Norfolk and Suffolk NHS Foundation Trust

Transcription

1 Inadequate Norfolk and Suffolk NHS Foundation Trust Forensic inpatient. Quality Report Hellesdon Hospital Drayton High Road Norwich NR6 5BE Tel: Website: Date of inspection visit: October 2014 Date of publication: February 2014 Locations inspected Name of CQC registered location Location ID Name of service (e.g. ward/ unit/team) Postcode of service (ward/ unit/ team) Norvic RMY04 Eaton Ward NR7 0HT Norvic RMY04 Acle Ward NR7 0HT Norvic RMY04 Catton ward NR7 0HT Norvic RMY04 Drayton ward NR7 0HT Norvic RMY04 Thorpe ward NR7 0HT Norvic RMY04 Earlham (Seclusion) NR7 0HT Hellesdon Hospital RMY01 Yare ward NR6 5BE Hellesdon Hospital RMY01 Whitlington ward NR6 5BE St Clements Hospital RMYX3 Foxhall House IP3 8LS St Clements Hospital RMYX3 Chilton Houses IP3 8LS This report describes our judgement of the quality of care provided within this core service by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each location or area of service visited. 1 Forensic inpatient. Quality Report February 2014

2 Summary of findings Our judgement is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Norfolk and Suffolk NHS Foundation Trust and these are brought together to inform our overall judgement of Norfolk and Suffolk NHS Foundation Trust. 2 Forensic inpatient. Quality Report February 2014

3 Summary of findings Ratings We are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings will always be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring data and local information from the provider and other organisations. We will award them on a four-point scale: outstanding; good; requires improvement; or inadequate. Overall rating for Forensic inpatient Inadequate Are Forensic inpatient safe? Inadequate Are Forensic inpatient effective? Requires Improvement Are Forensic inpatient caring? Requires Improvement Are Forensic inpatient responsive? Requires Improvement Are Forensic inpatient well-led? Inadequate Mental Health Act responsibilities and Mental Capacity Act / Deprivation of Liberty Safeguards We include our assessment of the provider s compliance with the Mental Health Act and Mental Capacity Act in our overall inspection of the core service. We do not give a rating for Mental Health Act or Mental Capacity Act; however we do use our findings to determine the overall rating for the service. Further information about findings in relation to the Mental Health Act and Mental Capacity Act can be found later in this report. 3 Forensic inpatient. Quality Report February 2014

4 Summary of findings Contents Summary of this inspection Overall summary 5 The five questions we ask about the service and what we found 6 Background to the service 10 Our inspection team 10 Why we carried out this inspection 10 How we carried out this inspection 10 What people who use the provider's services say 11 Good practice 11 Areas for improvement 11 Detailed findings from this inspection Locations inspected 12 Mental Health Act responsibilities 12 Mental Capacity Act and Deprivation of Liberty Safeguards 13 Findings by our five questions 14 Page 4 Forensic inpatient. Quality Report February 2014

5 Summary of findings Overall summary We rated the forensic service at Norfolk and Suffolk NHS Foundation Trust as inadequate overall because: Environmental risk assessments were completed however ligature risks were identified that had not been addressed to keep people safe. We had a number of concerns regarding the seclusion facilities across the forensic services. These did not promote the safety or dignity of patients. Some patients told us that restraint and seclusion were used too frequently at the Norvic Clinic. We were concerned about the high levels of face down (prone) restraint and that there was a punitive attitude towards patients. In order to maintain staffing levels the services had to rely on the use of temporary staff from NHS professionals. This sometimes had a direct impact on people s section 17 leave and activities being cancelled. Morale was low across the service and staff told us that they did not always feel supported or valued by the trust. Staff generally felt supported by colleagues and immediate managers but felt that locality and senior managers were distant. Not all staff had received their mandatory training and many staff had not received regular supervision and appraisal. The trust acknowledged that this was their major area of risk but did not have a sufficient plan to address this. There were committees and other mechanisms in place to support governance but these had not always resulted in learning or improvement. Staff and local management did not understand the governance processes sufficiently to describe them and did not feel they related to them in their role. Staff felt confident to report concerns. However not all felt that they had received feedback in these circumstances. Some staff told us that they had received limited support following an incident. We found that the prescribing, storage and administration of medication was not always safe. Staff were not clear about arrangements for rapid tranquilisation. Physical healthcare needs were not always sufficiently monitored or managed. The service at the Norvic clinic participated in the Royal College of Psychiatrists quality network for forensic services' audit. However recommendations from the latest audit had not been addressed. Systems were in place to ensure that the service complied with the Mental Health Act (MHA) and adhered to the guiding principles of the MHA Code of Practice. However, we found that staff did not always recognise and manage people s restraint or seclusion within the safeguards set out in the MHA Code of Practice. However: Generally we saw evidence of aspects of care and treatment for people who used the service being appropriately considered. We usually saw individual care plans had been devised to meet people s needs and found examples where good and effective communication had taken place between different services and comprehensive care plans had been written. We observed multi-disciplinary reviews taking place to ensure people received the right care and support. 5 Forensic inpatient. Quality Report February 2014

6 Summary of findings The five questions we ask about the service and what we found Are services safe? We rated the forensic wards as inadequate' for this domain because: Inadequate There were systems in place to assess and monitor the safety of the environment. However, we found ligature risks across the services which had not been addressed and were in areas used by people. Some wards had challenging layouts and poor lines of sight. This meant that staff could not always observe patients. Maintenance was not always carried out so that people had an acceptable level of facilities and cleanliness in their rooms. Seclusion rooms in the Norvic Clinic were situated away from the wards which meant patients needed to be moved to the rooms located on Earlham which were down stairs and along corridors. Earlham contained two seclusion rooms and both were for use by men and women. Toilet facilities were located away from the seclusion rooms. This meant that patients had to use urine bottles or bedpans if they were unable to leave the seclusion rooms. There were similar arrangements for seclusion at Foxhall House. High levels of face down (prone) restraint were used in some services. We observed that some episodes of restraint and seclusion may have been punitive. We found that open seclusion had occurred at Hellesdon hospital without the safeguards required by the MHA Code of Practice in place. Not all staff were clear regarding what constituted seclusion practice. The wards usually maintained staffing levels through the use of temporary staff from NHSP. However when temporary staff did not arrive low staffing numbers did impact on patients escorted leave and activities. We found that the prescribing, storage and administration of medication was not always safe. Staff were not clear about arrangements for rapid tranquilisation. Staff knew how to report incidents but did not always receive feedback or debriefing following incidents. Ward managers did not have access to incident forms following their submission to the incident reporting team. We heard about some incidents that may have been preventable that had not resulted in any learning or changes in practice. Risk assessments were not always updated following incidents. 6 Forensic inpatient. Quality Report February 2014

7 Summary of findings Generally staff knew about situations that would require safeguarding, but not all had received training or were clear about specific reporting procedures. Are services effective? We rated the forensic wards as requires improvement for this domain because: Requires Improvement Staff told us that they did not always receive the support they needed to do their job. Not all staff had received their mandatory training and many staff had not received regular supervision and appraisal. The trust acknowledged that this was their major area of risk but did not have a sufficient plan to address this. Physical healthcare needs were not always sufficiently monitored or managed. The units had daily activity plans that people could participate in whilst on the wards as well as in the community. However we heard that leave and activities could be cancelled due to staff shortages at the Norvic Clinic. The service at the Norvic Clinic participated in the Royal College of Psychiatrists quality network for forensic mental health services' audit. However recommendations from the latest audit had not been addressed. Systems were in place to ensure that the service complied with the Mental Health Act (MHA) and adhered to the guiding principles of the MHA Code of Practice. However, we found that staff did not always recognise and manage people s restraint or seclusion within the safeguards set out in the MHA Code of Practice. However: Generally staff considered all aspects of care and treatment when assessing the needs of people.we saw individual care plans had usually been devised to meet people s assessed needs and found examples where good and effective communication had taken place between different services and comprehensive care plans had been written. We observed multi-disciplinary reviews taking place to ensure people received the right care and support. Are services caring? We rated the forensic wards as requires improvement for this domain because: Requires Improvement 7 Forensic inpatient. Quality Report February 2014

