All inspections: Leeds and York Partnership NHS Foundation Trust

Our rating of this service stayed the same. We rated it as good because:

The service provided safe care. The ward environments were safe and clean. Staff knew how to report incidents, safeguarding concerns and handle complaints and used lessons learned from investigating them to improve the service.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
Staff engaged in clinical audit to evaluate the quality of care they provided and make improvements when necessary.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They involved patients and families and carers in care decisions.
Staff provided patients with good access to the community such as support to attend group walks, local services and family celebration events.
Staff had not placed patients in seclusion or long-term segregation within the last 12 months.
The provider promoted equality and diversity into its day to day work. The provider had a black and minority ethnic worker and staff shift patterns could be adapted to allow staff of the Muslim faith to participate in Ramadan. Staff within the service showed their support for the lesbian, gay, bisexual and transgender community by attending pride and Rainbow Alliance events.
The service was well led, and the governance processes ensured that ward procedures ran smoothly.
The wards were on track to meet their key performance indicators with compliance figures ranging between 89 and 97%.
Innovative practices were taking place within the service. They included the use of psychological formulation based on the Newcastle model, dementia care mapping, drop in sessions to provide advice and guidance around physical health and behaviours that challenge and training workshops for staff in relation to palliative care.

However, we found the following issues that the service needed to improve:

Staff did not follow national guidance on the use of restrictive interventions including rapid tranquilisation. Physical observations were either not carried out at all or not within the required frequency, paperwork was not fully completed, body maps were not always undertaken, and staff were unaware that olanzapine was a rapid tranquilisation medicine. Staff did not update risk assessments and risk management plans following the administration of rapid tranquilisation medicine.
The service’s use of bank and agency staff was high. Within the 12 months prior to our inspection, 1458 shifts had been covered by bank and agency staff. There were also three out of area placements and 92 delayed discharges within the service. However, we saw evidence that the service was actively taking steps to address these issues.
Staff were not up to date with all modules of their mandatory training. Only 66% of staff had completed their safeguarding children level 3 training.
The process for enabling agency staff to have access to the provider’s electronic records system was lengthy and complicated as they needed to be trained in its use and then be set up on the system.
On two occasions, weekly controlled drugs audits had not been completed on ward 1. However, we found the stocks of controlled drugs were correct at the time of our inspection.
One patient and two carers who spoke with us said that they or their loved ones possessions had been stolen from their bedrooms or that the safe in their bedroom had been broken into. These incidences related to wards 1 and 2. However, staff reported any missing or stolen items as incidents and routinely advised patients and carers how to safely store items

Our rating of this service went down. We rated it as requires improvement because:

Clinical premises where patients were seen were not always safe and clean. Fire and environmental risk assessments were incomplete or out of date for a number of buildings.
Staff did not complete and regularly review risk assessments for all patients. Risk management plans and crisis plans had not been completed or considered for all patients.
Staff did not complete care plans for all patients. Care plans that were created are varied in terms of quality, they were not always holistic or recovery-oriented and did not consistently evidence involvement of patients or carers. Staff did not consistently use recognised rating scales to assess and record severity and outcomes for patients.
Staff mandatory training compliance was low in a number of courses and there was no clear plan to drive improvement. Not all staff working with patients with dementia had received specific training in dementia. Staff at team level did not engage in clinical audit in order to evaluate the quality of care they provided.
Methods of gaining feedback from patients and their families and carers varied between teams and some patients and carers we spoke with were unsure how they could give feedback.
Whilst leaders had good oversight and understanding of areas for development within the service it was not always clear how they planned to make improvements. Staff at a team level did not have access to the service’s risk register.

However:

Staff provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients, including both mental and physical health needs.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received regular supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
The service was easy to access. Staff assessed and treated patients who required urgent care promptly. The criteria for referral to the service did not exclude people who would have benefitted from care.
The service was well led and staff felt respected, supported and valued.

Our rating of this service improved. We rated it as good because:

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

On one ward the junior doctor had not completed the annual physical health checks, however weekly physical checks using the Modified Early Warning Score tool had been completed, by the staff. The reason for this was the appointment of the current junior doctor had been after the due date for the annual checks.
One patient had been identified as part of the admission process as needing a specialist bed and this had not been provided in a timely manner.
A detained patient was refusing treatment in the form of an injection, while there were notes from the medical team about the injection being necessary to aid their recovery, and the staff were acting legally there was not an individual care plan or advanced decision on how to administer the injection with the use of restraint recording the patient’s wishes.

