Birmingham and Solihull Mental Health NHS Foundation Trust

Updated 25 January 2024

Birmingham and Solihull Mental Health NHS Foundation Trust provides mental health services for people of Birmingham and Solihull, and to communities in the West Midlands and beyond.

Birmingham and Solihull Mental Health NHS Foundation Trust was established on 1 July 2008. Before becoming a foundation trust, the organisation was created on 1 April 2003 following the merger of the former North and South Birmingham Mental Health NHS Trusts.

The trust provides a range of inpatient, community and specialist mental health services for people from the age of 16 years upwards in Birmingham and for all ages in Solihull. However, the trust provides services to children younger than 16 in forensic child and adolescent mental health services and Solar services. Other community mental health services for children and young people in Birmingham is provided by another NHS trust.

The trust provides services to 73,000 service users, with 700 inpatient beds across over 40 sites. The trust has an annual budget of £366 million and a workforce of around 4,000 staff.

We carried out this unannounced inspection of five of the mental health services provided by this trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall because at our last inspection we rated the trust overall as requires improvement.

The services we inspected;

• Acute wards for adults of working age and psychiatric intensive care units
• Mental health crisis services and health-based places of safety
• Rehabilitation services
• Wards for older people with mental health problems
• Forensic inpatient or secure wards

Following this inspection, due to concerns we found within the acute wards for adults of working age and psychiatric intensive care units, rehabilitation services and forensic inpatient or secure wards, we issued the trust with a Section 29A Warning Notice requiring the trust to make significant improvements regarding the trust deploying sufficient numbers of staff to work with patients and those staff receive the right training, professional development and have access to supervision and appraisal.

We did not inspect three other services previously rated good because we did not have intelligence which told us about risk in these services. We are monitoring the progress of improvements to these services and will re-inspect them as appropriate.

Our rating of services stayed the same. We rated them as requires improvement because:

• We rated caring and responsive as good, and safe, effective and well led as requires improvement.
• We rated all 5 of the trust’s services we inspected as requires improvement. In rating the trust overall, we took into account the current ratings of the 3 services not inspected this time.
• The trust leadership team had not ensured that all requirements from the last inspection had been actioned and embedded across all services. In 3 of the core services we visited the trust was not meeting its’ own safer staffing levels with regards to qualified staff. Across all core services we visited we found significantly low compliance rates with staff managerial and clinical supervision. Staff sited staffing levels and work pressures as the main reasons for this. As a result, we issued the trust with a Section 29A Warning Notice requiring significant improvement.
• Whilst the trust had made improvements since the last inspection with regards estates related to fixed ligature concerns, we were concerned that progress was slow, with the trust having known about concerns since 2014 and still not having completed estates work. Additionally, we found that staff on Avon ward were not adhering to ligature risk management plans, and whilst new anti-barricade doors had been installed on Citrine ward we were concerned that several staff could not safely and efficiently operate them.
• Whilst the trust had started to address culture related to bullying, racism and harassment, since our last inspection, staff were still raising concerns that this was taking place. The trust acknowledged there was still work to be done to drive improvement.
• Staff compliance with mandatory training in immediate life support and safeguarding was low in 3 of the 5 core services visited, and staff working in specialist areas did not always have the additional training required to support them.
• There was a lack of activities available for patients on most wards we visited. Activities were not taking place seven days a week and staff and patients cited staff shortages as the reason for this. Patient access to support from occupational therapists and psychologists was low on most wards and not all patients that required them had access to psychological therapies.
• Staff had not managed all risks to patients in services and leaders were not aware of or were not actively managing risks across the trust. Not all patients that needed them had risk assessments in place, and risk management plans did not always detail how identified patient risks were to be managed. There were blanket restrictions on some wards that were not individually risk assessed and staff on some wards were not consistently following trust policy with regards searching patients on return from leave. The trust board assurance framework was under development, with a lack of assurance present, and the overarching pharmacy risk register had not been updated for several years.
• Staff did not consistently promote dignity and respect as expected in all services. Patients were secluded in their bedrooms without the appropriate facilities on the acute wards and staff were observed discussing patient care in communal areas, staff had not considered the individual needs of patients with regards clothing on the older people’s wards, and patients at Reaside were concerned about the lack of privacy when using bathroom facilities due to the restricted environment.
• We identified two directors who did not have a current Disclosure and Barring Service (DBS) check in place and there was no programme of board visits due to take place to ensure visits to services took place regularly. Some staff told us that leaders rarely visited services with some staff being unaware of who senior leaders were.
• We were concerned that information about quality taken to the board was not sufficient for the board to have total oversight of quality. Many sub-groups fed information and data into the quality, patient experience and safety committee which meant only information by exception was delivered to the board. This process relied on the chair of the committee establishing what was pertinent for the board to hear about and we were concerned that this did not allow the board to have effective oversight and awareness of all quality issues and concerns.
• We were concerned that appropriate governance arrangements were not in place in relation to Mental Health Act administration and compliance. The trust previously ran a separate Mental Health Act legislation committee, but since our last inspection this committee had been dissolved following an internal governance review of all board committees. Information was now fed through the quality, patient experience and safety committee and members of the now sub-committee told us they now had no direct route to board and had escalated their concerns in relation to lack of scrutiny and oversight of legislation created by the new system.

