kentandmedwaynhsandsocialcarepartnership trust … · 2019-05-15 · locationsinspected locationid...

Locations inspected

Location ID Name of CQC registeredlocation

Name of service (e.g. ward/unit/team)

Postcodeofservice(ward/unit/team)

RXYL2 Littlebrook Hospital Amberwood Ward DA2 6PB

RXYL2 Littlebrook Hospital Cherrywood Ward DA2 6PB

RXYL2 Littlebrook Hospital Woodlands Ward DA2 6PB

RXYL2 Littlebrook Hospital Willow Suite DA2 6PB

RXYM1 Medway Maritime Hospital Emerald Ward ME7 5NY

RXYP8 Priority House Amherst Ward ME16 9PH

RXYP8 Priority House Brocklehurst Ward ME16 9PH

Kent and Medway NHS and Social Care PartnershipTrust

AcutAcutee wwarardsds fforor adultsadults ofofworkingworking agagee andand psychiatricpsychiatricintintensiveensive ccararee unitsunitsQuality Report

Trust Headquarters, Farm VillaHermitage LaneMaidstoneKentME16 9QQTel: 01622 724100Website: www.kmpt.nhs.uk

Date of inspection visit: 17 - 20 March 2015Date of publication: 30/07/2015

1 Acute wards for adults of working age and psychiatric intensive care units Quality Report 30/07/2015

RXY03 St Martins Hospital Bluebell Ward CT1 1TD

RXY03 St Martins Hospital Fern Ward CT1 1TD

RXY03 St Martins Hospital Foxglove Ward CT1 1TD

RXY03 St Martins Hospital Samphire Ward CT1 1TD

This report describes our judgement of the quality of care provided within this core service by Kent and Medway NHSand Social Care Partnership Trust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘IntelligentMonitoring’ 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 Kent and Medway NHS and Social CarePartnership Trust and these are brought together to inform our overall judgement of Kent and Medway NHS and SocialCare Partnership Trust.

Summary of findings


RatingsWe are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings willalways be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring dataand 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 the service Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Requires improvement –––

Are services caring? Good –––

Are services responsive? Requires improvement –––

Are services well-led? Requires improvement –––

Mental Health Act responsibilities and MentalCapacity Act / Deprivation of Liberty SafeguardsWe include our assessment of the provider’s compliancewith the Mental Health Act and Mental Capacity Act in ouroverall inspection of the core service.

We do not give a rating for Mental Health Act or MentalCapacity Act; however we do use our findings todetermine the overall rating for the service.

Further information about findings in relation to theMental Health Act and Mental Capacity Act can be foundlater in this report.

Summary of findings


Contents

PageSummary of this inspectionOverall summary 5

The five questions we ask about the service and what we found 7

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 inspectionLocations inspected 13

Mental Health Act responsibilities 13

Mental Capacity Act and Deprivation of Liberty Safeguards 13

Findings by our five questions 15

Action we have told the provider to take 28

Summary of findings


Overall summaryWe found significant differences in the quality of careprovided at the four main hospitals where acute wardswere situated. For example, we found most areas ofconcern regarding the care provided in the wards atLittlebrook Hospital in Dartford. There were some areasof concern on some of the wards at St Martin's Hospital inCanterbury and Medway Maritime Hospital in Gillingham.While, we found there were no significantly seriousconcerns at Priority House in Maidstone.

We gave an overall rating for acute wards for adults ofworking age and psychiatric intensive care units ofrequires improvement because:

• The trust did not have a system to maintain the privacyand dignity of women who were secluded on Willowsuite (psychiatric intensive care unit).

• Cherrywood ward and Amberwood ward (in Dartford),Emerald ward (in Gillingham), and Samphire ward (inCanterbury) did not have all their emergencyequipment and medication accessible and/or in date,or have effective systems for regularly checking thatthis was the case.

• Patients who had behaved aggressively, or who hadbeen restrained, had not had their care plans updatedto describe how to prevent, manage and de-escalatepotential future incidents.

• The storage and recording of medication, includingcontrolled drugs, was not safe and secure onCherrywood ward (in Dartford). We raised thisimmediately and this was rectified on the day of ourinspection.

• The seclusion room on Willow suite was not equippedin accordance with the Mental Health Act Code ofPractice. The trust had policies about themanagement of violence and aggression, andmonitored their usage, but had significant levels ofprone restraint which is contrary to the Department ofHealth guidance.

• The Mental Health Act was not consistentlyimplemented in accordance with the Code of Practice.For example, on Amberwood ward (in Dartford),patients were not informed of their rights inaccordance with the Mental Health Act and Code ofPractice; medication had been administered without

the proper consent, and there was poordocumentation of the treatment plan when a patienthad a second opinion from a second opinionappointed doctor (SOAD).

• There were delays in finding psychiatric intensive careunit (PICU) beds for patients.

• There was pressure on beds, which meant thatpatients might be moved for non-clinical reasons.

• The monitoring processes had not identified gaps andproblems in the services. For example, there were gapsin updating risks assessments and care plans; wefound out of date and missing resuscitationequipment; and the reasons behind high levels ofrestraint, including prone (face down) restraint had notbeen identified. There were also problems withmedication storage and recording, including therecording of consent to treatment provisions under theMental Health Act and Code of Practice.

However, patients were mostly positive about the carethey received on the wards and found most of the staffapproachable and caring. Patients had 1-1s with staff,although this could be difficult when staff were busy.Patients had access to advocacy on the ward. Patients’relatives were involved in their care where appropriate.There were community meetings on most of the wards.

There were environmental risks on many of the wards,but the trust had an extensive programme ofrefurbishment and was managing the risks until buildingworks were completed. Most of the wards weresatisfactorily managing medication. Most of the wardshad adequate emergency procedures. There were staffvacancies on most of the wards, particularly for band fivenurses, but this was being managed at a local andcorporate level, and the trust had a recruitment strategy.The trust had safeguarding policies and staff knew how toidentify and report safeguarding concerns. Staff knewhow to report incidents, and there were policies forreporting and managing this. There was a bulletin forsharing information including learning from incidentsthat was circulated to staff.

Priority House in Maidstone had introduced a number ofinitiatives which included the recovery clinic. Research

Summary of findings


into the effectiveness of the clinic was being undertakenby a member of staff as part of their PhD. We were toldthat recovery clinics had also been rolled out on all otheracute wards.

Peer support workers, who were people employed by thetrust who had experience of mental health services, werea positive addition to the wards, and helped reinforce thepatients’ perspective.

Summary of findings


The five questions we ask about the service and what we found

Are services safe?We rated safe as requires improvement because:

• The trust did not have a system to maintain the privacy anddignity of women who were secluded on Willow suite(psychiatric intensive care unit).

• Cherrywood ward and Amberwood ward (in Dartford), Emeraldward (in Gillingham), and Samphire ward (in Canterbury) didnot have all their emergency equipment and medicationaccessible and/or in date, or have effective systems forregularly checking that this was the case.

• Patients who had behaved aggressively, or who had beenrestrained, had not had their care plans updated to describehow to prevent, manage and de-escalate potential futureincidents.

• The storage and recording of medication, including controlleddrugs, was not safe and secure on Cherrywood ward (inDartford). We raised this immediately and this was rectified onthe day of our inspection.

• The seclusion room on Willow suite was not equipped inaccordance with the Mental Health Act Code of Practice. Thetrust had policies about the management of violence andaggression, and monitored their usage, but had significantlevels of prone restraint which is contrary to the Department ofHealth guidance.

There were environmental risks on many of the wards, but the trusthad an extensive programme of refurbishment and was managingthe risks until building works were completed. Most of the wardswere satisfactorily managing medication. Most of the wards hadadequate emergency procedures. There were staff vacancies onmost of the wards, particularly for Band five nurses, but this wasbeing managed at a local and corporate level, and the trust had arecruitment strategy. The trust had safeguarding policies and staffknew how to identify and report safeguarding concerns. Staff knewhow to report incidents, and there were policies for reporting andmanaging this. There was a bulletin for sharing informationincluding learning from incidents that was circulated to staff.

