmed that the

executive board had one (16%) black and minority ethnic (BME) member and three (50%) women.

The non-executive board had one (14%) BME member and three (42%) women.

A random selection of trust board member fit and proper person checks was reviewed. This

showed that all the necessary checks had been completed. This included disclosure and barring

checks, which was appropriate for people meeting patients and having access to confidential

information.

There was stronger leadership at executive, divisional and service delivery levels throughout the trust. Support and training for managers had improved and there was a greater focus on ensuring ward and service managers had the resources necessary to deliver improvements in patient care. Priority had been given by the trust to recruiting against key leadership roles such as divisional leads, matrons, service managers and ward managers. Where there were emerging service performance issues the trust had put in place experienced managers to support the local teams. For example, at the Abraham Cowley Unit the matron had moved across from the Deacon Unit to provide additional leadership. Outstanding improvements were made in a short period of time due to the support and leadership of the matron, the divisional director and the chief operating officer.

The chief pharmacist was supported by a senior team of pharmacists and pharmacy technicians.

The pharmacy service had a clear vision and strategy focusing on delivering person centred care

and developing the team. Staff said that managers were approachable and listened to their views

and ideas. There was strong leadership across all staff grades with the right skill mix. All staff

were encouraged to take part in service improvement. Pharmacy technicians managed the

dispensary and supported the clinical service, freeing up pharmacists to attend multidisciplinary

meetings to ensure patients received the best outcomes from their medicines. Staff involved

patients in decisions about their medicines and described how they provided additional support to

patients with disabilities and how they sourced medicines leaflets in different languages for

patients requiring them.

In the 2017 NHS Staff Survey, 40% of staff said there was good communication between senior

management and staff, which was better than the national average for Mental Health trusts of

36%. The staff we spoke with during this inspection told us that the senior management were

more visible now than they had been previously.


Vision and strategy

The trust’s vision is to help people live a better life.

The trust’s values are:

• Treat People Well

• Involve Not Ignore

• Create Respectful Places

• Be Open, Inclusive and Accountable.

Underpinning the values, the trust states it recognises the importance of:

• People - those we serve, their families and carers, our staff and partners.

• Prevention, Diagnosis and Early Intervention - people who use our services can expect us to

help them develop, sustain and recover independence

• Partnerships - we know we do our best for people when we work in partnership with them and

others important to them in their lives.

We aim to achieve for people one plan of care and support through our partnership working with

others. Everything we do aims to keep people connected, so they can live better lives.

Our belief in equality and human rights is the fundamental pre-requisite for all we do and together

with all of our employees we are tasked to conduct business in this spirit.

The trust’s Workforce Strategy has been one of several enabling strategies which underpin their

delivery. It is focused on continuing to enhance the trust’s culture for example, Joy at Work,

leadership, membership and equality; ensuring the consistent availability of excellent staff to meet

current and future needs including driving increased productivity and effectiveness. It is shaped to

deliver the trust’s ambition to be the best place to work. The trust has led the development of their

local sustainability and transformation plans/integrated care systems mental health workforce

strategies which aim to deliver collectively on their plans to meet the challenges of the Five Year

Forward Views.

The trust’s estates strategy was developed to consolidate the number of locations from which the

trust provided its care and treatment and to modernise the environments from which care and

treatment was delivered. Since our last inspection the trust had opened a new hub in Redhill for

community services and had made some improvement works to the Abraham Cowley Unit. The

trust had a plan to redevelop the Abraham Cowley Unit in order to modernise the wards, improve

the layout of the wards and to remove the dormitory bedrooms. At the time of our inspection the

plan’s target date for completion was late 2022.

The trust is actively working with health and social care across one sustainability and transformation plan area - Sussex and East Surrey – and two integrated care systems – Frimley Health and Care and Surrey Heartlands. In January 2019 the trust’s chief executive was asked to lead the Frimley Health and Care integrated care system.

The trust has an equality strategy with the following priorities:


• Provide accessible and inclusive services to all

• Eliminate unlawful discrimination, harassment and victimisation

• Advance equality of opportunity between different groups

• Foster good relations between different groups.

The trust has set equality objectives for 2016 to 2020 with targets for improvement each year. The objectives were:

• Staff report that they are free from discrimination and abuse in the workplace.

• Improve the representation of staff with protected characteristics across the Trust to proportionately reflect the workforce profile.

• Develop strong partnerships with groups representing people with protected characteristics at a local and national level to inform service developments and improve access to services for everyone.

• People who use services and carers report they are involved with decisions about their care

• Implement the Health Equality Framework (HEF) across all health services to ensure the health needs for people with learning disabilities are assessed and health outcomes are improved.

• Increase numbers of older people accessing Improving Access to Psychological Therapies (IAPT) services to reduce levels of mild/moderate depression and improve their health outcomes.

The trust produced an annual equality report which demonstrated its performance against the equality objectives.

The trust used the following frameworks to comply with relevant legislation and NHS England and commissioner requirements:

• The NHS Equality Delivery System (EDS2)

• The NHS Workforce Race Equality Standard (WRES)

• Accessible Information Standard (Disability).

The trust has carried out equality impact assessments for all of their policies and service developments.

The trust had a growing BME network but acknowledged that their LGBTQ (lesbian, gay, bisexual, transgender and queer) network was not as strong yet.

The latest staff survey results showed that the experience of BME staff in the trust had improved and showed better results than in the previous year.

Evidence provided prior to the inspection through the provider information request confirmed that the

four largest ethnic minorities within the trust’s catchment population are: Other White (non-British)

(5.5%), Indian (1.8%), Pakistani (1%) and Chinese (0.8%).

Culture

Managers across the trust promoted a positive culture that supported and valued staff, creating a

sense of common purpose based on shared values. Staff at all levels throughout the trust had

renewed positivity and pride in their work. Most staff we spoke with were eager and enthusiastic to

tell us about the improvements they had seen in the trust and the quality improvements they were

working on.


Between June 2017 and May 2018, clinical staff (excluding medical, dental, nursing and midwifery

staff) staff took 3.7% of working days as sick leave, which was better than the national average of

5.2%.

The NHS staff survey is mandatory for all trusts to complete. It is produced as a resource to NHS

trusts and commissioners to help them improve staff experience and drive improvements in the

trust itself and across the NHS. Questions elicit information on whether staff feel respected,

supported and valued. Outcomes for Surrey and Borders Partnership NHS Foundation Trust are

outlined in the tables below.

The trust’s engagement score shows how it compares with other mental health/learning disability

trusts on an overall indicator of staff engagement. Possible scores range from one to five, with one

indicating that staff are poorly engaged (with their work, their team and their trust) and five

indicating that staff are highly engaged. In the 2017 NHS Staff Survey, the trust's score of 3.84

was average when compared to trusts of a similar type.

In the 2017 NHS Staff Survey, the trust had better results than other similar trusts in 21 key areas:

Key finding Trust score Previous trust average Trend

Key Finding 3. Percentage of staff agreeing that their role makes a difference to patients / service users

90% 90%

Key Finding 4. Staff motivation at work 3.98 3.97

Key Finding 5. Recognition and value of staff by managers and the organisation

3.66 3.61

Key Finding 6. Percentage of staff reporting good communication between senior management and staff

40% 38%

Key Finding 7. Percentage of staff able to contribute towards improvements at work

76% 77%

Key Finding 8. Staff satisfaction with level of responsibility and involvement

3.93 3.91

Key Finding 9. Effective team working 3.89 3.89

Key Finding 10. Support from immediate managers 4.01 3.98

Key Finding 12. Quality of appraisals 3.42 3.39

Key Finding 13. Quality of non-mandatory training, learning or development

4.13 4.12

Key Finding 14. Staff satisfaction with resourcing and support

3.40 3.39

Key Finding 15. Percentage of staff satisfied with the opportunities for flexible working patterns

62% 62%

*Key Finding 17. Percentage of staff feeling unwell due to work related stress in last 12 months

36% 36%

*Key Finding 18. Percentage of staff attending work in the last 3 months despite feeling unwell because they felt pressure from their manager, colleagues or themselves

49% 49%

Key Finding 21. Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion

88% 87%

*Key Finding 26. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

17% 18%

Key Finding 29. Percentage of staff reporting errors, near misses or incidents witnessed in the last month

92% 89%

Key Finding 30. Fairness and effectiveness of procedures for reporting errors, near misses and incidents

3.85 3.81

Key Finding 31. Staff confidence and security in reporting unsafe clinical practice

3.85 3.81

Key Finding 32. Effective use of patient / service user feedback

3.76 3.74

Overall engagement score 3.84 3.84


In the 2017 NHS Staff Survey, the trust had worse results than other similar trusts in three key

areas:

Key finding Trust score Previous trust average Trend

Key Finding 11. Percentage of staff appraised in last 12 months

85% 86%

*Key Finding 16. Percentage of staff working extra hours 76% 71%

*Key Finding 20. Percentage of staff experiencing discrimination at work in the last 12 months

14% 13%

The Workforce Race Equality Standard (WRES) became compulsory for all NHS trusts in April

2015. Trusts have to 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. There is an increase of BME staff

in non-clinical band 8 (scale A, B and C), band 9 and VSM non- clinical posts between 2017 and

2018.

Non-Clinical

2018 2017

White BAME Total White % BAME% White % BAME%

Under Band 1 0 0 0 0% 0% 0% 0%

Band 1 2 0 2 100% 0% 80% 20%

Band 2 39 2 41 95% 5% 87% 13%

Band 3 105 15 120 88% 13% 86% 13%

Band 4 123 16 139 88% 12% 89% 11%

Band 5 63 7 70 90% 10% 94% 6%

Band 6 47 7 54 87% 13% 96% 4%

Band 7 39 7 46 85% 15% 81% 16%

Band 8A 25 8 33 76% 24% 84% 13%

Band 8B 9 2 11 82% 18% 100% 0%

Band 8C 17 5 22 77% 23% 92% 8%

Band 8D 7 0 7 100% 0% 100% 0%

Band 9 9 2 11 82% 18% 0% 0%

VSM 7 2 9 78% 22% 86% 14%

The recruitment of BME clinical staff is highest in band 2 posts (50% in 2018 and 52% in 2017).

15% of posts in band 7 and above, are filled by BAME staff.

Clinical

2018 2017

White BAME Total White % BAME% White % BAME%

Under Band 1 0 0 0 0% 0% 0% 0%

Band 1 0 0 0 0% 0% 0% 0%

Band 2 123 125 249 49% 50% 48% 52%

Band 3 108 81 190 57% 43% 56% 44%

Band 4 55 17 72 76% 24% 74% 26%

Band 5 72 60 132 55% 45% 47% 51%

Band 6 457 133 597 77% 22% 76% 22%

Band 7 228 45 276 83% 16% 78% 21%

Band 8A 100 16 117 85% 14% 86% 14%

Band 8B 33 6 39 85% 15% 83% 13%

Band 8C 15 2 17 88% 12% 95% 5%

Band 8D 6 0 6 100% 0% 100% 0%

Band 9 0 0 0 0% 0% 100% 0%

VSM 0 0 0 0% 0% 100% 0%


2. In 2018, White candidates were 1.24 times more likely than BME candidates to get jobs for

which they had been shortlisted. The trust performance against this measure has improved from

1.53 times more likely in 2017.

3. In 2018, BME staff were 5.13 times more likely to be disciplined when compared with White

staff. This has improved from 7.31 times more likely in 2017.

4. In 2018, White staff were 0.38 times more likely to take part in voluntary training than BME

staff.

5. 33.4% of BME staff experienced harassment, bullying or abuse from patients, relatives and

the public in the past year (2018 NHS staff survey) and was similar than the national average for

similar trusts (33.1%). The figure for White staff increased to 27% in 2018 from 26.85% in 2017

and was similar to the national average for similar trusts (28.1%). The difference between White

and BME Staff was statistically significant in 2017 and in 2016.

6. 19.4% of BME staff experienced harassment, bullying or abuse from staff in the past year

(2018 NHS staff survey) and was similar to the national average for similar trusts (24.4%). The

figure for White staff was 16.1%. This was better than the national average for similar trusts

(20.2%). The difference between White and BME Staff was not statistically significant in 2017 and

in 2016.

7. 81.9% of BME staff believed that the trust provided equal opportunities for career

progression and promotion (2018 NHS staff survey). This decreased from 81.01% in 2017 and

was better than the national average for similar trusts (73.4%). The figure for White staff increased

to 90.5% from 90.3%. This was similar to the national average for similar trusts (87.7%). The

difference between White and BME Staff was statistically significant in 2017 and in 2016.

8. 5.8% of White staff experienced discrimination from a colleague or manager in the past

year (2018 NHS staff survey). This was worse than the 4.49% in 2017 but similar to the national

average for similar trusts (6.2%). Figures for BME staff was better than the 10.5% in 2017 at 9.9%

in 2018. This figure was also similar to the national average for similar trusts (13.3%). The

difference between White and BME Staff was statistically significant in 2017 and in 2016.

9. The percentage of BME staff on the board was 23.1% compared with 26.7% BME staff in

the overall workforce. The percentage difference between the board voting membership and

overall workforce was 3.6%.

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 higher than the England average for patients recommending it as a place to

receive care for five of the six months in the period (January 2018 – June 2018).

The trust scored 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 five of the six months.


Trust wide responses England averages

Total

eligible

Total

responses

% that would

recommend

% that would

not

recommend

England

average

recommend

England

average not

recommend

Jan 2018 9190 341 89.1% 3.2% 88.5% 4.2%

Feb 2018 9190 309 89.6% 3.6% 88.7% 4.3%

Mar 2018 9190 257 94.6% 1.9% 89.0% 4.0%

Apr 2018 9190 353 89.2% 2.8% 88.7% 4.2%

May 2018 9190 202 90.6% 2.0% 88.9% 3.7%

Jun 2018 9190 294 87.1% 5.1% 88.8% 3.8%

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 2017/18 was

higher than the England average of 62.7% with 95.5%

The percentage of staff that would recommend the trust as a place to receive care in Q2 2017/18

was higher than the England average of 79.9% with 95.5%

There is no reliable data to enable comparison with other individual trusts or all trusts in England.

The trust had sufficient staff to deliver its services but had relatively high vacancy levels and used

bank and agency staff to fill posts. One of the trust’s priorities was to improve staff recruitment and

retention. The position of HR Director was vacant at the time of our inspection and the role was

under review whilst the executive team considered its future needs for this position. The trust had

an acting HR director in place. The trust had a range of initiatives to improve recruitment and

retention of staff including:

• a rolling programme of interviewing and recruiting for registered nurse posts

• a consultant recruitment programme

• an aspiring director programme

• specialist training

• mentoring opportunities.

Prior to our inspection the provider reported a vacancy rate for all staff of 18% as of between 31

August 2017 and 1 September 2018. By January 2019 this had improved to 14%.

Prior to our inspection the provider reported an overall vacancy rate of 24% for registered nurses

between 31 August 2017 and 1 September 2018. By January 2019 this had improved to 22%.

Prior to our inspection the provider reported an overall vacancy rate of 25% for nursing assistants

between 31 August 2017 and 1 September 2018. By January 2019 this had increased to 27%.


Between 1 September 2017 and 31 August 2018, of the 372,138 total working hours available,

15% 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 27% of available hours for qualified nurses and 3% of

available hours were unable to be filled by either bank or agency staff.

Core service Total

hours

available

Bank Usage Agency Usage NOT filled by bank

or agency

Hrs % Hrs % Hrs %

MH - Acute wards for adults of

working age and psychiatric

intensive care units

126000 9214 7% 30676 24% 6675 5%

MH - Wards for older people

with mental health problems 62850 14968 24% 11329 18% 1981 3%

MH - Mental health crisis

services and health-based

places of safety 52501 13454 26% 20412 39% 2460 5%

MH - Other Specialist Services 23430 2143 9% 7710 33% 518 2%

MH - Community-based

mental health services for

adults of working age 20874 2321 11% 2368 11% 345 2%

Other - ASC service 22201 7605 34% 4488 20% 441 2%

MH - Specialist community


children and young people 9505 1864 20% 3737 39% 34 0%



older people 33905 1827 5% 20195 60% 121 0%

MH - Community mental health

services for people with a

learning disability or autism 13102 3738 29% 13 0% 171 1%

MH - Substance misuse 7769 11 0% 0 0% 6 0%

MH - Wards for people with

learning disabilities or autism 0 0 0 0

MH - Long stay / rehabilitation

mental health wards for

working age adults 0 0 0 0

Trust Total 372138 57144 15% 100927 27% 12752 3%

Between 1 September 2017 and 31 August 2018, of the 475,470 total working hours available,

41% were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.


In the same period, agency staff covered 6% of available hours and 5% of available hours were

unable to be filled by either bank or agency staff.


Core service Total

hours

available


or agency

Hrs % Hrs % Hrs %

MH - Acute wards for adults of

working age and psychiatric


109440 70245 64% 6650 6% 8719 8%

MH - Wards for older people with

mental health problems 49500 14931 30% 494 1% 3025 6%

MH - Mental health crisis

services and health-based places

of safety 47644 27226 57% 4387 9% 1841 4%

MH - Other Specialist Services 60061 12081 20% 2295 4% 340 1%

MH - Community-based mental

health services for adults of

working age 0 0 0 0

Other - ASC service 127735 48062 38% 10209 8% 6029 5%

MH - Specialist community


children and young people 0 0 0 0

MH - Community-based mental

health services for older people 53820 16508 31% 2745 5% 2578 5%

MH - Community mental health

services for people with a

learning disability or autism 0 0 0 0

MH - Substance misuse 0 0 0 0

MH - Wards for people with

learning disabilities or autism 23580 6523 28% 858 4% 1620 7%

MH - Long stay/rehabilitation

mental health wards for working

age adults 3690 45 1% 0 0% 33 1%

Trust Total

475470

195621

41%

27638

6%

24184

5%

This provider had 236 (18%) staff leavers between 1 September 2017 and 31 August 2018. The sickness rate for this provider was 4.4% between 1 September 2017 and 31 August 2018.

The most recent month’s data, 31 August 2018, showed a sickness rate of 4.2%.

Core service Total % staff

sickness

(at latest month)

Ave %

permanent staff

sickness (over

the past year)

MH - Wards for people with learning disabilities or autism 4.1% 7.2%

MH - Specialist community mental health services for children and

young people 7.2% 6.2%

Other - ASC service 4.3% 5.9%


Core service Total % staff

sickness

(at latest month)

Ave %

permanent staff

sickness (over

the past year)

MH - Long stay/rehabilitation mental health wards for working age

adults 9.5% 5.8%

Other 5.3% 5.4%

MH - Acute wards for adults of working age and psychiatric

intensive care units 7.8% 5.3%

MH - Substance misuse 5.2% 5.1%

MH - Mental health crisis services and health-based places of

safety 6.0% 5.0%

MH - Wards for older people with mental health problems 5.5% 4.6%

MH - Community-based mental health services for older people 2.7% 4.6%

MH - Other Specialist Services 3.7% 3.8%

MH - Community-based mental health services for adults of

working age 1.9% 3.0%

MH - Community mental health services for people with a learning

disability or autism 1.9% 1.7%

Trust 4.2% 4.4%

The trust ensured staff received appropriate specialist and mandatory training. The compliance for

mandatory and statutory training courses at 31 August 2018 was 88%. Of the training courses

listed 11 failed to achieve the trust target and of those all scored above 75%.

The trust set a target of 95% for completion of mandatory and statutory training.

The trust stated that,

‘The training compliance data is reported on an ongoing monthly basis. Statutory training is

reported as part of the monthly board report dashboard produced by Workforce and a separate

dashboard is provided by the Learning and Development team for all other courses classified by

ourselves as role essential.’

The training compliance reported for this provider during this inspection was the same as the 88%

reported in the previous year.

Key:

Below CQC 75% Met trust target

✓

Not met trust

target

Higher

No change

Lower


Training Module YTD

Compliance

(%)

Trust

Target

Met

Compliance

change when

compared to

previous year

Health and Safety (Slips, Trips and Falls) 93%

Safeguarding Adults (Level 1) 92%

Clinical Risk Assessment 92%

Information Governance 90%

Safeguarding Children (Level 1) 89%

Mental Capacity Act Level 1 89%

Other 86%

Equality and Diversity 86%

Basic Life Support 86%

Manual Handling - People 86%

Mental Health Act 78%

Total 88%

Most of the trust’s staff received an appraisal. The trust’s target rate for appraisal compliance is

93%. At the end of last year (1 April 2017 to 31 March 2018), the overall appraisal rate for non-

medical staff was 80%. By the end of 2018, the appraisal rates were CAMHS 89%, Older people’s

services 90%, Services for People with a Learning Disability 89% and Adult of working age 89%.

Core Service Total number

of permanent

non-medical

staff requiring

an appraisal

Total number of

permanent non-

medical staff who

have had an

appraisal

% appraisals

(as at 31 August

2018)

% appraisals

(previous year 1

April 2017 -31 Mach

2018)

MH - Long

stay/rehabilitation

mental health wards for

working age adults

10 10 100% 91%

MH - Wards for people

with learning disabilities

or autism

3 3 100% 43%


mental health services

for adults of working

age

120 107 89% 83%

MH - Other Specialist

Services 192 165 86% 85%



for older people

65 53 82% 85%

MH - Community mental

health services for 46 37 80% 70%


Core Service Total number

of permanent

non-medical

staff requiring

an appraisal

Total number of

permanent non-

medical staff who

have had an

appraisal

% appraisals

(as at 31 August

2018)

% appraisals

(previous year 1

April 2017 -31 Mach

2018)

people with a learning

disability or autism

MH - Substance misuse 46 35 76% 88%

MH - Specialist

community mental

health services for

children and young

people

61 45 74% 86%

MH - Mental health

crisis services and

health-based places of

safety

53 38 72% 62%

Other - ASC service 117 84 72% 77%

MH - Wards for older

people with mental

health problems

65 40 62% 79%

MH - Acute wards for

adults of working age

and psychiatric


67 29 43% 73%

Other 13 3 23% 94%

Trust Total 858 649 76% 80%

The trust’s target rate for appraisal compliance is 93%. 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 99% (as at 31 August 2018). 11 of the 11 teams achieved the trust’s appraisal target.

Core Service Total number of

permanent medical

staff requiring an

appraisal

Total number of

permanent medical

staff who have had

an appraisal

% appraisals

(as at 31 August

2018)

% appraisals

(previous year 1

April 2017 -31 Mach

2018)

MH - Acute wards

for adults of

working age and

psychiatric

intensive care units 9 9 100% 100%

MH - Community

mental health

services for people

with a learning

disability or autism 5 5 100% 100%

MH - Community-

based mental

health services for

older people 20 20 100% 100%


Core Service Total number of

permanent medical

staff requiring an

appraisal

Total number of

permanent medical

staff who have had

an appraisal

% appraisals

(as at 31 August

2018)

% appraisals

(previous year 1

April 2017 -31 Mach

2018)

MH - Mental health

crisis services and

health-based

places of safety 2 2 100% 100%

MH - Substance

misuse 4 4 100% 100%

MH - Wards for

older people with

mental health

problems 5 5 100% 100%

Other 1 1 100% 100%

MH - Specialist

community mental

health services for

children and young

people 8 8 100% 100%

MH - Community-

based mental

health services for

adults of working

age 29 29 100% 100%

MH - Wards for

people with

learning disabilities

or autism 1 1 100% 100%

MH - Other

Specialist Services 16 15 94% 100%

Trust Total 100 99 99% 100%

The trust was unable to supply clinical supervision data as it is not recorded centrally.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different

ways.

Following Sir Robert Francis' Freedom to Speak Up review, published in February 2015, all NHS

trust are required by the terms of their NHS contract to appoint a Freedom to Speak Up Guardian

(FTSUG). The FTSUG provides an independent and confidential support to staff who want to raise

concerns. The trust’s FTSUG had been in post since 2017 and worked three days per week. In the

last 12 months the FTSUG had appointed five freedom to speak up advocates who championed

the work of the FTSUG and helped communicate the role across the organisation. The FTSUG

also spoke with management and leadership teams and encouraged staff to speak to the FTSUG

via an e-bulletin. The FTSUG reported to the board quarterly with information of number of cases,

themes, an anonymised case study, positive findings and areas for improvement.


Governance

On 25 April 2018, the trust was not categorised as ‘receiving mandated support for significant

concerns’ 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 meetings. The trust board had two formal committees reporting to it, the audit

committee and the quality assurance committee, which were both chaired by non-executive

directors. The executive board also reported to the trust board and was responsible for the quality,

risk and safety committee and sub-committees and the operations board. The divisional

management teams, quality assurance groups and ethical issues groups reported to the

operations board.

There was a thorough financial awareness in the board and senior leadership teams but also a

commitment to keep people at the heart of decision making. Board members regularly discussed

what was the right thing to do for the people of Surrey. Non-executive directors were aware of and

understood the priorities and challenges for the trust. Non-executive directors told us they had

seen an improved quality of reports to the committees and trust board and the executive directors

were open to discussion and challenge.

The trust was a foundation trust and therefore its governance structure included members and a

council of governors. Members of a foundation trust are members of the public and staff who are

kept informed of the progress of the trust and participate in governor elections. The council of

governors consists of governors elected by the members, including staff governors, and governors

appointed by partners organisations such as the local authority. Over the previous 12 months the

trust board and council of governors had recognised that they could improve how they worked

together and commissioned an independent review. The review reported in November 2018 and

had identified areas for improvement which the trust had started to work on at the time of our

inspection. Governors that we spoke with were positive about the review and told us they felt they

were better supported than they had previously felt. Governors were cautiously optimistic about

the future working relationship with the trust board.

The trust had four operational divisions each headed by a divisional director:

• Mental Health Services for Working Age Adults

• Children and Young People’s Services

• Learning Disability Services

• Older People’s and Specialist Services

The operational divisions each had their own management teams, team meetings and quality

assurance groups. The divisions had strong multidisciplinary senior leadership teams with a

shared commitment to improving the quality of care and treatment they delivered.

The trust operated 12 care homes for people with a learning disability. The care homes have been

inspected over the past two years by CQC adult social care inspectors as part of their rolling

programme of inspection. In January 2019 11 of the 12 care homes were rated as good and one

was rated as requires improvement.

The pharmacy team had developed their own set of values. The pharmacy team had held a whole

team away day to focus on the values and team development and were planning another, this was

supported by the trust management.


The pharmacy service had a clear focus on delivering high quality person-centred care. Effective

communication, attitudes and behaviours of the pharmacy staff had enabled them to be integrated

into the ward teams and respected by nursing and clinical colleagues. There was a strong culture

of learning and continuous improvement within the pharmacy team and all staff grades were

empowered to work at the top of their license. Each member of the team had a development plan

and we heard from several individuals how they had advanced their practice and gained

promotions.

Pharmacists and pharmacy technicians had networked and shared learning outside of the team

and were creating opportunities to work collaboratively with the acute and community sectors. For

example, a joint pre-registration pharmacist post with the acute trust had been created.

The Medication Safety Officer (MSO) had excellent oversight of medicines safety. There was a

comprehensive pharmacy audit programme and all staff grades, including pharmacy support

workers, were involved. This approach made staff feel valued in their roles. The MSO was

proactive to design audits for service improvement and produced a detailed ‘positive and safe’

report. This was shared across the trust.

The trust had robust oversight of the operation of its duties under the Mental Health Act (MHA).

The trust had a joint MHA and Mental Capacity Act (MCA) committee which reported to the quality

assurance committee. The MHA and MCA committee was attended by representatives from all

clinical divisions, MHA co-ordinators, MHA managers, the MHA lead consultant, the director of

nursing, the associate director for clinical safety and head of nursing and the trust chair. Use of the

MHA was reviewed by the committee. The annual MHA report included datasets on repeat

admissions data, BME representation against local population groups and causes of detention.

MHA data was used to identify MHA issues and risks which were actioned in partnership with

other organisations where appropriate. The trust worked well with the Police, Ambulance services

and approved mental health professionals (AMHP) service looking at people known to multiple

agencies and how to work better with them through the Surrey high intensity partnership

programme (SHIPP).

The trust had a section 75 agreement in place with the local authority in Surrey which allowed

resources and management structures to be integrated across the two organisations. Staff told us

that this agreement worked well in practice.

MHA training was available to all clinical staff. This was initially provided on induction with update

training being provided at least every year. This training could be provided as classroom training

or eLearning. The training was provided by the MHA co-ordinators. The compliance rate for MHA

training was over 86% at the time of our well-led inspection. Clinical staff were well supported by

the MHA co-ordinators and administrators.

The trust had a robust and effective complaints process led by qualified and experienced staff.

The trust had a caring and professional complaints team which prioritised resolving concerns at

the earliest opportunity for the complainant. The complaints team also delivered the patient advice

and liaison service (PALS) for the trust. The complaints/PALS team regularly visited all wards,

attended patient community meetings and focus groups (comprised of people who use services,

their families and carers). The complaints team had increased the number of complaints resolved

locally and had worked with local services and wards to implement learning from complaints

directly. We reviewed five complaints from the last year selected at random and found that the


complainants had been supported through the process, risk assessments were carried out,

investigations were thorough and the outcome was explained to the person who complained. Duty

of candour principles were followed where applicable. Learning from complaints was shared

across the trust using the trust’s divisional quality assurance groups. The complaints manager

produced a monthly complaints summary for the quality, risk and safety committee.

The trust was asked to comment on their targets for responding to complaints and current

performance against these targets for the last 12 months.

In Days Target

Performance

What is your internal target for responding to* complaints? 3 85%

What is your target for completing a complaint? 25 85%

If you have a slightly longer target for complex complaints please indicate

what that is here

n/a n/a

* 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 last 12

months

397 1 April 2017

–

31 March 2018

Number of complaints referred to the ombudsmen (PHSO) in the last 12

months

0 1 April 2017

–

31 March 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

This trust received 508 compliments during the last 12 months from 1 September 2017 to 31 August 2018. ‘MH - Other specialist services’ had the highest number of compliments with 37%, followed by ‘MH - Community-based mental health services for adults of working age’ with 22%.

The trust has submitted details of seven external reviews commenced or published in the last 12

months (1 September 2017 to 31 August 2018).

