Dorset Healthcare University NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We reviewed the shared direction and culture, capable, compassionate and inclusive leaders, freedom to speak up, governance, management and sustainability, and partnerships and community quality statements for the well-led key question.

Despite improvements, we found there was not sufficient oversight in the current systems of governance in both St Brelades and Herm wards to ensure staff members were working safely. We found a breach of the legal regulation in relation to governance.

However, staff members were doing their best to mitigate risk and the new interim manager in St Brelades Ward, who became the Service Lead for Older Persons Organic and Functional Older Persons Mental Health Inpatient Services and Herm Ward was putting in place safer systems of care and treatment for patients in both wards.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

In St Brelades and Herm wards, staff members were moving towards a shared direction and culture but this was not yet fully embedded.

Staff members, spoken to at our focus groups and on site, said that the culture on St Brelades Ward had improved significantly since the beginning of 2024 with improved, positive staff morale.

In Herm Ward, staff said the culture was improving but staff could do with more support. For example, by increased supervision both management and clinical. Staff said there was no time to complete training in working hours.

Managers had made changes to improve the culture on the wards. The trust identified in 2023 some staff bullying and a poor culture in the ward, where staff did not feel safe to raise concerns. As a result, an interim manager was put in place to address these concerns and both patient safety and the culture was improving.

The 2023 and 2024 improvement plan assurance report into Herm Ward and St Brelades Ward was overseen by the trust’s Quality Governance Group, along with senior leaders in the trust. This report identified actions to improve patient safety. These included changing the structure and consistency of multi-disciplinary team meetings, improving documentation of risks within patients’ wellbeing plans, providing additional staff development opportunities, especially for International Nurses, and improving the quality of physical health care on St Brelades Ward.

Both wards were signed up to NHS England’s Culture of Care programme. This was ongoing quality improvement programme that has begun for Dorset HealthCare in 2024 which looked at improving culture on inpatient mental health units.

These improvements ensured patients were receiving safer care and treatment. The work was ongoing and there were still improvements to be made at the time of inspection in relation to safe care and treatment and governance.

During the on-site inspection, ward managers and senior leaders were honest and open about the current challenges the service was facing in St Brelades and Herm wards. There was a strong, committed and capable leadership team led by the new interim manager. It was evident they had worked hard to make improvements; however, they recognised there was still work to do to drive improvement across the service.

Senior staff said there had been more focused oversight on St Brelades and Herms wards since our last inspection and felt that there was now managers in post who were listening and taking action to drive improvement. They felt the department was better supported.

Staff from the senior leadership team visited the wards regularly and overall staff felt supported.

Staff felt there was an improved culture of continuous learning and improvement.

In September 2024, the interim ward manager for St Brelades Ward became the Service Lead for Older Peoples Organic and Functional Mental Health Inpatient wards and was in the process of recruiting new ward managers. They demonstrated capable, consistent and compassionate management of the wards.

The matron worked flexibly to address identified significant shortfalls in staff knowledge and training. They reviewed and improved the current capability of the staff team and quickly addressed poor performance issues.

There were action plans and risk assessments for all wards including admission to wards. This was outlined in the guiding principles and trust-wide standards for admissions onto wards.

There was a succession planning document to support the trust leadership group with guidance on planning and career development.

The executives were engaged and knowledgeable about the issues in both St Brelades Ward and Herm Ward. Senior leaders acknowledged the improvements were a work in progress.

Leaders had implemented plans, to include the introduction of an expansion to Herm Ward for 2026 to ensure all patients had single rooms.

Staff felt they would be listened to and action would be taken to address their concerns. Staff on St Brelades were happy and confident with raising concerns and speaking up. They would raise any concerns they had about patient care and treatment.

They felt the new manager had introduced a more open culture that respected people and staff.

Staff said they would communicate on behalf of patients who are unable to and always have their best interests at heart.

There were sufficient processes in place to ensure staff could access and utilise the freedom to speak up pathways. Staff we spoke to knew who the freedom to speak up leads were and knew how to contact them and told us they would feel confident to contact them should the need to.

Staff felt that working conditions on the wards had improved since new management were in place. This included greater team working, staff job satisfaction and more substantive staff in post.