Requires improvement –––

Are services effective?We rated effective as requires improvement because:

• The Mental Health Act was not consistently implemented inaccordance with the Code of Practice. For example, on


Summary of findings


Amberwood ward (in Dartford), patients were not informed oftheir rights in accordance with the Mental Health Act and Codeof Practice; medication had been administered without theproper consent, and there was poor documentation of thetreatment plan when a patient had a second opinion from asecond opionn appointed doctor (SOAD).

Staff did not have a clear understanding of the Mental Health Actand Code of Practice. Records and patients’ feedback identifiedrepeated instances of patients being told, or care recordsdocumenting, that although they were informal (voluntary patients),if they wanted to leave they would be detained under the MentalHealth Act. On Amberwood ward (in Dartford) and Emerald ward (inGillingham), staff had not checked that drugs they had administeredwere included on the formal consent to treatment and emergencytreatment forms. Thus the lawfulness of the administration of thismedication could be under question.

Patients were assessed by the crisis team prior to admission, andwere assessed on admission to the ward. Patients had their physicalhealthcare needs monitored and responded to. All patients had arisk assessment and care plan, although this was not always patientor recovery focused, and reviewed when the patient’s situationchanged. Patient information was stored securely and, as it waselectronic, could be shared between the wards, crisis andcommunity teams. The wards followed NICE (National Institute forHealth and Care Excellence) prescribing guidance, andcompleted health of the nation outcome scales (HONOS). Care wasprovided by a multidisciplinary team of staff. Most staff receivedsupervision and appraisal, and had completed most of theirmandatory training. There were regular multidisciplinary teammeetings and handovers where patient care was discussed.

Are services caring?We rated caring as good because:

Patients were mostly positive about the care they received on thewards and found most of the staff approachable and caring. Patientshad 1-1s with staff, although this could be difficult when staff werebusy. Patients had access to advocacy on the ward. Patients’relatives were involved in their care where appropriate. There werecommunity meetings on most of the wards.

Good –––

Are services responsive to people's needs?We rated responsive as requires improvement because:

• There were delays in finding psychiatric intensive care unit(PICU) beds for patients.


Summary of findings


• There was pressure on beds, which meant that patients mightbe moved for non-clinical reasons.

There was an activity programme and/or an occupational therapysuite for all of the wards. Patients had access to phones on thewards. Patients had free access to drinks and snacks until midnight.There were disabled facilities available across the trust. There wereposters and information leaflets which included how to complain,how to access advocacy and local facilities and support services.There was access to interpreting services, and a choice of food forpeople with special dietary requirements. The trust managed andresponded to complaints.

Are services well-led?We rated well-led as requires improvement because:

• The monitoring processes had not identified gaps andproblems in the services. For example, there were gaps inupdating risks assessments and care plans; we found out ofdate and missing resuscitation equipment; and the reasonsbehind high levels of restraint, including prone (face down)restraint had not been identified. There were also problemswith medication storage and recording, including the recordingof consent to treatment provisions under the Mental Health Actand Code of Practice.

There were local and corporate governance systems that monitoredthe quality of care. The trust had a risk register which identified risksand the actions to reduce or mitigate them. Sickness and absencewere monitored by the local teams with support from humanresources. Staff had a 'green button' on the trust’s website for raisingconcerns or making suggestions.


Summary of findings


Background to the serviceThe acute wards for adults of working age and psychiatricintensive care units (PICU) provided by Kent and MedwayNHS and Social Care Partnership Trust are part of thetrust’s acute service line.

Acute wards for adults of working age and psychiatricintensive care units are provided across four sites:Littlebrook Hospital in Dartford, Medway MaritimeHospital in Gillingham, Priority House in Maidstone and StMartins Hospital in Canterbury.

Littlebrook Hospital has three acute wards for adults ofworking age: Amberwood ward, Cherrywood ward andWoodlands ward. Amberwood ward and Cherrywoodward both have 16 beds. Woodlands has 12 beds and istemporarily based in the former Rosewood Lodge duringrefurbishment. Amberwood and Woodlands wards admitboth men and women, and Cherrywood ward is forwomen only. There is one PICU called the Willow suite,which also provides a PICU outreach service to the acutewards in the trust. Willow suite has 12 beds and admitsmen and women.

Medway Maritime Hospital has one acute ward for adultsof working age: Emerald ward. Emerald ward has 16 bedsand is for men only.

Priority House has two acute wards for adults of workingage: Amherst ward and Brocklehurst ward. Both wardshave 18 beds and admit men and women.

St Martins Hospital has four acute wards for adults ofworking age: Bluebell ward, Fern ward, Foxglove wardand Samphire ward. Bluebell, Fern and Foxglove wardshave 18 beds, and Samphire ward has 15 beds. Bluebelland Foxglove wards admit both men and women. Fernward only admits women and Samphire ward onlyadmits men.

We have inspected the services provided by Kent andMedway NHS and Social Care Partnership Trust 38 timesbetween 2011 and 2015. At the time of the lastinspections, all services at these locations had met theessential standards inspected.

Our inspection teamThe teams that inspected the acute wards for adults ofworking age and psychiatric intensive care units

consisted of 17 people: an expert by experience, threeinspectors, three Mental Health Act reviewers, six nurses,two consultant psychiatrists, a social worker, and apharmacist.

Why we carried out this inspectionWe inspected this core service as part of our ongoingcomprehensive mental health inspection programme.

How we carried out this inspectionTo fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?

• Is it responsive to people’s needs?• Is it well-led?

Before the inspection visit, we reviewed information thatwe held about these services and asked a range of otherorganisations for information.

During the inspection visit, the inspection team:

Summary of findings


• Visited all 11 of the wards at the four hospital sites andlooked at the quality of the ward environment andobserved how staff were caring for patients;

• Spoke with 34 patients who were using the service;• Spoke with the managers for each of the wards;• Spoke with 55 staff members including doctors,

nurses, healthcare assistants, therapists, psychologistsand social workers;

• Spoke with five relatives;• Interviewed the senior management team with

responsibility for these services;• Attended and observed 15 multi-disciplinary clinical

meetings or handover meetings.

We also:

• Looked at 46 treatment records of patients;• Carried out a specific check of the medication

management on one ward and observed medicationrounds on three wards;

• Carried out a detailed and specific check of the MentalHealth Act on two wards;

• Looked at records of seclusion and medication charts;• Looked at a range of policies, procedures and other

documents relating to the running of the service.

What people who use the provider's services say• Patients were mostly positive about the staff on most

of the wards, and said they were approachable andcaring, treated them with respect, and were able tomeet their needs. However, some of the patients onthe acute wards at Littlebrook Hospital in Dartford toldus that the staff could be unhelpful, and some saidthey would not approach staff for help. Some informalpatients told us that they had been “threatened” withdetention under the Mental Health Act, or had beenprevented from leaving whilst they were informal.

• Patients told us that they had 1-1s with staff, but thisdidn’t always happen as staff were too busy.

• We saw positive interactions between staff andpatients when on most of the wards. We observedsome positive interactions on the acute wards atLittlebrook Hospital in Darford. However, on some ofthe wards at Littlebrook Hospital we observed somestaff being dismissive towards patients and the culturewas not patient focused. For example, in one staffhandover meeting patients were referred to by theirbed number and some staff did not know the actualnames of some of their patients, only their bednumber.

Good practice• Priority House in Maidstone had introduced a number

of initiatives which included the recovery clinic.Research into the effectiveness of the clinic was beingundertaken by a member of staff as part of their PhD.We were told that recovery clinics had also been rolledout on all other acute wards.

• Peer support workers, who were people employed bythe trust who had experience of mental healthservices, were a positive addition to the wards, andhelped reinforce the patients’ perspective.

Areas for improvementAction the provider MUST or SHOULD take toimproveAction the provider MUST take to improve:

• The trust must ensure it has a system to maintain theprivacy and dignity of women who are secluded onWillow Suite (psychiatric intensive care unit (PICU)).

