Dudley Integrated Health and Care NHS Trust

Updated 30 March 2020

Not used

Updated 30 March 2020

Our rating of the trust stayed the same. We rated it as good because:

We rated safe, effective, caring, responsive and well-led as good. We rated five of the trust’s six services as good and one as requires improvement. In rating the trust, we took into account the current ratings of the five services not inspected this time.

We rated well-led for the trust overall as good because:

• Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.
• Senior leaders understood the challenges to quality and sustainability the trust faced, with workforce, and service delivery, as key challenges. They were able to explain clearly the actions they had taken and the plans they had in place to further address those challenges.
• Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The trust was committed to improving services by learning from when things go well and when they went wrong, promoting training, research and innovation and enabled learning across the trust.
• Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution.
• Our findings from the other key questions demonstrated that governance processes mostly operated effectively at ward level and that performance and risk were managed well.
• Ward teams had access to the information they needed to provide safe and effective care and used that information to good effect.
• Staff engaged actively in local and national quality improvement activities.

However,

• In the Acute wards for adults of working age and psychiatric intensive care units we found that audits did not always operate effectively because issues identified on inspection had not been identified through audits.

Updated 7 February 2019

• The environments we checked in both services were clean, well presented and consideration had been given to their specific uses.
• Staffing levels were good across all services we inspected. There were low levels of vacancies and the trust had estimated staff numbers in line with caseloads. There was adequate staffing to ensure that there was cover for sickness at short notice and agency use was limited.
• There was always a risk assessment undertaken at initial triage. Appropriate crisis plans had been created where required. Staff were able to respond quickly to deterioration in patients’ health. Patients waiting for treatment were contacted regularly to ensure that risk had not increased. Staff knew what to report and how to report it. Staff received feedback from investigation into incidents at staff meetings and via the intranet. Staff meetings occurred regularly and there was evidence of changes to working practices as a result of feedback at these meetings. Comprehensive assessments were undertaken as soon as possible after referral to the service.
• Care records we checked contained up to date information that was personalised and recovery focussed. Staff followed best practice guidelines as set out by the national institute of health and care excellence in a range of areas of service delivery. The service had developed sub teams that were providing specific services. ICAMHS, Tier 2, Flash/Lighthouse and EI were small teams that worked independently but as part of the wider service. There was a full range of mental health professionals available including psychiatrists, psychologists and social workers. Staff were experienced and qualified for their roles.
• We observed staff interacting with patients and found them to be exceptionally caring and understanding. They had extremely good knowledge of patient’s needs, likes and dislikes and could engage them. They had also developed strong links top families and carers and could offer them support guidance and advice. Patients and carers, we spoke with were extremely complimentary about the staff, management and service. There was evidence of active involvement from patients and carers where appropriate. Patients thoughts, feelings, history and culture were always considered and every effort was taken to ensure that patients maintained the maximum level independence possible. There was access to a range of support services both within the trust and the local community to support patients and carers. The trust had set target times for referral to triage and assessment to treatment times depending on the type of referral. All of these targets were being met. Staff took active steps to make contact with patients who were not engaging with the service and those who had not attended appointments. There was a full range of rooms available for appointments. Thought had been given to how these rooms were set out. They were all clean tidy and well presented. There was plenty of information in waiting areas and on line that informed patients and carers about a range of local services and support. Patients and carers, we spoke to all knew how to make a complaint and felt that they could do so without fear of retribution. Staff knew how to handle complaints correctly and there was evidence that they had been given feedback linked to investigations of complaints.
• Senior leaders within the trust were visible and approachable within the service. Senior team leaders in the service were well respected and staff felt that they listened to them. There was a clear strategy linked to improvements within the service. The trust had a well-defined set of visions and values and staff we interviewed knew and agreed with them. Staff we spoke to felt supported, well respected and proud of the work that they did. They were happy working for the trust and would recommend it for others. There was a clear governance framework that enabled discussion and the transfer of information between management and staff. There was evidence of change and continuous review of working practice. There was evidence that staff had forged close links with teams from around the trust and externally and could work well with them to meet the needs of the patient group.

However;

• The service used an electronic recording system for patients care records but medical staff continued to record information on paper notes. This meant that it was difficult to navigate the care plans and finding the correct information was sometimes difficult. We found that all information was correct and there was a correlation between paper and electronic notes.
• There was a lack of parity across the services at Dudley and Walsall. Each service had a different upper age limit for patients. In Walsall stated the cut off age to receive care was at the end of the educational year on the patients 17th year and Dudley stated that it would be the end of the educational year on their 16th year. The limits were set as part of a commissioning contract but were being reviewed.

Updated 28 March 2017

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

• In both teams, the duty worker system enabled a same day response to urgent referrals and any crisis calls from existing service users, their carers or other professionals. Making use of the detailed crisis plans prepared by case managers, the duty worker was able to prepare an individualised response to a particular service user’s immediate needs.

• In our previous inspection in February 2016, we had found all of the service users’ records that we checked had completed risk assessments in place and there was clear evidence of review and update. The trust had conducted an internal case note audit in May 2016 that had identified incomplete risk assessments in a majority of the 40 records examined. Managers had put in place a plan to improve this shortfall. We found, on this inspection, that initial risk assessments were present for all service users. Staff had completed more detailed risk assessments in 75% of the care notes we reviewed. Where appropriate crisis management plans had also been.

• Managers at Walsall had acted promptly to ensure the safety of service users during a period of high levels of sickness. They used bank staff and experienced staff from other areas of the trust to monitor caseloads and maintain the duty worker system.

• We found both teams had regular meetings in which staff could discuss incidents and lessons learnt from their own team, the older adult service and other areas of the trust.

