County Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 3 quality statement from this key question. We have combined the scores for this area with scores based on the rating from the last inspection, which was Inadequate in 2022. Our rating for this key question is now good. We found staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. Staff carried out regular risk assessments, and training around mental health, consent and the deprivation of liberty safeguards were all up to date.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us that staff had assessed their needs including communication needs when they were admitted. Patients had their care and treatment needs, and their wellbeing and communication needs assessed on admission and reviewed regularly by appropriately trained staff. Patients and their carers were able to contribute to the information that was documented in their assessment and care plan and were involved in decisions about their care. Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual needs.

Staff assessed patients care needs using a care needs and risk assessment document for every patient admitted. This was reviewed regularly and when changes occurred. Risk assessments routinely included Mental health Act (MCA) assessments for patients who potentially lacked capacity. Staff routinely assessed patients care needs and conducted risk assessments for a range of physical, medical, social and communication needs. The care needs assessment document included a section to assess whether a patient lacked capacity to make decisions for themselves for a temporary or longer term period. This triggered staff to conduct a formal mental health (MHA) act assessment to check whether a patient had capacity to make decisions about their care. Leaders and staff told us that making risk assessments and conducting MCA assessments had become an integral part of the care they provided and they carried these out routinely and confidently. For patients who were admitted with a mental health issue, assessments and MCA assessments were conducted jointly with the mental health liaison team. Leaders and managers conducted audits on patient records to check that risk assessments and MCA assessments were being conducted routinely and effectively.

The trust had effective systems to identify people with mental health needs or lacked capacity. The trust had effective systems to identify people with previously undiagnosed conditions. When patients detained under the Mental Health Act (1983) were admitted to the acute medical unit as an inpatient, the discharge facilitator reviewed any accompanying paperwork detailing the detention. The discharge facilitator requested any missing paperwork or reviews to ensure patients were not being illegally detained for example if a detention period was due to expire. Staff could access patients' full medical notes if they needed to review past health information, including mental health related contact with the NHS. Staff protected the rights of patients subject to the Mental Health Act and followed the Code of Practice. The hospital completed several audits in relation to mental health across the trust. These included auditing the responsiveness of mental health services, auditing the Mental Health Act policy, auditing the mental health assessment tool in ED, auditing the Mental Health Act, auditing the deprivation of Liberty safeguards and auditing therapeutic observations. Staff had access to information about gaining consent for patients with mental health conditions or symptoms. The trust policy entitled ‘Consent to Treatment (incorporating Mental Capacity Act)’ provided guidance to staff about working with patients with mental health diagnoses who were or were not detained under the Mental Health Act. The policy also provided guidance for working with patients who were self-harming or who had suicidal ideation or behavior.

Staff met people’s nutrition and hydration needs. Staff protected the rights of patient’s subject to the Mental Health Act and followed the Code of Practice.

Patients we spoke with told us that all the staff appeared to work well together to help them, including doctors, nurses and physiotherapists. We were unable to speak with any patients who had been seen by the mental health liaison team during this inspection. Patients told us that staff, teams and services worked well together. They gave examples of physiotherapists working with nurses to help with mobilisation, and of doctors and nurses working together to provide explanation and care.

Staff told us that staff, teams and services worked well together. In particular, staff and leaders praised the mental health liaison team who had significantly improved their support offering by increasing the hours they were available for help and support. All staff we spoke with told us they worked well together and supported other teams when required. For example; where a team needed to provide extra monitoring for some patients. They also worked well and had a good relationship with the multi-disciplinary teams and were especially grateful to the mental health liaison team who had significantly improved their support offering by increasing the hours they were available for help and support. Staff said this had made a positive impact on patient care whereby patients received support from the mental health liaison team within 4 hours of admission and staff could get advice from them when needed. Staff also told us that the increase in support from the mental health liaison team enabled staff to manage their work more effectively, as well as providing safer care for patients.

We observed ward staff working effectively with other health professions including doctors, physiotherapists and radiographers. We saw in patients records that health professionals from the multi-disciplinary team contributed to the records and that staff took their comments into consideration when planning further care for patients. This included mental health clinicians from the local mental health trust when caring for patients being treated on the medical wards who were also under the care of a mental health clinician.

The trust’s intranet contained a comprehensive range of up-to-date policies and standard operating procedures which reflected current practice. It had guidance for staff around collaboration with multi-agency teams and for delegation of clinical tasks to ensure the right people delivered evidence-based care and treatment.

People told us that they felt supported and information around support and well being was available and easily accessible.

People we spoke with told us they were seen by the mental health teams promptly. Staff often asked questions around their well being and felt they could ask questions around their care.

There were regular and effective meetings led by a consultant and nurse who were leads for safety, audit, quality and governance. These discussed and addressed key areas of performance, risk, audit, culture and workforce. Minutes showed areas of concern were identified and actions were taken to learn and improve. Significant positive changes had been made since section 29a warning notice, mental health provision and service provided had improved and staff were extremely proud of the positive changes. We reviewed many audits with positive outcomes. Good practice was recognised and celebrated.

Patients told us they were asked for their consent before any staff carried out any care or intervention.

Staff encouraged people to make their own decisions about how their care and support was provided. Staff understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act (MCA) and had received training. Staff used supportive practice to avoid the need for physical restraint and had received training in ‘clinical holding’ in case this was needed to keep patients and staff safe. There was a sedation policy in place for situations where this might be required for patients who needed additional support to keep them safe. Staff knew how to apply for a Deprivation of Liberty Safeguard (DoLS) for patients who lacked capacity and required this additional support to keep them safe. They told us they were fully confident in making DoLS applications and did this routinely when required. Managers regularly audited DoLS applications to check for completeness and appropriateness of applications and whether these were reviewed when required.

Staff supported patients to make informed decisions about their care and treatment. They know how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Staff assessed capacity to consent or deprive patients of their liberty within legal frameworks or the trust policy. When patients were assessed as having a lack of capacity to consent to care or treatment, if the patient had no family, friends or carers to support them in decision-making, Independent Mental Capacity Advocates (IMCAs) should be instructed to represent and support people to make a best interest decision. The trust had access to system based IMCAs; staff had access to information on the trust intranet which told them how to request this service. Staff had access to information about gaining consent for patients with mental health conditions or symptoms. The trust policy entitled ‘Consent to Treatment (incorporating Mental Capacity Act)’ provided guidance to staff about working with patients with mental health diagnoses who were or were not detained under the Mental Health Act. The policy also provided guidance for working with patients who were self-harming or who had suicidal ideation or behaviour.