External review Key Outcomes

Abraham Cowley Unit Inpatient Review

SABP commissioned a review in the care we provide at the Abraham Cowley Unit and is yet to report.


Risk & Safety Team review External review of our Incident Management Processes which has been undertaken by East London Foundation Trust and is yet to report

Ashmount Independent review- NHSE Review following the inquest into the death of a person living at our Ashmount Learning Disability Care Home and yet to report

Information Commissioners Office- This was consensual audit which was welcomed by the Trust to help strengthen our information governance processes (submitted P118i)

This ICO audit found that we have the necessary governance arrangements in place to manage our information following the implementation of GDPR, the proposed Data Protection Act 2018 and the new DSP toolkit. We believe the findings to be fair and we will be working to produce an action plan to further embed additional learning from the following areas identified for improvement: • Limited Key Performance Indicators are used by the Trust to monitor compliance with GDPR and related regulations. • File backup details were published on the website as part of a policy, which compromises the integrity of security measures. • Due to the Trust’s interpretation of the Chair of the Independent Inquiry into Child Sexual Abuse’s (IICSA)” the Trust has not destroyed any records since this request. • The Records Management team is currently working with a reduced capacity • No Records Management component to the mandatory IG refresher training which could lead to an increase of poor records management • It is unlikely that the Trust currently has sufficient resources assigned to adequately process all requests for personal data it receives. • Trust staff with responsibility for handling requests for information have not had any specialised training for the role. Areas of Good Practice • The Trust’s Information Governance Steering Group (IGSG) is well established with well-defined terms of reference and good levels of attendance. The IGSG attendees include at least two clinicians and clinical approval must be given for the group to access System One. Outcomes from the other reviews are not currently available but the Risk & Safety and Inpatient reviews will be reporting in the next month

CAMHS independent review see P118ii of the Provider documents

Recently published Independent Homicide Review

The Independent NHS England review into the murder of E by her boyfriend S in Oxted in January 2014 was published May 2018 with our Trust Action Plan.

Recently published Independent Homicide Review:

The Executive Summary of the Independent HASCAS review into the manslaughter of Mr Y by Mr X. It is due to be published on 20th September 2018. Mr Y died after being punched by Mr X and falling between a train station platform and a moving train in 2013. The Independent Investigation Team concluded that Mr X’s involvement in the homicide was not preventable or predictable by mental health services.

Management of risk, issues and performance

The trust’s corporate risk register and board assurance framework were regularly reviewed by the

Board, the Audit Committee and the Quality, Risk and Safety Committee. The trust used a

standardised risk assessment tool to enable risks to be scored and graded. The Board assurance

framework included clear business and operating risks, with actions to mitigate.

Historical data Projections

Financial Metrics Previous financial

year (2 years ago) (1

April 2016 – 31 March

2017)

Last financial year

(1 April 2017 – 31

March 2018)

This financial year

(1 April 2018 – 31

March 2019)

Next financial year

(1 April 2019 – 31

March 2020)

Actual income £164,465,000 £193,474,000 £196,601,083

See annual plan

paper


Historical data Projections

Financial Metrics Previous financial

year (2 years ago) (1

April 2016 – 31 March

2017)

Last financial year

(1 April 2017 – 31

March 2018)

This financial year

(1 April 2018 – 31

March 2019)

Next financial year

(1 April 2019 – 31

March 2020)

Actual surplus

(deficit) £15,614,000 -£19,594,000 £3,205,000

See annual plan

paper

Actual

costs/expenditure -

full

£148,851,000 £213,068,000 £193,396,083 See annual plan

paper

Planned budget or

(deficit) £2,741,000 £2,521,000 £3,205,000

See annual plan

paper

The trust has submitted details of six serious case reviews commenced or published in the last 12

months.

The trust was committed to improving services by learning from when things went well and when

they went wrong, promoting training, research and innovation. The trust had improved their

serious incident investigation process and now produced more in-depth, considered and timely

serious incident investigation reports which identified learning and made recommendations for

improvement. Changes to the clinical safety team, processes and paperwork had significantly

improved the management of serious incident investigations and mortality reviews. In the 12

months prior to our inspection the clinical safety team had managed to work through its backlog of

serious incident investigations and did not have a backlog at the time of our inspection. The team

had also considerably improved the quality of the investigation reports which were now more

rigorous and received greater scrutiny. The scrutiny panel reviewed all serious incident

investigation reports and included the medical director, the nursing director, a GP representative,

representatives from the trust’s service divisions and pharmacy. The scrutiny panel reported to the

board. The team had also appointed a family liaison lead to improve engagement with families and

carers. Learning from incidents was shared on the trust’s dedicated learning from incidents page

on the trust intranet; was discussed at trust datix huddles (meetings) on the wards; and through

divisional quality assurance groups.

The pharmacy service held department and governance meetings where learning from medicine

related incidents was shared. Managers had oversight of medicines safety and assurances were

in place to minimise any specific risks identified. The pharmacy team communicated effectively

with wards and were integrated into the wider trust. The pharmacy training lead provided

medicines updates to both ward team and community teams.

All use of rapid tranquilisation was reported via DATIX for full investigation. Additional questions

had been added to DATIX forms for staff to record if physical checks had been carried out

following rapid tranquillisation. The team had also published a best practice guide to support

physical health monitoring of people taking mental health medication.

Prior to the inspection 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 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 September 2017 and 31 August 2018, the trust reported 105 serious incidents. The most

common type of incident was ‘apparent/actual/suspected self-inflicted harm’ with 61. Thirty of these

incidents occurred in MH – Community based 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 comparable with STEIS with 103 reported.

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 no never events

during this reporting period.

Core Service

Ap

pare

nt/

actu

al/su

sp

ecte

d

ho

mic

ide

Ap

pare

nt/

actu

al/su

sp

ecte

d

self

-in

flic

ted

ha

rm

Dis

rup

tiv

e/ ag

gre

ss

ive

/ vio

len

t

beh

avio

ur

Failu

re t

o o

bta

in a

pp

rop

riate

bed

fo

r ch

ild

wh

o n

eed

ed

it

Pen

din

g r

evie

w

Slip

s/t

rip

s/f

all

s

Un

au

tho

rised

ab

se

nc

e

To

tal

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

6 3 1 1 29 40

MH - Community-based mental health services for adults of working age

2 30 32

MH - Other Specialist Services 1 14 2 17

MH - Community-based mental health services for older people 5 5

MH - Wards for older people with mental health problems 4 4

MH - Substance misuse 3 3

MH - Mental health crisis services and health-based places of safety

2 2

MH - Specialist community mental health services for children and young people

1 1 2

Grand Total 3 61 2 4 1 5 29 105

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 42 days which means that it is considered not to be a consistent reporter.

The highest reporting categories of incidents reported to the NRLS for this trust for the period 1

September 2017 to 31 August 2018 were self-harming behaviour, patient accident and patient abuse

(by staff/third party). These three categories accounted for 905 of the 1154 incidents reported. Self-

harming behaviour accounted for 49 of the 52 deaths reported.

86% of the total incidents reported were classed as no harm (64%) or low harm (21%).


Incident type No harm Low harm Moderate Severe Death Total

Self-harming behaviour 272 138 53 5 49 517

Patient accident 164 54 29 1 248

Patient abuse (by staff / third

party) 96 34 10 140

Access, admission, transfer,

discharge (including missing

patient) 102 5 5 112

Medication 44 2 1 47

Treatment, procedure 18 5 4 27

Disruptive, aggressive

behaviour (includes patient-to-

patient) 15 5 3 23

Clinical assessment (including

diagnosis, scans, tests,

assessments) 10 2 2 14

Consent, communication,

confidentiality 7 1 8

Infrastructure (including

staffing, facilities, environment) 7 7

Documentation (including

electronic & paper records,

identification and drug charts) 3 3

Infection Control Incident 3 3

Other 3 3

Implementation of care and

ongoing monitoring / review 2 2

Grand Total 743 246 107 6 52 1154

• 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).

•

Level of harm 31 August 2017 –

1 September 2018

No harm 743

Low 246

Moderate 107

Severe 6

Death 52

Total incidents 1154


Between April and September 2017, the trust reported incidents to the National Reporting and

Learning System in only five out of six months.

Between July 2017 and June 2018, there were 0.0 patient safety incidents reported to the National

Reporting and Learning System for every mental health patient spell, which was much worse than

the national average of 0.2.

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 three ‘prevention of future death’ reports sent to the Trust.

Details of which can be found below

Daniel Maher – Date of report: 18 April 2017

Prevention of Future Death

The cause of death was hanging at his home address, the inquest conclusion was suicide.

The Coroner’s concerns were:

• The court was told that mental health professionals cannot access patient information which

is held on the computerised systems of mental health services outside their county. As a

result, they are dependent on seeking the information directly from their colleagues in other

counties which is time consuming and impractical in relation to mental health assessments

carried out during anti-social hours.

• The court was also told that it is common practice, after a mental health assessment has

been completed at the 136 suite at Langley Green Hospital, for a verbal referral to be made

by telephone in respect of patients being referred to community mental health services

outside of the county. Key paperwork is not routinely shared on the making of such

referrals. In fact, the approved MH professional employed by West Sussex County council

indicated that she was not allowed to fax such paperwork to other agencies for reasons of

data protection.

• Because of the above I am concerned that significant information relating to the clinical

history, presentation and risk of vulnerable individuals is not easily accessible by the

relevant healthcare professionals, in circumstances where in which an individual is

assessed at the s.136 suite in West Sussex, and has either previously been under the care

of, or is referred back into the care of mental health services in Surrey.

Stephen Tidey – Date of report: 8 May 2018


The cause of death was 1a. External Neck Compression, 1b. Hanging

The Coroner’s matters of concern were:

• How ‘Adult at Risk or Multi Agency Safeguarding Hub’ (MASH) reports are processed on

receipt


• Whether there is an effective system in place to ensure that MASH reports are followed up

by the appropriate Community Mental Health team (where necessary); and

• Whether there is an effective system in place to deal appropriately with MASH referrals

received outside of normal, weekday office hours, and that those completing MASH referral

forms (e.g. Police officers) know where these should be sent outside normal working hours

when a high risk is identified.

Ernest Wayne Smith – Date of report: 14 December 2017


The cause of death was 1a. Hanging

The inquest concluded with a short form conclusion of ‘suicide’

The Coroner’s matters of concern were:

• The system for considering correspondence received from GP’s, including request for

medication reviews, appears to remain the same as the system that was in place at the

time of Mr Smith’s death and which failed to identify (redacted) request for a medical review

on 7 March 2016.

• There are a number of CMHRS service users, who like Mr Smith, are not under the

CMHRS medical team, but whose care is led by other members of the multi-disciplinary

team, including clinical psychologists and care co-ordinators. The court heard that there is

a clear system in place in the medical team for updating GP’s on progress and also in the

event of failures to attend appointments (DNA’s). However, it did not appear to the court

that there was a clear system for updating GP’s when a medical team was not involved in a

patient’s care. This risks GP’s being unaware, as (redacted) was in this inquest, of

instances in which their patient begins to display signs of disengagement with the service.

Engagement

Patients, carers and staff had opportunities to give feedback on the service they received. Patients

and carers could feedback using the “Your views matter” survey and patients could contact the

patients’ advice and liaison service. The trust held regular FoCUS (forums of carers and people

who use our services) meetings across the areas covered by the trust’s services which offered

carers and people who use trust services an opportunity to get involved and give feedback on trust

services. FoCUS members were sent regular information and news about trust services.

The trust had an involvement strategy and had drafted a new participation strategy which was

being consulted on at the time of our inspection. Engagement work was led by the people’s

experience and participation team. The team produced a twice-yearly People’s Experience report

which provided information on compliments, PALS and complaints, feedback surveys, trust

priorities, CQC ratings, FoCUS meetings and the recovery college. The team promoted co-

production activities and volunteering opportunities.

The trust’s suicide prevention implementation plan was developed with a co-production approach.

The trust held a quarterly suicide prevention information network (SPIN) event which highlighted a

different area of suicide prevention. The events are open to staff, people who use services, their

families, friends and carers, members of the public and people from other organisations. The trust


had a co-production working group which looked at ways the trust could improve support for

people bereaved by suicide. The trust also had a co-production working group to develop training

in suicide prevention. The trust has produced training at the recovery college for people who use

services, families, friends and carers, and the general public; training for staff; and training for

GPs.

Learning, continuous improvement and innovation

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 table below shows services across the trust awarded an accreditation (trust-wide only) and

the relevant dates.

Accreditation

scheme

Core service Service accredited Comments and Date of

accreditation / review

Accreditation for

Inpatient Mental Health

Services (AIMS)

MH - Wards for people with learning disabilities or autism

Deacon service 16/01/2018

Accreditation for

Inpatient Mental Health

Services (AIMS)

MH - Wards for older people with mental

health problems

Spenser ward

4/12/2018

Quality Network for Inpatient Learning Disability Services

(QNLD)

MH - Wards for people with learning disabilities or autism

Deacon service

15/09/2017

Quality Network for Community CAMHS

(QNCC)

MH - Specialist community mental health services for children and young

people

Not supplied

Children’s eating disorders, HOPE service and CAMHS have completed self-assessments. Services have not

taken the next step to National Accreditation although various

managers have stated that this is an ambition.

ECT Accreditation

Scheme (ECTAS) Other ECT department Farnham

Road 12/12/17

Psychiatric Liaison

Accreditation Network

(PLAN) Other

Psychiatric liaison East Surrey

21/02/17

Memory Services

National Accreditation

Programme (MSNAP)

MH - Community-based mental health

services for older people

CMHTOP East Surrey CMHTOP Mid Surrey CMTOP Spellthorne CMHTOP Surrey Heath CMHTOP West Elmbridge

01/18

17/10/17

11/04/17

16/01/18

09/10/17 Accreditation for

community mental

health services

MH - Community-based mental health services for adults of

working age

CMHRS NE Hants 13/02/18


Accreditation

scheme

Core service Service accredited Comments and Date of

accreditation / review

Approved provider

standards - peer

mentoring

MH - Substance misuse

i-access 24/11/15

The trust has developed an outstanding and comprehensive internal accreditation programme

called the CARE excellence accreditation programme. CARE stands for communicate, aspire,

respond, engage. This programme carried out a robust annual review of the performance of every

team in the organisation and rated each team. The review included adherence to trust vision and

values, CQC fundamental standards and key lines of enquiry and health and safety standards.

Only teams that scored 95% or higher in mandatory standards progressed from the foundation

stage to the accreditation stage. Teams that scored below 85% were rated as requires significant

improvement and received additional support to help them improve their performance. Success

was celebrated at annual staff CARE awards and successful teams were awarded a CARE

excellence accreditation plaque. So far 11 teams have gained CARE excellence accreditation.

The trust was committed to improving services by learning from when things went well and when

they went wrong, promoting training, research and innovation. The trust had a director for

innovation and development who had responsibility for innovation, commercial development and

research and development. The trust’s chief executive’s vision was for the trust be a lead NHS

organisation for innovation. The director was passionate about her role and the improvements to

patient care that could be delivered by the projects her team were working on. The projects

include:

• The trust, working in partnership with the Alzheimer’s Society, the University of Surrey and

Royal Holloway University of London has developed an innovative system called

Technology Integrated Health Management (TIHM) for dementia. This system enables

people with dementia to stay in their own homes for longer and avoid readmissions to

hospital. A network of internet-enabled devices has been installed in people’s own homes

which remotely monitor the health, wellbeing and environment of the person with dementia.

If the technology identifies a problem, an alert is flagged and a clinical monitoring team of

healthcare practitioners decides on the necessary follow-up support. The system is part of

the NHS England Test Beds programme and won the Health Service Journal award 2018

for improving care through technology.

• Smart wards – being trialled on Spenser ward.

• The trust has developed a mobile app called My Journey. The app helps young people with

psychosis make informed choices to help improve their mental health. The app enables

young people to monitor their mood, keep track of their medication and gives advice on

what to do and who to contact if they need help.

There was a significant commitment to quality improvement in all of the services we inspected,

across the trust’s support services and in the senior leadership team. The trust had appointed a

quality improvement team who had expertise in quality improvement methodology and practice.

The trust had provided training across the organisation as part of the trust’s induction process for


new staff. Additional one-day training was also offered and advanced level training in quality

improvement was offered for quality improvement champions. The quality improvement projects

included:

• Increasing the reliability of nursing handovers using the SBAR (situation, background,

assessment, recommendation) model

• Reducing floor restraints by implementing Safety Pods

• Implementing physical health clinics on inpatient mental health wards

• Looking at the benefits of psychology-led staff reflection groups for staff working in adult


• Implementing a positive behaviour support clinic to improve the quality of and

responsiveness of support offered

• Assessing the impact of an immersive dementia experience for staff in the older adults

division

• Improving the structure and efficacy of multidisciplinary team meetings.

The pharmacy service managed a portfolio of clinical trials and had robust systems in place to

deliver this including a technician led dispensary service. All pharmacy technicians were trained to

be competent in all onsite clinical trials.


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 Peters site Acute Therapy

Service

n/a Mixed

Farnham Road Hospital Acute Therapy

Service

n/a Mixed

St Peters site Anderson ward 13 Female

St Peters Site Blake ward 20 Mixed

St Peters Site Clare ward 20 Male

Farnham Road Hospital Juniper Ward 18 Mixed

Farnham Road Hospital Magnolia Ward 15 Mixed

Farnham Road Hospital Mulberry Ward 15 Mixed

Farnham Road Hospital Rowan Ward 10 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 ward environments and reported any issues

through the trust facilities department.

In the Abraham Cowley Unit all three wards had multiple areas throughout their ward

environments where patients were not able to be seen easily by staff. This was due to the design

of the building. This was partly mitigated using convex mirrors and CCTV. The external areas of

the wards at the Abraham Cowley Unit had closed circuit television cameras constantly visible

from the nursing office, however we were told this was not being recorded by the trust. There were

areas such as the patient staircase to the garden on Anderson ward which were not easily visible


to the staff. This was mitigated by staff dedicated observations and rigorous recording systems

and regular walk arounds of the ward to ensure all patients were accounted for. Visibility across

the wards was not a problem at the Farnham Road Hospital as the wards had been purpose built

to ensure visibility across the communal areas and bedroom corridors which made it easy for the

staff to manage.

There was a system in place across all wards to ensure keys and personal alarms were managed

in a structured way. The single bedrooms and dormitories all had nurse call buttons. Staff all

carried personal alarms which were individually assigned to staff and on every shift, there was a

member of staff designated to be the first responder and these staff had up to date training in the

trust recognised de-escalation and physical management training which is called MAYBO.

Over the 12-month period from 1 September 2017 to 31 August 2018 there were no formal mixed

sex accommodation breaches identified within this service.

Blake ward was a mixed sex ward. On Blake ward there were gender separate sleeping areas

however it remains non-compliant with the Mental Health Act Code of Practice due to the access to

bathrooms/shared corridors. The single rooms were now used by female patients and could only

be accessed by using a fob key to get in to the corridor, single rooms which were allocated to patients

based on a risk assessment during the admission process.

Every patient had a care plan to promote privacy and dignity and the service had extensive plans to

redesign all the wards at the Abraham Cowley Unit which we reviewed in detail.

All wards had female-only lounges available for patients. However, the female-only lounge on Blake

ward was bland and uninviting, without pictures, information on the walls or activities for people to

carry out and would benefit from some additional refurbishment. No staff or patients we met with on

these wards raised any concerns or risk issues relating to the mixed gender environment and

patients felt this was due to the staff management of these areas.

There were ligature risks on all seven wards within this core service and all ligature risk

assessments were undertaken over the last 12 months (from 1 September 2017 onwards). All

seven of the wards were described by the trust as presenting a high level of ligature risk.

Staff across all wards inspected carried out annual ligature anchor point audits. A ligature anchor

point is a feature in the environment, such as a hook or a shelf, where someone might be able to fix

a ligature. All wards had daily environmental audits completed to review and manage all ligature

risks and we reviewed five sets of care plans and risk assessments which all had identified patients

that had a risk of tying ligatures.

Ward / unit name

Date of ligature

assessment

Briefly describe risk - one sentence preferred

High level of risk?

Summary of actions taken

Anderson ward

21/06/2018 We have identified a number of hazards that we have allocated for management or removal. Identified hazards include windows and a risk of them being used as ligature points

Yes Windows not in direct line of sight have been modified with a mesh insert that allows ventilation and reduces risk of ligature. Observation by Ward Team. Windows in communal areas have not been modified and are managed by Ward Team. Plan to remove and replace the windows as part of refurbishment works agreed and in place.


Ward / unit name

Date of ligature

assessment

Briefly describe risk - one sentence preferred

High level of risk?

Summary of actions taken

Blake ward 21/06/2018 We have identified a number of hazards that we have allocated for management or removal. Identified hazards include windows and a risk of them being used as ligature points

Yes Windows not in direct line of sight have been modified with a mesh insert that allows ventilation and reduces risk of ligature. Observation by Ward Team. Windows in communal areas have not been modified and are managed by ward team. Plan to remove and replace the windows as part of refurbishment works agreed and in place.

Clare ward 21/06/2018 We have identified a number of hazards that we have allocated for management or removal. Identified hazards include windows and a risk of them being used as ligature points

Yes Windows not in direct line of sight have been modified with a mesh insert that allows ventilation and reduces risk of ligature. Observation by Ward Team. Windows in communal areas have not been modified and are managed by ward team. Plan to remove and replace the windows as part of refurbishment works agreed and in place.

Mulberry ward

04/10/2017 We have identified a number of hazards that we have allocated for management or removal e.g. grab hand rails

Yes These are managed hazards by staff through environmental checks and observation of area by Ward Team

Magnolia ward

31/07/2018 We have identified a number of hazards that we have allocated for management or removal e.g. WC back support. Grab rails and handles.

Yes These are managed hazards by staff through environmental checks and observation of area by Ward Team, Areas to be kept locked when unattended

Juniper ward 03/11/2017 We have identified a number of hazards that we have allocated for management or removal e.g. Clock, WC back support, Grab handrails,

Yes These are managed hazards by staff through environmental checks and observation of area by Ward Team

Rowan ward 03/11/2017 We have identified a number of hazards that we have allocated for management or removal e.g. Notice Boards, Seat, Taps, Architraves, room safe, Wash hand basin Cupboard doors

Yes These are managed hazards by staff through environmental checks and Daily zoning to indicate RAG and staff vigilance of area by clinical team

Maintenance, cleanliness and infection control

For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018), the

Abraham Cowley Unit scored lower than similar trusts for cleanliness and for condition, appearance

and maintenance.

Site Core service(s) provided Cleanliness Condition appearance

and maintenance

Abraham Cowley

Unit

MH - Acute wards for adults of working age and

psychiatric intensive care units

94.4% 79.2%

MH - Other Specialist Services


Site Core service(s) provided Cleanliness Condition appearance

and maintenance

MH - Mental health crisis services and health-

based places of safety


MH - Wards for older people with mental health

problems

Farnham Road

Hospital



99.6% 98.5%




problems

Trust overall 97.8% 91.7%

England average

(Mental health

and learning

disabilities)

98.4% 95.4%

All wards had dedicated domestic staff who followed cleaning schedules which we reviewed with

the service manager. All the cleaning schedules were up to date and demonstrated that the ward

areas were cleaned regularly.

All the wards had good furnishings and the fixtures and fittings were well maintained.

The Abraham Cowley unit was due to have extensive refurbishment and we reviewed the plans

with the service manager. We were told that funding had been secured and the re-development

for the adult acute wards was due to start in the first quarter of 2019.

Staff adhered to infection control principles, including handwashing and all toilets and bathrooms

we inspected contained information showing correct hand hygiene.

All the bedrooms and dormitories across the two sites had viewing panels which could be

controlled from inside the room with a thumb turn and from outside by the staff using a key. The

default position for all the viewing panels was closed and this helped to maintain the privacy and

dignity of the patients.

Work had been undertaken to make the dormitories brighter and better lit and we could see that

the plans for the redesign of the Abraham Cowley Unit did not include any dormitories, so this

would no longer be an issue once the redevelopment had been completed.

Seclusion room

The seclusion room on Rowan had clear observation into the bedroom and toilet with working two-

way communication system in place and the ability to manage the temperature within the

seclusion room to keep a comfortable temperature. The toilet sink, and shower were found to be

working. There was a clock located in the seclusion room and a clock clearly visible from the

seclusion room.

Clinic room and equipment

Clinical rooms across both hospitals were clean and we found cleaning schedules in place with the

domestic staff. The ward staff completed additional cleaning duties to ensure rooms were tidy and

medications were kept in order. We found all medical equipment we checked to be in good order


and there was an electronic system in place across all wards ensuring items were kept under

calibrated and under regular review.

Emergency equipment we checked was found to be all in date and there were systems in place for

checking the equipment to make sure it was kept fully stocked and all date. Emergency medication

was also found to be all in date and get stocked with the trust list of stock emergency medications.

Safe staffing

Nursing staff

This core service has reported a vacancy rate for all staff of 31% as of August 2018.

This core service reported an overall vacancy rate of 37% for registered nurses at August 2018.

This core service reported an overall vacancy rate of 32% for nursing assistants.

Registered nurses Health care assistants Overall staff figures

Location Ward/Team

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Farnham Road

Hospital Juniper 1 13 100% 3 11 29% 3 10 32%

Farnham Road

Hospital Magnolia 1 13 100% 1 11 5% 0 10 -1%

Farnham Road

Hospital Mulberry 7 13 53% 5 14 32% 11 31 37%

St Peters Site Blake 5 10 52% 5 14 36% 10 27 38%

Farnham Road

Hospital Rowan 6 13 45% 6 14 45% 12 30 39%

St Peters Site Assessment

Suite ACU 4 13 32% 1 12 10% 5 27 18%

St Peters Site Assessment

Suite FRH 3 10 27% 2 12 18% 5 25 21%

St Peters Site Anderson 3 13 27% 6 14 44% 8 29 30%

St Peters Site Clare 1 10 14% 6 12 55% 8 24 34%

Core service total 31 84 37% 35 112 32% 63 213 30%

Trust total 157 616 25% 116 512 23% 265 1686 16%

NB: All figures displayed are whole-time equivalents

Between 1 September 2017 and 31 August 2018, of the 126,000 total working hours available, 7%

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 and patient

acuity.




Wards Total hours available

(qualified nurses)


or agency

Hrs % Hrs % Hrs %

Anderson Ward 16560 1627 10% 9176 55% 1045 6%

Blake Ward 22500 2828 13% 11329 50% 1133 5%

Clare Ward 16560 4591 28% 7635 46% 1355 8%

Juniper Ward 20700 16 0% 0 0% 1228 6%

Magnolia Ward 16560 153 1% 915 6% 894 5%

Mulberry Ward 16560 0 0% 1610 10% 614 4%

Rowan Ward 16560 0 0% 12 0% 406 2%

Core service total 126000 9214 7% 30676 24% 6675 5%

Trust Total 372138 57144 15% 100927 27% 12752 3%

Between 1 September 2017 and 31 August 2018, of the 109,440 total working hours available, 64% were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.

The main reasons for bank and agency usage for the seven wards/teams were vacancies and

patient acuity.

Agency staff covered 6% of available hours, 8% of hours were unable to be filled by either bank or agency staff.

Wards Total hours available

(nursing assistants)


or agency

Hrs % Hrs % Hrs %

Anderson Ward 12420 9997 80% 1534 12% 1282 10%

Blake Ward 22500 14843 66% 1129 5% 1371 6%

Clare Ward 12420 13929 112% 1589 13% 1562 13%

Juniper Ward 16560 3399 21% 0 0% 1068 6%

Magnolia Ward 16560 8596 52% 756 5% 1089 7%

Mulberry Ward 16560 9593 58% 919 6% 896 5%

Rowan Ward 12420 9888 80% 723 6% 1452 12%


Trust Total 475470 195621 41% 27638 6% 24184 5%

The trust had identified staffing resource as a risk indicator on the risk register and had taken

significant action. This included recruiting fully to the Farnham Road Hospital and to recruit 24 new

staff to the Abraham Cowley Unit. The trust had prioritised and fully recruited to all Band 6 and

Band 7 nurses. In addition, the trust had worked closely with local universities which had led to an

increase in student nurse placements with the intention of going on to recruit those students as

full-time nurse positions.

The ward managers confirmed that they could book agency staff when required to maintain the

safety of the wards and it was clear that the trust was committed to ensuring the wards were

running to their established numbers and all staff felt that the trust would always try to fill staffing

gaps when they occurred.

Wards used agency staff on long term contracts who were familiar with the wards and had worked

regular shifts so were familiar with the running of the wards and the management of all safety and

risk procedures. Agency staff had to complete a comprehensive induction when they worked their

first shift and they could access the same training and supervision as the established staff


members. Regular agency staff members were also able to access the trust’s electronic patient

records and incident reporting systems which meant that there was not additional pressure on the

regular staff to complete records at the end of each shift.

The wards all used staffing numbers boards in the wards which identified how many staff were on

duty and how many staff should be. Patients and visitors could easily see whether the wards were

up to numbers and the patients felt this was helpful as it gave them an idea of how many staff

were available on each shift.

Staff and patients felt that the wards were normally always up to numbers and activities and

escorted leave were rarely cancelled due to staff shortages.

A qualified nurse was present in the communal areas of the wards at all times.

The staffing levels allowed patients to have regular one-to-one time with their named nurse and

the patients confirmed this happened regularly across all wards.

Maybo training was used to support staff to physically manage patients safely, we found that all

wards had above 75% which meant that there were enough staff trained to carry out physical

interventions safely.

This core service had 26.8 WTE (23%) staff leavers between 1 September 2017 and 31 August 2018.

Ward/Team Substantive staff (latest

figure)

Substantive staff Leavers

(over the past year)

Average % staff leavers


Blake ward 16.5 6.2 41%

Clare ward 17.7 4.0 27%

Magnolia Ward 17.6 4.0 23%

Rowan Ward 20.1 4.0 22%

Juniper Ward 21.3 3.7 19%

Mulberry Ward 15.3 3.0 17%

Anderson ward 15.6 2.0 13%

Core service total 124.1 26.8 23%

Trust Total 1390.9 235.6 18%

The sickness rate for this core service was 5.3% between 1 September 2017 and 31 August 2018. The most recent month’s data (August 2018) showed a sickness rate of 7.8%.