Our rating of this service improved. We rated it as good because:

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and patients had access to doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and protected patients from abuse.
Staff ensured patients had a comprehensive assessment of their mental and physical health needs. They provided a range of treatments suitable to the needs of the patients and in line with national guidance. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

Not all staff had easy access to electronic patient record and not all paper records had a consistent structure across the service.
Not all patient safeguarding concerns were reported to the trust’s safeguarding team and not all patient medications were stored in line with trust policy.
Staff did not use recognised rating scales to assess and record severity of outcomes and they did not always inform and involve families and carers appropriately.
Not all patient care plans reflected the needs identified in the assessment and some were not up-to-date.
The trust did not adhere to best practice in implementing a smoke free environment

Our rating of this service stayed the same. We rated it as requires improvement because:

The service did not always provide safe care. Staff and managers had not ensured that regular fire evacuation drills took place and that fire risk assessments were reviewed for all wards. The seclusion room at Parkside Lodge was not compliant with requirements because it did not have a two-way intercom.
Staff at 2 and 3 Woodland Square had not ensured patient risk assessments were reviewed and updated on patients’ admission. They did not ensure that risks to patients’ physical health and well-being were assessed, managed and mitigated sufficiently. This included pressure care, bowel care and epilepsy care. Care plans did not contain all the information needed to ensure staff met patients’ needs to keep them safe and well.
Patients’ care and treatment records did not contain all the information needed. Three patients had bed rail assessments that provided no information why a bed rail was required to keep patients’ safe. Two patient records did not contain mental capacity assessments and/or a record of a best interest meeting in relation to resuscitation and physical health.
The service had not improved access to therapeutic activities or psychological therapies.
2 and 3 Woodland Square did not have adequate cooling systems in the clinic room to maintain a consistent recommended temperature range. Staff did not follow the trust’s policy on storage of medicines.
The trust did not provide staff with training on learning disabilities or autism. There was no assurance they had the right skills or knowledge to meet patients’ needs effectively.
Only 52% of eligible staff had received training in safeguarding children level three.

However:

Staff at 2 and 3 Woodland Square undertook comprehensive medicines reconciliation processes prior to and on patients’ admission.
Parkside Lodge had employed a speech and language therapist and they had completed communication assessments of all patients.
Staff planned and managed discharge well. They worked with other services who provided aftercare.
The service received 34 compliments in 12 months and carers provided positive feedback about how staff involved them in patients’ care and treatment.
Staff felt respected, support and valued.

Our rating of this service went down. We rated it as requires improvement because:

The service did not always provide safe care. There were some ligature risks on Ward 5 that had not been identified. Patients did not all have a crisis contingency plan in place.
There were gaps in the mandatory training that staff received. The monitoring of high dose antipsychotic medication was unclear and inconsistently recorded.
There were some blanket restrictions in place at Asket Croft and on Ward 5. These had not been ‘entered onto the risk register ‘as their policy stated that they should and also did not have ‘a demonstratable action plan in order to resolve the issue’.
The service did not work to a recognised model of mental health rehabilitation on Ward 5 Some patients had excessive lengths of stay on Ward 5 and there were delayed discharges on all of the wards. The trust had oversight of this and these patients were being monitored by the trust at team meetings, monthly discharge meetings and monthly delayed transfer of care meetings.
Governance processes did not operate effectively at ward level and performance and risk were not always managed well.

However:

The wards were clean and there were enough nursing and medical staff in place and staff managed risks to patients and themselves. Staff followed good practice with respect to safeguarding. They minimised the use of restrictive practices.
Managers ensured that staff received supervision and appraisals.
The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Staff at Asket Croft and Asket House, planned and managed discharges well and liaised well with services that would provide aftercare.
The rehabilitation and recovery team on site at the Asket Place provided all patients with intensive support and rehabilitation and were integral in providing a successful rehabilitation pathway for the patients. They provided care coordination during their stay and after discharge to ensure they had the right support when transitioning back into the community.

Our rating of this service stayed the same. We rated it as good because:

They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude patients who would have benefitted from care.

However

Clinical premises where patients received care were not always safe or clean. Staff could not be assured by accuracy of the equipment as they had not always been calibrated.
Fire and environmental risk assessments were not all up to date and were scheduled to be completed.