8 Summary of findings Overall, people told us that staff treated them with respect and dignity, and they were positive about staff's attitude towards them. The majority of people also told us that they were happy with their care, and that they felt supported and well-cared for by staff. However we had concerns about the punitive attitude of some staff at the Norvic Clinic towards patients. People were involved in their care planning and would sign to confirm their agreement with the plans. However not all patients felt fully involved in their care reviews or decisions about their medication. However: We saw how staff engaged and included people and their families in their care. Patients had access to advocacy and generally this was promoted. Are services responsive to people's needs? We rated the forensic wards as requires improvement for this domain because: Requires Improvement At the Norvic Clinic the seclusion facility was used for both male and female patients. We were made aware of occasions when patients of both genders were accommodated at the same time. Staff showed they were concerned for the patients privacy and dignity but stated they had no other option open to them. We were concerned about restrictive practices at the Norvic Clinic. We were told and observed that restraint and seclusion was used in a punitive manner. Patients told us that they did not always have easy access to drinks, fresh air or cigarette breaks. We heard that patients would not be granted leave until they had completed activities. Patients did not all have access to a telephone were they could make their calls in privacy. Facilities at the Norvic Clinic required some improvement. there was limited space for activities and meetings. Not all maintenance had been completed. Wards did not have deescalation rooms. Not all rooms were ensuite and in some wards there was limited bathroom and toilet facilities. However: We observed effective admission and discharge procedures. The wards had access to translation services and information for people in a range of different formats. 8 Forensic inpatient. Quality Report February 2014

9 Summary of findings Most patients told us that they were given information about how to complain about the service. This was contained within the ward information booklet and included information about how to contact the patients advice and liaison service (PALS). Information about the complaints process was displayed at the wards. Are services well-led? We rated the forensic wards as inadequate' for this domain because: Inadequate There were committees and other mechanisms in place to support governance but these had not always resulted in learning or improvement. Staff and local management did not understand the governance processes sufficiently to describe them and did not feel they related to them in their role. Morale was low across the services. Most staff felt supported at a local level but felt disconnected from locality managers, senior managers and trust executives. Staff felt confident to report concerns however not all felt that they had received feedback in these circumstances. Some staff told us that they had received limited support following an incident. Not all staff had received required training, supervision or appraisal. Some new staff told us that they had received limited training, supervision and support during their induction. 9 Forensic inpatient. Quality Report February 2014

10 Summary of findings Background to the service Norfolk and Suffolk NHS Foundation Trust provides secure inpatient mental health services for adults aged 18 years and over who are detained under the Mental Health Act. The Norvic Clinic has five medium secure wards and a seclusion ward. Low secure services are based at Hellesdon Hospital in Norwich and St Clements Hospital in Ipswich. Our inspection team Our inspection team was led by: Chair: Joe Rafferty, Chief Executive Officer, Merseycare NHS Trust Team Leader: Julie Meikle, Head of Hospital Inspection (mental health), CQC Inspection Manager: Lyn Critchley, Inspection Manager, CQC The team included CQC managers, inspection managers, inspectors and support staff and a variety of specialist and experts by experience that had personal experience of using or caring for someone who uses the type of services we were inspecting. The team that visited the forensic services included CQC inspectors and a variety of specialists including: A consultant psychiatrist in forensic services Two senior nurses experienced in forensic services Two mental health act reviewers A mental health social worker. An expert by experience in mental health. Why we carried out this inspection We inspected this core service as part of our on-going comprehensive mental health inspection programme. How we carried out this inspection To get to the heart of people who use services experience of care, we always ask the following five questions of every service and provider: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? Before visiting, we reviewed a range of information we hold about Norfolk and Suffolk NHS Foundation Trust and asked other organisations to share what they knew. We carried out an announced visit between 21 October and 23 October. Unannounced inspections were also carried out on the late evening of 06 November During the inspection we held focus groups with a range of staff who worked within the service, such as nurses, doctors, consultants and managers. We observed how people were being cared for and talked with carers and/ or family members and reviewed care or treatment records of people who use services. We met with people who use services and carers, who shared their views and experiences of the core service. Although the trust were aware we were visiting the service, they did not know in advance which services we would be visiting and when. 10 Forensic inpatient. Quality Report February 2014

11 Summary of findings What people who use the provider's services say People told us that most staff were respectful and caring. However some patients told us that certain staff did not care and only came to work for the money. We heard of occasions when requests made by patients were not always followed through. Some people said that they had usually had access to activities and were able to go out when they wanted. However we were told that at times staffing levels were low meaning their leave and activities could be cancelled. Most people told us that they felt safe. However some patients who had witnessed violence on the ward said they felt vulnerable because of other patients behaviour. Some patients told us that restraint and seclusion were used frequently at the Norvic Clinic. Not everyone we spoke with had help or support from advocacy services during their time in the service. People had regular contact with their psychiatrist and good access to therapies. Families felt the care and service their relatives received was generally good. Good practice In Whitlingham a buddying system had been set up where buddies were remunerated for their work in supporting new patients. Areas for improvement Action the provider MUST or SHOULD take to improve The trust must address environmental issues including poor lines of sight and ligature risks in patient areas. the trust must ensure that all maintenance issues are resolved in a timely manner. The trust must ensure that the seclusion facilities are appropriate at the Norvic Clinic and Foxhall House. The trust must ensure that patients at the Norvic Clinic do not have to be moved through corridors and down stairs to enter seclusion. The trust must ensure that there is no restrictive or punitive practice. The trust should ensure there are sufficient staff at all times so that patients leave and activities take place as planned. The trust must ensure effective recruitment and retention processes so that there is less reliance on temporary staff from NHS professionals. The trust must ensure that all statutory and mandatory training is undertaken, particularly management of violence and aggression training. The trust must ensure that staff have access to support, supervision and appraisal. This is particularly relevant to newly qualified staff. The trust must ensure that staff receive feedback where they have raised concerns and ensure that there is learning from incidents. The trust must improve care plans reflect the direct views of patients. The trust must ensure that physical healthcare needs are monitored and managed. The trust must improve the medicine management systems. The trust should improve staff understanding of the governance structures. 11 Forensic inpatient. Quality Report February 2014

12 Norfolk and Suffolk NHS Foundation Trust Forensic inpatient/secure wards. Detailed findings Locations inspected Name of service (e.g. ward/unit/team) Eaton ward Thorpe ward Acle ward Catton ward Drayton ward Earlham (seclusion) Whitlington ward Yare Ward Foxhall House Chilton Houses Name of CQC registered location Norvic Clinic Norvic Clinic Norvic Clinic Norvic Clinic Norvic Clinic Norvic Clinic Hellesdon Hospital Hellesdon Hospital St Clements Hospital St Clements Hospital Mental Health Act responsibilities Overall, we found that paperwork relating to the MHA was completed and filed appropriately as required by the MHA Code of Practice. The statutory detention paperwork was found to be correct and in good order. There was some evidence to show that patients had been read their rights under section 132 at monthly intervals, and had also been given written information regarding their detention. The majority of people we spoke with told us they understood their rights and the legal implications in relation to their detention under the MHA. On reviewing the notes of seven patients we noted inconsistent practice by the responsible clinician (RC). We 12 Forensic inpatient. Quality Report February 2014