Ward/Team Total % staff sickness

(at latest month)

Ave % permanent staff sickness


Blake ward 23.9% 13.7%


Ward/Team Total % staff sickness

(at latest month)

Ave % permanent staff sickness


Anderson ward 11.5% 8.5%

Juniper Ward 0.6% 6.7%

Rowan Ward 3.2% 3.1%

Magnolia Ward 5.0% 2.6%

Clare ward 7.4% 2.5%

Mulberry Ward 6.9% 1.5%

Core service total 7.8% 5.3%

Trust Total 4.2% 4.4%

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

All wards except for Blake were over 125% full for care staff for day shifts for the three months. No wards were under 90% for registered nurses or care staff during the three-month period. Key:

> 125% < 90%

Day Night Day Night Day Day

Nurses Care staff

Nurses Care staff

Nurses Care staff

Nurses Care staff

Nurses Care staff

Nurses Care staff

September 2018 August 2018 July 2018

Blake 93% 138% 93% 98% 90% 97% 106% 90% 102% 155% 91% 106%

Anderson 96% 176% 94% 210% 124% 246% 96% 319% 106% 182% 100% 222%

Clare 158% 166% 101% 327% 153% 136% 96% 320% 147% 138% 102% 300%

Juniper 101% 196% 101% 143% 97% 165% 94% 115% 109% 159% 97% 118%

Magnolia 94% 141% 97% 100% 101% 151% 98% 105% 97% 143% 98% 112%

Mulberry 108% 164% 105% 121% 104% 157% 104% 113% 101% 143% 103% 107%

Rowan 159% 169% 104% 320% 147% 163% 106% 320% 159% 175% 108% 303%

Medical staff

Between 1 September 2017 and 31 August 2018, of the 1,840 total working hours available, none were filled by bank staff to cover sickness, absence or vacancy for medical locums. Agency staff covered 72% of hours. No hours were left unfilled by bank or agency staff.


Ward/Team Total hours

available


or agency

Hrs % Hrs % Hrs %

Clare ward 440 0 0% 440 100% 0 0%

Blake Ward 680 0 0% 680 100% 0 0%

Juniper Ward 720 0 0% 200 28% 0 0%


Trust Total 13876 0 0% 8216 59% 0 0%

Mandatory training

Staff had completed and were up to date with their mandatory training. The trust set a target of

95% for completion of mandatory and statutory training.

The compliance for mandatory and statutory training courses at 31 August 2018 was 80%.

Of the training courses listed, 11 failed to achieve the trust target of 95%. In addition, two modules failed to score above 75%.

The trust has stated that “The training compliance data is reported on an ongoing monthly basis. Statutory training is reported as part of the monthly board report dashboard produced by Workforce and a separate dashboard is provided by the Learning and Development team for all other courses classified by ourselves as role essential”.

Key:

Below CQC 75% Between 75% & trust target Trust target and above

Training Module Number

of eligible

staff

Number of

staff

trained

YTD

Compliance

(%)

Trust

Target

Met

Compliance

change when

compared to

previous year

Health and Safety (Slips, Trips and Falls) 153 139 91% 93%

Safeguarding Children (Level 1) 153 129 84% 84%

Safeguarding Adults (Level 1) 153 128 84% 87%

Information Governance 153 126 82% 76%

Mental Capacity Act Level 1 129 105 81% 81%

Other 1050 836 80% 78%

Equality and Diversity 153 122 80% 74%

Clinical Risk Assessment 133 106 80% 79%

Manual Handling - People 125 99 79% 79%

Basic Life Support 90 67 74% 79%

Mental Health Act 129 88 68% 71%

Total 2421 1945 80% 80%

Additional information provided by the trust after the inspection indicated that at the end of

December 2018 the mandatory training in Mental Health Act for adult services was 84%.


Assessing and managing risk to patients and staff

Assessment of patient risk

We reviewed the care records for 29 patients which included individual patients risk assessments.

The wards used their own adapted risk assessment template which was stored on the electronic

recording system. The risk assessments showed evidence that a full and thorough risk

assessment was completed when patients were admitted including physical healthcare related

risks.

Management of patient risk

The risk assessments considered the range of risks that were relevant to each individual patient.

Risk assessments also had management plans which fed through from the care plans associated

with each of the individual risks.

We attended multidisciplinary ward round meetings at Farnham Road Hospital and the Abraham

Cowley Unit and observed clinical teams identifying and responding to changing risks within the

patient groups and amending risk assessments based on risks posed to or by patients.

The hospitals had a twice daily meeting and call between the ward managers and senior

managers to review any escalations in patient risk to make sure there were appropriate staffing

levels across the wards to maintain patient and staff safety.

Wards used a traffic light system for identifying patient risk “at a glance” which could be updated

dynamically throughout the shift by the nurse in charge and gave an overview of any elevated

risks across the patient group, this matched the risk assessments we reviewed which meant risk

was being effectively managed.

Wards had identified contraband items which were not permitted onto the ward due to the potential

risk and this was discussed with patients when they were admitted and clearly recorded in the

patient information leaflets.

Wards had regular handover meetings at the start of each shift where recent incidents on the ward

were discussed and all staff were made aware of any changes that had been made to risk

assessments and care plans. The wards used a system called SBAR (Situation, Background,

Assessment, Recommendation) tool. SBAR is a structured form of communication that enables

information to be transferred accurately between staff.

All wards were applying the trust guidance on reducing restrictive practices effectively. We saw

folders on each ward which identified all the restrictive practices being used on the ward and the

rational as to why those were in place. The wards were applying blanket restrictions to the patient

freedom only when there was a clear rational and when justified to maintain safety of the ward.

Wards adhered to the trust guidance on implementing a smoke free environment and there were

no areas of the inpatient wards where it was permitted for patients or staff to smoke. Wards had

identified leads in smoking cessation who developed care plans with the patients to support with

nicotine replacement therapy.

Across all wards Informal patients were aware that they could leave the wards if they chose to and

there were signs on the exit doors to the wards informing people of this.


Use of restrictive interventions

This core service had 313 incidences of restraint (on 185 different service users) and 100 incidences

of seclusion between September 2017 and August 2018. The below table focuses on the last 12

months’ worth of data: September 2017 to August 2018.

Ward name Seclusions Long term

segregations

Restraints Patients

restrained

Of restraints,

incidents of

prone

restraint

Rapid

tranquilisations

Anderson

(Female

Ward)

0 0 32 21 6 (19%) 19 (59%)

Blake 3 0 36 27 3 (8%) 26 (72%)

Clare (Male

Ward)

0 0 16 12 2 (13%) 16 (100%)

Juniper 6 0 36 23 3 (8%) 24 (67%)

Magnolia 8 0 46 21 0 (0%) 28 (61%)

Mulberry 5 0 23 21 1 (4%) 12 (52%)

Rowan 78 0 124 60 4 (3%) 71 (57%)

Core service

total

100 0 313 185 19 (6%) 196 (63%)

There were 19 incidences of prone restraint which accounted for 6% of the restraint incidents.

Over the 12 months, incidences of restraint ranged from 11 (in May 2018) to 45 (in July 2018) per month. The number of incidences (313) had increased from the previous 12-month period (249). Two wards, Delius and Elgar are included in the previous year’s restraint figure but have since been closed and are therefore not included in the current year’s figure.

There were 196 incidences of rapid tranquilisation over the reporting period. Incidences resulting in

rapid tranquilisation each month ranged from four (April 2018) to 38 (September 2017) over

(September 2017 – August 2018. The number of incidences (196) had decreased from the previous

12-month period (250). We saw a quality improvement programme in place at Farnham Road

Hospital which reviewed the use of rapid tranquilisation with a view to reduce its usage.

There have been no instances of mechanical restraint over the reporting period. Staff used restraint

only after de-escalation had failed and used MAYBO techniques to manage patients with full incident

report being completed post incident with a debrief system in place for staff and patients.

294 (94%) 19 (6%)

0 50 100 150 200 250 300 350

Restraints313

Number of incidences of restraint and prone restraint for this core service over the 12 months

Restraints


There have been 100 incidences of seclusion over the reporting period. Over the 12 months,

incidences of seclusion ranged from four to 16. The number of incidences (100) had increased from

the previous 12-month period (60).

We reviewed the seclusion paperwork at Farnham Road Hospital and found that seclusion was

being used appropriately and followed the trust policy and best practice when used. The paperwork

was completed and stored in an appropriate manner.

Segregation

There have been no incidences of long-term segregation over the 12-month reporting period.

Safeguarding

Safeguarding referrals1

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 262 safeguarding referrals between 1 September 2017 and 31 August

2018, of which 257 concerned adults and 5 children.

Staff knew the trust safeguarding policy and were aware of the link person within the trust and the

local authority that they should go to in the event of needing to raise a safeguarding referral. Staff

gave examples of how to protect patients from abuse and were aware of the different forms abuse

can take.

84% of the staff within the core service had completed safeguarding adults and children training.

Safeguarding concerns were regularly reviewed in handover meetings, multi-disciplinary ward

rounds and the twice daily managers meetings and the staff discussed any potential upcoming

safeguarding issues with the trust safeguarding leads.

Both Farnham road and The Abraham Cowley Unit had family visiting areas off the ward where

families and children under 18 could visit and the wards followed the trust safe procedure for

children visiting.

1 Safeguarding Referrals

Number of Referrals in this core service

Adults Children Total referrals

257 5 262


Serious case reviews

The trust has submitted details of no serious case reviews commenced or published in the last 12

months that relate to this core service.

Staff access to essential information

Staff use an electronic system to manage all information across this core service and all wards

had adequate administrative support to ensure documentation was uploaded onto the electronic

system, so it could be accessed by staff in the inpatient or community services.

The electronic records system could be accessed by all staff as locum agency and bank staff had

access to the system which enabled them to access the care notes and risk assessments when

required. There were no delays in accessing information.

Medicines management

We reviewed the medicines management across six inpatient wards and with support from a

pharmacist reviewed the individual medicines charts for 45 patients. We found that medicines

management was good. Staff followed good practice in dispensing, administration, medicines

reconciliation, recording and disposal.

We met with trust pharmacists and saw that they visited all wards regularly and were available for

advice to staff and patients when required.

We saw that clinical staff reviewed the effects of medicines on patient’s physical health regularly

and in line with NICE guidance, including when a patient was prescribed a high dose of

antipsychotic medicine.

Track record on safety

Serious incidents requiring investigation

Between 1 September 2017 and 31 August 2018 there were 40 serious incidents reported by this service. Of the total number of incidents reported, the most common type of incident was ‘unauthorised absence’ with 29. All four of the unexpected deaths were instances of ‘apparent/actual/suspected self-inflicted harm’.



by the trust incident reporting system was comparable with STEIS with 38 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.

Clare ward reported the highest number of incidences with nine, eight of these related to

‘unauthorised absences’.


Number of incidents reported

Type of incident

reported (SIRI)

Apparent/actu

al/suspecte

d self-

inflicted

harm

Failure to obtain

appropriate bed

for child who

needed it

Pending

review

Slips/trips/

falls

Unauthorised

absence

Anderson Ward 1 7

Blake Ward 2 1 2

Clare Ward 1 8

Juniper Ward 3 1 4

Magnolia Ward 3

Mulberry Ward 1 2

Rowan Ward 1 3

Total 6 3 1 1 29

Reporting incidents and learning from when things go wrong

Staff knew how to access the trust incident reporting system and what incidents should be

escalated using the electronic incident reporting system Datix. The Datix system was accessible

by all trust staff and locum agency workers.

Staff were familiar with the concept of duty of candour and could give us examples of occasions

when they had met with families and carers of patients when things had gone wrong on the wards.

All wards across the core service had a regular weekly risk meeting they called the “Datix Huddle”

where they reviewed all the incidents that had occurred in the precious seven days with the ward

teams and looked at what happened and how they could have managed the situation differently to

ensure similar situations do not occur again. We reviewed the minutes of these meetings and

could see that changes had been made as a result. This meeting also prompted debrief for the

staff teams and patients and staff from the ward and from the therapies team to support when

required.

‘Prevention of future death’ reports




In the last two years, there have been three ‘prevention of future death’ reports sent to Surrey and

Borders Partnership NHS Foundation Trust. None of these related to this service.

Is the service effective?

Assessment of needs and planning of care

We reviewed 29 sets of care records across six wards during this inspection. We found that all

patients had a care plan that was recovery focused and highlighted the patient’s strengths and


weaknesses. This core service used a standardised approach toward care planning which

covered basic areas of care but then the plans went on to go into more detail and give clear

descriptions on how to support the patient to meet their goals.

We found that there was clear evidence that patients’ views had been included in the co-

production of the care plans.

A comprehensive assessment of physical and mental health had been completed during the

admission process and we saw many examples of patients’ physical health care being met in a

timely manner after admission. One patient at Farnham Road Hospital was found to require

clarification around the management of diabetic medicine although there was a care plan in place

and the staff had sought advice from the diabetic nursing team from the local acute hospital.

When we discussed this with the clinical team they immediately acted to clarify the care plan and

made it more easily understandable in the event of a nurse not familiar with the patient

implementing the care.

Each of the wards in the core service had a system in place for ward managers to carry out a

regular audit of all care plans which had to be fed back to the modern matrons for the services on

a weekly basis. This audit was effective in immediately highlighting any gaps in the care planning

process. Most wards had a board in the office also identifying all the patients on the wards and

when the care plans had been reviewed so the nurse in charge and ward manager could see at a

glance when care plans were due for review.

Best practice in treatment and care

The modified early warning score (MEWS) tool was being used consistently in all the wards in this

core service. The MEWS tool is a simple, physiological score system that supports review and

improvement in the quality and safety of physical healthcare. It identifies trigger points for staff to

intervene and address issues around physical healthcare.

The multidisciplinary team provided a range of care and treatment interventions suitable for the

patient group.

The therapy team was well staffed with a lead occupational therapist, a consultant clinical

psychologist, a locum band 6 occupational therapist, a locum lead psychologist working three days

per week, two assistant psychologists, a wellbeing and fitness instructor and they had just

recruited a band 5 occupational therapist and a dietitian. The trust was recruiting to a

physiotherapist post. In addition to the core therapies team there were also staff on the wards

allocated to lead in the implementation of ward-based activities. These staff were called

engagement and recovery workers, and although counted in the numbers, they were dedicated to

ensuring therapies and activities were carried out on all the wards.

The patients at Abraham Cowley Unit had access to a well-appointed gym with support from the

wellbeing and fitness instructor and patients felt this was very beneficial to their mental health as

well as their physical health.

Activities were happening on the wards in the evening and at weekends and this was confirmed by

the patients who told us there was always something interesting going on.

The therapy team took a positive risk-taking approach and had developed a 15-week modular

group which could flex based on the needs of the group of patients. They were also involved in

psychological screening and formulation work to help patients and clinical teams to understand

their illness and how to best support their rehabilitation. There were many quality improvement


programmes being rolled out by the therapies team such as the pilot on Anderson Ward of a

trauma-informed care approach. This approach treats the whole person, considering past trauma

and the resulting coping mechanisms when attempting to understand behaviours and treat the

patient.

Clinical teams used the health of the nation outcome scales to measure the health and social

functioning of the patients across the core service.

Local audits

This service participated in ten clinical audits as part of their clinical audit programme 2017 –

2018.

Audit name Audit scope Core service Audit type Date

completed

Key actions following

the audit

Healthcare

associated

infections

(including

handwashing)

All services Provider wide Clinical and

environmental

Ongoing In relation to the IPC Environmental audits two areas of development identified included keeping an up-to-date COSHH risk assessment for bodily fluids in the IPC folder and domestic cleaning issues. All services have a tailored action plan in place.

Care planning

audit in

working aged

adult and

older people's

inpatient

services

All working

aged adult

and older

people's

inpatient

services

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive care

units

Clinical 01/10/2017 Development areas

identified for both OA and

WWAs inpatient services

include involving people

who use services and their

families and carers in

developing care plans.

Further training on the

completion of care plans

was identified. All wards

are being encouraged to

develop their own QI

projects to improve the

quality of people’s care

plans.

Patient safety

thermometer

All working

aged adult

and older

people's

inpatient

services

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive care

units

Clinical Monthly The main area where

harms are documented is

in relation to falls. Quality

improvement work around

falls reduction will

continue. The current aim

is to build a bundle of

effective falls reduction

resources.

Section 17

leave -

minimising

harm

All working

aged adult

and older

people's

inpatient

services

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive care

units

Clinical 01/12/2017 a) The Mental Health Act

training continues to focus

on how to record Section

17 leave decisions and

discussions

b) the Section 17 leave

forms include a space for

the patient signature which

has led to more people



completed


the audit

signing,

c) There is a plan to send

out news flashes through

the e-bulletin highlighting

the 5 areas where greater

focus is needed

d) The next audit will

include checking that Risk

Assessments have been

undertaken that relate

directly to the person

going on leave.

MH CQUIN

Indicator 3A

Cardio

Metabolic

Assessment

People using

services who

use our

inpatient or

Community

services, who

have a

diagnosis of

psychosis

relating to

either

schizophrenia

or bipolar

Provider wide Clinical 01/06/2018

(published)

A robust Trust-wide action

plan is in place to support

improvement in monitoring

physical health and

referring on for

interventions when

needed. In addition, there

has been a QI project to

support Health clinics to

operate within our

inpatient services. Health

clinics are in the process

of being rolled out to our

Community teams. Our

EIIP teams have

introduced the initiative of

a ‘lab in the bag’ which will

mean that the resources

needed for physical health

checks in the community

will be readily available. In

addition, our EIIP teams

will use the CMHRS health

clinics when they are

available in all areas

CARE

excellence

accreditation

All services Provider wide Service wide Ongoing -

self-

assessments,

peer reviews

and re-

reviews

All services have individual

action plans to work

through. Themed training

sessions have been

provided to help guide

staff as well as bite sized

information guides.

Supervision will be a

mandatory standard on

our Foundation standards

tool as from end 2018.

Record

keeping

audits

All mental

health

services

Provider wide Records Ongoing -

monthly

All teams must review their

information on a regular

basis and address any

gaps in supervision and

share good practice within

their teams. Record



completed


the audit

keeping is reviewed as

part of the Foundation

standards review.

Care Plan

Audit – local

audit

Mulberry

Ward

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive care

units

Clinical and

environmental

16/11/2017 A range of

recommendations to

address gaps in recording

were identified including

making better use of the

MDT meeting and

additional training.

Triangle of

care self-

assessments

All working

aged adult

and older

people's

inpatient

services and

Deacon

service

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive care

units

Clinical Oct 2017 to

March 2018

To support improvement in

practice we provide

training to promote a ‘think

family’ approach on the

wards, this was a task set

to the Carer Practice

Advisors (CPA’s) and they

all have their own

allocated services to

ensure equal cover in all

clinical services. Carer’s

information including a

new handbook is being

developed. The Carer

Practice advisors are

ensuring the gathered

information will be used to

progress improvements on

the ward.

Care plan

audit

Mulberry ward MH - Acute

wards for

adults of

working age

and

psychiatric

intensive care

units

Clinical 16/11/2017 A range of

recommendations to

address gaps in recording

were identified including

making better use of the

MDT meeting and

additional training.

Smoking Awareness Assessment of patients at Farnham Road Hospital

Magnolia ward MH - Acute

wards for

adults of

working age

and

psychiatric

intensive care

units

Clinical 1/12/2018 1. Circulate information across all clinical teams 2. Repeat on a larger scale 3. Amend questionnaire based on new 'smoke free' status of trust.

Skilled staff to deliver care


The trust’s target rate for appraisal compliance is 93%. 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 73%. There

was good evidence of up to date appraisals across all of the core services inspected.

Appraisals for permanent medical staff


March 2018), the overall appraisal rate for medical staff within this service was 100%. This year so

far, the overall appraisal rates this was 100% (as at 31 August 2018).

Ward name Total number of

permanent

medical staff

requiring an

appraisal

Total number of

permanent

medical staff

who have

had an

appraisal

% appraisals

(as at 31

August

2018)

% appraisals

(previous year April

2017 – March

2018)

Anderson ward 2 2 100% 100%

Mulberry Ward 1 1 100% 100%

Magnolia Ward 1 1 100% 100%

Blake ward 2 2 100% 100%

Rowan Ward 1 1 100% 100%

Clare ward 1 1 100% 100%

Juniper Ward 1 1 100% 100%

Core service total 9 9 100% 100%

Trust wide 100 99 99% 100%

The trust was unable to supply clinical supervision data globally as it is not formally recorded.

When we were on the wards we asked all managers to supply us with locally recorded data. We

could see across all wards that supervision was happening regularly every four to six weeks. The

teams used a locally produced “clinical supervision passport” document. This helped to clarify and

standardise staff experiences of clinical supervision and staff gave us positive feedback on it.

The teams across both hospital sites included or had access to the full range of specialists

required to meet the needs of the patient group. As well as nurses and allocated consultants to

each of the wards there were peer support workers, therapy teams including a dietitian, and

pharmacists.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of

the patient group. When additional training requirements were identified through supervision staff

felt that this was made available to them at the next available opportunity.

Wards were having regular monthly staff meetings and the minutes of those meetings were

available for all staff in the offices on the wards and circulated via email.

All ward managers could track and identify their sickness levels and completed a monthly return to

the HR department to ensure that sickness levels were managed effectively

When new starters came on to the wards they completed a full trust induction and then an

additional local induction to ensure staff are fully supported.


Multidisciplinary and interagency team work

All wards carried out a daily multidisciplinary risk review to consider the immediate risk level of all

patients on the ward. These reviewed patients based on a red, amber, green traffic light system to

make it easier for staff to highlight elevation in risk. In addition to this all wards held a weekly

multidisciplinary meeting to review all patients in detail and any progress or deterioration in their

behaviour.

All wards had a twice daily SBAR handover process which captured all relevant incidents and

changes in presentation of patients over the preceding 24 hours.

The managers and patient flow managers across the acute care pathway had a twice daily phone

call to discuss bed management, to review placement of all patients and any potential

safeguarding issues. This meant that all wards were aware of potential issues that may have led

to delays to discharge and supported each other when necessary.

The wards had effective working relationships with teams outside the organisation including local

authority social services and local police liaison services. Minutes from a monthly multi-agency

operations meeting showed strong and regular links between this core service and the local police

and social services where concerns were raised, and actions allocated to improve communication

and effectiveness.

Adherence to the Mental Health Act and the Mental Health Act Code of

Practice

As of 31 August 2018, 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. Updated figures supplied by the trust indicated

that this core service had increased their training compliance to 84% by the end of December

2018.

Staff had access to administrative support and legal advice across all wards from a central

location at Abraham Cowley Unit. The Mental Health Act (MHA) administrators could provide

guidance on the implementation of the Act and the code of practice. Staff were positive about their

support and guidance.

Clinical staff had a good working understanding of the MHA and its guiding principles and could

access trust policies and procedures and the code of practice via the intranet from any computer.

Advocacy services visited all wards on a minimum of once a week but could come more frequently

if required. Advocacy could be generic advocacy to support a patient’s day to day requests or

specific to MHA advocacy to ensure patients’ rights were properly communicated and upheld.

Each ward had a clearly displayed picture of the advocate that visited the ward and patients could

identify them and confirm they were frequently on the wards.

Wards had boards in the offices clearly indicating when patients’ rights under the MHA were due

to be discussed with the patients to make sure they knew their entitlements. We could see that

when patients were unable or unwilling for their rights to be explained to them there was a process

for ensuring that staff re-booked the time, so the patient would get additional chances to

understand their rights.


Wards were mostly able to ensure that patients could take their escorted or unescorted leave

when it was due. This was done by patients attending a morning planning meeting on the ward

and arranging with the ward staff and with each other when they would like to be able to arrange

their leave. This meant that patients felt more in control of what was happening during the day

and were also aware of the pressure on the ward and worked more collectively to try to arrange

their leave plans.

Good practice in applying the Mental Capacity Act


Capacity Act (MCA). The trust stated that this training is mandatory for all services for inpatient

and all community staff and renewed every three years.

Staff we spoke with across both hospital sites had a good working knowledge of the MCA and its

five statutory principles.

The trust had a policy on the MCA including the deprivation of liberty safeguards and the staff

were aware of the policy and where to access it on the trust internet. Staff were aware they could

get advice and guidance on the implementation of the MCA from the Mental Health Act

administrators.

It was the working practice to assess and review capacity to consent to treatment in the

multidisciplinary ward round meetings and for most of the patients we found capacity and consent

to treatment to be recorded and assessed appropriately. On Juniper ward we found one issue in

relation to a patient being restrained in order to be given non-psychiatric medication. Although the

staff team felt they were managing the situation under the patient’s best interests, no capacity

assessment had been completed and there was no best interest framework in place to direct this

care. The trust took immediate action to review this situation and put the correct framework and

care plans in place.

The trust told us that one urgent Deprivation of Liberty Safeguard (DoLS) application was made to

the local authority for this service between 31 August 2017 to 1 September which was approved.

Is the service caring?

Kindness, privacy, dignity, respect, compassion and support

Across all wards we found staff attitudes and behaviours when interacting with staff were positive,

patients felt that staff were respectful and responsive to them providing emotional support and

advice at the time they needed it. Patients were supported to understand and manage their care

and treatment.

We used our observation tool to observe and record interactions between staff and patients across

three wards and we found many examples of supportive and reassuring communication, with staff

maintaining the confidentiality of information about the patients.

Patients felt staff treated them well and gave examples of key nurses across the wards who they

felt they had made a positive connection with and that this had aided them in their support and

recovery. Staff understood the individual needs of the patients including their personal, cultural,

social and religious needs.


Staff were confident that they could raise concerns relating to disrespectful and abusive behaviour

or bad attitudes toward patients without the fear of consequences from the organisation.

The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for privacy, dignity

and wellbeing at both service location(s) scored the same or higher than similar organisations.

Site name Core service(s) provided Privacy, dignity and

wellbeing

Abraham Cowley Unit MH - Acute wards for adults of working age and


79.7%


MH - Mental health crisis services and health-based

places of safety



problems

Farnham Road Hospital MH - Acute wards for adults of working age and


91%


places of safety


problems

Trust overall 86.8%

England average (mental

health and learning

disabilities)

91%

Involvement in care

Involvement of patients

Across all wards we found staff had introduced a ward information leaflet or guidance document

which informed and orientated the patients to the ward and to the trust.

Staff involved patients in the care planning process and most of the care plans we reviewed

showed evidence that patients’ opinions and, if relevant, the opinions of carers and family

members. It was clear that patients had been offered a copy and that they had signed the care

plans if they were happy with the plan. We saw that if patients wanted parts of the care plan

reviewed there was a two-way communication process happening and changes had been made

based on the views of the patients.

Staff communicated with the patients finding appropriate ways to understand their care and

treatment accessing translation services when required.

All wards had a daily meeting with the patients to discuss and review the plans for the day and in

addition to this, wards had weekly community meeting with a set agenda which provided the

patients with an opportunity to feedback directly to the managers of the core service. The wards

had a “you said, we did” board on the wall which showed the minutes from the previous week’s

community meeting and any changes which had been prompted by the meeting. This information

was provided in a manner which was clear and easy to understand. Wards also used an iPad to

gather information regularly during the patients stay on the ward to understand how patient felt

about the stay in hospital.


We saw clearly identified information about access to advocacy services with pictures of the

advocacy staff that visit the ward to support patients to know how and who to contact if they

required additional support.

Involvement of families and carers

If patients gave recorded consent, then family members or carers were invited to attend

multidisciplinary meetings or care plan review meetings to be involved in the progress of their

loved one’s care.

Family members were invited to attend drop in meetings at both hospital sites and the Abraham

Cowley Unit had recently had a carers’ evening where the managers of the wards had invited and

met with family members and carers to review their thoughts and concerns in relation to the

management of the ward. There were plans to hold more of these meetings.

The wards had leaflets and information available to carers and families to advise them of guidance

and procedures relating to the running of the ward for example visiting times and how to contact

the ward and how to make a raise a concern or make a complaint if they were unhappy.

Carers we spoke with felt they could raise concerns and knew how to access information and

support if they needed it.


Is the service responsive?

Access and discharge

Bed management

Due to the nature of the wards and the pressure on beds it was not usual for a bed to kept open

for patients while they were on leave unless it was an agreed part of a clinical pathway.

All wards had a daily bed state call to review bed management across the core service to ensure

the most effective use of beds across the trust. This was attended by the complex care leads and

reviewed the patients on the wards but also the patients that were being supported out of area in

private beds.

Patients were not moved during an episode of admission unless it was justified on clinical grounds

and in the interests of the patient. Whenever possible patients were moved during office working

hours so there was the maximum amount of staff available to support the transition.

Staff were aware of the process for escalation of a patient to the psychiatric intensive care unit

(PICU) - Rowan ward at Farnham Road Hospital - and felt that the teams worked cohesively if a

patient were to require the additional level of support that the PICU could provide.

The trust provided information regarding average bed occupancies for seven wards in this service

between 1 September 2017 to 31 August 2018. Six of the wards within this service reported average

bed occupancies ranging above the minimum benchmark of 85% over this period.

Ward name Average monthly bed occupancy range

(September 2017 – August 2018)

Min Max

Blake 91.0% 100.0%

Clare 90.8% 100.0%

Juniper 91.3% 100.0%

Magnolia 89.4% 100.0%

Mulberry 88.4% 100.0%

Anderson 92.0% 100.0%

Rowan 46.7% 100.0%

The trust had identified that there was pressure on inpatient beds with more patients being acutely

unwell and higher levels of detention under the MHA which has led to more out of area

placements. Out of area placements were managed by the bed flow management team who

carried out daily calls with all wards across the core service. The team managed the flow of people

requiring inpatient care and brought them back into area as soon as possible with the support of

the Home Treatment Teams. In addition to this the trust had an Inpatient Complex Care Panel,

that reviewed the higher risk patients and the patients that had high re-admission rates to consider

how to best manage their care.