• Trust managers must ensure that emergencyequipment and medication are accessible and in dateand ensure that effective systems are put in place forregularly checking emergency equipment andmedication.

Summary of findings


• Systems must be put in place to ensure that, followingincidents of aggressive behaviour or restraint, the careplans for the patients involved are updated to describehow to prevent, manage and de-escalate potentialfuture incidents.

• Trust managers must ensure that the Mental HealthAct is consistently implemented in accordance withthe Code of Practice; and that staff working on theacute and PICU wards have sufficient understanding ofthe Mental Health Act and its Code of Practice toensure patients are given correct information abouttheir rights and to ensure medication is administeredlawfully under the Act.

• Trust managers must ensure that delays in findingPICU beds for patients are minimised.

• The trust must ensure that its monitoring processesidentify gaps and problems in the services, andidentify the reasons behind such issues.

Action the provider SHOULD take to improve

• The provider should review the seclusion room toensure it is equipped in accordance with the MentalHealth Act Code of Practice.

• The provider should make sure staff have access to areliable emergency alarm system.

• The provider should ensure there are robust processesin place for assessing and managing environmentalrisks, and that these are followed.

• The provider should ensure there are adequatenumbers of appropriately qualified and experiencedstaff.

• The provider should ensure that all patients have a riskassessment which is reviewed regularly and updatedin response to changes.

• The provider should ensure that staff understand thecircumstances and limitations within which de-escalation rooms can be used to nurse patients whoare violent or aggressive.

• The provider should ensure that all incidents ofrestraint are recorded correctly, and ensure any use ofprone restraint is consistent with Department ofHealth guidelines.

• All patients should have care plans that areindividualised, incorporate their views, and arerecovery focused.

• All staff should have an understanding of the MentalCapacity Act and DoLS.

• The provider should make suitable sleepingarrangements for patients who return from leave, andreduce the need for patients to change bedrooms fornon-clinical reasons.

Summary of findings


Locations inspected

Name of service (e.g. ward/unit/team) Name of CQC registered location

Amberwood Ward, Cherrywood Ward, Woodlands Ward,Willow Suite Littlebrook Hospital

Emerald Ward Medway Maritime Hospital

Amherst Ward, Brocklehurst Ward Priority House

Bluebell Ward, Fern Ward, Foxglove Ward, SamphireWard St Martins Hospital

Mental Health Act responsibilitiesWe do not rate responsibilities under the Mental Health Act1983. We use our findings as a determiner in reaching anoverall judgement about the Provider.

• Most nurses and healthcare assistants had receivedtraining about the Mental Health Act. However, we sawexamples on Emerald ward (in Gillingham), Samphireward (in Canterbury), Amberwood ward (in Darford) andthe Willow suite (psychiatric intensive care unit inDartford) that showed that staff were not always clear in

their understanding of the Act and its Code of Practice.For example, records and feedback identified repeatedinstances of patients being told, or care recordsdocumenting, that although they were informal if theywanted to leave they would be detained under theMental Health Act. This is potentially unlawful andcontrary to the Code of Practice. There were instanceson Amberwood ward where informal patients weredescribed as being on section 17 leave. Where patients

Kent and Medway NHS and Social Care PartnershipTrust

AcutAcutee wwarardsds fforor adultsadults ofofworkingworking agagee andand psychiatricpsychiatricintintensiveensive ccararee unitsunitsDetailed findings


were being seen by a second opinion appointed doctor(SOAD) there was either no, or a very limited, treatmentplan recorded. On Amberwood ward a patient had beentaking medication for over 30 days but it was notspecified on their consent to treatment form (T3).Another patient had, on nine occasions, been given adrug that was not included on their emergencytreatment form. This meant that staff had potentiallybeen administering the medication unlawfully. Theconsent to treatment forms were attached to themedication charts, but they had not been taken accountof when administering medication. We asked the trustto address this and it responded immediately, rectifyingthe situation.

• The completion of capacity assessments in accordancewith the Mental Health Act Code of Practice variedacross the wards. Capacity assessments had not alwaysbeen completed at Littlebrook Hospital (in Dartford),

but they had been at Priority House (in Maidstone). OnEmerald ward (in Gillingham) patients had not all hadtheir capacity to consent to treatment recorded inaccordance with the Mental Health Act Code of Practice.

• Most detained patients were informed of their rights andthis was documented accordingly for most patients.However, on Amberwood ward (in Dartford) patientswere not fully informed of their rights as required by theCode of Practice.

• There was a Mental Health Act administrator on thehospital sites who staff could contact for advice.

• An Independent Mental Health Advocate (IMHA)regularly visited all the wards. Information includingcontact details of the IMHA were on display on thewards. Staff knew how to make a referral to the IMHAservice and the days each week that the IMHA visitedtheir wards. Patients also knew how to contact an IMHA.

Mental Capacity Act and Deprivation of Liberty Safeguards• The trust had a policy for the implementation of the

Mental Capacity Act (MCA) and Deprivation of LibertySafeguards (DoLS). Most staff had completed mandatorytraining on MCA and DoLS. The staff we spoke with hadan understanding of some of the fundamental aspects

of the Act, such as acting in a person’s best interest andin the least restrictive way. Staff had less understandingof when a DoLS application should be made. There wasno one subject to DoLS at the time of our inspection.

• The implementation of the MCA and DoLS wasmonitored through the Mental Health Act office.

Detailed findings


* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatoryabuse

Summary of findingsWe rated safe as requires improvement because:

• The trust did not have a system to maintain theprivacy and dignity of women who were secluded onWillow suite (psychiatric intensive care unit).

• Cherrywood ward and Amberwood ward (inDartford), Emerald ward (in Gillingham), andSamphire ward (in Canterbury) did not have all theiremergency equipment and medication accessibleand/or in date, or have effective systems for regularlychecking that this was the case.

• Patients who had behaved aggressively, or who hadbeen restrained, had not had their care plansupdated to describe how to prevent, manage andde-escalate potential future incidents.

• The storage and recording of medication, includingcontrolled drugs, was not safe and secure onCherrywood ward (in Dartford). We raised thisimmediately and this was rectified on the day of ourinspection.

The seclusion room on Willow suite was not equipped inaccordance with the Mental Health Act Code of Practice.The trust had policies about the management ofviolence and aggression, and monitored their usage, buthad significant levels of prone restraint which is contraryto the Department of Health guidance.

There were environmental risks on many of the wards,but the trust had an extensive programme ofrefurbishment and was managing the risks until buildingworks were completed. Most of the wards weresatisfactorily managing medication. Most of the wardshad adequate emergency procedures. There were staffvacancies on most of the wards, particularly forband five nurses, but this was being managed at a localand corporate level, and the trust had a recruitmentstrategy. The trust had safeguarding policies and staffknew how to identify and report safeguarding concerns.

Staff knew how to report incidents, and there werepolicies for reporting and managing this. There was abulletin for sharing information including learning fromincidents that was circulated to staff.

Our findingsAcute wards for adults of working age and psychiatricintensive care units

Safe and clean ward environment

• The trust had an ongoing programme to rebuild andrefurbish the wards within the trust. The acute wardswere a mixture of new, refurbished and awaitingrefurbishment, so there were differences in the qualityand safety of the environment across the wards. Thenew and refurbished wards had fewer ligatures andenvironmental risks, and better lines of sight around thewards. The unrefurbished wards had some reducedrisks, but had poor lines of sight, and there were ligaturerisks in bedrooms and bathrooms where patients couldbe unsupervised. The nursing station on Amberwoodward (in Dartford) had a solid wooden door and nointernal windows, so staff in the office could not see theward or who was outside the door. All the wards had anenvironmental risk assessment, but the quality of thiswas variable and we found gaps between the riskspresented on the wards and those identified in theassessment. Where risks were identified there wereactions for how these were to be managed. Forexample, by assessing patient suitability to go intobedrooms that contained more risks, and the use ofobservation.