13 Detailed findings found some good assessments of patients mental capacity to consent to their treatment when treatment was authorised on a certificate of consent to treatment (T2). However, where a patient lacked capacity or required a second opinion doctor (SOAD) we found no evidence of these assessments. We noted that where a SOAD was required, the appropriate request was made and prescribed medication was in accordance with the authorised treatment authority. Patients we spoke with were aware of the medication they were prescribed and the reasons why they were prescribed it. We saw evidence which showed that staff had referred people to an independent mental health advocate appropriately. We saw evidence that demonstrated people had attended mental health review tribunals. The majority of people we spoke with, who had been granted section 17 leave by their consultant, told us that there were enough staff to enable them to take this. However; some people told us that their section 17 leave was often cancelled due to staff shortages. Mental Capacity Act and Deprivation of Liberty Safeguards People we met were detained under the Mental Health Act 1983 and therefore were not subject to Deprivation of Liberty Safeguards. In all the wards we visited we found that not all staff had received training in the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards legislation. 13 Forensic inpatient. Quality Report February 2014

14 Are services safe? Inadequate By safe, we mean that people are protected from abuse* and avoidable harm * People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse Summary of findings We rated the forensic wards as inadequate' for this domain because: There were systems in place to assess and monitor the safety of the environment. However, we found ligature risks across the services which had not been addressed and were in areas used by people. Some wards had challenging layouts and poor lines of sight. This meant that staff could not always observe patients. Maintenance was not always carried out so that people had an acceptable level of facilities and cleanliness in their rooms. Seclusion rooms in the Norvic Clinic were situated away from the wards which meant patients needed to be moved to the rooms located on Earlham which were down stairs and along corridors. Earlham contained two seclusion rooms and both were for use by men and women. Toilet facilities were located away from the seclusion rooms. This meant that patients had to use urine bottles or bedpans if they were unable to leave the seclusion rooms. There were similar arrangements for seclusion at Foxhall House. High levels of face down (prone) restraint were used in some services. We observed that some episodes of restraint and seclusion may have been punitive. We found that open seclusion had occurred at Hellesdon hospital without the safeguards required by the MHA Code of Practice in place. Not all staff were clear regarding what constituted seclusion practice. The wards usually maintained staffing levels through the use of temporary staff from NHSP. However when temporary staff did not arrive low staffing numbers did impact on patients escorted leave and activities. We found that the prescribing, storage and administration of medication was not always safe. Staff were not clear about arrangements for rapid tranquilisation. Staff knew how to report incidents but did not always receive feedback or debriefing following incidents. Ward managers did not have access to incident forms following their submission to the incident reporting team. We heard about some incidents that may have been preventable that had not resulted in any learning or changes in practice. Risk assessments were not always updated following incidents. Generally staff knew about situations that would require safeguarding, but not all had received training or were clear about specific reporting procedures. Our findings Norvic Clinic Safe and clean ward environment The ward areas were clean, generally well-maintained and had good furnishings. However we heard from several patients that their requests for maintenance on their rooms had not been followed through. We were shown two shower rooms that had not been adequately maintained as both had dirty standing water. One toilet would not flush. These matters had been reported over a period of several weeks. Three patients complained that the beds were overly hard and that this affected their sleep. They had reported this, but no action had been taken. We were told that environmental risk assessments were carried out annually however these could not be found for us to review on the unit. The trust had taken some steps to remove ligature risks within patient areas. Risk assessments had identified that all door hinges presented a ligature risk and needed to be changed. Doors had been replaced as a result. However, two patients demonstrated to us how potential ligatures could be formed and hung from bedroom and bathroom door hinges. This was acknowledged by staff. We toured all wards at the Norvic Clinic. There were good lines of sight when patients were out in the day areas. However sight lines from the nursing offices were restricted and staff could not always view bedroom corridors. In one ward there were no mirrors to enable staff to see along the corridors which had handles that could be used as ligature 14 Forensic inpatient. Quality Report February 2014

15 Are services safe? Inadequate By safe, we mean that people are protected from abuse* and avoidable harm points. Staff told us that they managed these risks through ensuring frequent observation. During the inspection we saw staff out in the ward areas and those undertaking observations regularly walked about. Each ward had a clinic room equipped with hand washing facilities, workspace and physical health monitoring equipment. The clinic rooms were equipped with resuscitation equipment and emergency drugs that were regularly checked. The rooms were clean and contained equipment to enable examination of patients and for the administration of treatment. The seclusion facilities for the Norvic Clinic were located away from the wards in a separate area known as Earlham ward. The area contained two seclusion rooms located in close proximity to each other. The area was used for both genders at the same time. Seclusion rooms did not have ensuite facilities. Toilet and washing facilities were located separately on the unit and were used by both genders. If patients needed to use the toilet or washing facilities, the seclusion door had to be opened. Patients who could not be allowed out to use the toilet and washing facilities were given a urine bottle or a bedpan when in seclusion. This is an unacceptable situation. Staff also informed us that prior to our inspection both a female and male patient had been secluded in the adjacent rooms. Staff showed they were concerned for the patients privacy and dignity but stated they had no other option open to them. Patients on Eaton ward needing to be secluded had to be moved in restraint down a set of stairs and along a busy corridor to reach Earlham. This meant that both staff and patients were at risk coming down the stairs and could be observed by anyone in the corridor during the transfer to the seclusion room. Safe staffing Each shift should have two qualified nurses but that was not always achieved because there were staff shortages. During our inspection we saw that the clinic used staff supplied by NHS Professionals (NHSP). We were told that where possible they used the same staff to cover shifts because they knew the wards and patients. Three members of staff told us that NHSP staff often cancelled which left wards short staffed. Patients told us that staffing levels were terrible at times with some shifts only having three staff on duty. Records confirmed this. This resulted in cancelled activities and section 17 leave, and in staff not having breaks. We heard from a patient who had been unable to attend a medical appointment at the general hospital due to staff shortage. We were told by nurses that it was a challenge to manage the wards particularly when they had to staff the seclusion and long term segregation area. We were told that nights were especially challenging. At the time of our inspection a person was in segregation which had impacted on staff availability. The unit s management told us that the shortage of staff had been raised and was on the trust s risk register. We met with some of the medical team during the inspection. They confirmed that there was sufficient medical cover on the wards although there was limited access to GPs. Assessing and managing risk to patients and staff Care and treatment was planned and delivered in a way that ensured patients safety and welfare. Care plans included the assessment and management of risk, for example increased observation levels due to concerns over a patient s safety and welfare. However some care plans did not contain evidence of people s involvement in the planning of their care and treatment. We found there were policies and procedures for observation in place to reduce the level of violence and self-harm. Whilst on the unit we saw that people who became violent were restrained and removed to the seclusion ward. Five people told us that they had been restrained and secluded following refusal to follow staff instructions. One person told us that if you do not sit correctly on the chairs you could end up being restrained and secluded. Restraint and seclusion were used regularly at the Norvic Clinic. Incidents of restraint and seclusion were recorded and reviewed by the trust. Details provided by the trust confirmed restraint had been used 313 times in the six months prior to July We were concerned that of these 11% had involved face down (prone) restraint. Seclusion had been used on 58 occasions. The trust told us that a report had recently been submitted to the trust s service governance committee outlining the trust s response to the Department of Health s recently published Positive and 15 Forensic inpatient. Quality Report February 2014

