The Aspen Centre is a purpose-built unit providing specialist treatment for people aged 16 and over who are living with a severe eating disorder. The unit has 16 inpatient beds (one of which is reserved for emergency admissions) with facilities for psychological therapies at the  Dover Street location. Inpatient treatment usually involves a programme of re-feeding or dietary stabilisation with group and individual therapy. Family work is also offered to some people. The outpatient service is offered Monday to Friday during office hours.

People received an effective service from all of the eating disorder teams to help them understand, as well as manage, their illness to stay healthy. People had personalised programmes of care when they were admitted as an inpatient, and they could choose to have their family work with them to help reach their therapeutic goals.

Staff across the service demonstrated a good understanding of safeguarding issues and there were many examples of good identification of and response to concerns. We found that this was not always recorded clearly in files. A better system was needed to ensure risk assessments were always used, concerns were highlighted and shared across the team, and that someone had responsibility for overseeing practice and outcomes around safeguarding.

All of the specialist eating disorder services we visited provided caring support to service users. People told us that they felt that staff were supportive while recognising that the treatment regime may at times needed to be strict. We found that care plans could be improved by being more personalised, and more consideration given to activities for people on the inpatient unit in addition to the therapy programme.

There was a lack of clarity in the staff guidance and training on use of passive restraint and promoting people’s privacy and dignity when restraint was being used.

Family therapy was not routinely considered for family members although this is recommended in national guidelines. It was not always clear that people, particularly those aged under 18 years old, had given informed consent to treatment.

People with eating disorders got a good, responsive service and benefited from the link between the inpatient and outpatient service at the Aspen Centre. People’s needs were well monitored and followed up, helping ensure that the service could identify and respond to their changing needs quickly. There was a good range of therapeutic support for people and staff ensured people were offered help to meet their emotional and psychological needs even when they were extremely unwell.

The service was well-resourced and staff felt valued and supported with good access to supervision and training, although there was no single overall manager for the Aspen Centre. This hampered the coordination of the service; for example there was no clear lead who could lead improvements across the multi-disciplinary team in the areas for development we identified. Arrangements for quality assurance and monitoring of practice also needed to be strengthened.

We rated Aspen Centre as requires improvement because:

• The governance structure for the service was unclear to staff. Some told us they did not know who led their service beyond ward manager or consultant level and felt the trust lacked of ownership of the service. They did not know to whom they should go to get things agreed. Local managers did not have the authority to effectively deal with issues such as a lack of action over consecutive fire safety audits dating back over nine years. The service had not included relevant risk areas on the risk register. Staff had ongoing issues with the e-rostering system, which the trust had failed to deal with. The trust had not engaged with staff to reduce the negative impact resulting from rumours that the unit was about to be relocated.
• The trust had continued to redeploy nursing staff into the service who had no specialist eating disorder experience. All but two

  one of the experienced nurses had left the service, one of whom was on maternity leave. The service continued to rely upon bank and agency nurses to fill a large number of shifts. Patients and staff reported that new and temporary staff were unfamiliar with the nuanced behaviours associated with complex eating disorders, how to identify them and how to maintain the boundaries that helped to make patients feel safe. This was also reflected in feedback the service had gathered from patients. One patient told us this meant some patients knew “what they could get away with” in terms of the behaviours they could adopt, which only the experienced staff were skilled to interpret. The risk associated with a lack of skilled and experienced staff was not on the risk register. Staff morale amongst the nursing team was mixed.

• The trust had not put in place a timely induction programme to provide new nursing team staff with the necessary support, training and professional development to undertake their duties. The wider multidisciplinary team had developed and presented a bespoke training package for new staff, but some of the nursing team could have been working on the unit for up to six months by the time the training sessions were held. Only one healthcare assistant and two nurses had attended each of the most recent learning sessions and one of those nurses had not yet started working at the service. There was only one nurse within the service who was sufficiently trained to deliver nasogastric feeding. This was not on the risk register.
• The service was slow to respond to maintenance problems and patient requests. Patients consistently reported the same problems with maintenance, sometimes waiting more than eight months for issues to be resolved. This disheartened patients, who felt they were not listened to, and created unnecessary work for staff as they continually chased the requests they had logged.
• The service routinely sought patient feedback but did not act to analyse and resolve issues in a timely manner. There were consistent themes throughout the 2017 patient feedback surveys, which included staffing pressures, staff knowledge and understanding of eating disorders.

However:

• Patients were involved and engaged with the overall treatment programme. They were involved in developing and updating their treatment plans and were encouraged to attend the weekly multidisciplinary ward meeting. Patients could invite family members to review meetings.
• Aspen Centre was a comfortable and suitable facility for patients. There was a secure garden and door entry system to prevent unwanted visitors to the ward. Staff undertook risk assessments for each patient. The trust provided training for staff in safeguarding children and adults and staff reported safeguarding concerns to the local authority. Aspen Centre had a good track record on safety. Staff knew how to report incidents, which managers investigated. The ward had safe systems to manage medication. There was an ongoing recruitment programme to fill vacancies.
• Staff supported patients to address their physical healthcare needs as well as their mental health needs. The different professionals worked well together to assess and plan for the needs of their patients. Staff used specialist tools to assess the severity of patients’ eating disorders and treatment plans focused on recovery, stabilisation and rehabilitation. There were different treatment programmes to suit individual patient needs. To aid their recovery, patients had access to specialist therapies such as family therapy, psychosocial, psycho-education, relaxation, coping skills and body awareness. Each treatment programme included individualised therapeutic goal setting. Patients had access to social activities, including arts and crafts sessions, flower arranging, knitting, crocheting and board games.

• Staff demonstrated their responsibilities under the Mental Capacity Act 2005 and the Mental Health Act 1983. There were improvements in the number of staff who had attended Mental Health Act training. Staff completed and stored Mental Health Act paperwork effectively. The trust had recently carried out an audit relating to Mental Health Act paperwork and had made recommendations to local managers. Staff routinely carried out mental capacity assessments with patients.
• Managers knew how to deal with performance management issues and staff received regular supervision and annual appraisals. Managers carried out regular audits of patient records, infection prevention and control, mattress safety and medication management. We found improvements in the way patient records were ordered and they were easier for staff to navigate as a result.
• There was only one formal complaint about the service but a number of compliments.
• The service was committed to becoming accredited with the Royal College of Psychiatrists’ Quality Network for Eating Disorders. Staff had completed a self-assessment of their service and the nurse leaders were scheduled to attend a national peer review event.