Surrey and Borders Partnership NHS Foundation Trust

We rated Surrey and Borders Partnership NHS Foundation Trust as requires improvement because:

• The board did not have a thorough oversight of incidents and complaints. Whilst the board discussed individual, high profile cases and received annual reports of incidents and complaints, there was no detailed regular report to the board which examined and analysed all incidents and complaints. This meant that board members were not aware of all trends or hot spots and could not adequately challenge each other on what needed to change or the lessons that should be learned from serious incidents and complaints
• The trust had weaknesses in their systems for reporting and learning from incidents. Some incidents logged by staff were not signed of by managers which resulted in a backlog. This means that the initial actions and learning from some incidents were not captured and documented.
• Medicines management practice was inconsistent across the trust. Issues included controlled drugs discrepancies on two wards and out of date drugs on three wards. Fridge temperatures were not recorded correctly at three sites.
• There was no consistent use of a recognised risk assessment tool or consistent recording of patient risk across all core services. In the community child and adolescent mental health service and the mental health crisis and place of safety teams there were poor risk assessments.