We rated three of the 11 core services as requires improvement overall. Our ratings took into account the previous ratings of services not inspected this time. Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.
The rating for the acute mental health wards for adults of working age and psychiatric intensive care unit had gone down, and the rating had gone down in one additional key question in the wards for people with a learning disability or autism. This suggested that these services had got worse since the last inspection. The requires improvement rating remained the same for the forensic and low secure services overall, and in the same key questions.
Issues that contributed to the breach of regulation at the last inspection in July 2016 had not been fully resolved at this inspection; in some services clinical supervision rates remained low and patient records were not always maintained in a consistent manner. Training compliance remained an area of concern in the forensic and low secure services.
The wards for people with a learning disability or autism was rated as requires improvement for caring as patients’ communication needs were not always assessed, nor were adaptive communication strategies used to enable patients to participate fully in their treatment and care. Also on these wards, blanket restrictions were in place, patients had limited access to psychological therapies and therapeutic activities, and there was an inconsistent approach to assessing risk and care planning for patients with epilepsy.
The National Inpatient Centre for Psychological Medicine was rated as requires improvement for responsive at this inspection because the premises were not suitable for the purpose they were being used. The trust still had no timescale or confirmed plans for the proposed new location for the service..
We had concerns relating to staff monitoring patients’ physical health following rapid tranquilisation in accordance with national guidance, best practice, trust policy and medicine administration on the acute wards for adults of working age with a mental health problem and the psychiatric intensive care unit.

However:

We rated the trust as ‘good’ in caring, responsive and well-led. Our rating for the trust took into account the previous ratings of services not inspected this time.
The trust rating in the well led key question at the trust level improved since the last inspection in July 2016.
The crisis and the health based place of safety core service had improved from requires improvement to good overall, and good in all five key questions at this inspection.
The supported living service had improved from requires improvement to good overall; outstanding in caring and good in safe, effective, responsive and well led.
The National Inpatient Centre for Psychological Medicine was rated as outstanding in effective and caring at this inspection.
All services now complied with the eliminating mixed sex guidance.
Mandatory training compliance across all the services had improved since the last inspection and remained on an upward trajectory. As at 30 September 2017, the overall training compliance for trust wide services was 90% against the trust target of 85%.
Non-medical staff appraisal rates had increased since the last inspection to 80% though they remained below the trust compliance rate. Appraisal rates were on an upward trajectory from September 2017 to January 2018.
Systems were effective to ensure that documentation was in place and readily available demonstrating that directors met the fit and proper person requirement, regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
There was good practice in relation to the application of the Mental Health Act and the Mental Capacity Act. Audits were completed to monitor the compliance with these Acts.
Governance systems were established to assess, monitor, and improve the quality and safety of the service, and manage risk, and operated effectively across the trust and were embedded in locally in most services.
The trust responded to requests for information from the Care Quality Commission and reported all incidents to the national reporting and monitoring systems, in a timely way.
Medication administration and storage, and physical health monitoring had improved.

The information needed to deliver patient care was not available to all relevant staff.
Staff did not maintain appropriate records of patients’ care and treatment.
There was limited evidence of patient involvement in decisions about the care and treatment provided by the service. There was limited evidence of that staff on Parkside Lodge and 3 Woodlands Square assessed patients’ communication needs, or used adaptive communication strategies to enable patients to participate fully in their treatment and care. Care plans did not address patients’ specific communication needs.
There were blanket restrictions on each unit.
The trust did not ensure staff were suitably supervised and appraised to carry out their role effectively.
The trust did not provide care and treatment based on national guidance. Patients had limited access to psychological therapies and therapeutic activities.
There was an inconsistent approach to assessing risks related to patients with epilepsy.
Whilst staff were clear on the concept of whistleblowing and the trust process for raising concerns, not all staff felt that they would be able to raise concerns without fear of retribution.

However:

Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
The trust now complied with guidance from the Department of Health on eliminating mixed-sex accommodation in hospitals.
The trust provided mandatory training in key skills to all staff and made sure everyone completed it. The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.

Risks to patients were assessed and mitigated. Staffing levels were calculated using a recognised staffing tool. Staff knew about different types of abuse and were confident about reporting concerns. Male and female accommodation was separated with the use of locked doors.
People who were referred to the crisis assessment service had mental health assessments carried out. Physical health checks were offered to patients who were admitted to the crisis assessment unit. Staff had regular supervision and appraisals. Staff understood their roles and responsibilities in relation to the Mental Health Act and Mental Capacity Act. Audits were carried out to ensure section 136 documentation was completed correctly.
Patients and carers said staff were kind and approachable. Staff supported patients appropriately. Agency staff were not used in the core service allowing for consistency of care.
There was good evidence of detailed discharge planning taking place on the crisis assessment unit. The crisis assessment unit continued to have a positive impact on the length of stay and discharges on the acute wards, as well as a positive impact on readmissions to the trust within 28 days. Staff supported patients to access services which may benefit them. Complaints were logged and investigated. People who made a complaint were given feedback.
Staff who worked in the crisis assessment service said they felt supported by senior staff members. The staff were aware of the trust’s values. Audits were carried out throughout the service to ensure a good rating was maintained.