However:

• Since our last inspection the trust had appointed a new chief executive a new trust board had been formed. The trust had developed a clear strategy and vision, and leaders were passionate and shared a clear drive to make positive change.
• Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. As a result, they used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Whilst we had some concerns about the environments at Reaside, and the Caffra seclusion suite, most ward environments were clean, well-maintained and fit for purpose.
• The trust were developing the presence of the patient voice at board level, and whilst leaders acknowledged there was work to be done in this area, there was a clear strategic aim to get this right.
• Staff managed discharge well; planning this from an early stage and making clear plans with patients. Patients had good access to services and waiting times were in line with trust policy.

How we carried out the inspection

During the inspection, our inspection teams carried out the following activities across the 5 core services visited;

• Spoke with 169 members of staff including managers, doctors, nurses, healthcare assistants, psychologists, and occupational therapists.
• Spoke with 111 patients and 15 of their families members or carers
• Reviewed 94 patient care and treatment records
• Reviewed 103 patient medication records
• Reviewed 4 seclusion care records
• Observed 9 community visits
• Observed 16 meetings including shift handovers, multidisciplinary team meetings and ward round
• Observed 2 activities on the wards and 3 patient appointments
• Reviewed a variety of documents, policies and procedures related to the running of the services provided
• During our well-led inspection, we spoke with 33 members of staff within focus groups, and conducted interviews with 36 senior leaders of the organisation and looked at a range of policies, procedures and other governance documents relating to the running of the trust.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Feedback from patients was generally positive. Across all 5 core services we visited patients told us that staff were kind, supportive, caring and respectful. Most patients told us they felt involved in their care planning, other than patients on the acute wards for adults of working age and psychiatric intensive care units told us they would like more involvement in creating their care plans.

Patients told us they received support with both their mental and physical health but across most services told us there was a list of individualised activities taking place on the wards.

Patients on the acute wards for adults of working age and psychiatric intensive care units, rehabilitation services and forensic inpatient or secure wards told us that leave from the hospital was regularly delayed or cancelled due to lack of staff available to facilitate this. Patients at Reaside raised concerns about the environment including the tannoy system which they told us was loud and disruptive, and the lack of ensuite facilities which they felt impacted on their privacy and dignity.

Family members and carers were able to visit patients and were involved in information sharing where appropriate.

Updated 17 July 2024

This was a follow up assessment following inspection in August 2023 when we served warning notices for Regulations 12 and 17 regarding medicine management, risk assessments and governance processes. We looked at 15 quality statements. We reviewed 32 records of people who use the service and 11 prescription charts, spoke with 11 people and 6 of their carers, spoke with 81 staff and accompanied staff on 4 visits to people at home. We found that the Trust had taken action and met the warning notices.

Updated 17 July 2024

Reaside is a medium secure unit for men provided by Birmingham and Solihull Mental Health NHS Foundation Trust. They provide assessment, treatment and rehabilitation to service users with severe mental health problems who have committed a criminal offence or who have shown seriously aggressive or threatening behaviour. The service accepts referrals of male service users with severe and enduring mental illness who require treatment and rehabilitation in a highly supervised and structured medium secure setting. The service is provided to people within the West Midlands region. There are 7 wards: Trent, Avon, Swift, Severn, Dove, Blythe, Kennet. Avon, Severn, Trent and Blythe wards are acute mental health wards. Dove, Swift and Kennet wards are rehabilitation wards. This was a responsive focused assessment following information of concern about safety on the wards, staffing and leadership of the hospital. We looked at 10 quality statements in the safe, caring and well led key questions. We found 3 breaches of the regulations in relation to good governance, treating people with dignity and respect and staffing. The provider's systems and processes had failed to identify, manage and mitigate some areas of risk. Audits and checks were not always effective in ensuring continuous improvement. Staff did not always respond to what people said and take action. The provider had not trained all staff in life support. In instances where CQC have decided to take civil enforcement action against a provider, we will publish this information after any representations and/ or appeals have been concluded. We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 9 September 2014