• Most of the wards were compliant with guidance aboutseparation of male and female accommodation. Therewere some single sex wards and other wards haddedicated corridors. However, the bedroom corridorswere mixed on Cherrywood ward (in Dartford), butbedrooms had ensuite shower rooms. Woodlands ward(also in Dartford) had recently moved to a new building,and there was a woman in a bedroom at the end of the

Are services safe?By safe, we mean that people are protected from abuse* and avoidable harm



male corridor. The wards had female lounges, althoughthe female lounge on Woodlands ward was in themiddle of the male corridor. The manager told us thatthey planned to move the female lounge.

• Willow suite (in Dartford) was the trust’s only psychiatricintensive care unit (PICU) and was for both men andwomen, although most patients admitted there aremale. The seclusion room at Willow Suite was used byall the wards at Littlebrook Hospital in Dartford. Theseclusion room was in an open corridor surrounded bybedrooms, which were all male at the time of ourinspection. We saw a female patient being secluded.Staff took her to the seclusion room through the malecorridors, and men approached and tried to talk to her.Whilst she was in the seclusion room, male patients hadto walk past the room to get to their own bedrooms andlooked into the room. This did not promote the privacyand dignity of the woman being secluded.

• Willow suite had the only seclusion room. This was notequipped to the standards recommended in the MentalHealth Act Code of Practice. There was no clock, nointercom to allow staff and patients to communicatewith each other through the closed door, and there wereligatures in the bathroom. The seclusion room was onan open corridor with four bedrooms. This did notsupport privacy for patients in the seclusion room.

• All the wards had equipment and medication for use inthe event of a medical or psychiatric emergency. Most ofthe wards regularly checked the equipment, andensured it was accessible and in working condition.However, some of the wards had items missing or out ofdate, and some wards had not regularly checked theemergency equipment. For example, on Cherrywoodward (in Darford) the staff could not find the emergencydrugs, but they were later discovered in a domesticplastic box at the back of a cupboard, which would nothave made them easily accessible in the event of amedical emergency. The equipment and drugs wererecorded as being checked daily. The emergency drugswere in date but there were some items missing; andsome of the emergency equipment was out of date. OnAmberwood ward (in Dartford) the oxygen cylinder wasnearly empty. Staff told us they had been aware of thisfor four days, but it was not reordered until the day afterwe had pointed this out. The ward did have emergencydrugs and equipment which were in order, but there

were only records of them being checked on twooccasions. On Emerald ward (in Gillingham) theequipment had not been signed as checked for threemonths, and there were items missing.

• There were emergency alarms on all the wards, and wesaw these being used and responded to correctly onsome of the wards. However, this was not the case on allthe wards. On Samphire and Fern wards (in Canterbury)there were 15 alarms for each ward but they needed 20.This issue had been on the risk register since June 2012,but had not been rectified. On wards at St MartinsHospital (in Canterbury) there was sometimes a delaybetween an alarm being activated and it sounding. Stafftold us there could be a 10 second delay. This raisedsafety concerns as staff did not know if their alarmwould sound immediately when activated. This issuewas being addressed with the contractor. OnAmberwood ward (in Dartford) we observed staffresponding when an individual alarm was activated.However, staff could not find who had activated thealarm so the response was cancelled without knowingthe cause.

• Most of the wards were clean and well maintained.However, Amberwood ward (in Dartford) had a brokentelevision and the 'sanctuary' room was out of usebecause of damage. The damage had happened overtwo weeks previously and had yet to be repaired.

Safe staffing

• All the wards had established staffing levels, and theward managers were clear about vacancy levels andlocal and trust strategies to address them. All the wardshad nursing and healthcare assistant vacancies. Stafftold us that the recruitment of band five qualified nurseswas a particular challenge, and we saw that most of thewards had a number of vacancies at this level. Forexample, Foxglove, Samphire and Fern wards (inCanterbury) and Woodlands ward (in Dartford) all hadfive vacancies at this level at the time of our inspection.The trust had a recruitment strategy to address thevacancy rate, and service directors met regularly withhuman resources to review this. There was a rollingadvert for nursing staff, and there were staff goingthrough the recruitment process across the service.

• The vacancies were filled by bank and agency staff, whowere used regularly on all the wards. Staff told us theytried to book agency staff who were familiar with the




ward, but this was not always possible. On some wardsagency staff were routinely used. For example, onAmberwood and Cherrywood wards (in Dartford) thenight staff were mostly regular agency staff.

• All the ward managers told us they were able to varytheir staffing levels depending on the needs of peopleon the ward. Feedback from staff and patients said thatleave and activities usually went ahead, but there weresome occasions when these were cancelled. Feedbackfrom patients was that if the wards were short staffed, orstaff were busy, then they would not be able to have 1-1time with them.

• There was adequate medical cover both during the dayand on call out of hours.

• All four wards at Littlebrook Hospital (in Dartford) hadsickness rates above the trust average of 3.9%, with oneward over 17%. The trust had policies for managingsickness and absence, which involved human resourcesand occupational health.

Assessing and managing risks to patients and staff

• All wards use a standard risk assessment tool that isrecorded in RIO, the electronic records system. Patientshad a risk assessment carried out when they wereadmitted to the service. However, the risk assessmentswere not always reviewed, or updated followingincidents or changes in risk behaviour. The risksidentified were not always identified and included in acare plan, and it was not always clear what action staffshould take to manage risk. For example, we observedthat an informal patient had threatened to harmthemselves and had left the ward, and was laterreturned by the police. They had been assessed by adoctor who found that the patient did not meet thecriteria to be detained under the Mental Health Act(MHA) but said that they should be detained if theywanted to leave, which is poor practice under the MHACode of Practice.

• All the wards were locked, and there were notices onmost of the ward doors stating that informal patientsshould speak with staff if they wished to leave. Weobserved that informal patients did come and go fromthe wards. However, some patients described occasionswhere they had been prevented by leaving from staff,but had not been detained under the Mental Health Act.Other patients gave examples of when they had beentold they would be detained if they asked to leave theward.

• The trust had clear policies on the use of observationwhich were accessible to staff. These included a smallquick guide for staff to refer to. Records weremaintained of the observations, and levels wereincreased in response to concerns about a person, andreviewed in the multidisciplinary team meetings.

• The trust had policies on the management of violenceand aggressive behaviour, and the use of de-escalationand restraint. Most staff were trained in techniques touse physical restraint safely. Restraint was used on allthe wards. Emerald ward had not used restraint recently,and did not admit patients to the ward who were at riskof aggressive behaviour because of the ward’s isolationfrom other mental health wards. The restraint records atSt Martins Hospital (in Canterbury) were completedcorrectly, and included full details of the restraint whichincluded the staff involved and the holds used. AtLittlebrook Hospital (in Dartford) the forms were notalways completed fully so it was difficult to analyse ifpatients had been restrained correctly. Prone restraintwas regularly used. For example, on Samphire ward (inCanterbury) 35 restraints had happened since 5 January2015, and of these 20 involved the use of prone restraint;on Foxglove ward (also in Canterbury) 64 restraints hadhappened since 2 January 2015 and 19 of these hadinvolved prone restraint. This was not planned inadvance, and was for the shortest possible time. Therecords at Littlebrook (in Dartford) were unclear; theyidentified that prone restraint was used but therationale was not identified.

• Staff had fortnightly reflective practice sessions with thepsychologist where they were able to discuss incidents,and how to work with patients who presented withaggressive behaviour. Details of incidents of restraintwere recorded on RIO, but the lead up to the incident orwhat attempts were made to de-escalate a situationwere not always recorded. Some of the records includeddetailed behaviour support plans for patients. However,we saw at least two records where patients had beenrestrained on multiple occasions but the care plan hadnot been updated to include how to manage or preventthese situations.

• The trust had a policy for the use of rapid tranquilisationwhich followed NICE guidance. Most of the wards usedrapid tranquilisation and this was in accordance withthe trust policy.