The trust provided information for average length of stay for the period 1 September 2017 to 31

August 2018.


Ward name Average monthly length of stay range


Min Max

Anderson 17 69

Blake 19 50

Clare 24 50

Juniper 14 115

Magnolia 22 115

Mulberry 11 92

Rowan 3 87

This service reported 61 out of area placements between 1 September 2017 to 31 August 2018.

This service reported 138 readmissions within 28 days between 1 September 2017 to 31 August

2018. 70 of readmissions (51%) were readmissions to the same ward as discharge. The average of

days between discharge and readmission was 11 days. There were two instances whereby patients

were readmitted on the same day as being discharged and nine where patients were readmitted the

day after being discharged.

Ward

name

Number of

readmissions

(to any ward)

within 28

days

Number of

readmissions

(to the same

ward) within

28 days

% readmissions

to the same

ward

Range of days

between

discharge

and

readmission

Average days

between

discharge

and

readmission

Anderson 14 6 43% 0 - 27 14

Blake 19 10 53% 1 - 26 10

Clare 26 12 46% 1 - 27 12

Juniper 10 4 40% 3 - 27 12

Magnolia 17 8 47% 1 - 27 11

Mulberry 45 29 64% 1 - 27 10

Rowan 7 1 14% 3 - 17 9

Total 138 70 54% 0 - 27 11

Discharge and transfers of care

Between 1 September 2017 and 31 August 2018 there were 1007 discharges within this service.

This amounts to 85% of the total discharges from the trust overall (1197).

There were 18 delayed discharges across the 12-month period, ranging from one to two per month.

These delayed discharges were delayed due to difficulties in finding suitable accommodation for

patients leaving hospital.

From the point of admission staff were proactive in supporting patients discharge from hospital and

had planned discharge dates which were clinically based and involved liaison with the care

managers and Home Treatment Teams.


Facilities that promote comfort, dignity and privacy

Patient-Led Assessments of the Care Environment (PLACE) assessments

Farnham Road Hospital is a purpose built modern mental health care hospital and all three wards

had clearly identified male and female sleeping corridors and bright well-maintained communal

areas, dining rooms and therapy areas. At Farnham Road Hospital patients could personalise their

bedrooms with rooms having Velcro boards for pictures and safes for people to be able to store

personal items securely.

All three wards at the Abraham Cowley Unit had separate sleeping areas but the layout of the

wards did not lend itself to modern mental health care. On all wards there were multiple corners

with poor visibility which relied on staff continuously walking the ward to maintain observations on

these areas and record they were safe and free from patient risk. Some areas had convex mirrors

and there was CCTV on the external areas of the ward but not the communal areas of the ward.

No staff member was designated to watch the CCTV.

On Clare ward a quality improvement project was trialling patients having their meals on the wards

and this was proving successful. However, Anderson and Blake wards were still using the main

dining room off the ward for patients to have lunchtime and evening meals. Blake and Anderson

wards had reviewed their arrangements for supporting patients to attend the dining room for

meals. These wards had a system for the staff to record how many patients were on the ward at

mealtimes and how many patients were in the dining room. This matched against an individual risk

management system to highlight which patients were considered safe to attend the dining room

and whether with staff or independently. The staff were aware how this system worked and used

considerable administrative time to ensure this was managed as safely as possible.

All patients across both wards had their own bed space. At Farnham Road Hospital all wards had

individual bedrooms with en-suite bathrooms. At the Abraham Cowley Unit all wards had a

combination of dormitory bedrooms and single rooms, each dormitory had a shower and each

dormitory was designated single sex. The dormitories had been repainted to try to increase the

amount of natural light that reached the bays furthest from the window and were brightly lit with

artificial light. However, the bays furthest from the window remained poorly lit. Patients at the

Abraham Cowley Unit did not have lockable spaces within their bedrooms or dormitories and if

they required to store items safely they had a storage room available on the wards.

Wards across both hospital sites had areas for patients to meet visitors and visitors were allowed

on to the wards during specific visiting times to support and maintain family contact. We saw

adequate rooms available for patients to meet with family members in private. Both hospital sites

also had a dedicated family room off the ward with children’s toys available, so children could visit

without having to access the main ward environment.

At Farnham Road Hospital activities were carried out on the wards in designated therapy areas. At

the Abraham Cowley Unit patients had the opportunity to carry out activity on the wards or at the

therapy area off ward which had multiple indoor and outdoor spaces allocated to art, craft and

therapeutic activity.

Patients across both hospital sites had individual risk management plans to enable them to access

mobile phones if it was considered safe for them and there was also a portable phone available

from the wards office for patients to make private phone calls.

All wards had managed secure outdoor spaces for patients to access. At Farnham Road Hospital

garden access was available between 7am and midnight. At the Abraham Cowley Unit garden

access was available with staff support due to the garden spaces being accessed via locked doors


which patient fobs could not open. Patients could access these areas when they requested, and

the areas were clean and secure.

Patients across both hospitals had access to hot and cold drinks whenever they required them and

could prepare snacks on the wards at any time of the day or night. On Anderson ward at the

Abraham Cowley Unit the drinks area was temporarily subject to restricted access due to the

presentation of an individual patient however this was subject to a restrictive practice assessment

and was kept under review by the ward and the trust working party on “reducing restrictive

practices”.

The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at

Farnham road hospital was higher than similar trusts. Abraham Cowley unit (80.1%) scored lower

than other similar trusts for ward food.

Site name Core service(s) provided Ward food



80.1%



places of safety


MH - Wards for older people with mental health problems



94.6%


places of safety


Trust overall 90.1%

England average (mental health and learning disabilities)

92.3%

Patients’ engagement with the wider community

Therapeutic staff ensured that patients had access to education and work opportunities, therapy

teams across both hospital sites accessed local colleges and had links with voluntary sector work

opportunities if it was considered suitable for patients.

Patients were encouraged to use their leave outside of the hospital as regularly as possible with

their family members or carers to ensure that relationships that mattered to them were maintained

both with services and with the wider community.

Meeting the needs of all people who use the service

For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018) Abraham

Cowley unit scored lower than similar trusts for the environment being dementia friendly and scored

lower than similar trusts for the environment supporting those with disabilities.


Site name Core service(s) provided Dementia

friendly

Disability

Abraham Cowley Unit MH - Acute wards for adults of working age and psychiatric


79.9% 82.9%


MH - Mental health crisis services and health-based places

of safety



Farnham Road

Hospital

MH - Acute wards for adults of working age and psychiatric


96.0% 95%

MH - Mental health crisis services and health-based places

of safety



England average

(Mental health

and learning

disabilities)

88.3% 87.7%

Farnham Road Hospital was well designed to support disabled patients with all reasonable

adjustments designed into the layout of the wards. The wards had designated bedrooms for

patients who may have mobility issues, and these were located nearer to the nursing office.

Abraham Cowley Unit had been designed prior to the introduction of the Disability Discrimination

Act and so the wards had not been designed to ensure that access to the wards was fully

compliant. However, the wards had taken steps to ensure that individual patients’ access needs

were addressed as and when they were required through individualised care planning and support

from referral to the physiotherapy team.

All wards across both hospital had strong connections with the local chaplaincy service and could

access support from spiritual leaders when required. The wards had access to a multi faith room

and we saw boxes on all wards containing religious texts were being stored respectfully.

Wards had lots of information around their walls in different languages informing patients of how

they could contact translation services and staff were aware of how this could be supported and

gave examples of when they have had to use the trust interpretation services.

Catering services could meet the needs of patients from different cultures and we were told by

patients that if they had dietary choices such as veganism or lactose intolerance that the hospitals

were able to meet this.

Across all wards we saw that information on the notice boards of the wards was presented in a

clear and concise manner and information was in a suitable format for all patients to be able to

understand. Wards had minutes from community meetings and “you said, we did” information

available on the boards so new patients to the ward could see what actions had been taken

because of patient participation. Patients felt involved in the day to day running of the wards and

that staff were responsive to their requests whenever possible.


Listening to and learning from concerns and complaints

Patients knew they could complain about their care by following complaint processes which were

clearly displayed on the notice boards across all wards. Patients also felt they could discuss their

concerns with their primary nurse in the first instance and that staff would take their concerns

seriously. In addition to this, patients took their concerns on the day-to-day running of the wards

to the weekly community meetings and minutes of these meetings showed that information was

carried forward and action was taken because of these concerns.

Patients received feedback when they had raised concerns whether through the community

meeting process or directly from the ward staff if they had raised a more formal complaint.

Identified advocates also visited the wards and had regular meetings with patients to ensure that if

they felt they couldn’t raise concerns with the wards staff there was another opportunity for them to

express their issues to an independent listener.

Staff were aware of the escalation process for complaints and spoke confidently about how they

would progress an informal and a formal complaint with the support of their manager.

Formal complaints

This service received 24 complaints between 1 September 2017 to 31 August 2018. Three of

these were upheld, ten were partially upheld and two were not upheld. None were referred to the

Ombudsman.

Ward

name Total Complaints Fully upheld Partially upheld Not upheld

Under

Investigation Withdrawn

Anderson

ward 6 1

2 1 1 1

Blake ward 5 2 1 1 1

Clare ward 6 3 3

Juniper

ward 3

2 1

Magnolia

ward 1

1

Mulberry

ward 3

1 2

Total 24 3 10 2 8 1

This service received 62 compliments during the last 12 months from 1 September 2017 to 31

August 2018 which accounted for 12% of all compliments received by the trust.

Is the service well-led?

Leadership

Established ward managers had the knowledge and experience to support their teams effectively

and newly appointed managers were all receiving supervision and guidance through training and


supervision. All ward managers had a good understanding of their wards and were clear on the

objectives and direction of the core service.

Clare ward at the Abraham Cowley Unit had recently been voted as the team of the year 2018 by

the Nursing Times due to the improvement and innovation the team had made under the

leadership of the ward manager.

Staff knew who the senior managers in the trust were and were aware of recent changes at board

level.

Consultants told us they felt valued as clinical team leaders since changes had been made at

board level and recent changes meant that consultants were now dedicated to work on specific

wards which had been a positive change.

Staff across both hospital sites told us the Matrons were a visible presence across their wards and

provided support and guidance to staff and patients.

There were leadership training opportunities for all nursing staff and it was clear the trust was

dedicated to improving and developing staff through leadership opportunities.

Vision and strategy

Ward managers and matrons felt their teams considered the trust’s values when carrying out their

work. They said that exploring these values with the staff was an important part of the

development of the team.

The trust’s vision and values were clearly displayed on all wards. Staff agreed with them and told

us they were discussed in supervision and recent team away days.

We spoke to staff who had recently attended the trust’s induction and they confirmed they were

emphasised throughout.

Staff at the Abraham Cowley Unit felt that they were being clinically involved and consulted in the

redevelopment of the acute wards. This meant there was a feeling of shared ownership which

helped to improve moral.

Ward mangers and Matrons explained how they were working to deliver high quality care within

the budget that was available to them and conversations around budget and finance were

regularly happening in managers supervision calls.

Culture

Staff enthusiastically told us about recent improvements made in areas such as care plans and

risk assessments, physical health monitoring and patients’ nutritional needs. They were proud of

their work and the progress patients were making.

The staff were core teams of motivated and passionate staff and this was seen by the inspection

team during our observations of interactions and planning meetings with the patient group.

Staff felt able to raise concerns to their direct managers and above if they were experiencing

bullying or harassment from their peers or patients. Staff had confidence in the managers and

were confident with using the “Whistle blowing” policy or taking concerns directly to the speak up

guardian.


Governance

There was a systematic governance-based approach to continually improve the quality of the

service. Several methods were used to achieve this, such as a monthly key performance indicator

system, a trust wide comprehensive clinical audit programme, and monitoring of specific indictors

relating to patient safety. These included a review of incidents, accidents, complaints,

compliments, allegations of abuse, absconding and use of restrictive physical interventions.

Managers used monitoring tools to ensure staff kept up to date with their mandatory training,

supervision and annual appraisal. We reviewed this information and the ward managers told us of

any associated plans in place for staff who were overdue.

Staff meetings, patient community meetings, Datix huddle meetings and Safety Huddle meetings

all had a clear framework and agenda of what was to be discussed and information concerning

learning from incidents and complaints was shared across the staff teams and the patient group

when appropriate.

We could see on Blake Ward that recommendations from previous incident reviews and CQC

inspections had been implemented and action plans had been developed to minimise the

opportunity for similar incidents to re-occur.

Managers and staff were committed to working with other acute wards and in the directorate also

understood the arrangements in place for working with other external agencies such as the police

and local authority.

All wards had a set list of clinical and operational audits which were regularly completed and

feedback into the governance system via the Matron.


Managers could access the directorate risk register and we could see that issues were discussed

with staff at the team meetings which related directly to concerns recorded on the risk register.

The most relevant recent issue was the staffing levels across the directorate and this was

addressed in the team meeting minutes and the actions that had been taken to address this.

Managers on the wards could access human resources support when required with performance

related issues and were confident they were reporting on a regular basis through their supervision

on staff team’s sickness levels. This was being audited regularly and information was captured

through the Trust electronic rota system.

The trust did not record supervision on an organisational level, so we were able to discuss and

review supervision levels on each of the wards individually. Staff were receiving regular

supervision and felt the supervision was meaningful for them.

All manager had access to occupational health services through the trust contracts. On Blake

ward we heard how staff who had long term sickness issues were effectively supported back into

the work environment and were complimentary about the way it was handled by the ward

managers and the Matron.

Information management

Staff across all wards had access to electronic systems that recorded patient care records and

incident reporting. Staff felt that these systems were adequate. The systems were readily


available with enough computers and laptops for staff to enable them to perform their roles. All

staff, including agency locum staff we interviewed had access to the systems and felt confident in

their usage.

Ward managers could access dashboards which contained all the relevant HR related issues they

needed to know to be able to manage their staff teams, this included information on staff

performance and patient care.

The wards all had a recognised system for raising safeguarding information with the local authority

and other external bodies when required.

Engagement

All staff could access the intranet for the trust which provided them with up to date policies and

information on the trust and regular bulletins and information updates were circulated both via

email but also with staff newsletters.

Patients had access to an iPad on all wards where they could provide live feedback on how they

felt about their care. This was collated directly by the trust and fed back through the governance

system.

The wards had recently had carers’ evenings at the Abraham Cowley Unit and Farnham Road

Hospital. These had been successful in staring to build a greater input from the carers as

stakeholder in improving the experiences of family members of inpatients.

Healthwatch had recently visited the wards at the Abraham Cowley Unit and spoken to the

managers. They had provided feedback to the ward to assist in improving the safety of the wards.


The wards were all passionate and dedicated to quality improvement plans. We saw multiple

projects across the core service in areas such as:

• monitoring the quality of staff shifts and the handover process,

• the introduction of the trauma informed model of care piloted on Anderson Ward,

• the delivery of the trust’s suicide prevention strategy which meant that 100% of the staff in

the inpatient wards had completed suicide prevention training

• the quality improvement project around the integration of patients dining on the ward into

Anderson Ward

• the project around the physical health clinic on Magnolia ward.

Accreditation of services

NHS trusts can participate in many accreditation schemes whereby the services they provide are

reviewed and a decision is made whether 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 to continue to be accredited. No accreditations have been awarded to

any wards within this service.


Wards for older people with mental health problems


Location site name Ward name Number of beds Patient group (male,

female, mixed)

West Park - The Meadows The Meadows 8 beds per ward = 24

St Peters Site Spenser Ward 20 Female

Farnham Road Hospital Victoria Ward 24

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.



Safety of the ward layout

• Staff carried out regular risk assessments of the ward environments and reported any

issues appropriately.

• The communal areas within each ward allowed staff to easily observe different parts of the

ward. There were corners within ward corridors, on some of those corners. convex mirrors

were installed to enable staff to see around them. However, some corners (particularly on

Victoria ward) did not allow staff to see around them.

• Staff mitigated risks posed by obscured lines of sight by regularly conducting checks within

all parts of the wards.

• Staff on each ward carried a personal alarm to enable them to access assistance from

colleagues when needed. During our visit we saw staff respond quickly and effectively

when an alarm was activated.

• All rooms contained a wall-mounted nurse call alarm for use by patients.

• Spenser ward and the three units at The Meadows were single sex wards, which meant the

provider complied with guidance on same-sex accommodation. Victoria ward operated as a

mixed-gender facility. There was a female-only lounge and each bedroom had an en-suite

toilet and shower. No staff or patients we spoke with raised any concerns relating to the

mixed gender environment and the layout of the ward complied with accepted guidance on

the issue.


• Staff conducted an annual audit of ligature anchor points for each ward. Some patient

bedrooms, en-suite facilities and communal toilets and bathrooms had been equipped with

anti-ligature furnishings and fittings. Although some rooms within each ward were not fitted

with anti-ligature furnishings and fittings (such as beds, taps and handrails), the furniture

and fittings were appropriate for the patients on the wards. All ward areas had been

comprehensively considered within the ward ligature audit and risks were managed via

individual risk assessment of the patient and staff observation within that area. The Bluebell

1 and Bluebell 2 units at The Meadows operated as dementia-friendly environment and as

such were equipped with appropriate fixtures and fittings for the patient group. Staff had

appropriately risk assessed dementia-friendly taps, hand rails within the two Bluebell units.

Over the 12-month period from 1 September 2017 to 31 August 2018 there were no mixed sex

accommodation breaches within this service.

There were ligature risks on three wards within this service. All of the wards had a ligature risk

assessment in the last 12 months.

Ward / unit

name

Briefly describe risk - one

sentence preferred

High level of risk?

Yes/ No Summary of actions taken

Spenser ward Risk of Bedframes not fixed in place, toilet seat being used as anchor points

Yes These are managed hazards by staff through environmental checks and individualised care planning driven by Risk assessment of the person's behaviour /needs. This also includes observation of location of hazard area by ward clinical team

Victoria ward A number of ligature hazards

identified and allocated for

management or removal e.g. Bed,

Radiator grill, Chairs, Window

Hooks, Curtain header tape,

Handles.

Yes Risk assessment of the person's

behaviour /needs & care planning to

include observation of area by ward

clinical team

The Meadows

(Primrose)

A number of ligature hazards

identified and allocated for

management or removal e.g.

Taps, Bedframes, Beds not fixed

in place, Wardrobe door hinges,

Windows, Curtain header tape.

Yes Risk assessment of the person's

clothing/behaviour /needs & care

planning to include observation of

area by ward clinical team

Maintenance, cleanliness and infection control

• Results of the most recent (2018) Patient-Led Assessments of the Care Environment

(PLACE) survey showed that The Meadows scored 100% for both cleanliness and condition,

appearance and maintenance. The Farnham Road hospital site, where Victoria ward was

located, scored 99% for cleanliness and 98% for condition, appearance and maintenance.


Both scores for Farnham Road hospital were above the national average for similar trusts.

However, the Abraham Cowley Unit site, where Spenser ward was located, scored 94% for

cleanliness and 79% for condition, appearance and maintenance. Both scores for the

Abraham Cowley Unit were below the national average for similar trusts. However, the scores

for Farnham Road hospital and the Abraham Cowley Unit are not specific to this core service

in isolation.

• Cleaning records were up-to-date and demonstrated that the ward areas were cleaned

regularly. On the morning of our unannounced visit, Spenser ward was clean and had no

unpleasant odours.

• The trust had secured funding to comprehensively redevelop the Abraham Cowley site.

Spenser ward was included in the agreed plans for the redevelopment.

• A heating malfunction shortly before our visit meant that patients on the Primrose unit within

The Meadows had been decanted to a neighbouring unit within the same building, whilst

the issue was being resolved. Staff had managed the temporary arrangement efficiently, to

ensure that any unsettling effects on patients were minimised.

• Patients at The Meadows and Spenser ward could not control their bedroom door viewing

panel from inside their room. Staff had external control of the vision panels. All panels were

kept in the closed position, to safeguard the privacy and dignity of the occupant. They only

opened the panel when performing routine observations. Patients on Victoria ward could

control their bedroom door viewing panel from the inside.

• Staff adhered to infection control principles, including handwashing.

For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018), two

locations scored higher than similar trusts for cleanliness and two scored higher than similar trusts

for condition, appearance and maintenance.

Site name Core service(s) Cleanliness Condition appearance and

maintenance

The Meadows MH - Wards for older

people with mental

health problems

100% 100%

Abraham

Cowley Unit



and psychiatric


94.4% 79.2%

MH - Other Specialist

Services

MH - Mental health

crisis services and

health-based places

of safety

MH - Substance

misuse


Site name Core service(s) Cleanliness Condition appearance and

maintenance


people with mental

health problems

Farnham Road

Hospital



and psychiatric


99.6% 98.5%

MH - Mental health

crisis services and

health-based places

of safety


people with mental

health problems

Trust overall Trust overall 97.8% 91.7%

England

average

(Mental health

and learning

disabilities)

England average

(Mental health and

learning

disabilities)

98.4% 95.4%

Seclusion room

No wards within this core service had a seclusion room.

Clinic room and equipment

Clinic rooms on all wards were fully equipped with accessible resuscitation equipment and

emergency drugs which staff checked regularly. All clinic rooms were well maintained, organised

and clean. Equipment displayed labels to indicate they had been cleaned recently. Staff checked

fridge temperatures regularly.

Safe staffing

Nursing staff

• The trust provided data on their staffing levels prior to this inspection. As of 31 August

2018, the trust’s establishment figure for qualified nurses in this core service was 38 whole

time equivalent posts and their establishment figure for nursing assistants was also 79

whole time equivalent posts. At that time, the number of qualified nursing vacancies was 10

(27%) and the number of nursing assistant vacancies was 14 (18%). The ward with the

highest level of qualified nursing vacancies was The Meadows, with 37%. The ward with

the highest level of nursing assistant vacancies was The Meadows, with 26%.

• Staff turnover during the 12-month period September 2017 to August 2018 was 11%. The

ward with the highest level of staff turnover was Victoria ward, with 19%. Staff sickness


during the same 12-month period was 4.6%. The ward with the highest level of staff

sickness was The Meadows, with 9.6%.

• The trust provided data on their use of bank and agency use to cover qualified nurse

sickness, absences and vacancies during the 12-month period September 2017 to August

2018. A total of 62,850 hours were available. Of that total, 14,968 hours were filled by bank

staff, which represented 24% of total hours; 11,329 hours were filled by agency staff, which

represented 18% of total hours; and, 1,981 hours were left unfilled by either bank or agency

workers, which represented 3% of total hours.

• The trust provided data on their use of bank and agency use to cover nursing assistant

sickness, absences and vacancies during the 12-month period September 2017 to August

2018. A total of 49,500 hours were available. Of that total, 14,931 hours were filled by bank

staff, which represented 30% of total hours; 494 hours were filled by agency staff, which

represented 1% of total hours; and, 3,025 hours were left unfilled by either bank or agency

workers, which represented 6% of total hours. There was no bank or agency usage for

nursing assistants at The Meadows.

• Wherever possible, ward managers used bank or agency workers who were familiar with

their ward and its patients. Wards block-booked some bank and agency staff, to maximise

continuity of care. Bank workers who worked regularly on a ward, were given access to the

same induction, training and supervision package as substantive staff. Agency workers who

were block-booked to a ward, had access to supervision from ward managers, but still

received training from their agency.

• Ward managers had the ability to adjust staffing levels to take account of the case mix.

There were sufficient staff to carry out physical interventions. Patients we spoke with told us

they had regular one to one time with their named nurse.

• According to staff and patients we spoke with, ward activities and escorted leave were

rarely cancelled due to staff shortages.

This core service has reported a vacancy rate for all staff of 19% as of 31 August 2018.

This core service reported an overall vacancy rate of 27% for registered nurses at 31 August

2018.

This core service reported an overall vacancy rate of 18% for health care assistants.



Location Ward/Team

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

West Park The Meadows 6 17 37% 9 36 26% 16 61 26%

ACU Spenser 3 10 30% 0 22 0% 3 38 9%

Farnham Road

Hospital

RXX22

Victoria 1 11 8% 5 21 23% 7 37 19%

West Park Primrose 1 11 8% 5 21 23% 0 0 0%


Trust total 157 616 25% 116 512 23% 265 1686 16%


Between 1 September 2017 and 31 August 2018, of the 62850 total working hours available, 24%

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 and to support

enhanced observations.



Wards Total hours available Bank Usage Agency Usage NOT filled by bank

or agency

Hrs % Hrs % Hrs %

Spenser Ward 15840 4075 26% 2681 17% 240 2%

Victoria Ward 15840 7648 48% 2456 16% 708 4%

The Meadows 31170 3245 10% 6192 20% 1033 3%

Core service total 62850

14968 24% 11329 18% 1981 3%

Trust Total 372138 57144 15% 100927 27% 12752 3%

Between 1 September 2017 and 31 August 2018, of the 49500 total working hours available, 30%

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 to support

enhanced observations.



Wards Total hours available Bank Usage Agency Usage NOT filled by

bank or agency

Hrs % Hrs % Hrs %

Spenser Ward 25740 4361 17% 22 0% 543 2%

Victoria Ward 23760 10570 44% 472 2% 2482 10%


Wards Total hours available Bank Usage Agency Usage NOT filled by

bank or agency

Hrs % Hrs % Hrs %


Trust Total 475470 195621 41% 27638 6% 24184 5%

This core service had nine (11%) staff leavers between 1 September 2017 and 31 August 2018.

Ward/Team Substantive staff (at

latest month)

Substantive staff

Leavers over the last 12

months


over the last 12 months

Spenser Ward 32 1 5%

The Meadows 44 2 11%

Victoria Ward 29 6 19%

Core service total 105 9 11%

Trust Total 1391 236 18%

The sickness rate for this core service was 4.6% between 1 September 2017 and 31 August 2018.

The most recent month’s data (31 August 2018) showed a sickness rate of 5.5%.

Location Ward/Team Total % staff sickness

(at latest month)

Ave % permanent staff

sickness (over the past year)

West Park - The

Meadows RXX2T The Meadows 8.2% 9.6%

St Peters Site

RXXW1 Spenser Ward 1.7% 3.6%

Farnham Road

Hospital RXX22 Victoria Ward 5.5% 2.5%



The below table covers staff fill rates for registered nurses and care staff during September 2018

and August 2018.

No wards fell below 90% fill rates.

Victoria ward had rates above 125% of planned shifts healthcare assistants and care staff for day

and night in all three months.

Key:


> 125% < 90%

Day Night Day Night Day Night

Nurses Care staff

Nurses Care staff

Nurses Care staff

Nurses Care staff

Nurses Care staff

Nurses Care staff

September 2018 August 2018 July 2018

Victoria 122% 184% 106% 167% 125% 197% 102% 181% 125% 180% 102% 176%

The

Meadows 90% 128% 138% 106% 91% 121% 127% 108% 106% 127% 135% 114%

Spenser 99% 121% 97% 107% 103% 134% 97% 116% 99% 130% 90% 111%

Medical staff

• There was adequate medical cover across all wards day and night which meant that a doctor

could attend quickly in the event of a medical emergency.

• During the 12-month period September 2017 to August 2018, there was no bank or agency

usage to cover medical locum hours reported for this core service.

There was no bank or agency usage to cover medical locum hours reported for this core service.

Mandatory training

• Staff had completed most mandatory training courses as of 30 November 2018. At the time

of our inspection, the completion rate for each course was over 75% for each course,

except for training in the Mental Health Act. As of 30 November 2018, 80% of staff on

Spenser ward, had completed up to date training in the Mental Health Act. However, only

55% of staff at The Meadows, had completed up to date training in the Mental Health Act;

and on Victoria ward, only 60% of staff had completed up-to-date training in the Mental

Health Act.

• Following our site visit, the trust supplied updated figures for training in the Mental Health

Act. As of 31 December 2018, 81% of staff from this core service had completed up to date

training in the Mental Health Act.

The compliance for mandatory and statutory training courses at 31 August 2018 was 82%. Of the

training courses listed 11 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 has stated that,


‘The training compliance data is reported on an ongoing monthly basis. Statutory training is reported as part of the monthly board report dashboard produced by Workforce and a separate dashboard is provided by the Learning and Development team for all other courses classified by ourselves as role essential.’

The training compliance reported for this core service during this inspection was higher than the

79% reported in the previous year.

Key:


✓

Not met trust

target

Higher

No change

Lower

Training Module Number of

eligible

staff

Number of

staff

trained

YTD

Compliance

(%)

Trust

Target

Met

Compliance

change when

compared to

previous year

Mental Health Act 66 44 67%

Equality and Diversity 107 83 78%

Manual Handling - People 66 52 79%

Other 699 562 80%

Mental Capacity Act Level 1 68 57 84%

Safeguarding Children (Level 1) 107 91 85%

Clinical Risk Assessment 68 58 85%

Health and Safety (Slips, Trips and Falls) 107 92 86%

Basic Life Support 42 36 86%

Information Governance 107 96 90%

Safeguarding Adults (Level 1) 107 100 93%

Total 1544 1271 82%



• We reviewed the care records for 23 patients, which included individual patient risk

assessments. Staff used a risk assessment template which was stored on their electronic

recording system. In general, most risk assessments we reviewed considered the range of

risk factors relevant for each individual patient (such as the risk of falls and pressure ulcers)

and included updates following incidents.

• Staff reviewed patients’ risk assessments regularly in multidisciplinary meetings and

whenever incidents occurred involving patients. We observed multidisciplinary patient

review meetings where staff discussed risk levels in relation to recent events. Staff worked

with colleagues from community teams to best ensure that risks were effectively managed

when each patient was ready to leave the ward.



• Staff received a handover at the start of each shift, from staff on the preceding shift.

• Staff avoided imposing blanket restrictions on patients where possible. However, some

doors within wards were kept locked so that patients could only access the area beyond

when supervised by a member of staff.

• All three hospital locations operated a no-smoking environment. Nicotine replacement

therapies, such as electronic cigarettes were available to patients. Staff worked

collaboratively with patients to facilitate off-site smoking breaks.

• All wards were kept locked. Informal patients could ask a member of staff to leave as

desired.