The specialist eating disorders services provided by Birmingham and Solihull NHS Foundation Trust are based at The Barberry. The services include an inpatient ward, Cilantro, which has 10 inpatient beds. There is also a day service adjacent to Cilantro ward where day patients attend between 8am and 4pm, Monday to Friday. The service also includes an outpatient service.

We found that this service was safe. The trust had identified potential risks to the service and had processes to ensure that these were avoided where possible. Incidents were reported and there were governance systems in place to make sure learning from incidents was used both in the service and across the trust.

The service used a number of specialist outcome measures to make sure that its effectiveness was assessed. There was a strong governance structure in the department was strong and used learning from incidents, complaints and internal audits. Staff had a good understanding of best practice and were aware of the evidence base of their work. Although the teams worked well across different disciplines, there were sometimes difficulties in working with other professionals outside the service.

We found that this service met the needs of the people who used them. People told us that they were treated with kindness and empathy by staff, who were well-trained and aware of their needs. People who used the service told us that staff treated them with respect and consideration.

Staff and patients raised concerns about the length of waits for outpatient therapy, which were long. There was a risk that this could impact on patient outcomes. The service understood the needs of different communities and was able to adapt. We also saw that staff worked closely with family members and were open to feedback from people who used the service.

Staff we spoke with felt that the service was well-led. They were able to deliver a good service and felt that they were supported by the trust at board level. Senior management in the trust were visible and staff told us that they felt able to raise concerns.

Updated 5 April 2019

We rated this service as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
• Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

Updated 8 March 2018

We changed the overall rating of inadequate to good because:

• On inspection we found that the trust had put systems and processes in place to address the actions we had told them they ‘must’ take to address regulatory breaches we had found on inspection in March 2017. The trust had also taken action to address the ‘shoulds’ we recommended they take to improve the service.

• Staff completed risk assessments for children and young people. These were recorded in the care records and updated every six months or as needed.

• Staff routinely established and recorded consent to treatment and documented evidence of considering Gillick competence and capacity where appropriate.

• Senior management had reviewed policies and procedures relating to the running of the service. These policies had been agreed by the trust and review dates for 2020 had been set.

• Staff ensured that prescription pads and prescriptions were stored in line with the trust policy.

• Staff monitored the cleanliness and working order of physical health monitoring equipment and therapeutic toys.

• Staffing vacancies had reduced and the service had 15 more whole time equivalent staff than on our previous inspection March 2017. Turnover had reduced from 25% to 13%.

• Staff compliance with mandatory training, supervision and appraisals was good and compliance rates above the trust target level of 90%.

• Work was in progress to make both sites more child and young person friendly and to increase the level of sound proofing within interview rooms.

However:

• The mobile phone staff safety application was not fully working or accessible on 50% of staff mobile phones.

• Staff were using trust templates on the electronic care record system to record care plans. However, we felt that there was further improvement required. Not all care plans were detailed, personalised and holistic. We found evidence of basic care planning in 15 of the 28 care records we reviewed. The majority of these basic care plans were found within the eating disorders team. Care plans did not always record or reflect the voice of the patient, or reflect the quality of care staff were providing.

•   The service did not undertake regular audits of care records to assure progress in this area.

• We were not assured that staff reported all incidents on the trust incident recording system or aware of what they should report. We were told of two incidents that should have been reported and had not been reported.

Updated 1 August 2017

We rated the community based mental health services for older people as good because:

• Staff routinely completed and updated patient risk assessments. They developed and recorded crisis plans with patients. This meant there were plans in place to reduce risks if patients were in crisis. Staff had a good understanding of safeguarding and the procedures to keep people safe from abuse. The service carried out regular environmental risk assessments to monitor and improve the safety of buildings.