16 Are services safe? Inadequate By safe, we mean that people are protected from abuse* and avoidable harm Proactive Care: reducing the need for restrictive interventions. The trust told us that the director of nursing had been appointed as lead for this work and a working group had recently been set up to look at restraint practice and training. However the trust was yet to comply with all requirements of the Department of Health's guidance by the target date of September 2014 as it was yet to formalise a reduction strategy or decide on future training options. This was acknowledged by the trust. In February 2014 the Health and Safety Executive issued a report setting out material breaches for standards of risk management and training for managing violence and aggression at the Norvic Clinic. The trust had developed an action plan to reach compliance by May However we found that not all staff had received mandatory physical intervention training. One seclusion room was in use when we inspected the unit. We were told that it was not a seclusion episode but that the person was segregated due to risk. Staff we spoke with did not understand the difference between seclusion and segregation and used the term indiscriminately. Security systems were not clearly followed by staff operating the airlock systems at the entrance to the unit. An example was when we entered the unit we were not shown the contraband list. No security alarms were offered and we had to ask before being given an alarm. Medicines were stored in British Standard wall cabinets. Medicines in current use were stored in a medicine trolley which was not secured at the time of the inspection. There was not a medicine refrigerator available on one ward. Medicine that needed to be stored in a refrigerator was stored on a neighbouring ward. We saw that a 28 day medicine chart was used which required frequent re-writing. It was noted that there was an agreement that a continuation sheet could be attached to the chart to minimise the need to re-write this. However, these sheets were attached by a staple to the original chart and could introduce an element of risk to the prescription and administration process. The unit was trialling an electronic prescribing project known as EMMA. Electronic prescribing has been shown to reduce prescribing errors, uncoded doses and missed doses and to enable monitoring of the amount of when required medicines given in a time period. However due to concerns regarding patient safety, one ward had decided to abandon their participation and reinstate traditional prescribing. The ward also had concerns around the extra time taken to complete the medicine rounds. Staff were unsure of the process for rapid tranquilisation and supporting policies did not clarify the agreed process. This is a significant risk. Reporting incidents and learning from when things go wrong Staff we spoke with were aware of the trust s incident reporting systems. There was no formal learning from incidents meetings but we were told that handover meetings were used to share information about incidents and where necessary, immediate plans were put in place to reduce further similar incidents from reoccurring. We were told that there was not always an immediate de-briefing for staff involved when serious incidents took place. We were unable to review records of incidents that had happened because no records were held on the wards and managers did not have access to these records once they had been sent off to the trust s incident team. There had been a very serious incident at the unit in the weeks prior to our inspection. Some staff stated that they had been offered support and a debrief however others stated that they had yet to receive a debrief. We were told that staff had yet to hear about any learning from this incident. Some patients told us that they had witnessed this incident and had wanted to share their concerns and observations however they had not been asked about these. Not all staff had received safeguarding training. However staff demonstrated a good understanding of what might constitute abuse and knew where they should go to report any concerns they had. Hellesdon Hospital - Whitlingham and Yare Safe and clean ward environment The ward areas were clean, well-maintained and had good furnishings. Environmental risk assessments were carried out earlier in the year and had identified ligature risks. The work to rectify some of the identified risks had been completed on the ward. However we found potential ligature points in bathrooms and toilets. We were told that 16 Forensic inpatient. Quality Report February 2014

17 Are services safe? Inadequate By safe, we mean that people are protected from abuse* and avoidable harm these were locked and access was managed dependent on patient observation levels. We also noted that the replacement hinges that had been installed in doors still posed a potential ligature risk. The bedrooms were located away from the staff areas along poorly lit corridors. This meant that people experiencing distress or displaying self-harming behaviour could be isolated. Staff on the ward told us that there had been an improvement to the door hinges and that shower doors were now curved to enable lines of sight but not compromise dignity. Safe staffing We found the wards had sufficient staffing levels to meet people s needs. The ward was carrying three vacancies for qualified nursing staff but regular temporary staff from NHS Professionals were used to cover that gap in staffing levels. Recruitment was said to be imminent and the managers were hopeful that the ward would have a full complement of staff in the near future. Assessing and managing risk to patients and staff We found that care was planned in a way that ensured patients safety and welfare. Care plans included the assessment and management of risk and contained evidence of people s involvement in the planning of their care and treatment. Observation policies and procedures were in place and staff were familiar with these policies and able to tell us about the procedures. The wards had welcome packs that were given to people at point of admission. The packs shared information about living in the unit and the items that are prohibited to people staying on the ward. People undergoing assessment prior to admission had information given to them about ward and the conduct required whilst staying there. On Whitlingham ward we saw they used a buddy system where patients were remunerated if they help to support newly admitted people. This system helped patients to understand the ward protocols. A Community Support Officer (CSO) visited the hospital on a regular basis to work with staff and patients. We were told that this had assisted with the prevention of absconcions. Restraint was used regularly at Yare Ward. Incidents of restraint were recorded and reviewed by the trust. Details provided by the trust confirmed restraint had been used 55 times in the six months prior to July We were concerned that of these 45% had involved face down (prone) restraint. We were told that seclusion was not practiced on the wards and that should this be required a patient would be moved to the PICU located at the hospital. Whitlingham ward has a de-escalation suite which was appropriately furnished. We were told that patients used this room frequently. We noted that one patient had recently used the room and this had been recorded as 'open seclusion'. We saw that staff had alerted the duty doctor as this seclusion commenced but found no evidence that he had attended. This does not meet the MHA Code of Practice. Generally arrangements were appropriate for the management and storage of medication. However we found that the medicine fridge temperature had not been checked for more than a month prior to our inspection. Staff demonstrated a good understanding of what might constitute abuse and knew where they should go to report any concerns they had. Most staff had received safeguarding training. Some staff told us they were unclear regarding the new structure for safeguarding since changes at Norfolk County Council just prior to our inspection. Reporting incidents and learning from when things go wrong The wards had an electronic incident reporting system in place which was completed following any incidents, allowing ward managers to review and grade the severity of incidents. Staff knew how to use the system and what their responsibilities were in relation to reporting incidents. Handover meetings were used to share information of incidents. We were unable to review records of incidents that had happened because no records were held on the wards and managers did not have access to these records once they had been sent to the trust s incident team. Some staff told us that they did not receive feedback following incidents and that they were unaware of any learning from incidents that had occurred elsewhere at the trust. 17 Forensic inpatient. Quality Report February 2014