• Staff used observation to mitigate risks around each ward. They increased their level of

vigilance to monitor specific risks as needed.

Use of restrictive interventions

• Staff recorded 39 incidents of restraint, on 29 different patients, during the 12-month period

September 2017 to August 2018. Of the 28 incidents of restraint, 20 occurred on Victoria

ward; 16 occurred on Spenser ward; and three occurred at The Meadows.

• Of the above 39 incidents of restraint, 27 resulted in the administering of rapid

tranquilisation. A total of 16 incidents of the administering of rapid tranquilisation were

recorded on Victoria ward; nine were recorded on Spenser ward; and two were recorded at

The Meadows.

• Staff actively sought to use verbal de-escalation techniques to resolve, and where possible

pre-empt, situations where one or more patients became distressed. Staff only used

physical restraint as a last resort, when verbal de-escalation was unsuccessful. Staff used

correct restraint techniques and worked within the Mental Capacity Act definition of

restraint.

• No instances of prone restraint were reported to have occurred during the 12-month period

September 2017 to August 2018. Prone restraint is face-down restraint where the individual

cannot freely move from that position.

• No instances of mechanical restraint, seclusion or long-term segregation were reported to

have occurred during the 12-month period September 2017 to August 2018.

This service had 39 incidences of restraint (29 different service users) and no incidences of

seclusion between 1 September 2017 and 31 August 2018.


The below table focuses on the last 12 months’ worth of data: 1 September 2017 and 31 August

2018.

Ward name Seclusions Restraints Patients

restrained

Of restraints, incidents

of prone restraint

Of restraints,

incidences of

rapid

tranquilisation

Bluebell 1 (Meadows)

0 2 2 0 1

Bluebell 2

(Meadows) 0 1 1 0 1

Spenser 0 16 13 0 9

Victoria 0 20 13 0 16

Core

service total 0 39 29 0 (0%) 27 (69%)

There were no incidences of prone restraint.

There were 27 incidences of rapid tranquilisation over the reporting period. Incidences resulting in

rapid tranquilisation for this service ranged from 0 to six. The number of incidences (27) had

decreased from the previous 12-month period (36).

There have been no instances of mechanical restraint over the reporting period.

There have been no instances of seclusion over the reporting period.

There have been no instances of long-term segregation over the 12-month reporting period.

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.

• Staff we spoke with understood the trust’s safeguarding policy and procedures on how to

raise a safeguarding referral. Approximately 90% of staff had completed the elements of

safeguarding training in relation to risks to adults and children.

• Safeguarding was a topic discussed during handover and multidisciplinary team meetings.

Staff received specialist support from the trust’s social work team, who were available to

discuss any concerns that arose.

• During the 12-month period September 2017 to August 2018, this core service made 42

safeguarding referrals to the local authority, of which 41 concerned adults and one

concerned children.

• All wards had strong working relationships with their local authority safeguarding team.

• All wards had access to a quiet room, where patients could meet visitors.





institutional.





should take place.


2018, of which 41 concerned adults and one child.

Number of referrals


41 1 42

The number of adult safeguarding referrals in month ranged from 0 to seven (as shown below).

The trust has submitted details of no serious case reviews commenced or published in the last 12

months that relate to this core service.


• Information across this core service was stored on the trust’s electronic recording system.

Staff uploaded all paperwork to ensure information was easily accessible.

• Electronic information was available to substantive staff, bank staff and regular agency

workers, to enable them to deliver and record patient care while on the wards and when

they were transferred between teams. Agency workers who were on short/ad-hoc

placements were not provided with access to trust electronic recording systems. However,

they worked alongside substantive staff, within the main team, who did have access to the

electronic patient records.


• We looked at the medicines management practices on each of the five wards and the

individual medicines charts for 26 patients. We found that overall medicines management

was good. Staff stored, dispensed, administered and recorded patient medicine

appropriately. The trust had a policy for the administration of covert medicines, which staff

applied appropriately.

• Staff received support from pharmacists, who visited each ward regularly. Pharmacy staff

were available when nursing staff needed to seek their advice; they regularly attended


multidisciplinary meetings; and, conducted regular audits of medicines management

systems.

• Staff monitored the effects of medicines on patients by carrying out regularly physical health

checks, such as electrocardiograms.


• During the 12-month period September 2017 to August 2018, there were four serious

incidents reported by this service. All four serious incidents were grouped within the

category ‘Slips/trips/falls’. There were no unexpected deaths reported.

• We reviewed the serious incidents reported by the trust to the Strategic Information Executive

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 four

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 the above 12-month period.

Ward Type of incident reported (SIRI) Total

Slips/trips/falls meeting SI criteria

Spenser ward 2 2

Victoria ward 2 2

Total 4 4


• Staff we spoke with knew what type of incidents they should report and knew how to report

them. Staff submitted incident reports using the ‘Datix’ electronic system accessible to

everyone, except ad hoc agency workers.

• Staff we spoke with were familiar with the duty of candour. They related how they ensured that

they were open and honest with patients and carers when things went wrong.

• Staff on each ward discussed learning from incidents during staff meetings and in a weekly

‘Datix huddle’ meeting, that focussed solely on sharing information and learning about recent

incidents.

• Staff were debriefed after incidents and received support from managers and members of the

psychology team.





In the last two years, there have been four ‘prevention of future death’ reports sent to this trust, none

of these related to this service.



• We reviewed the care records for 23 patients. The care plans we reviewed on Spenser

ward and Victoria ward were consistently up to date, personalised, holistic and recovery

oriented, incorporating patients’ strengths and goals. However, the care plans we looked at

on The Meadows were variable. Some were brief and could have been more expansive to

describe how the person’s needs were being met in relation to physical health needs such

as epilepsy, endocrine disorders, continence care as well as best interest decisions in the

personal care of people who lack capacity in these aspects of care. The trust took

immediate action to review and update all the patients’ records we had checked. We re-

checked the care records on 20 December 2018 and saw that all necessary care plans

were now in place.

• Staff completed a comprehensive mental and physical health assessment in most

instances. However, staff had easy referral access to a specialist physical health lead nurse

as required.

• The trust had a policy that all newly admitted patients should have physical observations

carried out on them by staff at least twice daily during their first three days of admission.

The tool used by the trust for physical observations was the modified early warning score

(MEWS) for clinical deterioration. The purpose of carrying out twice daily observations

during the first three days was to establish a baseline to inform future care delivery. In the

majority of care records we reviewed staff had not always followed trust policy in order to

establish a baseline to inform care delivery. For example, on Spenser ward, none of the

eight records we reviewed had had a baseline established in line with trust policy.


• Each ward had input from psychology staff. The psychology team supported the ward staff

teams in formulating and delivering individual positive behavioural support plans for

patients. They also delivered patient self-help groups, aimed at providing patients with the

capability to assist in the management of their own anxiety and depression.


• Each of the wards had good access to physical healthcare. However, access to a specialist

lead nurse was accessible only by referral. Staff could obtain support from a range of health

professionals, such as dietitians and physiotherapists.

• Staff used Health of the Nation Outcome Scales to measure the health and social

functioning of patients on the wards.

• The trust operated a smoke-free environment and staff supported patients with nicotine

replacement therapy. Staff also encouraged patients to improve their health by exercising in

the regular ward-based sessions. We observed an exercise session during our visit. The

session was well organised, inclusive and appropriate to the ability of the participants.

• Information was available on all wards to promote the importance of a healthy lifestyle,

including information on physical activities and healthy dietary choices.

• Staff participated in clinical audits, for example in infection control, record keeping and

Mental Capacity Act documentation.

This service participated in six clinical audits as part of their clinical audit programme 2017 – 2018.

Audit name Audit scope Core

service

Audit type Date

completed


the audit

Healthcare associated infections (including handwashing)

All services Provider wide

Clinical and environmental


MH CQUIN

Indicator 3A

Cardio

Metabolic

Assessment

People using

services who

use our

inpatient or

Community

services, who

have a

diagnosis of

psychosis

relating to

either

schizophrenia

or bipolar

Provider

wide

Clinical 01/06/2018

(published)

A robust Trust-wide

action plan is in place to

support improvement in

monitoring physical

health and referring on

for interventions when

needed. In addition, there

has been a QI project to

support Health clinics to

operate within our

inpatient services. Health

clinics are in the process

of being rolled out to our

Community teams. Our

EIIP teams have

introduced the initiative of

a ‘lab in the bag’ which

will mean that the

resources needed for

physical health checks in

the community will be



service

Audit type Date

completed


the audit

readily available. In

addition, our EIIP teams

will use the CMHRS

health clinics when they

are available in all areas

CARE

excellence

accreditation

All services Provider

wide

Service wide Ongoing - self-

assessments,

peer reviews

and re-reviews

All services have

individual action plans to

work through. Themed

training sessions have

been provided to help

guide staff as well as bite

sized information guides.

Supervision will be a

mandatory standard on

our Foundation

standards tool as from

end 2018.

Record

keeping audits

All mental

health services

Provider

wide

Records Ongoing -

monthly

All teams must review

their information on a

regular basis and

address any gaps in

supervision and share

good practice within their

teams. Record keeping is

reviewed as part of the

Foundation standards

review.

Positive

behavioural

support (PBS)

plans - staff

attitudes

Older people’s

inpatient wards

and community

services

MH -

Wards for

older

people with

mental

health

problems

Clinical 01/11/2017 Recommendations

following the audit

include

• Revising the targets for

completing PBS

• Consideration of a QI

project which would

focus on ‘five key things’

which would be shared

during person – centred

handovers.

The audit highlighted

different training needs

across Community and

Inpatient settings.

Inpatient staff wanted

more assistance with

writing the care plans,

whilst Community teams

request additional

support with putting the

PBS plans into practice.

Documentation of patient mental capacity to consent to assessment and treatment

Meadows MH -

Wards for

older

people with

mental

Clinical 11/10/2017 The auditors

recommended engaging

the Mid Surrey CMHT in

training and education

regarding the importance

of obtaining and



service

Audit type Date

completed


the audit

under The Meadows OPCMHT – local audit

health

problems

documenting patient

consent.


• The trust’s target rate for appraisal compliance was 95%. During the 12-month period April

2017 to March 2018, the overall appraisal rate for non-medical staff within this core service

was 79%.

• During the 12-month period April 2017 to March 2018, 100% of medical staff within this core

service completed revalidation.

• Staff on Spenser ward received regular supervision, approximately every four to six weeks.

However, staff on The Meadows and Victoria ward received supervision with varying

frequencies. Some members of staff received supervision every four to eight weeks, but other

members of staff received supervision only every three to four months. Managers of The

Meadows and Victoria ward cited pressures caused by staffing vacancies and the high

demands of their patient groups as reasons why staff did not consistently receive supervision

more frequently.

• Staff were experienced and qualified, and had the right skills and knowledge to meet the needs

of the patient group. The trust organised dementia training for staff, however no figure was

available to confirm the proportion of staff who had completed up-to-date dementia training.

• The ward teams had access to a comprehensive range of specialists required to meet the

needs of patients. As well as doctors and nurses, each ward team comprised occupational

therapy and psychology staff. Pharmacists and social workers visited each ward regularly.

Other health professionals, such as speech and language therapists, dietitians and

physiotherapists were available as part of the substantive staffing compliment. However, this

core service did not have a service level agreement in place to gain support from a specialist

tissue viability nurse.

• Staff on Spenser ward met for a monthly team meeting. Minutes for the meetings were

recorded and accessible to all staff. However, team meetings on The Meadows and Victoria

ward occurred only sporadically, every two to three months. Managers of The Meadows and

Victoria ward cited pressures caused by staffing vacancies and the high demands of their

patient groups as reasons for their team meetings not taking place at the scheduled monthly

intervals.

• Staff we spoke with felt that managers supported them to access training appropriate to their

current role and to support their continual professional development.


• New members of staff received a corporate induction from the trust and a ward-based

induction from the manager and team leaders.


March 2018), the overall appraisal rate for non-medical staff within this service was 79%. This year

so far, the overall appraisal rates was 62% (as at 31 August 2018). The ward with the lowest

appraisal rate was Spenser ward with an appraisal rate of 33%.

Ward name Total

number of

permanent

non-

medical

staff

requiring

an

appraisal

Total

number of

permanent

non-

medical

staff who

have had

an

appraisal

%

appraisals

(as at 31

August

2018)

%

appraisals

(previous

year April

2017 –

March

2018)

The Meadows 23 20 87% 73%

Victoria Ward 21 13 62% 91%

Spenser Ward 21 7 33% 74%


Trust wide 858 649 76% 80%



far, the overall appraisal rates this was 100% (as at 31 August 2018).

Ward name Total number

of permanent

medical staff

requiring an

appraisal

Total number

of permanent

medical staff

who have had

an appraisal

%

appraisals

(as at 31

August

2018)

% appraisals

(previous year April

2017 – March 2018)

Spenser Ward 2 2 100% 100%

Victoria Ward 2 2 100% 100%

The Meadows 1 1 100% 100%


Trust wide 100 99 99% 100%

The trust is unable to supply clinical supervision data as it is not formally recorded.


• All wards held weekly multidisciplinary meetings to review the care and treatment for

individual patients.

• Staff attended a handover session when commencing their shift.


• Multidisciplinary and management team members from all three sites met once a week for

a bed management meeting, to discuss planned and potential patient admissions,

discharges and transfers within the service.

• The staff team on each ward had effective working relationships with other teams within the

organisation, such as adult acute mental health wards and community-based mental health

teams. Staff from the wards were in regular contact with colleagues from community teams

when planning discharges and ongoing care needs.

• The staff team on each ward had effective working relationships with external teams such

as social services, advocacy services and GPs.


Practice

• As of 30 November 2018, 80% of staff on Spenser ward, had completed up to date training

in the Mental Health Act. However, only 55% of staff at The Meadows, had completed up to

date training in the Mental Health Act; and, on Victoria ward, only 60% of staff had

completed up-to-date training in the Mental Health Act.

• Following our site visit, the trust supplied updated figures for training in the Mental Health

Act. As of 31 December 2018, 81% of staff from this core service had completed up to date

training in the Mental Health Act.

• Staff we spoke with had a good understanding of the Mental Health Act, the Code of

Practice and the guiding principles.

• Staff had access to trust policies and procedures on the application of the Mental Health

Act. Staff also had access to appropriate administrative support and legal advice from a

central team within the trust.

• An advocacy provider visited the wards regularly. Patients could request specialist

independent mental health advocacy as desired. There was information displayed within

each ward on how to contact the advocacy service.

• In general, staff ensured that patients could take their allotted section 17 leave (permission

for patients to leave hospital) as arranged. Sometimes staff needed to move the time or

shorten the duration of escorted leave, due to time pressures within the ward, but they did

this in consultation with the patient concerned.

• Staff requested the input of a second opinion appointed doctor when necessary.

• MHA paperwork for patients was stored securely and was accessible to staff who required

them. We reviewed MHA paperwork for patients on all wards and found them to be correct

in most cases. However, we saw one instance on Spenser ward in which a patient had had

their period of detention ended and they continued their admission on the ward as an


informal patient. For a five-day period, their legal status was improperly documented as still

being detained, before their status was eventually recorded correctly. The patient was not

impacted negatively as a result of the recording error.

• We saw evidence that staff explained patients’ rights to them at the point of admission and

at regular intervals thereafter.

• Staff carried out regular audits of Mental Health Act documentation.



community staff and renewed every three years.


• As of 30 November 2018, 100% of staff on Spenser ward and The Meadows had

completed up-to-date training in the Mental Capacity Act; and, 96% of staff on Victoria ward

had completed up-to-date training in the Mental Capacity Act.

• Staff we spoke with had a good understanding of the Mental Capacity Act and it’s five

statutory principles.

• The trust had a policy on the Mental Capacity Act, including Deprivation of Liberty

Safeguards. Staff we spoke with were aware of the policy and had access to it. They knew

where to obtain advice on the application of the Mental Capacity Act, including deprivation

of liberty safeguards.

• Staff assessed the patients’ capacity to consent to treatment during multidisciplinary

meetings. Capacity and consent to treatment were recorded appropriately in the care

records we reviewed on Spenser ward and Victoria ward. However, the records for capacity

and consent to treatment we reviewed on The Meadows were inconsistent. They failed to

clearly demonstrate whether patients had capacity to make given decisions or whether they

had consented to their admission or elements of their treatment plan. The trust took

immediate action to review and update all the patients’ records we had checked. We re-

checked the care records on 20 December 2018 and saw that all relevant capacity

assessments were now in place.

• The trust told us that they made 32 Deprivation of Liberty Safeguard (DoLS) applications to

the local authority for this core service during the 12-month period September 2017 to

August 2018. None of the 32 applications were approved, since in each instance the patient

had been discharged from the ward prior to the local authority reaching a decision.


Capacity Act. The trust stated that this training is mandatory for all services for inpatient and all



The trust told us that 32 Deprivation of Liberty Safeguard (DoLS) applications were made to the

Local Authority for this service between 31 August 2017 and 1 September 2018.


‘The reason for variance in the figures is because the Applications were not progressed by the

Local Authority whilst the patient was still on the ward’.

Number of ‘Standard’ DoLS applications made by month

M M M M M M M M M M M M Total

Standard applications made 2 3 1 1 2 0 0 0 2 1 2 2 16

Standard applications approved 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of ‘Urgent’ DoLS applications made by month

M M M M M M M M M M M M Total

Urgent applications made 2 3 1 1 2 0 0 0 2 1 2 2 16

Urgent applications approved 0 0 0 0 0 0 0 0 0 0 0 0 0




• We observed staff interacting with patients in a caring, respectful and responsive manner.

We saw staff assisting patients both with practical tasks and in respect of their current

mental and emotional state. All wards had a calm and relaxed atmosphere.

• Staff supported patients to understand and manage their care, treatment or condition; and,

to access other services to meet their personal and spiritual needs.

• Staff displayed a high level of understanding of the individual needs and abilities of patients;

both when they interacted with patients and when they spoke about patients with their

colleagues or with members of the inspection team.

• Patients we spoke with were complimentary about the way staff treated them.

• Carers we spoke with told us they were happy with the care provided by staff.

• The 2018 patient-led assessments of the care environment (PLACE) score for privacy, dignity

and wellbeing was 93% for The Meadows, 91% for Farnham Road Hospital and 79% for the

Abraham Cowley Unit. Victoria ward is only one ward within Farnham Road Hospital and

Spenser ward is only one ward within the Abraham Cowley Unit. The remaining wards at

Farnham Road Hospital and the Abraham Cowley Unit belong with different core services. The

average score for similar trusts throughout England for privacy, dignity and wellbeing was 91%.

The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for privacy, dignity

and wellbeing at two service locations scored higher than or the same as similar organisations.


wellbeing

The Meadows MH - Wards for older people with mental health

problems

93%



79.7%






problems



91.0%




problems

Trust overall 86.8%



wellbeing

England average (mental

health and learning

disabilities)

91%

Involvement in care


• Staff used the admission process to inform and orient patients to the ward and to the

service.

• Staff involved patients in care planning and risk assessment, as evidenced in patient care

records we looked at. Staff offered patients a copy of their individual care plan and risk

assessment and recorded if the patient accepted a copy.

• Patients could provide feedback on the service during weekly community meetings. A

summary of the main points brought forward by patients was displayed on the “you said, we

did” board on each ward.

• Patients could access general and specialist advocacy support from an advocacy service

that visited each ward on a weekly basis. Posters were displayed on each ward informing

patients of advocacy services available.


• Staff invited carers to attend weekly multidisciplinary team meetings to discuss

developments in the care of their relative.

• Staff demonstrated that they sought input from carers when formulating individual risk

assessments and care plans in patient care records we looked at. Carers we spoke with

said they felt involved in their relative’s care.

• Carers had the opportunity to attend ward-based carers meetings. However, the meetings

were poorly attended in general.

• Carers we spoke with were happy that staff had provided them with the individualised

support they needed. Carers told us that staff welcomed their input and visits to the ward.

• Staff provided carers with information about how to access a carer’s assessment.

• Staff organised events where patients and carers could jointly attend, such as regular

musical performances and cream teas held at The Meadows.



Access and discharge

Bed management

• The trust provided information regarding average bed occupancies for the three wards in this

core service during the 12-month period September 2017 to August 2018. The average bed

occupancy for Spenser ward was 89%; for The Meadows the average was 85%; and, for

Victoria ward the average was 81%.

• The trust provided information regarding average length of stay for the three wards in this

core service during the 12-month period September 2017 to August 2018. The average

length of stay for patients at The Meadows was 98 days; the average length of stay for

patients on Spenser ward was 70 days; and, the average length of stay for patients on

Victoria ward was 65 days.

• The trust reported that they had no out of area placements for this core service, during the

12-month period September 2017 to August 2018.

• This core service reported 21 readmissions within 28 days during the 12-month period

September 2017 and August 2018. Of the total number of readmissions, 16 (76%) were

readmissions to the same ward as discharge. The average number of days between

discharge and readmission was 15 days. There was one instance where patients were

readmitted on the same day as being discharged and no instances where patients were

readmitted the day after being discharged.

• 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.

• Patients’ bedrooms were kept available for them when they were on leave.

The trust provided information regarding average bed occupancies for three wards in this service

between 1 September 2017 to 31 August 2018.

One of the wards within this service reported average bed occupancies ranging above the minimum

benchmark of 85% over this period.

Ward name Average monthly bed occupancy range

(1 September 2017 – 31 August 2018)

Spenser 65% 98%

Meadows 1 75% 100%

Victoria 61% 92%

The trust provided information for average length of stay for the period 1 September 2017 to 31

August 2018.


Ward name Average monthly length of stay range


Meadows 1 0 144

Spenser 46 107

Victoria 36 110

This service reported no out area placements between 1 September 2017 to 31 August 2018.

This service reported 21 readmissions within 28 days between 1 September 2017 to 31 August

2018. 16 of readmissions (76%) were readmissions to the same ward as discharge. The average of

days between discharge and readmission was 15 days. There was 1 instance whereby patients

were readmitted on the same day as being discharged and no instances where patients were

readmitted the day after being discharged.

Ward name Number of

readmissions

(to any ward)

within 28

days

Number of

readmissions

(to the same

ward) within

28 days

%

readmissions

to the same

ward

Range of

days

between

discharge

and

readmission

Average days

between discharge

and readmission

Meadows 1 2 2 100% 0 -27 14

Spenser 5 3 60% 14 - 27 21

Victoria 14 11 79% 2 - 21 11

Discharge and transfers of care

• The trust reported that during the 12-month period September 2017 to August 2018, there

were 182 discharges within this core service. Of the 182 total discharges, 20 were reported

to have been delayed.

• Staff we spoke with told us that the primary cause of delayed discharge was difficulties in

securing suitable ongoing accommodation.

• Staff supported patients in planning ahead for their discharge from hospital. This was done

by involving the trust’s community mental health teams and carers from the point of

admission.

• Managers participated in a weekly bed management meeting, where they discussed

planned and potential patient admissions, discharges and transfers within the service.

Between 1 September 2017 to 31 August 2018 there were 182 discharges within this service. This

amounts to 15% of the total discharges from the trust overall (1197).

There were 20 reported delayed discharges across the 12-month period ranging from 0 to five per

month.



The Meadows comprised three small inpatient units, along with a fourth, vacant unit, used flexibly

by the trust to temporarily house patients when there was an issue on another ward. At the time of

our visit, patients from Primrose unit were accommodated on the vacant unit, whilst a fault with

their unit’s heating system was being rectified. The Meadows was a relatively modern, purpose-

built facility with a range of rooms available for meetings, therapy sessions, relaxation and

activities. Staff had created an excellent, centrally located reminiscence room, for use by patients

from any of the three units.

Spenser ward and Victoria ward were both large, single wards that had sufficient rooms to meet

the basic needs of staff and patients. All communal areas within Victoria ward were at/near one

end of the elongated, linear layout of the ward. Spenser ward and Victoria ward were less homely,

welcoming environments than the smaller units at The Meadows. Spenser ward had been

included within plans to fundamentally redevelop the Abraham Cowley Unit, in which it was

located.

Patients on Victoria ward all had their own bedroom, complete with en-suite shower and toilet.

Patients at The Meadows had their own bedroom, but had to share communal toilets and

bath/shower rooms. There were sufficient communal facilities in each of the three units at The

Meadows for the number of patients. On Spenser ward, there were five single bedrooms and three

dormitories, each of which accommodated five patients. Each dormitory had a toilet and shower,

shared between the five occupants. The visual privacy and dignity of each patient was protected

by a curtain around their personal bed space. A relatively low amount of natural light entered the

dormitories. However, the central communal space within each dormitory was well lit by artificial

ceiling lights. There were ample communal toilets and bath/shower rooms on Spenser ward, to

meet the needs of patients.

Patients had a lockable space in their bedroom, or bed space in the case of patients on

dormitories on Spenser ward. Patients could also store valuable items in the ward safe.

Patients could personalise their bedroom with pictures and items of their choice.

Every ward had a well-equipped clinic room that was large enough to enable staff to conduct

physical examinations on patients.

Patients had access to their own mobile telephone whilst on the ward. Staff charged patient

telephones on their behalf, in the ward office. Staff retained the mobile telephone charger for each

patient. Each ward had a cordless telephone, which patients could use at any time.

Patients on Spenser ward and The Meadows had access to an enclosed garden. Although

patients on Victoria ward also had access to a garden, the route to it was very difficult for patients

to negotiate, so the garden was rarely used.

All wards had quiet space for patients to meet with visitors on the ward.


Patients had access to hot or cold drinks and snacks at any time of day or night. Each ward had a

fruit bowl in the main communal area for patients.

Patients told us they were happy with the quality and choices of food on offer.

The 2018 patient-led assessments of the care environment (PLACE) score for ward food was 100% for

The Meadows, 94% for Farnham Road Hospital and 80% for the Abraham Cowley Unit. Victoria ward

is only one ward within Farnham Road Hospital and Spenser ward is only one ward within the

Abraham Cowley Unit. The remaining wards at Farnham Road Hospital and the Abraham Cowley Unit

belong with different core services. The average score for similar trusts throughout England for

privacy, dignity and wellbeing was 92%.

The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at two

locations scored higher than similar trusts.

Site name Core service(s) provided Ward food

The Meadows MH - Wards for older people with mental health

problems

100%



80.1%






problems



94.6%




problems

Trust overall 90.1%

England average (mental health and learning disabilities)

92.2%


• Staff supported patients to have escorted and unescorted leave from the wards when

appropriate to ensure they developed and maintained relationships with other services and

their friends and relatives.



• The internal environment in each ward was level access and therefore suitable for people

with restricted mobility.

• The trust’s chaplaincy service visited each ward every week. They could access spiritual

support for patients from different religions and faiths upon request.

• Staff could access interpreters as needed. They could also arrange for information leaflets

to be translated into different languages upon request. Staff had attempted to support one

patient who did not communicate in English by learning some basic phrases in their

preferred language.

• Patients had the choice of eating food from different cultures and selections that met

specific dietary requirements.

• Information on a variety of topics was displayed around each ward, from details of how to

complain or give feedback; how to access advocacy support; contact details for other local

agencies; and, information on physical and mental health issues and treatments.

• Two of the three units within The Meadows (called Bluebell 1 and Bluebell 2) had been

assigned to accommodate patients with dementia. The environment within the two Bluebell

units had been adapted with dementia friendly colour schemes, fittings and signage.

However, staff had been unable to offer patients dementia friendly food menus, due to a lack

of cooperation from their food supplier.

• The 2018 patient-led assessments of the care environment (PLACE) score for being dementia

friendly was 96% for The Meadows, 96% for Farnham Road Hospital and 79% for the Abraham

Cowley Unit. Victoria ward is only one ward within Farnham Road Hospital and Spenser ward is

only one ward within the Abraham Cowley Unit. The remaining wards at Farnham Road

Hospital and the Abraham Cowley Unit belong with different core services. The average score

for similar trusts throughout England for privacy, dignity and wellbeing was 88%.

• The 2018 patient-led assessments of the care environment (PLACE) score for environment

supporting people with a disability was 97% for The Meadows, 95% for Farnham Road

Hospital and 82% for the Abraham Cowley Unit. Victoria ward is only one ward within Farnham

Road Hospital and Spenser ward is only one ward within the Abraham Cowley Unit. The

remaining wards at Farnham Road Hospital and the Abraham Cowley Unit belong with different

core services. The average score for similar trusts throughout England for privacy, dignity and

wellbeing was 87%.

For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018) two

locations scored higher than similar trusts for the environment being dementia friendly and two

scored higher than similar trusts for the environment supporting those with disabilities.

Site name Core service(s) provided Dementia friendly Disability


The Meadows MH - Wards for older people with mental health problems 96.5% 97.4%

Abraham Cowley

Unit



79.9% 82.9%



places of safety



Farnham Road

Hospital



96.0% 95%


places of safety



England average

(Mental health

and learning

disabilities)

88.3% 87.7%


• This core service received a total of two complaints during the 12-month period September

2017 to August 2018. Both complaints were partially upheld.

• The service received a total of 19 compliments during the 12-month period September 2017 to

August 2018.

• Information boards within the wards displayed information about the complaints process.

Information about the complaints process was also contained within the information pack

issued to new patients.

• Local advocacy services regularly visited each ward.

• Staff we spoke felt they received sufficient feedback on the outcome of patient complaints.

This service received two complaints between 1 September 2017 to 31 August 2018, both were

partially upheld.


August 2018 which accounted for 4% of all compliments received by the trust as a whole.


Leadership


• Ward managers and matrons in this core service had the skills, knowledge and experience

to perform their roles. They had a thorough understanding of the services they managed

and could explain clearly how the teams were working.

• Ward managers and modern matrons maintained a visible presence in their wards to

provide support to staff and patients.

Vision and strategy

• Staff we spoke with understood the trust’s visions and values and team objectives and how

they applied to the work of their team.

• All staff we spoke with contributed their ideas towards the development of their wards and

the core service.

• Some staff we spoke with on Spenser ward expressed concern at their perceived lack of

clear communication from senior managers within the trust. The concerns centred around

the planned redevelopment of the Abraham Cowley site and if Spenser ward was going to

be included within the plans.

