Archived: Fulwood House

The findings of this inspection do not impact on the ratings from the last inspection, undertaken in November 2014.

At this inspection we found the following areas of good practice:

• The trust had a clear vision and values, supported by a set of strategic aims and there was a clear governance structure and arrangements.
• Surplus funds were used to improve quality and safety for patients.
• The board assurance framework had 14 identified risks, which had clear links to the trust’s strategic objectives, none of these risks, was rated as high.
• Following a review undertaken by the Good Governance Institute, a change in executive roles is to take place to ensure a balance between roles and capacity to deliver each portfolio.
• There was service user involvement in service design, planning and evaluation.
• The chief executive and chief nurse spent time each month in a clinical area and staff told us they valued this.
• The chief nurse and the medical director were trained as coaches and were providing training and individual coaching to staff in the organisation.
• Learning from incidents and complaints was visible at all levels of the organisation.
• The trust participated in external peer review and service accreditation.
• There was a commitment to engage with people who use the services of the trust in planning, implementing and evaluating services across the trust.

However:

• The uptake of mandatory training was below the trust target of 80%.
• We found a number of policies that had not been reviewed on time.
• Redecoration and improvements were required to some areas in a unit for people with dementia. Improvements, which had been identified as being necessary to provide a more suitable environment for people with dementia, had not been completed.
• The trust had not implemented the 2015 MHA code of practice across all services of the trust.
• Compliance with mandatory Mental Health Act, Mental Capacity Act and Deprivation of liberty training was very low for all staff and was not monitored for effectiveness by senior management of the trust.