This review has been carried out in response to a formal request made on 10 January 2012 from the office of Mr Tom Osborne, HM Assistant Deputy Coroner for Gloucestershire. Mr Osborne, in his summary of an inquest held in November 2011, into the death of a patient in the community, said he had concerns that the trust was a “fragmented” service and “not patient centred”. We carried out this review to look at these concerns with the trust. A copy of this report has been sent to Mr Osborne within the required deadline.

To complete this review we spent time with members of the board of directors and the executive team at headquarters on 31 January and 1 February 2012. On 1 February 2012 we also visited a clinic in one of the local services and talked with three patients about their experiences. On 2 and 3 February 2012 we talked with five other patients at some length by telephone, and a carer who was also involved with the trust service experience committee. We talked with three local GPs who refer people to the trust, and/or were involved in the commissioning of care in the county. We also talked with a member of the Gloucestershire Local Involvement Network (LINk).

The staff we met and talked with included the chief executive, the medical director, the director of quality and performance, the head of quality development and assurance, and the assistant director of governance and compliance. We also met and talked with the community services manager for entry level services, the systems manager for the Improving Access to Psychological Services (IAPT) team, and the acute psychiatric services matron manager. The acute psychiatric services matron manager was responsible for all inpatient locations, the substance misuse service, the three locality crisis teams, and the learning disability services. At the clinic we visited, we met the team manager for the recovery team in Gloucester.

We looked at patient records in the IAPT service and for people accessing other services, including primary and secondary mental health services. We followed the care records for one person who had accessed services since 2009 and had a number of episodes of care. We reviewed with the executive team the report into the death of a community patient that was the basis for the Coroner to request this review. Where we had areas of concern over parts of the report around the care pathway, we asked the trust to tell us how they had taken action to address these areas.

Patients and their carers told us about their experiences or the experiences of people they spoke for. We were told that care was “absolutely amazing” and “I would not be here today without the staff”. People told us that the care provided had “significantly improved”. We heard that people had received what they saw as “poor” care in the past, but that they felt that staff were now “very caring”, “wanting me to get better”, and “staff have helped me feel no longer like a victim and that I can move on with my life”. A person who was an inpatient told us that staff were “good and kind” and “want me to make my own choices”. We were told that staff “don’t try to manipulate me by taking away my leave”. The patient said “I am treated respectfully. This is the best care I have ever had in the system and I feel very positive about the future”.

We looked at information provided by the trust. This included clinical and practice audits, minutes of governance meetings, service user experience reports, reports to the board and the governance committee, information given to patients, and electronic information and systems for patients developed by the trust.

The trust had responded to concerns about access to services and to people feeling, as people told us, uncertain of how the trust “fitted together” and “who did what”. As a response, the trust will be reorganised and a new initiative ‘Fair Horizons’ will be rolled out for Gloucestershire in April 2012. This initiative is intended to provide people with a ‘one stop shop’ approach to care. The trust said that it will also remove “many of the barriers associated with the traditional approach to diagnosis and treatment” (Source: Statement on Quality from the Chief Executive, 2gether NHS Foundation Trust Quality Report 2010/11 & Quality Account 2011/12, p3).

Staff at the trust that we met were open, honest and approachable. The trust was focussed upon quality and safety through governance and audit. We found it willing to address any shortcomings and ambitious to use and bring to patients the best practices in psychiatric care. We found the trust compliant with outcome 4: care and welfare of people who use services.

The trust had a coherent system of executive oversight and governance and demonstrated that it made improvements to its services from evaluating outcomes for patients. We found the trust compliant with outcome 16: assessing and monitoring the quality of service provision.

Please see the full report for our review in more detail.