The regular workforce felt listened to and included.

We saw evidence of equality monitoring in staff records and culturally appropriate care being delivered.

Staff members in the focus groups said the after-action reviews following the choking incidents in February 2024 had influenced learning. The ward manager had started to make a difference on St Brelades Ward and had improved patient care. Staff recognised this was an ongoing piece of work.

At the time of our inspection, there was not always sufficient oversight in the current governance systems in both St Brelades and Herm wards to ensure staff members were working safely.

There were issues about the administration of medicines to patients and senior staff oversight. Information about risk was not always easily accessible to staff on Herm Ward as it was recorded in many places and also inconsistent. There were policies about the use of shared rooms, but apart from the initial risk assessment there was little evidence of patient consent. Staff did not record they had assessed the capacity of patients to consent to share rooms. There was covert use of camera in room designated for patients at risk of falls, however, there was no signage on the entrance to the room to warn others entering the room of the covert camera in place. There was no record that the use of a camera was subject to a best interest meeting.

However, the trust had produced an action to improve governance systems, and introduced a new manager to St Brelade ward to implement improvements which we saw evidence of during our inspection.

Governance meetings with senior staff were introduced where improvements to improve safety and quality of care were identified and ensured oversight and and action was taken to address the concerns in a timely way. This included staffing, training and implementation of speech and language assessments. The governance groups, senior leadership team and the managers identified any action needed and assigned them to a member of staff to complete.

The manager of St Brelades Ward told us there had been a decrease in complaints. They had also improved how they recorded all complaints and acted on these. Before the improvements staff were only recording serious complaints.

Relatives were positive about the wards working in partnership with them about the care and treatment of patients.

Staff members in the focus group spoke positively about working closely with carers, other teams within the trust like safeguarding teams and the local authority. They felt they had good working relationships with the rest of the multidisciplinary team.

We did not receive any feedback from partners , however, we saw evidence of members of the multidisciplinary team working well together. For example, tissue viability nurses and speech and language therapists.

In St Brelade and Herm wards staff worked closely with other teams, such as the infection control teams and equality and diversity teams. The senior leadership team monitored the action plan for improvement to ensure service development.

Staff worked well together, treated each other with respect and looked to learn and drive improvement as a result of any incident that occurred.

Managers in all wards told us they had good relationships with commissioners and were able to make recommendations about people’ future care.

Staff welcomed the new implementation of improvement but recognised it was not yet fully in place or embedded. For example, managers had identified that the service required additional specialist speech and language staff, and they were in the process of recruiting to this post.

In both St Brelades and Herm wards, staff had started completing training scenarios, including managing a choking patient, deteriorating patients and national early warning score (NEWS) scores. They had changed staff practices at mealtimes, with a trained nurse overseeing patients eating food safely.

Staff now all completed after action reviews which further influenced learning.

Improvements were evident across all wards including reducing patient capacity on St Brelades ward, which has helped staff adapt, attend training and support patients and each other. The Executive team now reviewed all admissions and change in patient flow with robust plans to not just accept everybody.

Staff reported increased learning and sharing of information following previous incidents. Staff said they gained knowledge from attending simulation scenario training. Staff felt their training needs were being addressed.

There were improvements but there remained shortfalls in its implementation around recoding of information about patients to ensure their safety and medicines management. The oversight was in the process of being developed but had not yet fully ensured safe staff consistent working practises. Further work was required to continue to drive improvement.

St Brelades Ward had started to implement and embed learning and improvements following the death of patient in February 2024. For example, there were urgent internal patient safety alerts issued to other services with regards to do not attempt cardio-pulmonary resuscitation (DNACPR) status and choking episodes.

There were new procedures around mealtimes in St Brelades Ward. For example, all meals were serviced from the kitchen and all patients needs were identified on a white board in the kitchen.

Staff were in the process of completing the additional training. This included resuscitation training, choking and dysphagia training including swallow plans across both wards.

In order to improve patient safety St Brelades Ward was closed to admissions February 2024 to September 2024. The reduced bed base was assessed regularly at the senior leadership oversight meetings.