• The service had clear policies to support staff when they worked alone. Staff were aware of the lone working policy and the procedures to follow if they needed support when working alone. Staff knew how to report incidents and felt able to report concerns.

• Staff knew their patients well. They kept records of patient care and treatment up-to-date, including any changes in circumstances. Staff routinely carried out mental capacity assessments when necessary and supported patients to manage their physical health needs.

• The service worked well with other teams and agencies to enable patients to move between services as their needs changed. Staff communicated promptly and effectively with patients’ GPs and other relevant agencies.

• Staff treated patients with kindness, dignity and respect. They routinely involved patients and carers in developing their assessments and care plans. The service was responsive to the needs of patients, carers and care homes. Patients told us they could get appointments when they needed them and doctors were accessible to both staff and patients. They said they could contact their allocated worker if they needed to speak with them. Patients were very positive about the service they received. The trust employed a team to gather feedback from patients and carers and used the information to make improvements to the service.

• Staff had access to regular supervision and there were some opportunities for them to develop their skills and career. They were up-to-date with their mandatory training. Staff had a working knowledge of the Mental Health Act and the Mental Capacity Act.

• Local leaders were visible and accessible to staff. Senior managers sometimes visited the teams.

• Managers carried out regular audits, including audits of patient records. The service recorded referral and discharge data. They used dashboards to inform staff and managers if they were meeting their key performance indicator targets. This meant they could tell how long people waited to be seen by the teams and if staff carried out reviews in a timely manner.

However:

• The service did not have a consistent process to audit safe and secure handling of medicines within the community teams. The trust pharmacy team carried out audits at each site in early 2017 but prior to this, there were gaps of over three years in some teams. There was no effective monitoring of clinic room temperatures in three teams and the clinic rooms in two teams were dusty and cluttered. Staff in most teams told us they believed their caseloads were too high and many told us they felt they needed to work at home, in their own time, to perform essential activities such as updating care plans and risk assessments.

• Caseloads were high and some staff worked unpaid hours to complete essential case recording.

• In some areas of the service, staff told us there were long waiting times for patients to access psychological therapies. The trust told us the longest waiting time was four weeks.

• Most carers and patients did not know how to make a complaint about the service. Despite this, they told us they were sure they could find out how make a complaint if they needed to and were confident they would be listened to.

• Consulting rooms where staff saw patients at the East Hub were very poorly soundproofed which meant conversations could be easily overheard. Consulting rooms at the North Hub had glass panels, which meant people using the corridor, could easily look in.

• Some staff felt senior managers did not listen to the feedback they provided about organisational change and they had not received a response when they had used the trust formal feedback process called “Dear John”. Three staff said they did not have confidence in the whistleblowing process or in the Dear John process.

• A number of staff felt unsettled about the organisational changes taking place within the trust and this led to a degree of low morale within most teams.

Updated 14 April 2023

Updated 25 January 2024

Birmingham and Solihull Mental Health NHS Foundation Trust provides mental health services for people of Birmingham and Solihull, and to communities in the West Midlands and beyond. Birmingham and Solihull Mental Health NHS Foundation Trust was established on 1 July 2008. Before becoming a foundation trust, the organisation was created on 1 April 2003 following the merger of the former North and South Birmingham Mental Health NHS Trusts. The trust provides a range of inpatient, community and specialist mental health services for people from the age of 16 years upwards in Birmingham and for all ages in Solihull. However, the trust provides services to children younger than 16 in forensic child and adolescent mental health services and Solar services. Other community mental health services for children and young people in Birmingham is provided by another NHS trust. The trust provides services to 73,000 service users, with 700 inpatient beds across over 40 sites. The Trust has an annual income of £429 million.

We carried out this unannounced inspection on the three core services of acute wards for adults of working age and psychiatric intensive care units, long stay/ rehabilitation mental health wards for working age adults and forensic inpatient secure wards. This was an unannounced focused inspection to review progress against the conditions we imposed on the trust's acute wards for adults of working age and psychiatric intensive care units on 16 December 2020. This required the trust to take steps to address the ligature risks on all acute wards and implement an effective system to improve risk assessments and care planning. We also reviewed progress following the S29a warning notice we issued the trust with on 3 January 2023 on all three core services. This required the trust to make significant improvements regarding the trust deploying sufficient numbers of staff to work on the wards with patients and those staff receive the right training, professional development and have access to supervision and appraisal.