• There was a seclusion room in the Willow suite atLittlebrook Hospital (in Dartford), which was also used




by the acute wards on the site. Records were completedappropriately. A patient at St Martins Hospital (inCanterbury) had been nursed in a de-escalation roomfor several days whilst awaiting a bed elsewhere. Staffgave us conflicting messages about whether the personhad been allowed to leave the room or not, and it wasnot clear from the incident forms or the patient’srecords. Not all staff understood that 'de facto' seclusionis when a patient is nursed in a room they cannot leave,but without the safeguards of a designated seclusionroom and its related policies.

• The trust had safeguarding policies that were accessibleto staff. Staff had completed safeguarding training, andknew which concerns could be considered assafeguarding concern and how to make a referral. Staffdescribed examples of safeguarding concerns that hadbeen identified, referred to the safeguarding team, andaction taken. The records confirmed that safeguardingissues were being recorded and referred appropriately.

• The trust had policies for the management ofmedication. Prescribing was in line with NICE guidance.The trust pharmacist visited regularly to check theprescription charts and medication, and an externalpharmacist also visited some sites. There were somegaps on medication charts on most of the wards, so itwas not clear if a patient had taken a medication at theprescribed time. For example, on Cherrywood ward (inDartford) of the current 18 patients, there were 36 gapsover the last month.

• Medication was not stored securely on Cherrywoodward (in Dartford). The medication cupboard in theclinic room was of an approved design, but it hadbowed. When locked, it was possible to reach into thecupboard and take out medication, so medic ation wasnot stored securely. Legislation and polices for thehandling and storage of controlled drugs were not beingfollowed on Cherrywood ward. The controlled drugsregister stated that a bottle of Oramorph (a controlleddrug) had been returned to a patient. However, thebottle was still in the cupboard. It was in the main partof the cupboard, not the designated part for controlledsubstances, and was accessible due to the poorcondition of the cupboard. The ward had corrected thiserror by the end of our inspection.

• The medication fridge temperatures on most of thewards were within the acceptable range (2-8 degreesCelsius), and were checked regularly. However, onAmberwood ward (in Dartford) the checks had last been

completed a month prior to our visit, and at that timehad been just above the acceptable range at 10 degrees.There was no record of any action that was taken, butthe fridge was in range on the day of our inspection. OnCherrywood ward (in Dartford) the fridge temperaturewas recorded as 17 degrees, well above the acceptablerange, for several weeks but no action had been taken.

• Children were not allowed onto the wards. There was afamily room on each of the main hospital sites that allthe wards used for child visitors. Emerald ward (inGillingham) had limited facilities, so child visits had tobe agreed in advance and staff arranged to use thefamily room in the onsite general hospital.

Track record on safety

• The trust published a bulletin for staff working in theacute service line, which shared information andlearning from incidents. Staff were able to describeexamples of learning from incidents in their own andother wards. For example, a person had modified anitem and used it to harm themselves severely, so thisitem was now highlighted as a risk across the trust. Thisinformation had been circulated to all wards shortlyafter the incident so immediate action could be taken.

• The trust had identified that many of its buildings,including its acute wards, were not up to modernstandards of safety. In response the trust had identifiedthe risks from its current premises and the actionsneeded to manage and mitigate against them in theshort to medium term. To remove or significantly reducethe risks the trust had an ongoing programme ofrebuilding and refurbishment to make its wards saferand more therapeutic and attractive for patients. Forexample, the new wards at St Martins Hospital (inCanterbury) had ligature free fittings in bedrooms andbathrooms, and all patients had a swipe card whichlimited access to their rooms, and to male/female areas.The other wards will be moved or refurbished as part ofthe programme.

Reporting incidents and learning from when thingsgo wrong

• The trust had policies for the reporting andmanagement of incidents. Most staff were familiar withthis policy and knew how and to whom to reportincidents. The trust currently had a paper-basedincident reporting system. The paper forms werecompleted by staff, and reviewed and approved by the




ward and service managers. The forms were then sent toa central team for review. The trust collated thisinformation but not all staff knew what happened to thisinformation. Staff told us that the paper-based systemwas due to be replaced by an electronic system in April,which they thought would make the process quickerand easier to audit.

• Incidents were recorded, feedback was given to staffand information shared. For example, plastic bags were

contraband in the service but they were available on acleaning trolley. This had been identified following anincident, and the information shared across the trust.Incidents were discussed with staff in team meetings,through individual supervision where appropriate, andthrough the acute service line learning bulletin.

• Staff were offered debriefing following serious incidents.




Summary of findingsWe rated effective as requires improvement because:

• The Mental Health Act was not consistentlyimplemented in accordance with the Code ofPractice. For example, on Amberwood ward (inDartford), patients were not informed of their rightsin accordance with the Mental Health Act and Codeof Practice; medication had been administeredwithout the proper consent, and there was poordocumentation of the treatment plan when a patienthad a second opinion from a second opionnappointed doctor (SOAD).

Staff did not have a clear understanding of the MentalHealth Act and Code of Practice. Records and patients’feedback identified repeated instances of patients beingtold, or care records documenting, that although theywere informal (voluntary patients), if they wanted toleave they would be detained under the Mental HealthAct. On Amberwood ward (in Dartford) and Emeraldward (in Gillingham), staff had not checked that drugsthey had administered were included on the formalconsent to treatment and emergency treatment forms.Thus the lawfulness of the administration of thismedication could be under question.

Patients were assessed by the crisis team prior toadmission, and were assessed on admission to theward. Patients had their physical healthcare needsmonitored and responded to. All patients had a riskassessment and care plan, although this was not alwayspatient or recovery focused, and reviewed when thepatient’s situation changed. Patient information wasstored securely and, as it was electronic, could beshared between the wards, crisis and community teams.The wards followed NICE (National Institute for Healthand Care Excellence) prescribing guidance, andcompleted health of the nation outcome scales(HONOS). Care was provided by a multidisciplinary teamof staff. Most staff received supervision and appraisal,and had completed most of their mandatory training.There were regular multidisciplinary team meetings andhandovers where patient care was discussed.


Assessment of needs and planning of care

• The local crisis teams were the 'gatekeepers' for theinpatient beds, and assessed patients to decide if theyrequired admission. At admission, patients received anursing and medical assessment which included aphysical examination. Patients had care plansdeveloped within 72 hours of their admission tohospital.

• A patient had been admitted to Littlebrook Hospital (inDartford) to restart medication. However, after eightdays they had still not been given the medicationdespite asking for it. The medication was prescribed for10pm, but the patient was usually asleep by then so ithad not been administered and alternativearrangements to administer the medication had notbeen made. The patient was discharged without havinghad the medication and was due to start it at home.When we discussed this issue with the ward theyidentified it as an incident that required investigationinto the rationale behind the admission, and why it wasnot picked up sooner that the medication was not beingadministered.

• Patients had their physical observations taken as part oftheir initial assessment, and then had this monitoredas/if necessary on a medical early warning system(MEWS) chart. This chart highlights if a person’sobservations are outside the normal range, so that thiscan be quickly picked up and reviewed by a doctor. Theobservations include blood pressure and pulse. TheMEWS records were not always completed as regularlyas prescribed. For example we saw that a person wasdue to have their observations taken four times a day,but they had not been done at all. However, we did seethat physical healthcare was discussed in themultidisciplinary ward round meetings, and that therewere detailed individualised care plans for a person whohad complex physical healthcare problems. The trusthad commenced recruitment of a physical healthcarenurse to improve the monitoring and management ofpatients’ physical health.

• All patients had care plans. However, the quality ofthese varied across the wards. For example, most

Are services effective?By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.



patients at Priority House (in Maidstone) had copies oftheir care plans which were responsive, patient-focusedand recovery orientated. However, many of the careplans for patients at Littlebrook Hospital (in Dartford)were not patient-focused, contained limited informationthat was specific to individual patients, and were notrecovery focused.

• The trust used an electronic care records system calledRIO. This was accessible to all employed staff, whichincluded those in the community and crisis teams. Thismeans staff were able to access information aboutpatients when and before they moved between services.RIO was the primary care record and should contain allthe information about a patient. However, paperrecords were still used for some information, such as theMEWS charts, and these were stored in lockable filingcabinets in lockable staff offices. Staff logged into RIOwith a smart card and password, so information wasstored securely. Staff told us that RIO could break down,and access to the internet was not always reliable,which could cause frustration and made it difficult toaccess information.