Culture

• Staff we spoke with were passionate about their work and motivated to deliver high quality

care to patients. Staff told us that they felt supported by their ward manager and matron.

We saw evidence of strong partnership working between the ward manager and matron on

each ward, to support their staff teams.

• Staff we spoke with said they felt able to raise concerns and propose suggestions to

improve the service without fear of being victimised. Staff were familiar with the trust’s

whistleblowing policy and the role of the freedom to speak up guardian. They told us that

each of the ward managers and modern matrons were approachable and open to feedback.

• The primary concern raised by staff we spoke with was the impact of high levels of staff

vacancies on the team and the running of the service. They spoke of the extra stress

placed on substantive staff when the ward was operating with a high proportion of bank or

agency workers.

• Staff sickness within this core service was 4.6% during the 12-month period September

2017 to August 2018. This was slightly higher than the trust average of 4.4%, during the

same period.

Governance


• Staff used clear processes to ensure that important information such as learning from

incidents and complaints was shared during team meetings. Staff on each ward met for a

weekly meeting, specifically to discuss recent incidents.

• Staff we spoke with had a good understanding of, and implemented recommendations

identified from reviews of recent incidents, complaints and safeguarding alerts. However,

staff appeared to have limited knowledge of specific learning from the review into a death

within this core service in 2016.

• Staff took part in clinical audits, which were regularly reviewed to identify areas for

improvement.

• Staff we spoke with had a good understanding of the arrangements in place for working

with other services within the trust and with external agencies.


• The trust maintained a corporate risk register and each ward maintained their own individual

risk register. Staff could propose concerns for inclusion onto the risk register. Recruitment and

retention of staff was the primary concern voiced by staff we spoke with.


• Staff had access to information and technology to support them in their work.

• Information governance systems included maintenance of confidentiality of patient records

across all wards.

• Ward managers we spoke with had access to information to support them in their role, for

example service performance, staffing and patient care.

Engagement

• The core service provided updates about their work to staff, patients, and carers through

the intranet, newsletters, social media and bulletins.

• All wards had systems in place which ensured that patients and carers could feedback in a

range of ways to ensure they could respond and make improvements.

• Patients and carers were involved in decision-making about changes to the service.

• Managers engaged with external stakeholders such as clinical commissioners and Health

Watch.


• Spenser ward had gained national accreditation with the quality network for inpatient mental

health services, operated by the royal college of psychiatrists.


• One member of staff at The Meadows had visited Ireland, to complete training in the delivery

of Sonas multi-sensory therapeutic activity sessions for people with dementia. The training

was unavailable in England.

• Staff on Spenser ward had secured funding for a pilot project to study the therapeutic benefits

of dog therapy in an inpatient setting for older people with functional mental illness. The

project was due to commence in January 2019 and will examine the effects of twice weekly

dog therapy sessions on appropriate patient volunteers who have an affective disorder, such

as depression.

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 to continue to be accredited.

The table below shows which services within this service have been awarded an accreditation

together with the relevant dates of accreditation.

Accreditation scheme Core service Service accredited Comments

Accreditation for Inpatient Mental Health Services (AIMS)

MH - Wards for older people

with mental health problems Spenser ward


Mental health crisis services and health-based places of safety


Location site name Team name Number of clinics Patient group (male,

female, mixed)

Farnham Road Hospital Health based places of safety (s136 assessment suite)

2 Mixed

St Peters site Health based places

of safety (s136

assessment suite)

2 Mixed

Trust HQ, 18 Mole Business

Park, Randalls Road,

Leatherhead, Surrey, KT22 7AD.

Home Treatment

Team East Surrey

1 Mixed




Home Treatment

Team – North West

Surrey

1 Mixed




Home Treatment

Team – South West

Surrey

1 Mixed




Safe Havens x 5 Mixed




Crisis Advice Line 1 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.

Mental Health Crisis Services Is the service safe?


Staff completed regular risk assessments of the care environment. All services had areas where

staff could meet with patients when they visited, however, staff mainly carried out home visits.

Interview rooms at Guildford (the base of the South West Surrey Home Treatment Team (HTT) and

Chertsey (North West Surrey HTT team base) were equipped with emergency alarms. However, at

Redhill (East Surrey HTT team base) used interview rooms which were not equipped with alarms.


The service mitigated the risk by providing staff with personal alarms. Staff in all HTTs told us that

patients would always be accompanied in the interview rooms.

The office environments for all HTTs had adequate rooms for staff.

The trust conducted weekly fire alarm testing at all locations. All locations had a fire evacuation plan

and fire exits were clearly signed.

None of the HTTs had clinic rooms which they would see patients in. Staff said they most often saw

patients at home and could take a kit bag containing basic physical health monitoring tools, such as

a blood pressure monitor. All HTTs had an area to store a limited amount of stock medication as

well as patients’ prescriptions. All of the teams had access to a clinic room where they could see

patients, if they needed it.

All areas appeared clean and well-maintained, and had good furnishings. Staff had access to hand

washing facilities and hand sanitiser. The North West Surrey team was based at the Abraham

Cowley Unit which was planned to be refurbished.

All teams had access to an automated external defibrillator (AED) and crash bag. This equipment

was checked regularly to ensure it was calibrated and functioning. This was something that the trust

had improved on from our last inspection in March 2016.

As part of our inspection we also visited two Safe Havens. There were five Safe Havens operating

across Surrey to support people during the evenings and weekends when they are in crisis or to

help prevent them reaching crisis. The services were run in partnership with voluntary sector

organisations. The two Safe Havens that we visited in Guildford and Redhill had interview rooms

where staff could speak with people who attended the service. None of these rooms contained

alarms. Staff at the Redhill Safe Haven told us that there had been a number of incidents recently

of aggression from people using the service, which had left them feeling less safe. Staff told us that

there was a video intercom so they could see who was at the door and they had recently had some

safety improvements at the centre but they felt there was more that could be done. At Redhill, staff

had access to a personal safety alarm device.

A new single point of access (SPA) had recently been introduced at the same site as the Redhill

home treatment team. The single point of access also incorporated the crisis line. At our last

inspection we found that people calling the crisis line were sometimes not called back and that

calls were diverted to an answerphone. On this inspection we saw that this was no longer a

problem as the new SPA did not have a voicemail facility and in the event that a call handler was

not immediately available the caller was placed into a queue whilst they waited.

Safe staffing

The service had enough nursing and medical staff, who knew the patients and received basic training to keep people safe from avoidable harm.

The provider had determined safe staffing levels by calculating the number and grade of members

of the multidisciplinary team required using a systematic approach. At night, there were two nurses

that covered the whole of Surrey. One nurse was based at Chertsey and another at Redhill. Staff

we spoke to felt that the night time staffing levels made home visits difficult.

This core service has reported a vacancy rate for all staff of 39% as of 31 August 2018. This included

a vacancy rate of 46% for registered nurses and 31% for nursing assistants.


The service managers told us that recruitment was carried out centrally and that the trust was

actively recruiting for the vacant positions, including offering financial incentives and developing

newly qualified nurses. The service had also recently filled some vacancies but were waiting for staff

members to start their roles. We found the same issue with vacancies at our last inspection in 2016

and the trust continued to actively recruit.

Service managers assessed the size of the caseloads and could adjust the staffing levels according

to needs and risk.

The teams used bank and agency staff appropriately. Managers could book bank and agency staff

easily when demand for staff increased. Managers always tried to use agency staff who were familiar

with the service to ensure consistency, long term agency staff members and only used agency staff

who had access to the patient electronic record system.

Team managers reviewed caseloads daily. At the time of our inspection South West Surrey HTT

had a caseload of 16. The North West Surrey HTT had a case load of 26 patients and the East

Surrey HTT had a case load of 31. The teams told us that their caseloads fluctuated. At our last

inspection in March 2016 we found that there was not a true reflection of patients on the case load

as some were inpatients. During our inspection we saw that the teams identified which patients were

inpatients so were easily separated from the live caseload. Having the inpatient cases within the

overall caseload did not affect them taking on new referrals.

There was no maximum caseload number which ensured that patients who were referred in an

emergency could be taken on by the team as necessary. Managers told us that they could request

additional staff to deal with a high caseload.

The service managers at the South West Surrey and East Surrey teams also oversaw the

management of their local Safe Havens. The managers told us that this was helpful in trying to

bridge the gap between the Safe Havens and the HTTs.

One nurse and two support workers staffed each Safe Havens. During our inspection we visited two

Safe Havens, one in Guildford and one in Redhill. The trust provided the nurse and the partnership

voluntary organisation provide the support workers for the Safe Havens. Staff at the Safe Havens

were not always aware of who would be on shift that week and had reported issues with the nurse

not turning up for their shift. Staff reported that this happened on average twice a month and when

it did the Safe Haven was unable to open.

New staff in the home treatment team were provided with a comprehensive local and trust induction

and provided with a mentor.

The service had rapid access to the psychiatrist on duty when required. Staff used the duty on-call

medical staff if a psychiatrist was required out of hours.

The new single point of access was only in the first few weeks and had not yet been rolled out for

the whole trust. The plan was for it to be active for the whole trust at the start of 2019. Recruitment

for the SPA was ongoing with some vacancies filled, some staff shortly to start and other positions

that were still vacant.



Location Ward/Team

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Trust HQ, 18

Mole Business

Park

Safe Haven

Epsom Downs 1.2 1.3 92% 0 0 0 1.3 1.4 92%

Trust HQ, 18

Mole Business

Park

HTT East

Surrey 16.8 25.4 66% 5.5 10.5 52% 24.7 41.7 59%

Trust HQ, 18

Mole Business

Park

Safe Haven

Guildford 0.6 1.3 45% 0 0 0 0.7 1.4 49%

Trust HQ, 18

Mole Business

Park

Safe Haven

Aldershot 0.6 1.6 39% 0 0 0 0.7 1.7 43%

Trust HQ, 18

Mole Business

Park

HTT North

West 4.0 11.0 36% 0.5 2.5 20% 3.4 14.9 23%

Trust HQ, 18

Mole Business

Park

HTT South

West 2.1 9.1 23% -1.0 1.6 -63% 1.7 11.3 15%

St Peters Site HTT NEH and SH

2.0 10.0 20% 0.5 3.0 16% 1.4 13.9 10%


Trust total 157 616 25% 116 512 23% 265 1686 16%


Between 1 September 2017 and 31 August 2018, of the (52, 501) total working hours available,

26% were filled by bank staff to cover sickness, absence or vacancy for qualified nurses.




Wards Total

hours

available

Bank Usage Agency Usage NOT filled by

bank or

agency

Hrs % Hrs % Hrs %

Home Treatment Team- North West

Surrey 16, 976 5, 939 35% 3, 489 21% 1, 224 7%

Crisis Advice Line 1, 574 0 0% 668 42% 7 0%

Home Treatment Team East Surrey 17, 063 688 4% 12, 415 73% 546 3%

Health based places of safety (s136

assessment suite) 1, 311 806 61% 494 38% 11 1%

Home Treatment Team South West 9, 701 4, 748 49% 1, 335 14% 468 5%


Wards Total

hours

available


bank or

agency

Hrs % Hrs % Hrs %

Safe Havens x 5 5, 876 1, 273 22% 2, 012 34% 204 3%

Core service total 52, 501 13, 454 26% 20, 412 39% 2, 460 5%

Trust Total 372, 138 57, 144 15% 100,

927 27% 12, 752 3%

Between 1 September 2017 and 31 August 2018, 57% of the total working hours available

(47,644) were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.




Wards Total hours

available


bank or

agency

Hrs % Hrs % Hrs %

Home Treatment Team-Surrey 3302 2087 63% 0 0% 315 10%

Crisis Advice Line 0 0 0% 0 0% 0 0%

Home Treatment Team Redhill

Surrey 3934 704 18% 670 17% 310 8%


assessment suite) 12845 6023 47% 0 0% 384 3%

Home Treatment Team-Guildford

Surrey 17042 12741 75% 2630 15% 495 3%

Safe Havens x 5 0 0 0% 0 0% 0 0%


assessment suite) 2890 345 12% 0 0% 296 10%

HTT South West Surrey 7631 5326 70% 1088 14% 42 1%


Trust Total 475470 195621 41% 27638 6% 24184 5%

This core service had six (7%) staff leavers between 1 September 2017 and 31 August 2018.

Wards Substantive staff (at

latest month)

Substantive staff

Leavers over the last

12 months

Average % staff

leavers over the last

12 months

Safe Havens x 5 6 1 31%


Wards Substantive staff (at

latest month)

Substantive staff


12 months

Average % staff

leavers over the last

12 months

Home Treatment Team East

Surrey 14 2 30%

Home Treatment Team-South

West Surrey 10 3 28%

Health based places of safety (s136 assessment suite)

11 0 0%

Health based places of safety

(s136 assessment suite) 10 0 0%

Crisis Advice Line 4 0 0%


(s136 assessment suite) ACU 7 0 0%


(s136 assessment suite) FRH 10 0 0%

Home Treatment Team-North

West Surrey 23 0 0%

Core Service Total 95 6 7%

Trust Total 1391 236 18%

The sickness rate for this core service was 5% between 1 September 2017 and 31 August 2018.

The most recent month’s data (31 August 2018) showed a sickness rate of 6%.


(31 August 2018)


sickness (1 September

2017 – 31 August 2018)

Trust HQ, 18 Mole

Business Park

Home Treatment Team

East Surrey 14.8% 13.9%

Trust HQ, 18 Mole

Business Park

Home Treatment Team-

South West Surrey 2.0% 5.2%

St Peters site RXXW1 Health based places of

safety (s136 assessment

suite) ACU

6.0% 4.9%

Trust HQ, 18 Mole

Business Park

Home Treatment Team-

North West Surrey 2.6% 2.9%

Trust HQ, 18 Mole

Business Park

Crisis Advice Line 0.0% 0.8%

Trust HQ, 18 Mole

Business Park

Safe Havens x 5 0.6% 0.1%



Medical staff

Between 1 September 2017 and 31 August 2018, 0% of the 1, 200 total working hours available

were filled by bank staff to cover sickness, absence or vacancy for medical locums.





Staff we spoke to in the South West HTT felt that additional medical input from junior doctors would

help in improving the confidence in the team, as they would be able to review patients more

frequently.

Ward/Team Total

hours

available


bank or agency

Hrs % Hrs % Hrs %

Home Treatment Team-North West Surrey

840 0 0% 840 100% 0 0%

Home Treatment Team-South West

Surrey 360 0 0% 0 0% 0 0%

Core service total 1, 200 0 0% 840 70% 0 0%

Trust Total 13, 876 0 0% 8, 216 59% 0 0%

Mandatory training

The service provided mandatory training in key skills to all staff and the majority of the staff had completed it, although this fell short of the trusts target.


training courses listed nine failed to achieve the trust target and of those, none failed to score above

75%. The trust set a target of 95% for completion of mandatory and statutory training.

Managers informed us that training was discussed at supervision meetings and where there were

gaps, training had been booked.

At the last inspection in March 2016, the HTTs did not always support staff to complete their mandatory training. At this inspection improvements had been made. The trust provided mandatory training in key skills to all staff. Overall staff compliance with training at the time of the inspection was 86%. However, this was below the trust target of 95%. Managers monitored staff attendance at required training during individual supervision.

Key:


✓

Not met trust

target

Higher

No change

Lower


eligible

staff

Number of

staff

trained

YTD

Compliance

(%)

Trust

Target

Met

Compliance

change when

compared to

previous year

Clinical Risk Assessment 61 59 97% ✓

Information Governance 78 74 95% ✓






eligible

staff

Number of

staff

trained

YTD

Compliance

(%)

Trust

Target

Met

Compliance

change when

compared to

previous year



Other 475 394 83%

Manual Handling - People 52 42 81%



Total 1140 979 86% ✓


Assessment of patient risk At the last inspection in March 2016, we found that staff in the home treatment team had not ensured

its risk assessment process identified, assessed and managed the risk to the health and safety of

patients. At this inspection we saw that this had improved, although there were some risk

inconsistency and omissions in the South West Surrey team records and handover. We spoke to

the manager about both of these during the inspection and they assured us that they would be

corrected. The manager informed us that the team was working to improve the care plans and

records.

Staff completed and updated risk assessments for each patient. They followed best practice and the Mental Health Act when restricting patients’ freedoms to keep them and others safe. We saw that comprehensive risk assessments were recorded in the care records.

Staff told us that they would discuss any sudden deterioration of a patient with the shift coordinator,

team leader or doctor and take the appropriate action, as well as being discussed in the daily

handover meeting.

Staff completed a risk assessment for every patient during an initial assessment. Staff used the

trust’s risk assessment tool, which was part of the electronic patient record system. We saw all the

HTTs revisited every patients risk level every morning at the morning meeting and after specific

incidents or visits.

Staff told us that where patients were already known to services their crisis plans and advance

decisions were already developed by the community mental health teams and that the role of the

crisis team was to develop the short-term plan for treatment whilst the patient was in crisis and with

the home treatment team.

As part of the expectations on the first appointment with a patient, staff were expected to complete

a crisis and contingency plan. However, staff told us that this was not always appropriate to complete

with the patient whilst they were in crisis and that it was more appropriately completed once the

patient was no longer in crisis by their community team. In effect the home treatment team care plan

was the crisis plan for the period of time that the person was receiving support from the home

treatment team.

We saw that patients’ views were incorporated where possible.


Staff gave patients the home treatment team contact numbers, crisis line number and details of the

Safe Havens to use whilst they were receiving home treatment team support if they needed to

contact someone or had worries about their health.

The HTTs were provided with an admission and discharge checklist to assist them in ensuring all

the appropriate steps were taken with each patient.


All three teams had a comprehensive daily handover meeting where they discussed the patients on

their caseloads. We attended a daily handover meeting in each team.

East Surrey HTT managed the patients using a white board, we noted that there was no

safeguarding, nor carers information noted on the board, despite the team discussing safeguarding

and carers during the meeting. The other two HTTs used an electronic projection of the electronic

patient notes. During the South West Surrey HTT handover we saw the manager checked all the

care plans and risk assessments and discussed any discrepancies with the team. During the

morning handover meeting all three teams updated the patients’ electronic records as they were

being discussed.

All three teams had recently introduced the SBAR handover. This was introduced following learning

from a serious incident. SBAR stands for situation, background, assessment, recommendation. This

is an easy to use, structured form of communication that enables information to be transferred

accurately between individuals. There was some concern from staff in the South West Surrey HTT

that there was a lack of clarity about which is the ‘master’ document for records, risk assessments,

progress notes and care plans on SBAR. It had only very recently been introduced at East Surrey

HTT and the team was still getting used to using it.

Staff held clear discussions about individual patient risks and documented these discussions in each

patient’s progress notes. Discussions included social needs, safeguarding needs and patients’

medicines.

None of the three HTTs had waiting lists and accepted all referrals.

Staff followed the trust’s lone working policy to ensure their safety on home visits. Staff used

electronic personal devices (Skyguard), which were able to track their location and had mobile

phones. If the risk was deemed high, staff were able to go in pairs on visits. At night there were

only two lone nurses covering the whole of Surrey and staff told us they would not feel comfortable

doing lone visits at night.

A twice daily telephone conference with all the HTTs and inpatient wards discussed bed availability

across the trust. We observed two of these calls, which were well organised and well attended by a

representative of the wards and HTTs. Patients who were waiting for a bed were monitored in the

community by the home treatment team until a bed was found. At the time of our inspection none of

the HTTs were seeking an inpatient bed for a patient on their caseload.

Staff told us that there was no policy to follow up high risk patients in the 48 hours after they were

discharged. In the event that they were referred to the community mental health team they would

be followed up within 7 days of the referral.

Safeguarding





institutional.




to determine whether an external referral to Children’s Services, Adult Services or the police should

take place.


2018, of which six concerned adults and 12 children.

The number of adult safeguarding referrals in month ranged from zero to two.

The number of child safeguarding referrals ranged from zero to four.

Staff understood how to protect patients from abuse and the service worked effectively with other

agencies such as the local authority in a joint effort to protect patients. The trust trained staff in

safeguarding vulnerable adults and children. All the teams reported a good relationship with the

local safeguarding structures. During our inspection, members of staff in the teams we visited were

able to tell us about safeguarding concerns that had been raised over the previous year.

We were told that where safeguarding concerns were identified, these were raised through the trust

incident reporting system to ensure that the numbers of referrals made could be tracked through the

trust governance systems.


At our previous inspection in 2016 the trust had not ensured that the patient electronic record system

met the needs of the trust and staff. On this inspection staff told us that they received regular training

and support to use the patient electronic record system. Staff were able to contact the support team

for specific questions and gave an example of when they recently contacted the support team to get

information about linking care plans and risk assessments.

Staff used electronic records to keep information updated about individual patients. This meant

that all information needed to deliver patient care was available to all relevant staff when they

needed it and in an accessible form.


At our previous inspection in March 2016 we found the trust did not ensure that staff completed

records to include all patient information including allergies. However, on this inspection we saw

that this was now being routinely done.

We checked the medication charts at East Surrey HTT and North West Surrey HTT and found no

problems.

The South West Surrey HTT had a nurse prescriber in the team.


Staff stored medicines securely within locked clinical treatment rooms. No medicines requiring

refrigeration were kept in the services we inspected, but there were fridges available if needed. No

controlled drugs were kept on the premises.

Clozapine and lithium care plans were in place for patients who needed them.

All teams were well supported by pharmacy colleagues. The pharmacists audited the medication

cupboards on a regular basis.

Occasionally the teams had patients who were prescribed high doses of anti-psychotic medication,

if they were they would be monitored by the team in line with national guidance.


Between 1 September 2017 and 31 August 2018 there were two serious incidents reported by this

service. Of the total number of incidents reported, both incidents were ‘Apparent/actual/suspected

self-inflicted harm’. There were no unexpected deaths relating to this core service.



by the trust incident reporting system was comparable with STEIS with two reported.



reporting period.


Type of incident reported (SIRI) Apparent/actual/suspected self-inflicted harm Total

Home Treatment Team- East Surrey 1 1

Home Treatment Team- North West

Surrey

1 1

Total 2 2


Staff knew what incidents to report and how to report them. Staff reported incidents on the trust’s

electronic incident reporting system. Staff were clear about the types of incident they should report,

including missed visits, safeguarding, and violence and aggression.

Staff understood the duty of candour. They were open and transparent and explained to patients

and families when something went wrong. The duty of candour is a regulatory duty that relates to

openness and transparency.

Some staff at all the HTTs were able to give examples of learning from serious incidents that

happened within their teams. However, not all staff knew all the serious incidents that had happened

recently in their team, nor in the other HTT. Staff told us that an email bulletin was sent around with

them in and that they were discussed at team meetings.


We saw a document produced by the trust which shared the learning and reflected on an earlier

death which had occurred of a patient who was under the care of the home treatment team.

The teams made improvements following incidents to prevent similar incidents re-occurring in future.

Managers debriefed and supported staff after a serious incident. Staff told us that the trust also

operated a voluntary support group for staff to receive support from other staff during a Serious

incident being investigated.

The North West HTT received monthly reflective practice sessions. The East Surrey team had

recently restarted their monthly complex case and reflection sessions.

All three teams had recently introduced the SBAR handover, following learning from a serious

incident.

Health-based places of safety Is the service safe?

Safe and clean environment The HBPoS at Farnham Road Hospital, in Guildford, contained two custom built, wheelchair

accessible suites with en-suite toilets located next to the home treatment team. There was also

access to a shower. At the time of our visits one of the suites was temporarily closed for

refurbishment, due to damage caused by a patient. The suite had its own entrance for ambulance

staff or police at the back of the hospital. There was and no access to fresh air from either suite.

Both suites had CCTV cameras and the CCTV images were viewable in the nurses’ office. There

were blind spots in both bathrooms. However, staff mitigated the risks through observations. In the

event that the emergency alarm was triggered staff from the home treatment team or ward would

be allocated to respond. The assessment suite was clean and tidy and the HBPoS used furniture

that would not cause injury. For example, the bed was made of foam. Resuscitation equipment was

kept in the nurses’ office and was checked by staff on the weekends. There was a two-way

communication system and a clock visible for patients in the suite.

However, in one of the suites we saw raised screw heads which could be used by a patient to hurt

themselves. We informed staff of this during the inspection.

The HBPoS at the Abraham Cowley Unit in Chertsey was accessed by one of two ways, either by

a small yard for staff only or by one of the inpatient wards, Blake ward. Two suites, both with en-

suite toilets were situated with the nurses’ office in-between. Both suites had CCTV which could be

viewed in the nurses’ station. Staff who worked in the suite told us that they did not feel safe as if

the patient came out of the suite they would be in the nurse’s office. The suites contained a normal

bed, which could be used by a patient to cause harm and would mean that it could be difficult to

manage a disturbed person in the suite. If staff required the use of a clinic room or resuscitation

equipment they could use the clinic room on the ward.

Both suites appeared clean with the furniture in good order.

There was no privacy screen on the window which backed onto the yard in the HBPoS in Chertsey,

which meant that patients could be seen from the yard.


During our inspection staff told us that there was an action plan to address the environmental

problems at the Chertsey HPBoS, the bed was due to be replaced with a soft foam bed and a soft

door was going to be placed on the bathroom door, a privacy screen was going to be placed on the

window and they were going to re-locate the nurse’s office, The new office had been set up and was

due to be opened once it had a IT connection.

Staff carried out regular risk assessments of both suites and a yearly ligature assessment was

carried out to manage and reduce the risk of ligature points. A ligature anchor point is an

environmental feature or structure, to which patients may fix a ligature with the intention of harming

themselves.

Safe staffing

Both health-based places of safety were staffed 24 hours a day with two dedicated health care

assistants, however they did not have a dedicated nurse. We were told that they were recruiting to

enable each HBPoS to have a dedicated nurse. At the Guildford HBPoS the team leader was

supporting the HBPoS whilst they recruited.

Staffing levels could be increased depending on the needs of the patients.

The Guildford health-based place of safety was based next to the Guildford (South West Surrey)

home treatment team and the home treatment team provided support if an alarm was activated. The

Chertsey health-based place of safety was based on Blake ward at the Abraham Cowley Unit and

the ward staff provided a response if needed.

There was good medical cover day and night. Overall, staff in this service had undertaken 87% of the various elements of training that the trust had set as mandatory.


Staff used the trust risk assessment tool, this was then updated following the Mental Health Act

assessment.

When a new patient arrived at the HBPoS the duty doctor was only called to do an initial check of the patient if they appeared intoxicated, were under the age of 18, needed medication, had been in an accident and emergency department or if the full assessment by the doctor and approved mental health professional was likely to be in more than three hours’ time. We checked the records and saw evidence of the duty doctor seeing patients who were on medication or intoxicated. The healthcare assistants carried out a basic physical health check when the patient was admitted to the HBPoS and repeated it if the patient’s risk was high.

Staff reported that they sometimes used rapid tranquilisation when patients were being assessed

on the unit. During our inspection staff treated a patient with rapid tranquilisation. We looked at the

records for this patient. The doctor had not indicated in the records the legal rationale for

administering the medication and there was no record that staff had monitored the patient’s physical

health following the medication. After the inspection the trust confirmed that the legal rationale had

been recorded for this patient.

Staff told us that there were no delays in accessing AMHPs or section 12 doctors.


The manager told us that no staff had been injured in the past three months.


Staff were able to respond promptly to a sudden deterioration in a patient’s health as they were

able to view them on CCTV as well as carrying out hourly checks.

Staff told us that they were trained in conflict management, conflict resolution, physical

intervention and restraint reduction.

Safeguarding

Staff had completed safeguarding training as part of their mandatory training programme with the

trust. Staff we spoke with understood safeguarding processes and how to respond to concerns

relating to both adults and children. Staff were able to discuss safeguarding concerns with the

approved mental health professionals (AMHPs) and the service manager.


All information needed to deliver patient care was available to all relevant staff when they needed

it and was in an accessible form. Staff used a specific section 136/135 monitoring form that

included information on contact with the police, accident and emergency, AMHPs and section 12

approved doctors. Section 12 approved doctors are doctors who are specially trained in the Mental

Health Act. Section 135 and section 136 of the Mental Health Act allow a person to be taken to a

place of safety from a public or private place, if there is concern that they are suffering from a

mental disorder.

All the trust’s policies and procedures were easily accessible on the intranet for staff and most

staff were aware of them.

Medicines management The trust had recently made changes to the service’s medical management following learning from

a serious incident. A memo to all staff had recently been sent updating them regarding the

prescribing and supply of medication in the HBPoS.

The Medication Safety Pharmacist told us that they reviewed medicines incidents on a quarterly

basis and had developed a new health-based place of safety supply procedure following on from

an incident earlier this year.

An additional nurse was being recruited to work at either Farnham Road or Chertsey health-based

place of safety to provide additional support and an additional team leader would be recruited who

would oversee medications.

However, we found that there was still some uncertainty amongst staff as to who was responsible

for storing and administration of patients own regular medications whilst in the HBPoS.


A small stock of nicotine replacement products was stored safely and securely in a locked medicines

cupboard. Keys to the medicines cupboard were held by one of the healthcare workers.

Prescriptions were written on a Home Treatment Team Medicines Administration Record and small

supplies of other medicines, sufficient to cover up to a 48-hour period, were obtained from the home

treatment team or other wards as required.

Medicines brought in by patients were checked, held securely and recorded and then returned to

patients on discharge.

We reviewed three prescriptions for recent patients and saw that allergies were accurately recorded,

and that prescribing of medicines was appropriate, legible, signed and dated.

Overall, from the prescriptions reviewed, there was minimal medicines use in the health-based

places of safety. Out of the three prescription charts, only one patient had had one medication

(oral lorazepam 1mg) administered once. However, staff were aware of how to access pharmacy

support if needed.

We saw that treatments to help manage the symptoms of alcohol withdrawal were prescribed so

that they were available to people at the health-based place of safety who needed it.

There were no emergency medicines in the health-based places of safety but there was a green

Grab Bag (including oxygen) and a defibrillator and suction pump.