We also used the mental health observation tool across the wards observing staff interactions with patients and speaking with patients. This was to inform our work on Observing, Understanding and Improving Cultures on mental health wards.

We inspected some of the key lines of enquiry relating to Safe, Effective and Well led at this inspection. We did not rate at this inspection.

Following our previous inspection, we rated long stay/ rehabilitation mental health wards for working age adults as Requires Improvement overall, safe, effective, and well led as Requires improvement and Caring and responsive as Good.

At this inspection we found:

The trust had implemented a system where the patient’s care plan was reviewed and discussed in their multidisciplinary team meeting. In some care plans and risk assessments this review was not updated into the patient’s care plan or risk assessment so that all staff working with the patient may not know of changes. However, this information could be found elsewhere on the system for staff to access. Whilst further improvements were still needed to embed, the system had been implemented to improve care planning, therefore overall, this condition had been met.

We found that not all patients had been offered a copy of their care plan and there was not a record that the patient or their family or carers were involved in their care plan.

Following the warning notice we served on 3 January 2023 we found at this inspection that staffing had improved across the wards however further improvements were needed. The trust was using a safer staffing tool which assessed the staffing levels needed for each ward based on the patients' needs. However, staff told us that sometimes they were moved to other wards to work which meant there may be only one qualified nurse remaining on a ward. Qualified nurses said they did not always get their breaks. Patients and staff told us that their authorised leave was sometimes delayed because of staffing. Some patients told us they did not have support from an occupational therapist.

Improvements had been made to staff appraisal rates since our inspections in October 2022. Staff said improvements had been made to them receiving supervision and data showed this had improved. However, the system to electronically record these was still difficult for staff to use and some staff still did not have access to this system. Therefore, the data received from the trust did not show that all staff had received regular supervision or an annual appraisal.

Some staff had not completed their mandatory training. These included training in emergency and immediate life support.

At Grove Avenue we saw that national guidance was not followed on mixed sex accommodation and male patients were using the female lounge. Patients did not always have privacy during visits with their family and friends.

What people who use the service say:

We spoke with 12 patients across the wards we visited in this core service.

Most patients told us that the staff were good and supported them to feel safe.

Patients told us on the rehabilitation wards that they were supported to go out into the community and staff supported them to cook and do their own laundry.

Patients who were ward representatives on the ‘Residents Council’ were proud of this role. They said they had the opportunity to improve all wards and that staff listened to their suggestions and acted to improve the wards.

Patients said their physical health needs were monitored and they always saw a doctor if they needed to.

Some patients were not aware what an advocate was. However, on all wards we saw that there was information displayed about the advocate with contact details. Staff told us the advocate visited at least weekly and was available by telephone if needed.

Patients had mixed views about the food and some patients said it lacked taste. However, all patients said they had a choice of food and where appropriate met their cultural and dietary needs.

Updated 14 April 2023

Updated 1 August 2014

Perinatal services consisted of Chamomile Suite, an inpatient ward with nine beds, a one bedroom supported flat, and a specialist perinatal community mental health team. There was also an outpatient service, a crèche and therapeutic groups.

Staff understood about safeguarding children and adults. There was also a culture of learning in the service, with reported incidents learned from and changes made when needed. Care was provided in a clean and hygienic environment by staff that were trained and understood their roles.

The multidisciplinary teams worked well together and provided a joined-up pathway of care for people. The service worked well with partner agencies, for example local acute trusts and other professionals such as health visitors. This made sure that people who used the service, or needed to access the service, were provided with all-round support.

People gave us very positive feedback about the care and kindness they had received from staff, and we observed good care being provided. Feedback from people and their families was used to plan the service. People were also encouraged to get involved in the annual review of the service through service user groups.

The service understood the needs of the local community and actively identified areas where referrals were low. This was to make sure that different community needs were met. Pathways through the service were established for planned, emergency and urgent admissions.

There were strong governance systems in place. Staff were aware of the areas where the service needed to improve and also what actions were being taken to improve it.