Best practice in treatment and care

• Staff followed NICE guidance when prescribingmedication. The psychologists provided group work andlimited 1-1 work with patients. Their primary role was toassess patients and if they determined they wouldbenefit from, and were suitable for psychologicaltherapies they would signpost or refer them tocommunity based psychology services. Thepsychologists offered reflective sessions with staff, andhad provided training to support staff to work withpatients in a therapeutic way.

• The wards completed health of the nation outcomescales (HONOS), a recognised outcome scale, and otheraudits required by the trust such as the nursing matrix.The nursing matrix was an audit generated through RIO,which included checking if physical healthcare checkshad been carried out and care plans reviewed. Therewere some local audits being carried out, but this variedbetween the wards. For example, some wards carriedout regular infection control, care plan, prescriptionchart and Mental Health Act audits.

Skilled staff to deliver care

• There was a multidisciplinary team of staff providingcare to patients on all the wards. This includedconsultant psychiatrists, nurses and healthcareassistants, occupational therapists, and psychologists.

• The trust had policies to ensure staff received appraisal,supervision and training. Most staff had completed mostof their mandatory training. For example, uptake wasabove 90% for all wards at Littlebrook Hospital (inDartford) and Priority House (in Maidstone), exceptAmherst ward (in Maidstone) at 78%. Uptake of trainingwas monitored locally and by the central training team.Most staff received supervision, though not always asfrequently as stated in the trust’s policy. Many staff toldus that they were able to access additional training. Forexample some staff had completed masters degrees ornurse training. A central team monitored the completionof appraisals. Staff had to confirm that they hadcompleted their appraisal before they could receivetheir annual pay increment. Most staff had received anappraisal within the last year.

• We saw examples of where poor staff performance hadbeen addressed.

Multi-disciplinary and inter-agency team work

• There were regular multidisciplinary team (MDT)meetings and care programme approach (CPA) ordischarge planning meetings for each patient.

• There was a meeting each weekday morning that wasattended by the ward-based MDT, plus the crisis teamand other staff such as the pharmacist. The purpose ofthese meetings was to briefly review any specific issueswith patients which included care and social needs,including discharge planning. The crisis teams couldalso access information on RIO about patients on thewards, so information was easily shared.

• The quality of handovers/daily meetings varied acrossthe wards. For example, at the nursing handover on Fernward (in Canterbury) each patient was discussed, therelevant information was handed over, and staffdemonstrated that they had a good understanding ofindividual patients’ needs. However, a staff handover atLittlebrook Hospital (in Dartford) referred to patients bytheir bed number rather than their name, theinformation was not patient focused, and containedlimited information.




Adherence to the MHA and MHA Code of Practice

• Most nurses and healthcare assistants had receivedtraining about the Mental Health Act. However, we sawexamples on Emerald ward (in Gillingham), Samphireward (in Canterbury), and Amberwood ward and theWillow suite (in Dartford) that showed that staff were notalways clear in their understanding of the Act and itsCode of Practice. For example, records and feedbackidentified repeated instances of patients being told, orcare records documenting, that although they wereinformal (voluntary patients), if they wanted to leavethey would be detained under the Mental Health Act.This was potentially unlawful and contrary to the Codeof Practice. There were instances on Amberwood wardwhere informal patients were described as being onsection 17 leave. Where patients were being seen by asecond opinion appointed doctor (SOAD) there waseither no or a very limited treatment plan recorded. OnAmberwood ward (in Dartford) a patient had beentaking medication for over 30 days but it was notspecified on their consent to treatment form (T3).Another patient had been administered another drug onnine occasions that was not included on theiremergency treatment form. This meant that staff hadpotentially been administering the medicationunlawfully. The consent to treatment forms wereattached to the medication charts, but they had notbeen taken account of when administering medication.We asked the trust to address this.

• The completion of capacity assessments in accordancewith the Mental Health Act Code of Practice variedacross the wards. Capacity assessments had not always

been completed at Littlebrook Hospital (in Dartford),but they had been at Priority House (in Maidstone). OnEmerald ward (in Gillingham) patients had not all hadtheir capacity to consent to treatment recorded inaccordance with the Mental Health Act Code of Practice.

• Detained patients had been informed of their rights, andthis was documented accordingly for most patients.However, on Amberwood ward (in Dartford) patientshad not been fully informed of their rights as required bythe Code of Practice.

• There was a Mental Health Act administrator on thehospital sites, who staff could contact for advice.

• An independent Mental Health Advocate (IMHA)regularly visited all the wards. Information, includingcontact details of the IMHA, were on display on thewards. Staff knew how to make a referral to the IMHAservice and the days each week that the IMHA visitedtheir wards. Patients also knew how to contact an IMHA.

Good practice in applying the MCA

• The trust had a policy for the implementation of theMental Capacity Act (MCA) and Deprivation of LibertySafeguards (DoLS). Most staff had completed mandatorytraining on MCA and DoLS. The staff we spoke with hadan understanding of some of the fundamental aspectsof the Act, such as best interest and acting in the leastrestrictive way. Staff had less understanding of whenDoLS applied, and when it should be used. There wasno one subject to DoLS at the time of our inspection.

• The implementation of the MCA and DoLS wasmonitored through the Mental Health Act office.




Summary of findingsWe rated caring as good because:

Patients were mostly positive about the care theyreceived on the wards and found most of the staffapproachable and caring. Patients had 1-1s with staff,although this could be difficult when staff were busy.Patients had access to advocacy on the ward. Patients’relatives were involved in their care where appropriate.There were community meetings on most of the wards.


Kindness, dignity, respect and support

• Patients were mostly positive about the staff on most ofthe wards and said they were approachable and caring,treated them with respect, and were able to meet theirneeds. However, some of the patients on the wards atLittlebrook Hospital (in Dartford) told us that the staffcould be unhelpful and some patients said they wouldnot approach staff for help.

• Patients told us that they had 1-1s with staff, but theydid not always happen as staff were too busy.

• We saw positive interactions between staff and patientswhen on most of the wards. We observed some positiveinteractions on the acute wards at Littlebrook Hospital(in Dartford). However, on some of the wards weobserved some staff being dismissive towards patientsand the culture was not patient focused. For example, ina staff handover patients were referred to by their bednumber and some staff did not know the actual name ofsome of their patients only their bed number.

The involvement of people in the care they receive

• Patients on most of the wards told us that they hadbeen orientated to the ward on admission. For exampleon Willow suite (in Dartford) staff ensured that on

admission all patients were given a good introduction ofthe ward, including the patient handbook that allowedthem to understand their rights, their treatment, make acomplaint, and gave feedback and details of how toaccess the advocacy service. However, patients onSamphire ward (in Canterbury), and Amberwood andWoodlands wards (in Dartford) told us they had had noorientation or welcome pack when they were admittedto the ward.

• Some of the patients we spoke with felt involved in theircare planning. For example, we saw patients’ viewsrecorded in their records and care plans on the Willowsuite (in Dartford), and on the wards at Priority House (inMaidstone). However, this was not the case on all thewards. We found limited evidence of patients beinginvolved in their care planning, or their views recorded,on the acute wards at Littlebrook Hospital (in Dartford)and on Samphire ward (in Canterbury).

• There was information on display about generaladvocacy services, and specific Independent MentalHealth Advocacy (IMHA) for patients detained under theMental Health Act. Some of the patients we spoke withhad used the advocacy services and found them helpful.Some of the wards had IMHAs who regularly visited.Staff were familiar with the role of the advocates,particularly the IMHAs, and knew how to contact themfor patients.

• Patients’ families were involved in their relatives’ carewhere appropriate. Relatives were invited to andattended multidisciplinary meetings.