The Medication Safety Pharmacist showed us the quality checks they undertook per ward and told

us that there was a specific quality check for the health-based places of safety that comprised a

number of audits and a summary report. The checks were undertaken every six months.

Reporting incidents and learning from when things go wrong Staff knew how to report an incident using the trust electronic system and did this when necessary. Staff told us that they received feedback from incidents at supervision and meetings. Staff were debriefed and received support after serious incidents.

Mental health crisis services Is the service effective?


At our last inspection in March 2016 we found that care plans were not holistic nor comprehensive

and did not demonstrate patient involvement. On this inspection we saw the trust had made

improvements.

We checked 14 care records across the three HTT teams we visited. All care records contained an

up to date holistic care plan and an up to date risk assessment. However, we found that care plan

documentation at the Guildford and Redhill teams on the electronic database was not consistently


recorded to a standard that reflected the work which was undertaken in the team. Staff had a good

understanding of the care that patients received.

Staff told us that care plans were not always as detailed as they could be due to time restraints. We

found that care plans were not always patient-centred in terms of looking at patients’ views and

needs and were more about the HTT actions. The South West Surrey team were aware of this issue

and told us that there was a trust-wide initiative to improve care plans.

We did not find this at the North West Surrey home treatment team where we found the care plans

and risk assessments to be comprehensive.

We also saw at the South West Surrey team that the allocated shift coordinator allocated new

referrals by cross referencing the SBAR plans and clarified at the handover. We were told that in

the South West Surrey home treatment team if the shift coordinator was out on visits then new

referrals would go to an answerphone machine.

We saw that records indicated family/carer involvement and most patients had a consent to share

information form completed.

We saw that there was basic physical health monitoring of patients, often limited to blood pressure

and weight.


This service participated in four provider wide clinical audits as part of their clinical audit

programme 2017 – 2018, all of them were provider wide and not specific to this core service.

Audit name Audit scope Audit type Date

completed

Key actions following the audit

Healthcare associated infections (including handwashing)

All services Clinical and environmental


MH CQUIN

Indicator 3A

Cardio

Metabolic

Assessment

People using

services who

use our

inpatient or

Community

services, who

have a

diagnosis of

psychosis

relating to

either

schizophrenia

or bipolar

Clinical 01/06/2018

(published)

A robust Trust-wide action plan is in place to

support improvement in monitoring physical

health and referring on for interventions

when needed. In addition, there has been a

QI project to support Health clinics to

operate within our inpatient services. Health

clinics are in the process of being rolled out

to our Community teams. Our EIIP teams

have introduced the initiative of a ‘lab in the

bag’ which will mean that the resources

needed for physical health checks in the

community will be readily available. In

addition, our EIIP teams will use the

CMHRS health clinics when they are

available in all areas

CARE

excellence

accreditation

All services Service wide Ongoing -

self-

assessments,

peer reviews

All services have individual action plans to

work through. Themed training sessions

have been provided to help guide staff as

well as bite sized information guides.

Supervision will be a mandatory standard


Audit name Audit scope Audit type Date

completed

Key actions following the audit

and re-

reviews

on our Foundation standards tool as from

end 2018.

Record

keeping

audits

All mental

health

services

Records Ongoing -

monthly

All teams must review their information on a

regular basis and address any gaps in

supervision and share good practice within

their teams. Record keeping is reviewed as

part of the Foundation standards review.

The service provided patients with a range of evidence-based treatments based on national guidance suitable for the patient group. The interventions were in line with National Institute for Health and Care Excellence guidelines, including prescribing medicines and psychological therapies. Staff supported patients and encouraged them to live healthier lives.

Patients under the care of the South West Surrey and North West Surrey HTTs could access a full

timetable of psychology, therapy and occupational therapy. This was provided by the acute care

therapy service (ATS) which was integrated into the acute care pathway, based on the nearby ward.

The East Surrey team did not have access to this but were able to refer patients to psychology and

occupational therapy through the Community Mental Health Teams. The Guildford ATS only had

psychology provided by a part time staff member, which meant that at times it could be difficult to

access psychology for HTT patients.

The psychologist at the North West Surrey HTT attended the handover meeting once a week.

Staff were able to signpost patients to local organisations and charities.

Both the South West and North West Surrey HTTs had full time social workers in the teams.

Staff supported patients to live healthier lives. For example, through participation in smoking

cessation schemes, acting on healthy eating advice and healthy living.

Staff participated in clinical audits and quality improvement initiatives. This included audits of treatment, consent from patients and care plans.




so far, the overall appraisal rates was 72% (as at 31 August 2018). The wards with the lowest

appraisal rate at 31 August 2018 were Safe Havens with an appraisal rate of 0% and the Crisis

Advice line with an appraisal rate of 33%


permanent non-

medical staff

requiring an

appraisal

Total number of

permanent non-

medical staff who

have had an

appraisal

% appraisals

(as at 31

August 2018)

% appraisals

(April 2017 –

March 2018)

Home Treatment Team-South West Surrey

6 6 100% 50%



permanent non-

medical staff

requiring an

appraisal

Total number of

permanent non-

medical staff who

have had an

appraisal

% appraisals

(as at 31

August 2018)

% appraisals

(April 2017 –

March 2018)

Home Treatment Team-North West

Surrey 17 15 88% 45%


assessment suite) FRH 10 8 80% 70%

Home Treatment Team East Surrey 9 5 56% 71%


assessment suite) ACU 7 3 43% 57%

Crisis Advice Line 3 1 33% 100%

Safe Havens x 5 1 0 0% 100%


Trust wide 858 649 76% 80%

Managers made sure they had staff with a range of skills need to provide high quality care. They supported staff with appraisals, supervision, opportunities to update and further develop their skills.

The trust’s target rate for appraisal compliance was 93%, all the staff at the HTTs had received

their appraisals for this year.

The teams at South West Surrey and North West Surrey included a range of specialists and health

care professionals to meet the needs of patients, included doctors, nurses, healthcare assistants

and social workers. The East Surrey team consisted of doctors, nurses and healthcare assistants.

The service manager at the South West Surrey team informed us that staff could access additional

training in courses such as nurse prescribing, positive risk taking and Autistic Spectrum Disorder.

At all three sites we saw that staff were regularly receiving supervision. There were gaps in the

supervision in the East Surrey team prior to the new manager starting three months ago. Since the

new manager started the supervision was regular. The teams used the trust’s prescribed supervision

format.

Staff at the new single point of access were regularly supervised and reflection sessions for difficult

cases were held at team meetings.

All three teams received administrative support, which included amongst other things, support in the

daily handover meeting, answering the telephones, and contacting patients to make appointments.


Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care.


All members of the multidisciplinary team regularly attended the individual team’s daily morning

handover meeting. Each HTT also held a monthly team meeting. The team meeting was used to

review lessons learnt from complaints, incidents, serious incidents, and safeguarding. The three

HTTs also met to share good practice and discuss any issues.

We were told by the doctors that they often contacted the patients’ GPs to check when the

patients last received a physical health check.

All three HTTs liaised with their local inpatient wards. Staff felt that communication could be

improved as they were not always involved in the decision making to discharge patients from the

wards to the HTT.

Some staff that we spoke to had concerns about the recruitment to the single point of access. As

part of the roll out of the single point of access the trust worked with all staff and understood the

concerns that people in HTTs had about the interface with the single point of access. The trust had

spoken to staff as part of the consultation process and explained that they would not be asked to

work in two teams at the same time. To date no HTT staff have been required to cover the single

point of access.

The South West Surrey HTT had conference calls with the community mental health recovery

service to discuss cases and work together.


Practice

Staff understood their roles and responsibilities under the Mental Health Act. As of January 2019,

85% 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 three years.

Staff had easy access to administrative support and advice on the implementation of the Mental Health Act and its Code of Practice. Social workers were based in the South West Surrey and North West Surrey teams. The approved mental health professionals (AMHPs) were based in the same building and staff could approach them for guidance.


Staff that we spoke to understood the Mental Capacity Act and the five statutory principles that

underpin it.

At the time of the inspection, 90% 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 and renewed three years.

The Guildford team had produced a card for staff with the key principles of the Mental Capacity

Act as a reminder whilst out on visits.

Health-based places of safety Is the service effective?



The HBPoS had a clear process for how to manage a person who was detained under section 136

of the Mental Health Act. The trust had a specific form for staff to document key information, such

as time of arrival and time the assessment was completed. A comprehensive mental health

assessment was carried out of each patient by an AMHP and two doctors.

A twice daily telephone conference with all the HTTs and inpatient wards discussed bed availability

across the trust.

The two HBPoS were coordinated centrally at Guildford (Farnham Road Hospital) health-based

place of safety.

Best practice in treatment and care Staff used technology to support patients effectively, for example the health based places of safety

contained interactive screens.

Patients had access to food and drink throughout their stay in the health-based places of safety.

However, staff at the Chertsey HBPoS were unable to provide patients with a safe bowl so

patients had to eat their breakfast out of a plastic cup.

Skilled staff to deliver care At our last inspection in March 2016 we saw that the assessments of young people and people with a learning disability took longer to achieve due to the availability of section 12 approved doctors. The team included or had access to the full range of specialists required to meet the needs of patients at the HBPoS. For example, the unit had access to a child and adolescent, older persons and learning difficulty specialist consultant, as required. We checked the records and saw evidence of a child and adolescent doctor seeing a patient under the age of 18.Seeing a child and adolescent doctor did not cause a delay in the assessment. Staff were experienced and qualified, and had the right skills and knowledge to meet the needs of the patient group. Staff in the HBPoS received monthly supervision from the service manager of the HTT. An approved mental health professional (AMHP) was allocated each day to the HBPoS and staff reported a good working relationship with the AMHP team.

Multidisciplinary and interagency team work The HBPoS had a good working relationship with both the police and the ambulance service and

met with the police. The trust also had a police liaison officer, provided by Surrey Police.

The trust held an up-to-date local crisis care agreement, which agreed the roles and responsibilities of the trust, local authorities, the police and acute trusts within Surrey and North-East Hampshire in respect of sections 135 and Section 136 of the Mental Health Act 1983 (as amended in 2007). The trust and Surrey Police were working together to try to reduce admissions to the health-based places of safety through their Surrey High Intensity Partnership Programme (SHIPP). This


programme involved the police and trust working together to support some of the most vulnerable and high-risk patients in the county. Staff told us that the police called ahead before they brought a patient to the HBPoS and that the

central coordination of the two sites was by Farnham Road Hospital. This system ensured that

before the detained individual arrived at the HBPoS arrangements could be made for the person to

be assessed as soon as possible.

The HBPoS had a good relationship with the AMHP service and found the AMHP service to be

responsive


Practice

Staff had a good understanding of the Mental Health Act and completed Mental Health Act training

as part of their mandatory training requirements.

Staff worked collaboratively with external agencies, such as the police to ensure patients brought to the places of safety under section 135 or detained under section 136 were not held for longer than 24 hours, in line with the Mental Health Act. In the three-month period from September to December 2018 only 10 patients who were held for longer than 24 hours. Most of the 24-hour length of stay breaches were caused by staff not being able to locate an inpatient bed. Comprehensive records were centrally kept with the Mental Health Act administration team. We saw, amongst other things, that all the start times of the detention in the HBPoS suite were kept, as well as all the assessment times by the section 12 doctor and AMHP. In light of our inspection, the Mental Health Act Administration team carried out a spot check audit on 16 of their records which demonstrated that the correct documentation for their detention under the Mental Health Act was complete, including that their rights had been explained to them.


Staff had training relating to the Mental Capacity Act as a part of their mandatory training. Staff should document consent for any treatment given whilst a patient is in a health-based place of safety. Section 135/136 does not give power to treat without consent (although emergency medicines may be prescribed under common law). We saw a patient being given rapid tranquilisation without the reason documented. After our inspection the trust confirmed that this had been recorded.

Mental health crisis services Is the service caring?



Staff attitudes and behaviours when interacting with patients showed that they were discreet, respectful, and responsive providing patients with help, emotional support and advice at the time they needed it. However, in the East Surrey HTT we observed some slightly inappropriate comments whilst discussing patients such as derogatory and generalised comments about patients with mental health diagnosis.

Staff directed patients to other services when appropriate. For example, fellowship meetings. We spoke to one patient who said that they found the staff to be very professional and caring. They also told us that they had the opportunity to attend therapy groups which were supported by the HTT. The patient felt involved in their care planning.

Staff understood the individual needs of patients, including their personal, cultural, social and religious needs. We saw staff addressing patients’ cultural and social needs when discussing them in the daily handover.

Staff we spoke with discussed patients and carers with respect and this was reflected in the progress notes and documentation that we saw. Staff had a good understanding of the individual needs of patients and displayed enthusiasm in their desire to provide a positive experience of the service to people who used it and to carers.

During our inspection we visited Safe Havens in Guildford and Redhill and spoke to six people using the services. They were very complimentary of the service and had found it very useful. However, they reported that the hours had recently changed and they had found this difficult. People who used both the Safe Haven in Guildford and Redhill commented that they had had occasions when they were waiting outside for the service to open, to be told that the service was unable to open due to insufficient staffing.

Involvement in care


Staff communicated with patients so that they understood their care and treatment, including

finding effective ways to communicate with patients with communication difficulties, staff told us

that they could easily access interpretation and British sign language.

Staff gave patients an information pack on admission. This included information about the service, a phone number and out-of-hours contact line. Staff told us that there was an independent advocacy service that patients could access, if they

wanted to.


We saw that carers were involved where patients had given consent and that the input of carers was discussed within the team. Staff emphasised the importance of engaging with family and carers in order to gain information about the patient and to support the patient in their recovery. Staff at the East Surrey HTT told us that they were able to refer carers for assessments from the community mental health team carers lead and to local groups for support.


Health-based places of safety Is the service caring?


Staff attitudes and behaviours when interacting with patients showed that they were discreet, respectful and responsive providing patients with help, emotional support and advice at the time they need it. Staff gave patients information about the HBPoS on their arrival and in the event that an interpreter was required, staff were able to obtain one.

Mental health crisis services Is the service responsive?

Access and waiting times

People could access the service closest to their home when they needed it. The service had clear

criteria for which patients would be offered a service and did not have an exclusion criterion. The

service did not use waiting lists and aimed to assess all patients referred within a four-hour

window. All teams stated that they were meeting this four-hour target most of the time.

Referrals came from liaison psychiatry teams, GPs, inpatient wards, Safe Havens and community

teams. The new Single Point of Access (SPA) was operational in the East Surrey team. Staff who

worked on the SPA said that once it was fully rolled out across Surrey it would take self-referrals.

The new Single Point of Access incorporated the crisis line. At our last inspection in March 2016

we saw that not all calls from the crisis line were being answered. This was no longer an issue as

calls were placed in a queue rather than being sent to an answer phone if a call handler wasn’t

available.

Staff could be flexible in the appointments which were offered to patients. Most often staff saw

patients at home or at the home treatment team base. However, staff also gave us examples where

they had seen patients in other places, such as college, if there was somewhere appropriate to

meet.

Staff told us at the North West Surrey HTT that it was important for appointments to run on time

and that staff were mostly able to keep to appointment times.

The Safe Havens were open every day of the year between 6pm and 11pm. Between 6pm and

8pm people could drop in for peer or well-being support and then between 8pm and 11pm the

service was designed for patients to drop in who were in crisis. Patients and staff told us that there

had been occasions when the Safe Haven’s did not open due to insufficient staffing.

The facilities promote comfort, dignity and privacy

The design, layout, and furnishings of the services supported patients’ treatment, privacy and

dignity. The service had a range of rooms and equipment to support treatment and care. Each site


had access to interview rooms and chairs in the reception area where patients waited. Interview

rooms had adequate sound-proofing.

The service had a wide range of leaflets and information available in the offices for patients to take

away and read. This included information about local services on offer as well as information leaflets

about mental health, health promotion and medication. Information was available in a variety of

community languages on request.

The teams also had the option of referring patients to third sector overnight stay in a crisis house.

This could be used a short-term stay, as an alternative to an inpatient stay. Crisis houses offer

intensive, short-term support to help you manage a mental health crisis in a residential setting

(rather than in a hospital).


Staff told us that they could refer patients to voluntary organisations who are able to assist with

finding employment, alcohol or substance issues and employment support.


The service was accessible to all who needed it and took account of patients’ individual needs. Staff within the teams we visited also spoke a variety of languages which helped in supporting diverse communities.

Listening to and learning from concerns and complaints Staff told us that they received few complaints but that when they did, they knew how to handle complaints appropriately. Staff could give us examples of past complaints and how they were appropriately handled. Patients knew how to complain or raise a concern and were provided with information in their welcome packs on how to complain.

Health-based places of safety Is the service responsive?


Patients had access to the health-based places of safety 24 hours a day, seven days a week.

The trust did not restrict access to people who needed to access the health-based place of safety based on age (they accepted under 18s), if they had a history of violence, had committed a criminal offence or possible intoxication. In the event of a person under the age of sixteen being brought in, Farnham Road Hospital was the designated HBPoS.

Neither HBPoS had required to be closed in the 12 months prior to our inspection. Both places of

safety contained two beds, so even if one bed was closed for refurbishment the suite could remain

open.


Staff worked hard to ensure that an assessment by the doctor and AMHP began as soon as possible. The service recorded numbers and outcomes of assessments for patients who were brought to the

health-based places of safety on section 136 of the Mental Health Act, including the use of the local

acute hospitals. Between 1 September 2018 and 9 December 2018, there were 163 admissions to

the places of safety under section 136. Between September 2018 and 9 December 2018, there were

33 admissions to the places of safety under section 135.

Of these, 16 had breached the 24-hour limit. Staff told us that the majority of the breaches were

caused by a lack of suitable beds. Staff understood the processes by which to record the times of

arrival at the place of safety and the assessment times, including time of contact with the AMHP,

time of assessment by doctor and actions taken following an assessment. This information was

used to inform the trust about access to the respective facilities.

Of the 196 patients detained under Section 135 and section 136, 30 went on to be either detained

under section 2 or 3 of the Mental Health Act or remained informally on an inpatient ward. All the

other patients were discharged home.

The facilities promote comfort, dignity and privacy

The suites all had en-suite toilets and there were shower facilities in the Farnham Road Suites

Patients had somewhere to lie down, a clock, arrangements for food and drink, and appropriate toilet facilities. Additionally, patients had somewhere secure to store their possessions.


All the health-based places of safety were on the ground floor and could be accessed by people

who had mobility needs if necessary.

There was written information available about the rights of people detained under section 136 and

section 135 which could be made available in different languages if necessary.

Staff could book interpreters for patients if this was required and were aware of the process by which they could do so.


Staff were aware of how to handle complaints and staff tried to resolve complaints locally where possible.

Mental health crisis services Is the service well-led?

Leadership


The service managers had the skills, knowledge and experience to perform their roles and had a

good understanding of the services they managed. They could explain how the teams were working

to provide high quality care.

Most staff found the senior leaders to be visible within the services and said they knew who the

senior leadership team were and that they were approachable.

Staff at the East Surrey home treatment team felt well supported by their management and gave

examples such as protected supervision time and information emailed to them about additional

training.

Vision and strategy

Staff knew and understood the trust’s vision and values and how they were applied in the work of

the team. For example, staff were very clear about the importance of working together to promote

the best care for patients.

Staff said that they had been consulted on recent changes to the service and had the opportunity to

contribute to discussions about the strategy for their service. Staff had been consulted regarding the

development of the Single Point of Access. However, some staff felt that more information about the

new Single Point of Access would have been helpful prior to it being commenced in their area.

Some staff that we spoke to felt it would be supportive to have a senior champion in the organisation.

They sometimes felt that they were expected to accept referrals which may not be suitable for the

service, such as patients who did not wish to engage, which resulted in wasted time.

Culture

Staff we spoke with felt respected, supported and valued. Staff were positive about working within the team and morale was good. Staff at all three HTTs were complimentary about their colleagues of all disciplines. Managers felt that their teams worked hard and prioritised patients’ care and that the teams had responded well to a lot of change.

Staff knew how to use the whistle-blowing process and felt confident that they could raise concerns

without fear of retribution.

Teams worked well together. We observed the daily handover at each team. Staff were comfortable raising issues with planning the day and discussing challenging situations.

Governance

Staff had implemented recommendations from reviews of deaths, incidents, complaints, and

safeguarding alerts, such as the SBAR handover.

Staff took part in clinical audits. We were told that there was a trust wide initiative to improve care

planning.

Staff understood arrangements for working with other teams, both within the provider and external,

to meet the needs of the patients.



Staff maintained, and had access to, the trust risk register at a service and team level. The risk

register contained pertinent risk issues to staff and patients within the crisis service.

Staff had access to the equipment and information technology needed to do their work. In order to

monitor physical health during home visits, the South West Surrey team had access to a bag

containing equipment to monitor blood pressure, temperature and oxygen saturation levels. The

team felt that more kits were needed and after raising this with the management staff told us that

the new kits are now being ordered.

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 – for example, through the intranet and email bulletins.

Staff did not always feel that they received a lot of positive feedback from the managers and some

staff reported that it could be difficult to give feedback to managers and know whether it was being

listened to.


Staff were given the time and support to consider opportunities for improvements and innovation

and this led to changes. For example, one nurse had been supported to complete their nurse

prescriber course.

The Safe havens provided easy access to support for people in crisis in the community.

The North West Surrey HTT were participating in a quality improvement program to improve carers

involvement.

Health-based places of safety Is the service well-led?

Leadership

Responsibility for the health-based placed of safety sat within the Home Treatment Team. One

service manager had oversight of both health-based places of safety. Leaders, which included the

services manager had a good understanding of the HBPoS.


There were adequate arrangements in place to support a multi-agency policy, the ambulance and

police service were signed up and contributing to its effectiveness.

Leaders were visible on the unit and approachable for patients and staff.

Culture

Staff felt able to raise concerns without fear of retribution.

Governance

Staff had implemented recommendations from reviews of the serious incidents.

Staff understood the trust had provided guidance to staff regarding the use of the HBPoS in

exceptional circumstances as an area for secluding a patient and a procedure for when an individual

remained in the assessment suite for longer than 24 hours.


Staff had access to the equipment and information technology needed to do their work. Staff had

support and training on how to use the electronic record system.


Specialist community mental health services for children and young people


Location site name Team name Patient group (male,

female, mixed)

Trust HQ, 18 Mole Business Park, Randalls Road, Leatherhead, Surrey, KT22 7AD

CAMHS Community Team north east surrey

Mixed

Trust HQ, 18 Mole Business Park,

Randalls Road, Leatherhead,

Surrey, KT22 7AD

CAMHS Community Team- north west

surrey

Mixed



Surrey, KT22 7AD

CAMHS Community Team - south

west surrey

Mixed



Surrey, KT22 7AD

CAMHS Community Team – south

east surrey

Mixed

Ramsay House Children and Young People Learning

Disability Services - East

Mixed



Surrey, KT22 7AD

Children and Young People Learning

Disability Services - West

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.



The three child and adolescent mental health service (CAMHS) locations we inspected had

dedicated clinical and waiting areas for patients. The patient areas at the Epsom team were in a

separate building adjacent to the team base. The Guildford CAMHS team had sole use of their

building. The Redhill base was shared with adult mental health services and the CAMHS team had

exclusive use of the first floor. The ground floor waiting areas for young people and adults were

separated by a partition.

Therapy rooms had fixed wall alarms or the staff carried personal alarms which were stored in the team rooms. This meant that staff could call for assistance from colleagues if they needed to. Staff had completed environment risk assessments for each building. Some risks were managed by young people not having access to rooms without supervision from a member of staff or other adult. Staff completed annual fire safety training and were carrying out regular fire drills at each team

base.


Services had the equipment to carry out basic physical health checks such as weight, blood pressure and height. At Epsom staff brought the weighing scales to the therapy room to use as there was no clinic room on site. At Redhill staff had responded to comments from young people and moved the weighing scales to an alternative room. All the patient areas were clean with adequate and comfortable seating. The waiting area at Guildford was cramped and located in the corridor outside the main team room. Staff were making the best they could of the cramped space and using a radio at low volume to reduce the risk of confidential staff conversations about patients being overheard by people in the waiting area. It was policy for staff to clean toys and equipment after each use to prevent the spread of infection. Staff told us that this was regular practice.

Safe staffing

Nursing staff

The trust had started a process of job planning with staff in all the teams. This was a method to

calculate the capacity of staff to respond to the different demands on their time such as

assessments, treatments and care planning. Staff said that it was a helpful process as responding

to demand was a challenge.

The average sickness rate for this core service was 6.2%. This was higher than the trust average

sickness rate of 4.4%.

The core service had a staff turnover of 26% in the period September 2017-August 2018.

Managers told us that there had been considerable staff turnover in this period but following a

recruitment drive the community teams were mostly fully staffed. Exceptions were at Epsom where

there were vacancies for a non-medical prescriber and a nurse, and there was a psychiatrist

vacancy at the Frimley base of the Guildford team.

A trust review of the CAMHS service in April 2018 identified that staff caseloads were higher than

the 40-45 per clinician that the trust expected, and that the non-medical prescribers and doctors

were holding cases of up to 287. During inspection we found that caseloads for all staff had

reduced because of the interim plan the trust deployed to slow down referrals to the CAMHS

service for 16 weeks between June and October 2018.

Most staff caseloads for full-time staff were lower than 45, and for prescribing staff they were

within the trust expected averages of 100-130. Staff told us that this had a positive impact on their

ability to carry out the different functions required in their jobs.

Staff spoke with us about the pressure of managing their caseloads and meeting the other

demands such as completing assessments and delivering treatments. They said that they were

well supported by their team manager and colleagues. Staff discussed caseloads at supervision

and they took complex cases to the weekly multidisciplinary team meeting. This helped support

staff and ensured good patient care.

This core service has reported a vacancy rate for all staff of -3% as of August 2018.

Between 1 September 2017 and 31 August 2018, 20% of available hours for qualified nurses were

filled by bank staff to cover sickness, absence or vacancy.



In the same period, agency staff covered 39% of available hours for those teams using agency

staff for qualified nurses and 0% of available hours were unable to be filled by either bank or

agency staff.

Total hours

available


bank or

agency

Hrs % Hrs % Hrs %

Core service total 9, 505 1864 20% 3, 737 39% 34 0%

Trust Total 372, 138 57144 15% 100,927 27% 12752 3%

There was no reported bank or agency usage reported for health care assistants.

This core service had 23 (26%) staff leavers between 1 September 2017 and 31 August 2018.

Substantive staff (at

latest month)

Substantive staff


12 months


over the last 12

months

Core service total 90 23 26%

Trust Total 1, 391 236 18%

The sickness rate for this core service was 6.2% between 1 September 2017 and 31 August 2018.

The most recent month’s data (August 2018) showed a sickness rate of 7.2%.

Medical staff

Between 1 September 2017 and 31 August 2018, of the 1044 total working hours available, there

was no reported bank staff usage reported for this core service. The main reasons for agency

usage for the wards/teams was vacancies.

In the same period, consistent locum medical staff covered 13% of available hours and 0% of


Each community team had consultant psychiatrists who were experienced specialists in the

mental health of children and young people.


(at latest month)


sickness (over the past year)

Trust HQ Children and Young People

Learning Disability Services - West 7.2% 6.2%




Both consultants at Redhill were locums. One doctor was long-standing and the second was

recently in post. The trust is actively recruiting to these positions.

Staff told us that doctors were accessible to them for advice and consultation about the patients

they were supporting. The consultant at Redhill kept three appointment slots per week for staff to

meet with him to discuss complex patients.

Ward/Team Total hours

available


bank or

agency

Hrs % Hrs % Hrs %

CYPS Community South East 756 0 0% 136 18% 0 0%

CYPS Community South West 288 0 0% 0 0% 0 0%


Trust Total 13876 0 0% 8216 59% 0 0%

Mandatory training


training courses listed all ten 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 training compliance data is reported on an ongoing monthly basis. Statutory training is reported as part of the monthly board report dashboard produced by Workforce and a separate dashboard is provided by the Learning and Development team for all other courses classified by ourselves as role essential.’

The training compliance reported for this core service during this inspection was lower than the

82% reported in the previous year.

Staff received mandatory training in infection control, basic life support, clinical risk assessment

and safeguarding children and adults.

We requested up to date mandatory training compliance information whilst on inspection and saw

that the majority of CAMHS teams were achieving between 82-100% completion rates for

mandatory training.

The most recent Mental Health Act training completion rate had improved and was at 90% at the

time of the inspection.

Managers received updated training figures each month and we saw that these were reported to

the monthly directorate meeting for discussion and review.

Key:


✓

Not met trust

target

Higher

No change

Lower



eligible

staff

Number of

staff

trained

YTD

Compliance

(%)

Trust

Target

Met

Compliance

change when

compared to

previous year

Information Governance 106 96 91%


Clinical Risk Assessment 65 56 86%






Other 613 454 74%


Total 1407 1109 79%



All patients referred to the service received an initial risk assessment from clinical staff at the

service’s single point of access team. This enabled the level of urgency of response to be set by

the service. Teams then fully implemented a thorough patient risk assessment at the first

appointment. We saw that risks were included as part of the initial assessment.

Staff spoke highly of the role of the pre- and post-assessment meetings with colleagues. At these

planning and reviewing meetings, staff discussed the risks and complexity of all new patients

whose needs were being assessed. This ensured that patient risks were considered in a multi-

disciplinary way.

We reviewed 17 care records across the three teams. At the last inspection we found that the trust

was not always adequately recording and mitigating patient risks. At this inspection in all records

we saw that risk had been assessed and recorded on the clinical notes. The trust standard for

review was a minimum of every six months or sooner if significant events had happened. We saw

that teams were meeting this requirement in most of the risk assessments that we reviewed.

When staff had assessed patients with medium or high risks they completed a crisis and

contingency plan with the young person. We saw good quality crisis plans in place in all cases

where patients had high and medium risks identified. Patients had participated in creating their

contingency plan and were given a copy of the plan at their appointment. The plans included

strategies and activities that could help the young person manage their own risk and resources in

the community and online that could assist them such as phone apps and the trust’s children and

young people’s Haven centres.