Updated 25 January 2024

Birmingham and Solihull Mental Health NHS Foundation Trust provides mental health services for people of Birmingham and Solihull, and to communities in the West Midlands and beyond. Birmingham and Solihull Mental Health NHS Foundation Trust was established on 1 July 2008. Before becoming a foundation trust, the organisation was created on 1 April 2003 following the merger of the former North and South Birmingham Mental Health NHS Trusts. The trust provides a range of inpatient, community and specialist mental health services for people from the age of 16 years upwards in Birmingham and for all ages in Solihull. However, the trust provides services to children younger than 16 in forensic child and adolescent mental health services and Solar services. Other community mental health services for children and young people in Birmingham is provided by another NHS trust. The trust provides services to 73,000 service users, with 700 inpatient beds across over 40 sites. The Trust has an annual income of £429 million.

We carried out this unannounced inspection on the three core services of acute wards for adults of working age and psychiatric intensive care units, long stay/ rehabilitation mental health wards for working age adults and forensic inpatient secure wards. This was an unannounced focused inspection to review progress against the conditions we imposed on the trust's acute wards for adults of working age and psychiatric intensive care units on 16 December 2020. This required the trust to take steps to address the ligature risks on all acute wards and implement an effective system to improve risk assessments and care planning. We also reviewed progress following the S29a warning notice we issued the trust with on 3 January 2023 on all three core services. This required the trust to make significant improvements regarding the trust deploying sufficient numbers of staff to work on the wards with patients and those staff receive the right training, professional development and have access to supervision and appraisal.

We also used the mental health observation tool across the wards observing staff interactions with patients and speaking with patients. This was to inform our work on Observing, Understanding and Improving Cultures on mental health wards.

We inspected some of the key lines of enquiry relating to Safe, Effective and Well led at this inspection. We did not rate at this inspection.

Following our previous inspection, we rated the core services of acute wards for adults of working age and psychiatric intensive care units as Requires improvement overall, Inadequate for Safe and Requires Improvement for effective, Caring, Responsive and well Led.

At this inspection we found:

Work had been completed to reduce the risk of ligature points on the acute and PICU wards which meant the conditions imposed on the trust on 16 December 2020 had been met. The trust had plans to reduce these risks on the forensic and secure wards also. The trust had prioritised the acute and PICU wards due to the increased risks of people using these services. However, in the interim they reduced risks on the forensic and secure wards. This included locking the ensuite doors back and increasing patient observation levels where needed.

The patients’ care planning and risk assessment system had improved since we imposed the condition on 16 December 2020. The trust had implemented a system where the patient’s care plan was reviewed and discussed in their multidisciplinary team meeting. In some care plans and risk assessments this review was not updated into the patient’s care plan or risk assessment so that all staff working with the patient may not know of changes. However, this information could be found elsewhere on the system for staff to access. Whilst further improvements were still needed to embed, the system had been implemented to improve care planning, therefore overall, this condition had been met.

We found that not all patients had been offered a copy of their care plan and there was not a record that the patient or their family or carers were involved in their care plan.

Following the warning notice we served on 3 January 2023 we found at this inspection that staffing had improved across the wards however further improvements were needed. The trust was using a safer staffing tool which assessed the staffing levels needed for each ward based on the patients' needs. However, staff told us that sometimes they were moved to other wards to work which meant there may be only one qualified nurse remaining on a ward. Qualified nurses said they did not always get their breaks. Patients and staff told us that their authorised leave was sometimes delayed because of staffing. Some patients told us they did not have support from an occupational therapist which meant they had not been assessed for their rehabilitation skills.

Improvements had been made to staff appraisal rates since our inspections in October 2022. Staff said improvements had been made to them receiving supervision and data showed this had improved. However, the system to electronically record these was still difficult for staff to use and some staff still did not have access to this system. Therefore, the data received from the trust did not show that all staff had received regular supervision or an annual appraisal.

Some staff had not completed their mandatory training. These included training in emergency and immediate life support.

On George ward there was litter in the courtyard which did not make it a pleasant environment for patients to spend time off the ward and have fresh air.

What people who use the service say:

We spoke with 46 patients across the three core services we visited.

Most patients told us that the staff were good and supported them to feel safe.

Patients who were ward representatives on the ‘Residents Council’ were proud of this role. They said they had the opportunity to improve all wards and that staff listened to their suggestions and acted to improve the wards.

Patients said their physical health needs were monitored and they always saw a doctor if they needed to.

Some patients were not aware what an advocate was. However, on all wards we saw that there was information displayed about the advocate with contact details. Staff told us the advocate visited at least weekly and was available by telephone if needed.

Patients had mixed views about the food and some patients said it lacked taste. However, all patients said they had a choice of food and where appropriate met their cultural and dietary needs.