18 Are services safe? Inadequate By safe, we mean that people are protected from abuse* and avoidable harm We were informed of a recent incident in which a staff member was assaulted. The patient involved in this had previously assaulted another patient. Both incidents were stated to have been preventable however there was no obvious learning from the incidents. St Clements Hospital - Foxhall House and Chilton Houses Safe and clean ward environment Staff at Foxhall House told us that health and safety assessments were undertaken on a yearly basis and these assessments included ligature audits. We saw that these had been conducted in 2013 and showed the measures put in place to mitigate the risk to patients. Chilton Houses was built in a domestic style and this presented particular difficulties for staff in carrying out observations. The building had poor lines of sight and bedroom doors did not contain a viewing panel. There were multiple potential ligature points around the unit. These risks were on the risk register but there had been no mitigating action. The manager told us that changes in patients presentation were assessed with environmental risks in mind and where appropriate this was managed by increasing relational or procedural security or a review of the placement. The wards were clean, tidy and well decorated. Patients at Foxhall House told us they were happy with the standard of their bedroom and the ward environment. Chilton Houses appeared clean and we saw up to date cleaning schedules on the notice board. Patients we spoke with told us they felt the ward was clean.the wards areas were in reasonable decorative order with dedicated male and female areas and quiet designated communal areas. The atmosphere was calm throughout our visit to both wards. Patients had free access to gardens, smoking areas and local community facilities. During this inspection we saw that the seclusion area at Foxhall House consisted of a seclusion room, a deescalation area, a separate toilet and washing area, with a room for nursing staff to observe people in seclusion. We established that there was CCTV in the seclusion room. The CCTV relied on staff watching the monitor in the observation office whilst patients were secluded. Patients in seclusion were provided with a urine bottle or bedpan to use if they were too disturbed to leave the seclusion room to use the toilet facilities. This is not acceptable. Safe Staffing The management team explained that they had experienced challenges with the recruitment and retention of staff, especially registered nurses. However the service had recent success recruiting some new staff. At Foxhall the staffing levels meant that each shift had one registered nurse. However with new staff recruited they would be able to have two trained nurses per shift. Chilton Houses staff told us there had been some issues with regards to the staffing levels in the previous few months. High levels of sickness throughout the main holiday period over the summer had caused some difficulties in arranging cover. Staff and patients told us they felt the staffing numbers were now sufficient. There had been a series of locum psychiatric consultants at Foxhall House since the last substantive consultant had left. However the trust had secured a long term locum and had successfully recruited a new consultant who would join the team in the new year. During the period of locum consultants' consistent medical cover was provided by an experienced middle grade doctor. At Chilton Houses there was limited consultant psychiatrist cover as there was a locum employed only two days per week. Daily medical cover was provided by an on call system and staff we spoke with said that it had not always been easy to access medical assistance at night. Assessing and managing risk to patients and staff We found that risk assessments were routinely completed to determine the level of security and risk management that patients needed, such as for off ward and community leave. We found that risk assessments were not always updated following incidents. Staff told us that the assessments were not always updated because the risk levels had not changed. A system was in place to restrict items coming on to the unit that may pose a risk. On Chilton Houses within the care records we saw that each patient had a risk assessment completed on admission and this process was reviewed at least every six months to monitor any changes in risks. 18 Forensic inpatient. Quality Report February 2014

19 Are services safe? Inadequate By safe, we mean that people are protected from abuse* and avoidable harm At Foxhall we were informed and saw that observations were undertaken by staff, which meant walking around the ward, checking where patients were. There were good security measures in place. For example, upon arrival at the hospital we were asked to show our identity badges and to sign in and on leaving we had to sign out. We saw that people who had unescorted leave were searched on return to the ward where appropriate. We spoke with staff about safeguarding and the training they had undertaken. Staff told us they had undertaken safeguarding training but were not able to tell us who the trust s safeguarding lead was and where to report any abuse they saw other than to the unit manager. Our specialist pharmacy inspector reviewed medication charts and discovered one patient prescribed lithium had not had any tests for lithium levels taken since March 2014 this must be repeated at 3 monthly intervals. We bought this to the attention of the nurse in charge who arranged for an immediate blood test to be undertaken. Reporting incidents and learning from when things go wrong All the staff we talked with felt confident to report incidents and concerns and were quite confident in using the incident reporting system. They felt they could raise issues if and when they saw them happen. Staff could not describe the trust s process for disseminating learning from incidents although they discussed incidents on the unit in their handovers. The manager confirmed that team meetings were now being established and sharing information about incidents would be a standing agenda item. 19 Forensic inpatient. Quality Report February 2014

20 Are services effective? Requires Improvement By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Summary of findings We rated the forensic wards as requires improvement' because: Staff told us that they did not always receive the support they needed to do their job. Not all staff had received their mandatory training and many staff had not received regular supervision and appraisal. The trust acknowledged that this was their major area of risk but did not have a sufficient plan to address this. Physical healthcare needs were not always sufficiently monitored or managed. The units had daily activity plans that people could participate in whilst on the wards as well as in the community. However we heard that leave and activities could be cancelled due to staff shortages at the Norvic Clinic. The service at the Norvic Clinic participated in the Royal College of Psychiatrists quality network for forensic mental health services' audit. However recommendations from the latest audit had not been addressed. Systems were in place to ensure that the service complied with the Mental Health Act (MHA) and adhered to the guiding principles of the MHA Code of Practice. However, we found that staff did not always recognise and manage people s restraint or seclusion within the safeguards set out in the MHA Code of Practice. However: Generally staff considered all aspects of care and treatment when assessing the needs of people. We saw individual care plans had usually been devised to meet people s assessed needs and found examples where good and effective communication had taken place between different services and comprehensive care plans had been written. We observed multi-disciplinary reviews taking place to ensure people received the right care and support. Our findings Norvic Clinic Assessment of needs and planning of care We found that there were systems and processes in place to ensure multidisciplinary assessment prior to admission. Newly admitted patients had an initial risk assessment and treatment plan. All care was delivered under the Care Programme Approach (CPA) framework. Each person had a comprehensive assessment completed as part of the admission process which included social, cultural, physical and psychological needs and preferences. Some people s records that we saw had a relapse prevention plan which provided specific details of interventions which should be put in place if the person s mental health deteriorated. People s care and treatment was reviewed regularly through formulation meetings. Staff told us that Care Programme Approach (CPA) meetings took place before a person was discharged to make sure that they were supported during their discharge or transfer from the wards. We were told that the associate doctor took the lead in monitoring the physical healthcare of the people. Despite the availability of the health monitoring equipment we were told by nursing staff and junior doctors that the wards could not meet the physical health needs of their patients. Patients were not registered to any local general practice (GP). Instead, the clinic contracted with a local GP to provide support. Patients and staff told us that that accessing timely support could be difficult, particularly if someone became unwell over a weekend. When GPs visited the unit there was no dedicated clinic area for the service which caused disruption to people in the wards. Best practice in treatment and care We found that patients had access to a varied programme of group activities which were also linked to individual programmes. There were meetings that took place on a daily basis to discuss the day s activities and community meetings took place weekly and were attended by members of the clinical team. Patients generally appreciated activities however told us that these would be cancelled if there was insufficient staff. The unit managers told us that care was planned using the my shared pathway tool. At Acle ward staff had begun to use the recovery star method. From our review of patients records we did not always see that these tools were being used to plan care or measure patient outcomes. The service at Norvic participated in the Royal College of Psychiatrists quality network for forensic mental health 20 Forensic inpatient. Quality Report February 2014