• Community meetings took place on all the wards andpatients could raise any concerns or suggestions atthese meetings. Most were scheduled to take placeweekly, but these did not always happen. Theavailability and detail of the minutes of these meetingsvaried so it was not possible to see what action hadbeen taken as a result. On some of the wards, forexample at St Martins Hospital (in Canterbury), theminutes were displayed along with 'you said, we did' sothat patients could see any changes that had beenmade as a result of their feedback.

Are services caring?By caring, we mean that staff involve and treat people with compassion,kindness, dignity and respect.

Good –––


Summary of findingsWe rated responsive as requires improvementbecause:

• There were delays in finding psychiatric intensivecare unit (PICU) beds for patients.

• There was pressure on beds, which meant thatpatients might be moved for non-clinical reasons.

There was an activity programme and/or anoccupational therapy suite for all of the wards. Patientshad access to phones on the wards. Patients had freeaccess to drinks and snacks until midnight. There weredisabled facilities available across the trust. There wereposters and information leaflets which included how tocomplain, how to access advocacy and local facilitiesand support services. There was access to interpretingservices, and a choice of food for people with specialdietary requirements. The trust managed andresponded to complaints.


Access, discharge and bed management

• Crisis teams were the 'gatekeepers' for the inpatientservices, and decided who needed to be admitted.There was a daily bed management conference callacross the trust, so beds were managed across the trust,not at a local level. There was a discharge co-ordinatorwho approved and reviewed patients in out of areaplacements, and co-ordinated their return to theservice, though this was due to change. Staff told usthere was a lot of pressure on beds, and this wasexacerbated by taking patients from out of the ward’slocality. There was also pressure to discharge patientsas soon as possible. The crisis teams worked with thewards to facilitate discharges.

• Staff told us that they only moved people to a differentbed if absolutely necessary but patients were moved forbed management rather than clinical reasons. Emeraldward (in Gillingham) and Woodlands ward (in Dartford)

were not admitting patients who might present a risk ofviolence and aggression, due to their isolation fromother services. This meant that patients may betransferred to these wards, to create beds elsewhere.

• There was usually a bed available for patients when theyreturned from leave. However, in February, a patientreturned from leave and as there was no bed availablethey spent two nights in the room of another patientwho did not use their room. The patient who hadreturned from leave spent the first night sleeping on abean bag and the second in the bed, until they weresubsequently found a room of their own.

• There was one psychiatric intensive care unit (PICU)ward for the trust – the Willow suite - based atLittlebrook Hospital (in Dartford). The number of PICUbeds had reduced. The PICU ward was supplemented bya PICU outreach service that assessed patients todetermine if they required psychiatric intensive careand, if not, provide advice on their management toenable care to be provided in the least restrictiveenvironment. This could result in very unwell patientsbeing nursed on the acute wards. There had been atleast three occasions (at Priority House (in Maidstone),Samphire ward and Fern ward (in Canterbury)) wherepatients were nursed in the section 136 suite (healthbased place of safety) or in a quiet room/lounge as theywere not suitable to be cared for in the main patientarea of an acute ward. Some staff were very positiveabout the PICU outreach service and found themsupportive, but they felt that a very disturbed patient onthe ward impacted on the patients and staff as theenvironment was fundamentally unsuitable. The PICUoutreach service currently assessed patients, wasresponsible for gatekeeping the PICU beds, and gaverecommendations on how to manage aggressivebehaviour. The service manager said they hadrequested additional funding so that the outreach staffcould provide more direct support. There were four staffwho provided assessment and advice as part of theoutreach team. There was an on-call system, with alimited service at weekends.

• Most of the wards had one or two people who no longerneeded to be on the ward but were waiting for asuitable placement. One patient was waiting severalweeks for a local bed but most patients were awaiting

Are services responsive to people’s needs?By responsive, we mean that services are organised so that they meet people’sneeds.



confirmation of funding, housing, or specialistplacements. There were two patients in the PICU whowere 'delayed discharges' because they were waiting forbeds to become available in another service.

The ward optimises recovery, comfort and dignity

• There were occupational therapy (OT) and activitiesprovided on the wards or in dedicated areas. Forexample, Littlebrook Hospital (in Dartford) had adedicated OT suite where most activities were provided.Patients could access the OT department if they werewell enough to leave the ward but there were limitedactivities on the ward. For those too unwell, OT staffworked to support ward staff to provide a specificprogram with specially designed activity boxes.

• There were clinic rooms on some of the wards, oralternatively patients were examined in their bedrooms.

• All the wards had a quiet room and/or a place wherepatients could meet visitors.

• There were ward phones for patients to use and patientscould use their own mobile phones.

• All the wards had outdoor space.• Patients gave mixed feedback about the quality of the

food but most patients thought it was ok or good.• There was access to tea, coffee and snacks in the

kitchen on the wards until midnight.• Patients had storage for personal items or had their own

room they could lock or access with a swipe card or key.However, the bedrooms at Littlebrook Hospital (inDartford) were either unlocked (Woodlands ward) orcould only be locked and unlocked by staff (Amberwoodward). Patients had lockers on the ward, but these wereaccessible only with staff and were primarily for riskitems should as razors and some toiletries.

• Patients had access to activities during office hours, butthis was limited at weekends and evenings. Activityboxes were being introduced across the wards. Theseincluded jigsaws, colouring books and anagrams. Mostpatients were positive about the activities that wereavailable, but some patients thought some of theactivities, such as colouring, were “babyish”.

Meeting the needs of all people who use theservice

• There were disabled facilities across the service, thoughthis was limited on some of the wards such as Emeraldward (in Gillingham). Disabled facilities wereincorporated into the trust’s refurbishment plans.

• Information leaflets were not on display in differentlanguages. However, staff told us that some of theleaflets were in different languages on the internet andthey would print them if necessary.

• There were leaflets and posters on display on all of thewards. These included how to complain, how to accessadvocacy services, the activity programme and detailsof local helplines and services.

• Patients had access to an interpreting service if Englishwas not their first language.

• Patients had some choice of food at mealtimes. Theywere able to order food to meet their dietaryrequirements, such as vegetarian, halal or for patientswith diabetes.

• Information was available on how to contact localreligious groups. A chaplain visited the wards and couldbe contacted if required.

Listening to and learning from concerns andcomplaints

• The trust had policies for receiving, managing andresponding to complaints. There was information abouthow to complain on display on the wards. Patients knewhow to make a complaint and the service investigatedand responded appropriately. A manager tried to meetwith the complainant to discuss their complaint beforethey responded to it. The complaints process wascoordinated by a central patient experience team andreviewed by a senior manager before a response wassent. We looked at a sample of complaints submitted toAmberwood ward (in Dartford), and Amherst andBrocklehurst wards (in Maidstone) and saw that theyhad been responded to appropriately. There was nomeans of monitoring or identifying themes from lowlevel or verbal complaints.

• Staff were familiar with the complaints procedure andknew what to do if a patient wanted to make acomplaint. Staff told us that when complaints wereinvestigated the findings were shared appropriately withstaff, as was any broader learning.

Are services responsive to people’s needs?By responsive, we mean that services are organised so that they meet people’sneeds.



Summary of findingsWe rated well-led as requires improvement because:

• The monitoring processes had not identified gapsand problems in the services. For example, therewere gaps in updating risks assessments and careplans; we found out of date and missingresuscitation equipment; and the reasons behindhigh levels of restraint, including prone (face down)restraint had not been identified. There were alsoproblems with medication storage and recording,including the recording of consent to treatmentprovisions under the Mental Health Act and Code ofPractice.

There were local and corporate governance systemsthat monitored the quality of care. The trust had a riskregister which identified risks and the actions to reduceor mitigate them. Sickness and absence were monitoredby the local teams with support from human resources.Staff had a 'green button' on the trust’s website forraising concerns or making suggestions.


Vision and values

• The organisation’s values were on display around thetrust’s services and staff were familiar with them. Staffon the wards knew who their service manager was, butdid not necessarily staff above the level of servicemanager. Staff at Priority House (in Maidstone) told usthey knew who the chief executive was as she hadrecently visited the unit.