The trust had worked with young people and the CAMHS Youth Advisors (CYA) service to re-

design the content of their crisis plans to ensure they met the needs of young people and were in

a format they found most useful.



The service implemented a priority system in which those assigned to the crisis pathway were

initially assessed within 24 hours by dedicated crisis workers, urgent cases were seen by staff

within five working days and routine referrals assessed within eight weeks.

Following assessment, patients were placed on waiting lists for specific therapeutic treatment

pathways. The service had lead practitioners on each pathway who held the responsibility for

managing the waiting lists and patient risk. Patients were given a red, green or amber risk rating

when they were added to the list. Staff made monthly or three-monthly contact, dependent on risk

level, with patients waiting to review their risks while they were waiting for treatments.

There was a duty service at each team responding to calls from young people and carers. Each

team had clear guidance how to direct the call to the right part of the system dependent on

circumstance and risk. Each team had access to crisis workers who responded to any patient who

needed a 24-hour response.

The trust, in partnership with other agencies, provided four Havens across Surrey where children

and young people aged 10-18 could get support from a mental health worker and a youth worker.

Children and young people could visit a Haven, based in centrally located buildings in the four

towns, without an appointment. There they could talk about their mental health worries and take

part in activities and crafts. The Havens were open 4pm to 8.30pm in the evenings, and Saturday

daytime, in Guildford, Redhill, Staines and Epsom. Attending the Havens was a key part in many

young person’s crisis and contingency plans and we heard very positive feedback from parents

and young people who had accessed the service.

All locations followed the trust wide lone working policy and staff were aware of the policy and its

associated procedures.

The service implemented a missed appointment policy that incorporated an active engagement

procedure for patients who did not attend appointments.

Safeguarding




institutional.





should take place.


2018, of which 19 concerned adults and 126 children.

CAMHS staff completed mandatory training in safeguarding children and adults. The compliance

rates for training were 86% of staff had completed training in safeguarding adults and 79% had

completed training in safeguarding children. Staff we spoke with knew how to make a


safeguarding alert, and did so when appropriate. The CAMHS electronic risk management tool

allowed safeguarding issues to be included in the patient’s overall risk assessment. This ensured

that staff had access to all relevant information relating to risk.

The social workers embedded in the teams allocated 50% of their time to supporting the social

care needs of patients and the safeguarding processes in the teams.

Services had good links with the local authority and we saw evidence of multi-agency working and

information sharing for vulnerable young people. Each team managed a safeguarding log and this

was shared across health and social care agencies. This was reviewed monthly by senior trust

safeguarding leads

The trust had a named doctor responsible for child protection and safeguarding

At the Guildford team we tracked a safeguarding concern regarding a young person. We saw that

the team had appropriately responded to information from a partner agency regarding a young

person to raise a safeguarding alert. This was clearly recorded on the patient’s care notes, and in

a team incident report and the progress of the safeguarding was monitored monthly.

Number of referrals


19 126 145

The number of adult safeguarding referrals in month ranged from 0 to five.

The number of child safeguarding referrals ranged from six to 16.

The trust has submitted details of no serious case reviews commenced or published in the last 12 months that relate to this core service.


All staff had access to the trust’s Systmone electronic patient record system which contained

specific sections for clinical information such as a progress record and care planning and risk

tools.

There was variance in how staff were using the individual domains within Systmone such as the

dedicated care plan and risk assessment sections. In some cases, updates to care plans and risk

assessments were in the progress notes and referenced back to the dedicated domain. We gave

feedback to managers at the inspection that although all clinical information was present it was not

always quick to find and that it may interfere with the process of staff auditing their records.

It was not clear during inspection that all staff were aware of trust standards and expectations in

using all aspects of the Systmone system.

The way management information was presented to team leaders did not fully reflect how the trust

was currently organising its teams. For example, the Systmone information understood an east

and west division for CAMHS teams across the county, but the trust had subdivided this again in

to four teams and these identities were not reflected by the information system. This meant that


teams spent time cleansing their information to get to their specific team. This affected staffing and

caseload information.


The teams we inspected did not hold medicines on site. When prescriptions were issued from the

service patients used local pharmacies to obtain their medicines.

CAMHS consultants maintained time slots for GPs to offer advice and support regarding treatment

pathways and medicines by telephone. The service had begun to offer this during the 16-week

improvement plan and had decided to continue this initiative as GPs and the teams found this

helpful in meeting patient needs.

Non-medical prescribers were present in the teams and there was a nurse prescribing forum for all

nurse prescribers to give staff the opportunity for reflective practice and knowledge updates. The

Epsom team was recruiting to fill a recent vacancy in their non-medical prescriber post.


Between 1 September 2017 and 31 August 2018 there were two serious incidents reported by this

service.

We reviewed the serious incidents reported by the trust to the Strategic Information Executive


by the trust incident reporting system was comparable with STEIS with two reported.



reporting period.


Type of incident reported (SIRI) Apparent/actual/susp

ected self-inflicted

harm

Failure to obtain

appropriate bed for

child who needed it

Total

CAMHS Weekend Assessment

Service

1 1 2

Total 1 1 2





In the last two years, there have been three ‘prevention of future death’ reports sent to this Trust,

none of these related to this service.


The service used an electronic incident reporting system, datix. All staff had access to this and

could raise a report. Reports were escalated to the team manager to review and grade according

to severity. All serious incidents were sent on to service leads.

We reviewed two recent incidents at the Guildford team and saw that the datix had been

completed and there were appropriate records placed within the young person’s progress notes

and their risk assessment had been reviewed due to the nature of the incident.

Staff said that they were confident using the system and that lessons learned from incidents were

discussed at the monthly business meeting.



The service offered assessment times within three bands: crisis, urgent and routine. Following

receipt of referral, patients were placed upon a waiting list for a clinician to complete an initial

assessment. Those patients with high risks of self-harm, suicidal ideation with intent, and evidence

of symptoms of psychosis were placed on to the crisis pathway and were offered an appointment

for assessment with dedicated CAMHS crisis workers within 24 hours.

Patients in severe distress with symptoms that may include significant deterioration in behaviour,

emotional state and functioning were offered an assessment by community team staff within five

working days of referral.

The target for routine referrals was 28 working days to the first assessment.

The patient’s initial appointment focused on creating a holistic assessment which included patient

history, presenting concerns, and identifying risks. Where a young person presented with complex

needs a multidisciplinary post-assessment meeting was led by the clinician to aid the formulation

of a treatment plan and care plan.

Assessments included questions about physical health and information about health conditions

was recorded in the assessment. Should a patient require further support and investigation for any

physical health problem this was conducted through a young person’s GP or other relevant

specialist. Where a patient was prescribed medicines, CAMHS staff recorded blood pressure,

weight and height at regular intervals.

We saw that care plans were in place in the patient records that we reviewed. Care plans reflected

the assessed needs of the patient and were holistic and personalised to each patient. The plans

were mostly detailed with good patient involvement, personalisation and evidence that copies of

the plans were given or offered to patients and carers.

Staff were using a new tool to audit patient clinical records for quality and completeness. This was

a new initiative and the tool was very comprehensive and included auditing patient care plans and

risk assessments.

There was inconsistency where the care plan information was stored by staff. At times the plans

were recorded in the care plan section of the clinical record and at other times the care plan was

uploaded as an attachment as it formed part of a letter to the patient containing their assessment

and their care plan.



This service participated in five clinical audits as part of their clinical audit programme 2017 –

2018.


service

Audit type Date

completed

Key actions

following the

audit

Healthcare

associated

infections

(including

handwashing)


wide

Clinical and

environmental

Ongoing In relation to the

IPC Environmental

audits two areas of

development

identified included

keeping an up-to-

date COSHH risk

assessment for

bodily fluids in the

IPC folder and

domestic cleaning

issues. All services

have a tailored

action plan in

place.

MH CQUIN

Indicator 3A

Cardio

Metabolic

Assessment

People using

services who

use our

inpatient or

Community

services, who

have a

diagnosis of

psychosis

relating to

either

schizophrenia

or bipolar

Provider

wide

Clinical 01/06/2018

(published)

A robust Trust-

wide action plan is

in place to support

improvement in

monitoring

physical health

and referring on for

interventions when

needed. In

addition, there has

been a QI project

to support Health

clinics to operate

within our inpatient

services. Health

clinics are in the

process of being

rolled out to our

Community teams.

Our EIIP teams

have introduced

the initiative of a

‘lab in the bag’

which will mean



service

Audit type Date

completed

Key actions

following the

audit

that the resources

needed for

physical health

checks in the

community will be

readily available.

In addition, our

EIIP teams will use

the CMHRS health

clinics when they

are available in all

areas

CARE

excellence

accreditation


wide

Service wide Ongoing -

self-

assessments,

peer reviews

and re-

reviews

All services have

individual action

plans to work

through. Themed

training sessions

have been

provided to help

guide staff as well

as bite sized

information guides.

Supervision will be

a mandatory

standard on our

Foundation

standards tool as

from end 2018.

Record

keeping

audits

All mental

health

services

Provider

wide

Records Ongoing -

monthly

All teams must

review their

information on a

regular basis and

address any gaps

in supervision and

share good

practice within

their teams.

Record keeping is

reviewed as part of

the Foundation

standards review.

Service

evaluation for

CAMHS MH -

Specialist

community

Clinical 01/09/2017 Include

psychotherapy as



service

Audit type Date

completed

Key actions

following the

audit

CYPS

CAMHS

mental

health

services

for

children

and young

people

a treatment option

within the service

Staff provided a range of care and treatment interventions suitable for the patient group in line with

the National Institute for Health and Care Excellence (NICE) guidance. These included psychiatric

assessment and medicines, psychological therapies such as eye movement desensitisation and

reprocessing (EMDR), cognitive behavioural therapy (CBT), family therapy and talking therapy and

early intervention by primary mental health workers.

Additionally, the service provided group therapy sessions that benefitted the patients and provided

support to young people who would have to wait longer to start individual therapy sessions. The

service was seeking to expand the number of group treatments offered. We saw that Guildford

was completing their first anxiety group in January 2019 and five young people had completed the

course.

Each child or young person was allocated a named worker once they had been assessed and

accepted in to the service.

We observed staff delivering two generic assessments of patients attending with parents. During

the assessments we saw staff had detailed discussions about patients’ mental health needs,

physical health needs, such as allergies, any physical observations required, diet, medication and

parental health issues.

We observed a therapist and patient during a CBT session. The therapist’s approach was

sensitive and skilful throughout the appointment and the therapist was well engaged and caring in

their manner. The family told us after their appointment that they considered the clinical staff to be

very caring and helpful.

The service was supporting families to develop skills and strategies to support the children and

young people in their lives who were experiencing mental health distress. This included a non-

violent resistance group offered mostly to parents of young people with an autistic spectrum

disorder (ASD) diagnosis. This eight-week long group focused on helping parents re-build

relationships with the young person. The CAMHS staff also ran a 10-week group for families

learning about self-harm (FLASH). The parents we spoke with felt that these support groups had

been helpful.

The service used a wide range of routine outcome measures for patients. These included the

children’s global assessment scale (CGAS), session feedback questionnaires (SFQ), goal based

outcomes (GBO) and the child outcome rating scale (CORS). These were routinely used at first

assessment, first treatment and review. We saw that staff were also using the outcome measures

as part of the discharge process. The measures were aimed to record the progress of patients in

both the short and long term following therapeutic interventions and to feedback on the service

provided.


CAMHS staff had received training in using goal-based outcomes.

The service was anticipating that outcome measures would be standardised as the CAMHS teams

were training staff and preparing to be part of NHS England’s children and young people’s

improving access to psychological therapies (CYP IAPT) programme. This programme would

recommend scales to use for each treatment programme.




so far, the overall appraisal rates was 74% (as at 31 August 2018). The rate of appraisal

compliance for non-medical staff reported during this inspection was lower than the 86% reported

during the previous year.

The trust’s target rate for appraisal compliance is 93%. At the end of last year (1 April 2017 to 31


far, the overall appraisal rate was 100% (as at 31 August 2018).

The trust was unable to supply clinical supervision data centrally as it was not formally recorded.

The team included, or had access to, a range of specialists required to meet the needs of young

people. Each team included doctors, clinical psychologists, psychotherapists and trainees.

Individual teams also had nurses and family therapists. In the team meetings that we observed,

we saw that staff could professionally challenge one another and explore different clinical

perspectives appropriately. Staff were experienced and qualified, and had the right skills and

knowledge to meet the needs of the patient group.

Previously in 2016 we identified that staff were not always receiving regular support and

supervision within the CAMHS teams. At this inspection we sampled the supervision records at

two teams and found that this had improved. There was a clear supervision structure in place and

staff were receiving monthly supervision which they and their supervisor recorded and signed.

Staff told us that they were being supported via regular supervision meetings. They said the

supervision meetings provided a place to discuss case management, was a space to reflect and

learn from practice, and a place for personal support and professional development.

The trust’s target rate for appraisal compliance was 93%. The CAMHS service was slightly below

the trust target at 86% for non-medical staff, but it was higher than the trust average of 80%. The

medical staff appraisal rate was 100%.

Managers provided new staff with an appropriate induction.


Managers ensured that staff had access to regular team meetings. The multidisciplinary team met

once a week to discuss cases of concern and cases ready for transition, and the management of

young people rated as high risk. Once a month staff met for a business meeting to discuss items

relating to the service, such as new staff, recent incidents, complaints and learning from them.

The CAMHS teams had working links with primary care, social services, and other teams external

to the organisation, including schools. We saw that staff recorded in clinical notes where there had

been involvement from other agencies which was good practice. Families and young people told

us that CAMHS staff had worked with staff from schools in developing their safety plans.


The team managers maintained a log of any referral issues between the CAMHS teams and the

single point of access team so that both services could identify any learning and make

improvements to the referral pathway into the service. These were discussed at a monthly meeting

attended by one general manager.

Consultant psychiatrists within each team protected time for GPs to contact the service for advice

about treatments and referrals.

The teams were following up quality issues in the assessments for attention deficit hyperactivity

disorder (ADHD) and autistic spectrum disorder (ASD) which had been outsourced to another

agency during the 16-week improvement plan. Staff and some parents told us that information in

their child’s assessment was missing or incomplete in several instances. We saw that staff were

recording any missing component of the assessment as an incident so that it could be logged and

the trust had requested updates from the external assessor.

Staff were working on two CQUIN plans which involved other parts of the health pathway. One

initiative was to improve the options for young people in crisis so that they got the support they

needed and did not need to attend the accident and emergency department. The second plan was

looking to identify improvements in the pathways for young people transitioning from CAMHS to

either their GP or to adult mental health services. This helped ensure that all patients had clear

pathways out of the service and information was given to them about which services could support

them if they needed to return to services during this time.


Practice




The training compliance reported during this inspection was lower than the 77% reported during

the previous year (1 April 2017 – 31 March 2018).

Training in the Mental Health Act was a mandatory training for staff working in CAMHS. The

compliance rate at the time of the inspection visit in December 2018 was 90%.

Staff we spoke with were knowledgeable of the role of the Mental Health Act. In the teams we

inspected there were no patients subject to the Mental Health Act receiving treatment from the

service.



Capacity Act. The trust stated that this training is mandatory for all services for inpatient and all


The training compliance reported during this inspection was lower than the 88% reported during

the previous year (1 April 2017 – 31 March 2018).

Training in the Mental Capacity Act was a mandatory training for staff working in CAMHS and 85%

of the staff had completed this at the time of inspection in December 2018.


The trust had clear procedures for staff to follow for gaining and recording valid consent from a

young person or parent. We saw consent forms saved in care records. Parents we spoke with said

the staff had verbally asked for their consent to start treatment with their child and that attending

the service was a form of consent to treatment.

Staff were aware of their responsibilities to consider Gillick competence and could describe how

and when this was relevant to their work. Gillick competency means young people are under the

legal age of consent but deemed capable of consenting for themselves. We saw evidence of

discussions and consideration of Gillick competence in multidisciplinary case reviews and care

records.



Feedback from people who use the service and those who were close to them was positive about the way staff treated people. We observed positive and caring interactions between staff and patients across all locations. Patients and carers spoke positively about the attitudes and the contacts they had with staff. We witnessed staff speaking sensitively and respectfully in all interactions regarding patients. Patients and parent/carers we spoke with said they had never had therapy cancelled. They said that they had good access to services outside of regular follow-up sessions. The teams we visited offered early review appointments and could quickly rearrange appointments if patients and carers could not attend. Staff were in contact with the patients’ schools to help them understand the young persons’ needs. One patient told us that they had safety plans for school and for the CAMHS service.

Involvement in care


Staff could access signers, translators and could produce easy-read leaflets when needed. Each service we visited had a large selection of leaflets in various age appropriate formats. The service proactively sought the feedback of patients and carers and implemented change because of this. One service moved their weighing scales and height measures to the clinic room because patients did not like it being in the CAMHS waiting room. The CAMHS Youth Advice group (CYA) regularly checked feedback from patients and carers to review and inform the service provided. Although the young people we spoke with were not actively involved in the design and running of the service, the provider liaised with an active Surrey CAMHS Youth Advice group that had a say in the running of CAMHS services. Staff told us that children and young people who were members of CYA could sit on the interviewing panels when recruiting staff. We spoke with two staff members who were interviewed by patients before being recruited. Staff told us that the CYA group did regular walk rounds of the CAMHS sites to make sure the premises were fit for purpose. The group were actively involved in decorating the premises and were consulted on any changes made to the service.


Some patients told us that they were given a copy of their care plans. However, all patients and parents/carers were aware of the treatment plan they were working through. Patients told us that they were involved in creating their care plans, crisis plans and safety plans.


Staff were aware of the requirements to involve patients in decision making, especially if they were deemed to be competent in understanding and retaining the information to decide. Staff were informed about protecting patients’ confidentiality and safely handling personal information. There was evidence in patient records that confidentiality and sharing information had been discussed with patients and carers.

Some of the patients and parents/carers we spoke with were not aware of the complaints procedure. However, they all felt confident that they could raise concerns with any member of staff and these would be taken seriously. Leaflets on the complaints procedure were available in the waiting areas of all the services we visited. One service had a “you said, we did” board in their waiting area. Therapy and support was open to parents and carers alongside the treatment of the young person. Parents and carers told us that they had completed courses run for them by the CAMHS staff. These included a non-violent resistance course for parents of young people who show aggression at home (NVR), and a parent course which gave parents strategies to cope with supporting young people who self-harm (FLASH). Those who had attended the training told us that they found it useful. Patients and carers told us that they could arrange appointment times that were responsive and flexible to their needs such as changing appointments due to family holidays or having appointments outside of office hours in some occasions.

Although some parents and carers felt that the service could keep them better updated whilst on the waiting list for assessment and treatment, most parents and carers we spoke with said they felt involved in the patients’ care and that they were well informed by the service.



The trust has identified the below services in the table as measured on ‘referral to initial assessment’

and ‘referral to treatment’. The service met the referral to assessment target in none of the targets

listed.

The service met the referral to treatment target in none of the targets listed.

Name of hospital site

or location

Name of Team Days from referral to

initial assessment

Days from referral to

treatment

Target Actual

(median)

Target Actual

(median)

Gatton Place CAMHS Community East

40 61.5 20 71

Theta House CAMHS Community

West

40 58 20 92


Name of hospital site

or location

Name of Team Days from referral to

initial assessment

Days from referral to

treatment

Target Actual

(median)

Target Actual

(median)

EAST: Gatton Place

WEST: Berkeley House

CAMHS LD 40 80 20 79

Referrals to the service could be made by all health, social care and education practitioners for

children and young people registered with a GP in Surrey. The referrals were received by a single

point of access team who did the triage of the referral and then matched the referral to services on

the pathway. People could refer to the service by telephone, in writing or using the secure online

web portal.

The trust target was eight weeks from referral to assessment, and four weeks from initial

assessment to the start of treatment. While the service had significantly improved its waiting time

for assessments and could meet its target for generic assessments, it was not reaching its target

for waiting times for treatment.

A trust review of the service in April 2018 had reported significantly longer waiting times for

assessment with the average time at seven months and the longest time for a routine appointment

was 19 months. The review estimated 1875 children and young people were waiting for a CAMHS

assessment.

During the inspection we asked for more information about the outcomes for these patients. The

trust provided data showing that, after review, the interim plan identified a total of 1640 patients on

the waiting list for assessment. By November 2018 the interim improvement plan had completed

assessments for 1381 patients. A further 73 of these patients had their assessments completed

after the interim plan had come to an end. The remaining 186 patients were discharged without

being seen. The trust provided a breakdown of the reasons these patients were discharged which

included that some were duplicate referrals, some patients had not attended an appointment and

the policy for non-attendance was followed, some parents had opted for a private assessment and

that some patients no longer required the service.

The trust improvement plan to improve assessment waiting times lasted for 16 weeks. This

involved closing the CAMHS teams to new referrals, excluding urgent referrals. This measure

freed staff time to address assessment waiting lists. Some patients on the BEN pathway waiting

for specialist assessments for autistic spectrum disorder (ASD) and attention deficit hyperactivity

disorder (ADHD) had their assessments carried out by an external clinical provider.

As a result of this improvement plan the waiting times for assessments had dropped significantly

as had the numbers of patients waiting to have their initial assessment. Trust data during the

inspection showed that teams had capacity to offer a generic assessment within the trust target

time of four weeks (28 days).

Waiting times for treatment varied dependent upon the treatment pathway. An average time for

cognitive behavioural treatment (CBT) was 26-30 weeks. For psychotherapy, patients were waiting

between 12-24 weeks dependent upon which team was providing the treatment. This was true

also for cognitive assessment where in one team the waiting time was 24 weeks and in another it

was 60 weeks.


The trust confirmed that its CAMHS strategy was to improve the waiting time to treatment and that

this was the focus of a CAMHS improvement and development plan.

The service had transition protocols in place to support the transition of patients from community

CAMHS to adult services, or the GP, if required. This was also a focus of a trust quality

improvement initiative.

All patients who were on waiting lists for treatment received a risk assessment and regular contact

from team staff to ascertain if their needs were changing during their wait. The waiting lists were

monitored by senior clinical staff in each team.

There was a consistent approach across the service to responding to and dealing with urgent

referrals. All locations held a duty rota that included urgent appointment slots for the duty clinician

and psychiatrist. Team doctors retained appointment slots for seeing patients urgently.

Each team we inspected provided a longer opening time on one day per week. This allowed

flexibility to patients and carers for some patient appointments to happen outside standard office

hours.


All locations had a variety of rooms available for staff to use. These included clinic rooms to

undertake basic physical health monitoring such as height, weight and blood pressure

measurements.

All team bases had appropriately sized therapy rooms with well-maintained furniture and age

appropriate toys for child use.

The waiting areas at Epsom and Redhill had sufficient seating for patients and carers. The

Guildford waiting area was small and cramped as it formed part of the entrance corridor in to the

building. Staff told us that it sometimes was difficult for everyone to manoeuvre at times such as

when families were waiting with pushchairs.

All waiting areas had a range of leaflets and information to browse that included information on an

advocacy service, treatment information and details for external support groups.


There was a large range of information available at the CAMHS teams which gave contacts and information about other services and sources of support for patients and carers. Staff told us that patients were encouraged to develop and maintain relationships with people that mattered to them. This included encouraging patients to include parents in their care planning where the young person was deemed competent and engaging in social activities outside the service. Parents were supported by the CAMHS staff in developing skills to communicate and maintain positive relationships with the young person. Staff were knowledgeable about other services and this was reflected in patients’ contingency plans. Young people were signposted to online supports such as the kooth online counselling and mental health advice portal. Patients were also regularly linked in to the mental health and youth advisory support that was available at the four young persons’ Havens in Guildford, Epsom, Staines and Redhill. Support from qualified mental health nurses was available in the evenings and at weekends.


Patients said that the CAMHS staff were liaising with teachers at their school to ensure that they better understood how to help and respond to their needs when they were there. The CAMHS teams were linked to the CAMHS youth advisors. This was a network where young people could make friends, attend training courses, events and conferences. Young people were supported to become reps within the service and contribute to how the service was run including staff recruitment.


This service received 17 complaints between 1 September 2017 to 31 August 2018. Four of these

were upheld, five were partially upheld and three were not upheld. None were referred to the

Ombudsman.

This service received 17 complaints between 1 September 2017 to 31 August 2018. Four of these

were upheld, five were partially upheld and three were not upheld. None were referred to the

Ombudsman.

Ward name Total Complaints Fully upheld Partially upheld Not upheld Under

Investigation

CAMHS Community Team - east surrey

1 1

CAMHS

Community

Team - south

west surrey

1 1

CAMHS

Community

Team mid surrey 3 1 1 1

CAMHS

Community

Team- north west

surrey

5 1 1 1 2

CAMHS

Community

Team-east surrey 5 2 2 1

CAMHS One

Stop 1 1

Hope- Guildford 1 1

Total 17 4 5 3 5


August 2018 which accounted for 12% of all compliments received by the trust.


We reviewed how complaints were handled at the three teams and saw that team managers

attempted to resolve concerns from patients and carers at a local level. Each team kept a

complaint log. This ensured that complaints were managed in a quick and efficient way and made

it easier for patients and carers to raise complaints informally.

Patients and carers told us that staff were approachable and responsive when they raised

complaints and concerns.

Formal complaints were handled and managed via the trust’s Complaints and PALS service.

Managers said that some complaints had been due to the long waiting times for assessment and

treatment. Issues regarding the long waiting time to assessment had improved but waiting times

still remained for treatment. These concerns were partially mitigated by team leads maintaining

periodic contact during the waiting time with patients and parents.

We saw that complaints and compliments were regularly reviewed and outcomes and learning

shared amongst the team at the monthly business meetings.


Leadership

Staff told us that the service was well led at a team level and by service and clinical leaders. They

said that they felt the directorate was listening and responding to their concerns and needs and

pointed to the recent improvement plan as an example of things getting better for staff and

patients.

The team managers were involved in the day to day running of their teams and were visible within

the team at each location we inspected.

The team managers we spoke with were recent appointments and demonstrated enthusiasm and

a positive outlook about their teams. They took an active approach to the wellbeing of team

members which included positive statements, using mindfulness and relaxation sessions, and

planning regular team building activities.

Vision and strategy

The trust’s vision and values was displayed at each location. The values included treating people

well and being open and accountable and we saw staff demonstrating these qualities when

engaging with patients.

Staff were aware of the directorate leadership and trust wide senior managers. They said that

senior leaders had visited the services and were visible and approachable.

Staff told us that the recent improvement plan had made a big impact on their caseload sizes and

had enabled them to better carry out their roles. They considered the strategy for CAMHS to be

having a positive impact and they felt that they had been able to contribute to the strategy.

However, there was acknowledgement form others that the strategy needed to address the waiting

times for treatments.

Staff felt that the current job plan reviews were useful but expressed anxiety that the result may

indicate they have insufficient resources to meet all the demand.


Culture

All the staff we spoke with were very proud of their work and had strong bonds with their team

members. There was a real sense of mutual respect and support within the teams and this was

supported by team processes such as positive items on team meeting agendas and protected time

for team relaxation.

Most people told us that morale had benefitted from the recent improvement plan and that many

new-starters, including managers, had joined the teams and this was a positive experience.

Staff we spoke with said that their wellbeing was important and this was often discussed and

reinforced by colleagues and managers.

Staff knew how to use the whistle-blowing process and were aware of the Freedom to Speak Up

Guardian. This role can support staff in finding the best way to speak up about an area where they

feel improvements are needed.

There were regular conversations about staff development in appraisals and staff said that training

opportunities were routinely supported.

Managers dealt with poor staff performance when needed and could clearly explain the trust

process for doing this.

Staff had access to support for their own physical and emotional wellbeing via an occupational

health scheme.

Governance

There were clear systems in place to ensure that staff received regular supervision and yearly

appraisals. There was oversight of supervision by the service leads in each team and we saw that

these sessions were regularly scheduled and completed.

All locations had clear processes and policies to address complaints, incidents and safeguarding

concerns. The learning from these was shared with staff in a timely and efficient manner.

There were regular forums at each team to discuss clinical and business matters. These meetings

were weekly and were attended by the full multidisciplinary team.


The team managers had access to a local risk register for their services and could add new risks

to it. The managers said that they could easily escalate any risk issues to service leads and these

would be responded to and if appropriate they would be added to the trust risk register.

The service had mitigation plans in place for emergencies and contingency plans for staff

shortages.


Staff had access to appropriate equipment and information technology to be able to carry out their

roles.


Managers said that they had sufficient assistance to interpret and improve the data that their

management systems gave them. They acknowledged that at times their data about training,

caseloads and team composition was a challenge to interpret but this had been improved by the

responsive support of business intelligence colleagues.

The care records system was used across the trust and ensured that patient information was

accessible at the time it was needed. The social care staff maintained their own system which

meant that some patient data required inputting on two systems.

Engagement

Staff, patients and carers were kept up to date regarding the service and trust wide initiatives via

leaflets, newsletters, and social media. Young people were directed to websites and mobile phone

apps which they could use to help them understand their mental health and get support away from

the service.

The service continually collected feedback from patients and carers. The outcomes of feedback

were displayed in public areas of the team bases, and feedback from patients was discussed by

staff at team business meetings.

The service was engaged with the CYA which gathered feedback and recruited young people as

representatives. This included having young people on recruitment panels.


NHS trusts can 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 to continue to be accredited.

The table below shows which services within this service have been awarded an accreditation

together with the relevant dates of accreditation.

Accreditation scheme Comments

Quality Network for Community CAMHS (QNCC)

Children’s eating disorders, HOPE service and CAMHS have completed self-assessments. Services have not taken the next step to National Accreditation although various managers have stated that this is an ambition.

The CAMHS service had completed the self-assessment for the Quality Network for Community

CAMHS (QNCC). Service managers had not yet taken the next step for accreditation but this was

an ambition.

The CAMHS service was involved in two plans with commissioners to improve patient experiences

when transitioning from CAMHS and as an alternative to using Accident and Emergency.

Documents

Surrey and Borders Partnership NHS Foundation Trust...lead the Frimley Health and Care integrated care system. The trust has an equality strategy with the following priorities: Post-inspection