21 Are services effective? Requires Improvement By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. services' audit. We looked at the audit report for the service from February 2014 and noted the review had highlighted issues with the toilet facilities in the seclusion area and ligature points in the wards that had not been addressed. Skilled staff to deliver care The service had dedicated clinical psychological support, an occupational therapist (OT) and OT assistant. Patients also had access to technical instructors (who supported people to access the community, educational programmes, art therapy and a cognitive behavioural therapy (CBT) nurse. Not all staff had received their mandatory training. The service manager told us that all areas of mandatory training were not meeting the trust's compliance targets. Many staff had not received regular supervision and appraisal. We met some new staff told us that they had not received sufficient support during their induction. They described a lack of training, supervision and support during this period. One staff member told us that they had worked on the unit for many months before they received their management of aggression training. Other staff told us that they struggled to access training due to staff shortages. The trust acknowledged that this was their major area of risk but did not have a sufficient plan to address this. Multi-disciplinary and inter-agency team work We observed multi-disciplinary reviews taking place to ensure people received the right care and support. During a formulation meeting we saw evidence of all aspects of care and treatment for people who used the service being appropriately considered. We saw individual care plans had been devised to meet people s assessed needs and found examples where good and effective communication had taken place between different services and comprehensive care plans had been written. Senior staff told us that they had well developed links with community teams and other relevant services. Adherence to the MHA and the MHA Code of Practice Overall, we found that paperwork relating to the MHA was completed and filed appropriately as required by the MHA Code of Practice. The statutory detention paperwork was found to be correct and in good order. There was some evidence to show that patients had been read their rights under section 132 at monthly intervals, and had also been given written information regarding their detention. The majority of people we spoke with told us they understood their rights and the legal implications in relation to their detention under the MHA. On reviewing the notes of seven patients we noted inconsistent practice by the responsible clinician (RC). We found some good assessments of patients mental capacity to consent to their treatment when treatment was authorised on a certificate of consent to treatment (T2). However, where a patient lacked capacity or required a second opinion doctor (SOAD) we found no evidence of these assessments. We noted that where a SOAD was required, the appropriate request was made and prescribed medication was in accordance with the authorised treatment authority. Patients we spoke with were aware of the medication they were prescribed and the reasons why they were prescribed it. We saw evidence which showed that staff had referred people to an independent mental health advocate appropriately. We saw evidence that demonstrated people had attended mental health review tribunals. The majority of people we spoke with, who had been granted section 17 leave by their consultant, told us that there were enough staff to enable them to take this. However; some people told us that their section 17 leave was often cancelled due to staff shortages. Good practice in applying the MCA People we met were detained under the Mental Health Act and therefore were not subject to Deprivation of Liberty Safeguards. In all the wards we visited we found that not all staff had received training in the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards legislation. Hellesdon Hospital - Whitlingham and Yare Assessment of needs and planning of care We looked at eight patient s notes and found they were organised in a way that could be confusing unless you were 21 Forensic inpatient. Quality Report February 2014

22 Are services effective? Requires Improvement By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. aware that there were more than one set of notes for some people. We saw some good examples of how people had been fully involved in all aspects of their care and treatment. The care plan records we looked at showed examples of the therapeutic approach in the service which encouraged independence and made reasonable adjustments. On Whitlingham ward we found that two patients had not had physical health checks as scheduled. One patient had a significant long term condition but had not had a physical health check since admission in January People told us they received really good support from the psychologist with their health difficulties. We saw a psychologist working with people and discussing their care and treatment so that it would be delivered in the way that they found meaningful and that staff would be able to work with. We received good feedback from people across wards regarding their access to activities. We saw that a range of activities and therapies were planned that people were able to participate in. People told us having activity workers was good because they engaged well with people. Best practice in treatment and care Outcomes were identified during the planning process to encourage people who used the service to move through the treatment pathway. These outcomes were appropriate for the type of services provided at Whitlingham. Risk assessments were used on a regular basis and recorded. People we spoke with could tell us what they needed to do to move on either to another ward or to the community. Skilled staff to deliver care Staff received annual appraisals and monthly supervision that they had to attend. Staff training records showed that they were up to date with their mandatory training. Multi-disciplinary and inter-agency team work The unit held handover meetings three times per day that were attended by staff coming onto duty and occupational therapy staff would attend some of those handovers when appropriate. Good practice in applying the MCA People we met were detained under the Mental Health Act and therefore were not subject to Deprivation of Liberty Safeguards. In all the wards we visited we found that not all staff had received training in the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards legislation. St Clements Hospital - Foxhall House and Chilton Houses Assessment of needs and planning of care At Chilton Houses care records we looked at contained up to date recovery based care plans and showed an annual physical examination has been undertaken. Staff on Chilton Houses told us they had good access to physical healthcare which was available at the nearby general hospital. People received care that was tailored to their individual needs and which were regularly assessed and reviewed by the multi-disciplinary team. Each person who used services had an assessment in respect of identified needs such as violence and aggression, and self-harm, which informed their care pathways. Some people had restricted conditions and this was taken into account. Foxhall House had an occupational therapist who delivered structured groups and supported people to engage in activities. However, people told us they did not always have a lot to do and became bored on the ward. One person, who enjoyed playing football, told us that playing football regularly was part of their activity plan. Best practice in treatment and care Staff told us they felt that they were able to manage their workload. The thought they had a good understanding of the needs of the people they were involved with. The ward had embedded the principles of the recovery model within clinical practice to assist people in their recovery. There was evidence of a range of activities which were made available to people who used the service. The psychologist who told us they were able to offer psychological therapies but these were hampered by a lack of community placements for patients to access. 22 Forensic inpatient. Quality Report February 2014

23 Are services effective? Requires Improvement By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. We saw and patients told us there was a programme of ward activities throughout the week and weekends. We were told there was an activity worker employed on the team but at the time of the inspection they were escorting a patient to a community facility. Skilled staff to deliver care The training records showed that staff had not always undertaken training that was relevant to their role. Staff told us that the manager has been supportive in relation to training. Staff did not receive regular clinical supervision and annual appraisals in line with trust policy. The manager confirmed this but had commenced the process of ensuring there was a formal supervision in place for all staff. Foxhall ward had an established; reflective practice group which staff attended to discuss clinical issues. Staff told us they valued these sessions and found them very beneficial. Staff were aware of policies and procedures and told us there was an expectation that they were required to read, and sign to confirm their reading of a policy. Staff also told us this was checked by managers to ensure it had been done. Multi-disciplinary and interagency team work We attended a ward round. There was representation from different professions including a consultant psychiatrist, a staff grade doctor, nurses, occupational therapist, and psychologists. There was no social work representation at the meeting but we were told they were easily contactable. We were told that there is a multi-disciplinary team meeting every Monday morning to discuss events and issues that may have arisen during the weekend. Staff told us that there were poor levels of communication between the units and other wards, one staff said, Trying to discuss the needs of patients with the medium secure units is really difficult. We sat in on a CPA meeting chaired by the patient on Chilton Houses and saw staff working well as a team. However, no one from the patient s community team was present and this was attributed to the great distances to be travelled. Good practice in applying the MCA People we met were detained under the Mental Health Act and therefore were not subject to Deprivation of Liberty Safeguards. In all the wards we visited we found that not all staff had received training in the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards legislation. 23 Forensic inpatient. Quality Report February 2014

24 Are services caring? Requires Improvement By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Summary of findings We rated the forensic wards as requires improvement because: Overall, people told us that staff treated them with respect and dignity, and they were positive about staff's attitude towards them. The majority of people also told us that they were happy with their care, and that they felt supported and well-cared for by staff. However we had concerns about the punitive attitude of some staff at the Norvic Clinic towards patients. People were involved in their care planning and would sign to confirm their agreement with the plans. However not all patients felt fully involved in their care reviews or decisions about their medication. However: We saw how staff engaged and included people and their families in their care. Patients had access to advocacy and generally this was promoted. Our findings Norvic Clinic Kindness dignity, respect and support Overall, people we spoke with told us that staff treated them with respect and dignity. We received many positive comments from people regarding staff s attitude towards them. One person told us, I am quite happy, staff are alright and respectful. Another person said they were treated well by staff. They told us they thought staff did, A good job under the circumstances with their staffing levels. During our visit to the wards, we observed staff speaking with people who used the service in a respectful manner. However a small number of people told us that they did not always feel respected by staff. One person told us that some staff refused requests they had made without offering an explanation for their decision. Following an incident where a person was secluded we overheard a staff member say they have to learn they can t hit staff and get away with it. We were also told this on a separate occasion. We also observed a situation where a patient was secluded without any attempt at de-escalation. One person we spoke with said staff are quick to seclude us whenever anything happens instead of calming the situation down. Other patients supported this view. Five people told us that they had been restrained and secluded following refusal to follow staff instructions. One person told us that if you do not sit correctly on the chairs you could end up being restrained and secluded. The involvement of people in the care they receive The care plans were developed with the involvement of people and we saw that they signed to confirm their agreement. Whilst we found people had signed their care plans we did not find their views were always included in the care plans. Care plan review meetings occurred frequently but some people told us they did not feel fully involved in the meetings. Some people told us that they were only invited to the end of the meeting and did not feel their views were listened to. The unit had established meetings with people who used the service to receive feedback. People who attend these meetings told us they felt listened to overall. Once a month patients could attend the service user forum which was also attended by the service manager. Patients also had access to an independent mental health advocacy (IMHA) service. Hellesdon Hospital - Whitlingham and Yare Kindenss, dignity, respect and compassion People we spoke with gave positive feedback regarding staff saying they could approach them with any issues they had, that staff treated them with respect and were caring. Examples included one person said ward staff were, brilliant they are all very individual and all bring something to the mix. The involvement of people in the care they receive We found positive examples of staff engaging people in their care and treatment. However three people we spoke with told us that they did not always feel listened to and engaged in decisions about their medicines. They said they would be put on a drug without discussion or enough information about it. 24 Forensic inpatient. Quality Report February 2014