Good governance

• There were local and corporate governancearrangements in place. The local arrangementsincluded monthly health and safety and governancemeetings, and staff meetings on the wards. The minutesshowed that the meetings included highlightingdevelopments; monitoring information; and reviewingincidents, complaints and safeguarding. There was anacute service line which incorporated the acute wards,

psychiatric intensive care unit (PICU) and crisis teams.Each hospital had a service manager who held regularmeetings with their teams, the service line director andtheir deputy held regular meetings with all theservice. However, there were still inconsistencies ofpractice across the hospitals.

• It was of concern that gaps in updating risk assessmentsand care records, gaps in checking resuscitationequipment and problems identified with poormedication storage and recording, including in relationto consent to treatment and the Mental Health Act hadnot been identified through the existing governanceprocesses.

• The trust had identified that the highest use of physicalrestraint was on Foxglove, Bluebell, Fern and Samphirewards (all in Canterbury), and the highest number ofprone restraints on Foxglove ward. However, there wasno rationale for why this was. Managers had discussedthe introduction of a 'safer wards' initiative to addressthe number of restraints.

• Managers had access to the trust's risk register andincident management system, on which risks in theservice were rated, and actions and plans recorded tomitigate or remove the risks. There were risk registers forthe acute service line, and risk registers for each of thewards. The highest risks included bed management,staffing (recruitment), and others such as demand onbeds (acute and PICU), access to acute hospital bedswhen required, and bank and agency staff not trained inpromoting safer and therapeutic services (PSTS). Staffcould access and add items to the risk register.

• Ward managers had authority to carry out their role andhad support from senior managers. Training andappraisal management were monitored through acentral team and this information was shared with localmanagers. Staffing levels and recruitment weremonitored locally and fed into the corporaterecruitment strategy.

Leadership, morale and staff engagement

• Sickness and absence rates were monitored locally andcentrally. Managers told us the trust had strategies tomanage sickness and absence, whilst being supportiveof staff, which involved an absence manager andoccupational health. There were policies for managingsickness and absence in the trust. A central team inhuman resources provided a monthly sickness report tothe service manager, who discussed it with the ward

Are services well-led?By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.



manager. The trust monitored the absence centrally andlocally. If a person had three episodes of absence in ayear they automatically met with the ward manager toset a target for future absence. If they did not meet theabsence target, or had enduring health problems, thenstaff from the human resources department supportedthe process.

• The trust target for sickness was 3.9% but many of theacute wards were above this. For example, at LittlebrookHospital (in Dartford), Woodlands ward had the lowestrate at 6.75% (from most recent data in January 2015),and Cherrywood ward had the highest rate at 17.23%. AtPriority House (in Maidstone), Brocklehurst ward wasbelow average at 2%, but Amherst was well aboveaverage at 15%. The service managers were aware ofthese issues and were able to give a broad rationale forthe levels.

• Staff told us they knew how to raise concerns. The trusthad a 'green button' on the internal website that staffcould use to ask questions, raise concerns, or makesuggestions. Some staff said they were unsure aboutconfidentiality, as they had to be logged in to raise theconcern. However, other staff said they had raised issuesand they had been dealt with appropriately.

• We received mixed feedback from staff about their viewof staff morale, job satisfaction and how much influencethey had in the service. Staff thought the recruitmentproblems put pressure on staff and impacted on theeffectiveness of the teams. Some staff thought they hadbeen listened to, for example regarding theimprovement in physical health care. In other areas staffdid not feel they were involved. For example, regardingthe psychiatric intensive care unit service – they felt the

acute wards were having to care for patients whoneeded to be in a PICU. They did not know if, or how, theeffectiveness of the PICU outreach service was beingmonitored and had not had this information fed back tothem.

• There was information in the January 2015 'acuteservice line lessons bulletin' about the 'duty of candour'requirement placed on trusts, and what this meant forstaff. There were posters around the trust giving basicinformation about the duty of candour for patients. Forexample, in the reception area of Littlebrook Hospital (inDartford).

Commitment to quality improvement andinnovation

• Two of the acute wards at Littlebrook Hospital (inDartford) had been accredited by the Royal College ofPsychiatry using their accreditation for inpatient mentalhealth services (AIMS) programme in 2007, and were lastassessed in 2011. Staff at Priority House told us they hadbeen participating in the AIMS accreditation scheme buthad stopped as it was too time consuming.

• Priority House (in Maidstone) had introduced a numberof initiatives which included the recovery clinic.Research into the effectiveness of the clinic was beingundertaken by a member of staff as part of theirdoctorate studies. We were told that recovery clinicshad been rolled out on all wards.

• Peer support workers, who were people who hadexperience of mental health services, were employed bythe trust. They were a positive addition to the wards andhelped reinforce the patients’ perspective.

Are services well-led?By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.



Action we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.

Regulated activityAssessment or medical treatment for persons detainedunder the Mental Health Act 1983

Treatment of disease, disorder or injury

Regulation 10 HSCA (RA) Regulations 2014 Dignity andrespect

We found that Kent and Medway NHS and Social CarePartnership Trust did not have a system to maintain theprivacy and dignity of women who were secluded onWillow suite (in Dartford).

This was in breach of regulation 17(1)(a) of the Healthand Social Care Act 2008 (Regulated Activities)Regulations 2010, which corresponds to regulation10(1)(2)(a) of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014.



Regulation 15 HSCA (RA) Regulations 2014 Premises andequipment

We found that Kent and Medway NHS and Social CarePartnership Trust did not always have available andadequately maintained equipment in the event of amedical emergency. This included on Cherrywood wardand Amberwood ward (in Dartford), Emerald ward (inGillngham), and Samphire ward (in Canterbury) whichdid not have all their emergency equipment andmedication accessible and in date, or have effectivesystems for regularly checking that this was the case.

This was in breach of regulation 9(2) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2010, which corresponds to regulation 15(1) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014.

Regulated activity

Regulation

Regulation

Regulation

This section is primarily information for the provider

Compliance actions


Assessment or medical treatment for persons detainedunder the Mental Health Act 1983


Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

We found that Kent and Medway NHS and Social CarePartnership Trust did not always have up to date careplans for patients that reflected their needs. Patientswho had behaved aggressively, or who had beenrestrained, had not always had their care plans updatedto describe how to prevent, manage and de-escalatepotential future incidents.

This was in breach of regulation 9(1)(a)(b)(i)(ii)(iii) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2010, which corresponds to regulation9(1)(3)(a)(b)(c) of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014.



Regulation 11 HSCA (RA) Regulations 2014 Need forconsent

We found that Kent and Medway NHS and Social CarePartnership Trust did not always consistently implementthe Mental Health Act in accordance with the Code ofPractice. This included on Amberwood ward (in Dartford)and Emerald Ward (in Gillingham) where patients hadnot been informed of their rights, informal patients hadbeen told they would not be allowed to leave,medication had been administered without the properconsent, and there was poor documentation of thetreatment plan when a patient had a second opinionfrom a second opinion appointed doctor (SOAD).

This was in breach of regulation 18 of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2010, which corresponds to regulation 11(4) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014.



Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

Regulation

Regulation


Compliance actions


We found that Kent and Medway NHS and Social CarePartnership Trust did not always have psychiatricintensive care unit (PICU) beds available, which led todelays in finding a suitable bed for unwell patients.

This was in breach of regulation 9(1)(b)(i)(ii)(iii) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2010, which corresponds to regulation9(1)(a)(b) of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014.



Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

We found that Kent and Medway NHS and Social CarePartnership Trust had monitoring processes that did notalways identify gaps and problems in their services. Thisincluded gaps in updating risk assessments and careplans, out of date and missing resuscitation equipment,problems with medication storage and recording whichincluded in relation to consent to treatment and theMental Health Act, and identifying the reasonsbehind physical restraint including prone restraint onsome incident forms.

This was in breach of regulation 10(1)(a)(b) of the Healthand Social Care Act 2008 (Regulated Activities)Regulations 2010, which corresponds to regulation17(1)(2)(a)(b)(c) of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014.

Regulation


Compliance actions


Action we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.


Enforcement actions


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