• Service users and carers told us that they felt safe in the care of the teams and confident that staff would respond promptly to any urgent concerns they might have.

Updated 7 February 2019

Our rating of this service has stayed the same; we have rated it as good because:

• The service had enough nursing and medical staff, who knew the patients and received basic training to keep people safe from avoidable harm. There was a low turnover of staff and no bank or agency staff had been used to ensure a high standard of care and consistency within the teams. Staff said that they liked their jobs and enjoyed working for the trust and supported each other across the teams.
• Staff completed and updated risk assessments for each patient and used these to understand and manage risks individually. Patients had crisis plans and knew who to contact in the case of an emergency. All patients had a comprehensive, up to date care plan and risk assessments were reviewed regularly support was also offered for their carers and families.

• There was evidence that staff followed the national institute for care and excellence guidelines when prescribing medication. Interventions also covered support for employment, housing and benefits. All patients had had their physical healthcare needs considered and offered treatment and support for these if required.
• We observed comprehensive, thorough and effective multi-disciplinary team meetings and handovers between teams. The trust had a Mental Health Act administrator who ensured that the Act was followed and offered support to staff.
• We observed staff being respectful, sensitive, kind and compassionate when supporting patients and their families and carers. Patients said they were able to give feedback on the service they received and felt supported.
• Patients were seen as soon as possible and within set times and were offered flexible appointments to ensure that they were able to access the service.
• Staff knew and agreed with the trust’s values and were consulted about what they should be. Staff said they felt able to raise concerns without fear of victimisation and felt supported by the managers.

However;

• Staff did not receive adequate support from management though appraisal and supervision. We found non-medical staff were not all in receipt of an annual appraisal or regular supervision. This limited their ability to develop and reflect on their clinical practice.
• The service provided mandatory training in key skills to all staff but had not made sure everyone completed it.

Updated 7 February 2019

Our rating of this service stayed the same. We rated it as good because:

• All wards were safe, clean well equipped, well furnished and well maintained. The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff kept detailed records of patients’ care and treatment secure. Staff completed and updated risk assessments for each patient and used these to understand and manage risks individually. Staff recognised and managed incidents well and reported them appropriately.
• Staff worked collaboratively with patients to formulate care and treatment plans that addressed their individual needs. Staff had appraisals, supervision and were encouraged and supported to access opportunities to update and further develop their skills.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and Mental Capacity Act 2005.

• 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.

• Patients had their own bedrooms where they could keep personal belongings safely. At Bloxwich hospital there is dormitory accommodation. The design, layout, and furnishings of the ward/service supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as community groups, attending religious venues or maintaining family relationships. The service managed concerns and complaints well and learned lessons from the results.

• Ward managers and clinical leads were knowledgeable and passionate about their service and provided visible leadership on wards. Staff were passionate about their work, working for the trust and with their patients.

Updated 30 March 2020

Our rating of this service went down. We rated it as requires improvement because:

• There were environmental risks on some wards. Staff did not always mitigate them, document them and were not always aware of them.
• Care plans across all wards were not always of a good quality. There were some gaps in recording of physical health observations taken soon after admission. However, staff did record patients’ physical health needs in their care plans.
• There were omissions in the recording or obtaining of patients’ physical health observations soon after admission.
• There were blanket restrictions in place on all wards, namely the use of plastic crockery for all patients.
• Ward-based audits were not effective. They did not prompt staff to check some important things, which meant they did not identify errors and issues.

However

• Wards had enough nurses and doctors. They managed medicines safely and followed good practice with respect to safeguarding.
• Managers ensured staff received training, supervision and appraisal. Ward staff worked well together as a multidisciplinary 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.
• Staff felt well supported by managers and involved in changes within the service and trust.

Updated 7 February 2019

Our rating of this service stayed the same. We rated it as good because:

• Staff were supervised and appraised and had access to regular team meetings. We reviewed the supervision records for each team and saw that staff were receiving supervision every four weeks in line with the trust policy. There were effective governance processes throughout the service. Managers had systems in place to monitor staff compliance with mandatory training, supervision, appraisals, and the performance of the service.
• Staff completed comprehensive assessments of patients’ needs at the start of the treatment, including their mental health, physical health and social care needs. Staff completed risk assessments of each patient at initial assessment. We reviewed 14 care records. These showed that staff completed thorough and detailed risk assessments and that they updated them regularly.
• Patients were actively involved in the planning of their care. We saw evidence in patients care plans, where they had given their views. Families and carers had appropriate involvement in patients care. Care records showed that, where appropriate, families and carers were invited to attend care programme approach reviews where they were able to share their opinions on patients care treatment.
• Patients were able to access psychological therapies recommended by the National Institute for Health and Care Excellence. The psychology team were able to offer cognitive behaviour therapy, dialectic behaviour therapy, steps programme, and mindfulness. However, patients needing to see a psychologist could wait between six months and one year.
• Managers had the skills knowledge and authority to perform their roles. We saw that managers were available to staff and regularly attended multidisciplinary meetings, patient meetings and were available to support staff when required
• Services had systems in place to share lessons learned from incidents and complaints. Senior managers met twice a month to discuss incidents across the trust. The service had systems in place to manage information. The trust used electronic systems to collect data from the service. The trust had electronic systems to recording incidents, risks, and patient information.

However:

• All five centres had presented problems with the environment, space or access. Two centres were not well maintained and another two had limited space to deliver care and treatment. Staff told us that it was often difficult to book rooms to see patients, especially on days when the doctors had a clinic.
• Systems did not allow staff ready access to Mental Health Act and Mental Capacity Act paperwork. Mental Health Act administrators kept all Mental Health Act paperwork off site and there was not a system in place to store these electronically to allow staff access.

Consent to treatment forms were not attached to patient’s medication charts.