25 Are services caring? Requires Improvement By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. People said they had advocacy involvement when they wanted it. People told us they mostly received the support they needed. We saw examples of the ward philosophy that promoted self-care and coping skills. People told us about their distress signatures which helped them cope if they became distressed. People were encouraged to adopt healthy lifestyles and were given a choice of menus and access to the activities. We were told about, and saw minutes of, community meetings on where people could meet with staff and talk about any issues and how to address them. People also told us about these meetings. Most people told us they could discuss issues with staff, if needed, at any time. We spoke to six people who told us they had attended reviews about their care. Many of the care plans we saw had either been signed by the person or documented that the person had refused to sign it. St Clements Hospital - Foxhall House and Chilton Houses Dignity, respect and compassion Most people we spoke with said they were treated with kindness and respect, although one person said that some staff were disinterested and did not listen to them. During our inspection we observed staff treated people respectfully and with kindness. Involvement of people using services We spoke to a carer on the telephone who said she was more than happy with the care her son was receiving. She felt included in all the care planning and attended CPA meetings. People signed their care plans showing they had seen and agreed with it. People decided who could attend their care review meetings and whether they wanted relatives to attend or not. We were told about days for carers which were held to support carers and we saw an information pack which was given to carers about the services. There were visiting rooms for families to visit with children. This was thoroughly risk assessed beforehand and documented. 25 Forensic inpatient. Quality Report February 2014

26 Requires Improvement Are services responsive to people s needs? By responsive, we mean that services are organised so that they meet people s needs. Summary of findings We rated the forensic wards as requires improvement because: At the Norvic Clinic the seclusion facility is allocated to both male and female patients. We were made aware of occasions when patients of both genders were accommodated together. Staff showed they were concerned for the patients privacy and dignity but stated they had no other option open to them. We were concerned about restrictive practices at the Norvic Clinic. We were told and observed that restraint and seclusion was used in a punitive manner. Patients told us that they did not always have easy access to drinks, fresh air or cigarette breaks. We heard that patients would not be granted leave until they had completed activities. Patients did not all have access to a telephone were they could make their calls in privacy. Facilities at the Norvic Clinic required some improvement. there was limited space for activities and meetings. Not all maintenance had been completed. Wards did not have de-escalation rooms. Not all rooms were ensuite and in some wards there was limited bathroom and toilet facilities. However: We observed effective admission and discharge procedures. The wards had access to translation services and information for people in a range of different formats. Most patients told us that they were given information about how to complain about the service. This was contained within the ward information booklet and included information about how to contact the patients advice and liaison service (PALS). Information about the complaints process was displayed at the wards. Our findings Norvic Clinic Access, discharge and bed management The wards accepted referrals from a range of services including the acute wards, psychiatric intensive care wards, courts and high secure services. Referrals were discussed at weekly MDT meetings. Staff told us that Care Programme Approach (CPA) meetings took place before a person was discharged to make sure that they were supported during their discharge or transfer from the wards. We saw evidence in patient records that discharge planning was in place. The ward environment optimises recovery, comfort and dignity We found that generally the environment was clean and reasonably maintained, although some maintenance issues in patient bedrooms had not been addressed. Staff and patients told us that the unit had recently been decorated in preparation for our inspection. Some patients and staff told us that the building was not fit for purpose. Some bedrooms had been decommissioned due to a damp problem. Bedrooms were not all ensuite and on some wards there were limited bathroom and toilet facilities. All wards had day areas and a quiet room. However some felt that more space was needed. People told us that they had to remain in their rooms during staff meetings which they were not happy with. This was due to limited space for staff to meet. We noted that not all wards had de-escalation rooms. Visiting rooms were available on the wards and a family room, for when children visited, was available off the wards. We observed that there was a patient shop and a library at the unit. All wards at the unit were single gender. However the seclusion facility was allocated for both male and female patients. Staff informed us that prior to our inspection both a female and male patient had been secluded in the adjacent rooms. Staff showed they were concerned for the patients privacy and dignity but stated they had no other option open to them. All wards had a payphone available located in corridors. However we noted that on most wards these did not have a privacy hood so it was possible to overhear people s conversations. People told us they were able to make a hot drink during the day but there was a blanket rule that they had to ask staff to allow them access to the water heater which was locked and the key kept by staff. 26 Forensic inpatient. Quality Report February 2014

27 Requires Improvement Are services responsive to people s needs? By responsive, we mean that services are organised so that they meet people s needs. Generally we heard that the food was good with a reasonable selection and portion size. However we noted that there was no menu in evidence on Acle ward. We were informed by a patient that you know what's to eat when you get to the servery. Some people we spoke with told us they had been granted escorted leave as part of their recovery, but that this was sometimes cancelled due to staff shortages. Patients also told us that there was not enough to do at the weekends. Ward policies and procedures minimise restrictions Staff told us that patients were cared for in the least restrictive environment to meet their needs. However whilst on the unit we saw that people who became violent were restrained and removed to the seclusion ward. Five people told us that they had been restrained and secluded following refusal to follow staff instructions. One person told us that if you do not sit correctly on the chairs you could end up being restrained and secluded. Patients told us that were also rules around when drinks were available and the number of times you could have a cigarette or access fresh air. Some patients told us that there were rules about completing activity sessions before being granted leave. Meeting the needs of all people who use the service The wards had access to translation services and information for people in a range of different formats. There was a multi faith room within the unit which people could access. The wards had a range of leaflets and information displayed to provide people with information about services available, health promotion and activities on offer. Information was available in a range of different formats. Listening to and learning from concerns and complaints People were provided with information in their welcome packs about how they could raise complaints or concerns about the ward. The ward sought feedback from people through the use of regular patient meetings. Hellesdon Hospital - Whitlingham and Yare Access, discharge and bed management Staff on Whitlingham ward told us there was no difficulty admitting and discharging patients to the unit because the demand for female beds was not as high as in the male units. This meant that people were able to move into and out of the unit when they were ready to do so. One person told us they would be moving to another ward soon and was not concerned that their transfer would be delayed because they had a bed waiting for them. The ward environment optimises recovery, comfort and dignity Individual needs were catered for in relation to diets and people told us they received the correct food. We found that the unit had a telephone room but the telephone was broken so people had to access a telephone in the ward office; we saw that people had access to their bedrooms with their own card keys, subject to risk assessment. All the people on the ward had a card key to access their own bedrooms. People had their own lockers to keep their valuables and the keys were kept by the staff. People were not allowed to use the own mobile phone on the ward but could use a public telephone in reception area. Meeting the needs of all people who use the service There was a multi-faith room at the unit for people to practice their religious rituals. The wards had a range of leaflets and information displayed to provide people with information about services available, health promotion and activities on offer. Information was available in a range of different formats. Listening to and learning from concerns and complaints Most patients told us that they were given information about how to complain about the service. This was contained within the ward information booklet and included information about how to contact the patients advice and liaison service (PALS). Information about the complaints process was displayed at the wards. St Clements Hospital - Foxhall House and Chilton Houses Access, discharge and bed management 27 Forensic inpatient. Quality Report February 2014

28 Requires Improvement Are services responsive to people s needs? By responsive, we mean that services are organised so that they meet people s needs. There had only been two patients discharged from Chilton Houses in the last 12 months and this reflected the normal pattern of previous years. There were two current vacancies and staff thought these would be soon filled but did not know any further details. Staff and two of the patients we spoke with at Foxhall told us that a lack of community provision for patients with ongoing mental health issues did affect discharge arrangements. The ward environment optimises recovery, comfort and dignity Foxhall House was clean and well decorated with posters and information. Adaptations to the wards had been carried out for those people who were not allowed to leave so that they could access a gym to exercise. Chilton Houses appeared clean and we saw up to date cleaning schedules on the notice board. Patients we spoke with told us they felt the ward was clean.the ward area was in reasonable decorative order with dedicated male and female areas and quiet designated communal areas. Patients we spoke with told us they felt the ward was clean. The atmosphere was calm throughout our visit to the wards and patients had free access to gardens, smoking areas and local community facilities. The wards had sufficient equipment and facilities to meet people s needs. These included an assessment kitchen, laundry room, access to a garden area and private meeting rooms. There were a range of activities available for people on the wards. Meeting the needs of all people who use the service There was a multi- faith room that contained artefacts and space for people to practice their religious rituals. We observed staff discussing support for one person to pray according to the teachings of their religion. We saw that the units were supported by a Chaplin who would come to the ward and meet with people to support them and provide spiritual care. The wards had a range of leaflets and information displayed to provide people with information about services available, health promotion and activities on offer. Information was available in a range of different formats. Learning from concerns and complaints The nurse in charge on Chilton Houses knew about the trust s complaints policy but told us they had received no formal complaints over the last year. She told us people were encouraged to voice concerns either at their regular one to one sessions with their key worker or in the ward community meeting. People we spoke with told us they felt they could raise issues anytime and didn t feel they would not be acted upon. 28 Forensic inpatient. Quality Report February 2014

29 Are services well-led? Inadequate By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. Summary of findings We rated the forensic wards as inadequate' because: There were committees and other mechanisms in place to support governance but these had not always resulted in learning or improvement. Staff and local management did not understand the governance processes sufficiently to describe them and did not feel they related to them in their role. Morale was low across the services. Most staff felt supported at a local level but felt disconnected from locality managers, senior managers and trust executives. Staff felt confident to report concerns however not all felt that they had received feedback in these circumstances. Some staff told us that they had received limited support following an incident. Not all staff had received required training, supervision or appraisal. Some new staff told us that they had received limited training, supervision and support during their induction. Our findings Norvic Clinic Vision and values None of the staff we spoke with could articulate the trust vision and strategy. Staff told us that they felt very disconnected from the trust management teams. Staff did not feel engaged in processes to develop the trust strategy. Good governance The service had governance structures in place in the form of meetings that were held twice per month. However none of the staff we spoke with could describe the structure and how they fitted in to it. The wards held regular staff meetings that had an agenda which was focussed on ward and unit issues. These meetings linked into the unit wide governance meetings which dealt with local issues and escalated other issues. However we saw no evidence of ward staff receiving feedback from these meetings. Leadership, morale and staff engagement All of the staff we spoke with told us that morale in the clinic was very low. One staff member said to us, morale is shockingly low. Generally staff told us that they felt supported by their ward managers and felt they could approach them if needed. Some staff told us they had not seen locality or senior managers at the clinic. Four staff we spoke with confirmed they were aware the chief executive had visited the unit but said that he had not stayed very long. One staff member said, some middle managers are not supportive and totally absent from the unit. Some new staff told us that they had not received sufficient support during their induction. They described a lack of training, supervision and support during this period. Hellesdon Hospital - Whitlingham and Yare Vision and values Most of the staff we spoke with told us they understood the aims and objectives of the trust however they had not understood some of the changes that had been made. Some staff said that they had not been engaged in the transformation process or planning for their service. Good governance Staff we spoke with were clear about their responsibilities in relation to raising concerns about quality of care. Four staff told us they had previously raised concerns about the staffing levels not being sufficient to meet demand. They told us the manager had improved the staffing levels as a result and they did not have to use as many agency staff as before. The manager told us that they were supported to manage their budget and this had enabled them to ensure the staffing levels on the unit were sufficient to meet the clinical needs of people living there. Leadership, morale and staff engagement Some staff reported having contact with their manager and next level of managers on a regular basis and they felt able to approach their manager at any time. Staff reported less contact with locality managers, senior managers or board members. We were told that, since the change of managers on the unit, staff were clearer about their roles and responsibilities and, where the need had arisen, staff had been supported to actively manage junior staff so that they fulfilled their responsibilities to patients and their colleagues. 29 Forensic inpatient. Quality Report February 2014

30 Are services well-led? Inadequate By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. Staff told us that they would feel comfortable raising concerns with their immediate manager. However not all staff had received feedback when they had raised concerns. One staff member told us that they had felt unsupported following an incident and as a result intended to leave the service. St Clements Hospital - Foxhall House and Chilton Houses Vision and values Staff were unable to articulate the trust's vision and strategy. Staff on Chilton Houses were aware of the changes to the trust management structure but did not feel engaged with any vision or values. Good governance At Foxhall we spoke to five staff and only two of the senior ward staff could clearly explain the governance arrangements for the ward and how clinical improvement was developed and shared with them. Staff told us that the manager shared information about incidents through the team meetings and through the handover. Staff were unaware of any learning from incidents that occurred at other services. Chilton House staff felt the governance arrangements did not impact on their work and were unsure about any learning from other areas of the trust. At Foxhall a new manager had recently taken up post. We saw that he had created an action plan to address a number of issues in the unit, including supervision. Staff confirmed that they did not receive regular supervision but the manager had started this. Managers told us they have good relationships with their senior managers. Staff told us they supported each other within the teams and felt the wards had a collective, positive culture. Leadership, morale and staff engagement Staff at Foxhall House said they could raise any concerns with their manager and said they felt the concerns would be addressed. They all said their manager was approachable and kept them informed. They told us they were aware of the trust s whistleblowing policy and their responsibilities in relation to reporting concerns. Some staff were not aware they could also contact the Care Quality Commission directly with any concerns. Staff at Foxhall told us that the units had had several locum consultants since the departure of the last substantive consultant with many of the locums coming for short periods. Since June a long term locum had helped to bring senior medical leadership and the trust had been successful in recruiting a substantive consultant who would be starting soon. During the period of changing consultants staff and people in the service told that they had received excellent support and care from the middle grade psychiatrist for the unit. The long term absence of a consultant psychiatrist on Chilton Houses was cited by staff as having a negative effect on the ward's leadership. They told us the locum doctor was very skilled but was only employed two days per week so could not actively lead the team. 30 Forensic inpatient. Quality Report February 2014