The trust had acted upon our feedback from our previous inspection and the service had made improvements in the safety of patient care.
Safety was a high priority for the service. Staff had measures in place to monitor the safety and quality of the service and took timely action when changes were needed. Staff regularly assessed and monitored risks to patients, and protected them from avoidable harm and abuse.
The service provided care, treatment and support that was based on the best available evidence and achieved good outcomes for patients. The outcomes exceeded the expectations of patients and made a real difference to the quality of their lives. Patients were fully involved in decisions about their care and treatment and all patients had clear discharge plans.
The service had a strong, visible person-centred culture. Staff respected their relationships with people who used the service and empowered patients to be partners in their care. Care plans were personalised and contained meaningful goals for individual patients. Feedback from people who used the service was consistently positive and we observed staff that were kind, caring, respectful, and compassionate.
The service had a clear pathway and model of care that provided flexibility for staff to plan and deliver care to meet the needs of individual patients. The service provided an integrated person-centred pathway of care, which provided continuity of care for people with severe and complex needs and people in vulnerable circumstances. Staff planned and managed admissions and discharges to the service so that patients had timely access to the service and were discharged successfully.
The service was well-led with a culture that promoted the delivery of high quality and person-centred care. There was high levels of staff satisfaction and motivation. Staff felt proud to work at a service where managers were visible and supported their learning and development needs. Senior staff were knowledgeable and understood the issues the service faced and continued to take action to address the challenges.

However:

Staff did not routinely complete care plans for all patients who were prescribed as required medication.
The premises were not suitable for the purpose they were being used; the ward did not have enough space and facilities to support occupational therapy, physiotherapy, and recreational activities. Staff and patients used communal areas and rooms for multiple purposes which impacted on places for visitors and quiet areas, and access to outside space. The kitchen area did not suit the needs of people who required lowered facilities. Patients’ bedrooms did not contain anywhere for patients to keep their belongings secure. Whilst the managers recognised the limitations of the environment and the difficulties to secure a long-term estates strategy remained on the trust risk register, the trust still had no timescale or confirmed plans for the proposed new location for the service.

Our overall rating of this service went down. We rated it as requires improvement because:

Staff did not do all that was reasonable practicable to mitigate risks to the health and safety of patients. Staff did not monitor patients’ physical health needs following use of rapid tranquilisation in accordance with national guidance and trust policy. Not all patients received a physical health check in a timely manner. Staff did not monitor patients’ physical health observations consistently.
Patients’ care needs were not individualised and care plans did not provide clear and current information to enable staff to deliver consistent, personalised support. There was a lack of information about what de-escalation techniques staff should use for patients in a crisis, and to try to avoid the need for restraint.
Patient information was stored in different formats, updates about care interventions were not always contemporaneous and did not always reflect the current care provisions the patient received.
Staff did not always follow good practice and policy for the storage and administration of medicines. There were areas of the ward environment in need of attention with regards to cleanliness and maintenance.

However:

Patients and carers gave predominantly positive feedback about the staff and the care they received. There were opportunities for patient and carers to give feedback about, and influence the service.
Staff felt supported in their roles and had regular supervisions, training, and opportunities for personal development. There was a multidisciplinary team in place at the service to provide support and treatment to patients.
The trust had identified where improvements were required within the service which supported our findings also. There was work underway or planned to use clinical audits to try to make improvements.

Our rating of this service stayed the same. We rated it as good because:
The service had made improvements since our last inspection. They were now clear about what constituted seclusion and seclusion paperwork was filled in correctly and reviews carried out on time.
There were adequate staffing levels to ensure patients were well looked after and got one to one time with staff.
The service provided a safe environment and risks were managed well. Patients told us they felt safe on the ward. All patients had an up to date risk assessments that was updated when risks changed.
There was effective multi-disciplinary team working evident on the ward.
Patients and their carers gave positive feedback about the ward and the service they received. Staff involved patients in decision about their care. They engaged with and supported families and carers where appropriate. Staff contacted them with updates on patient progress and invited them to ward rounds.
Staff told us that they felt supported by the ward manager and the senior leadership team were visible. Although there had previously been a high vacancy rate, these gaps were now filled and staff felt more positive because of this.
The ward had been inspected and was awaiting accreditation with the Quality Network for Inpatient child and adolescent mental health services.
The ward was involved in a research project to validate a recovery measure for use in tier four, child and adolescent mental health services.

However:

On the day of our visit the ward was very hot. Staff informed us that this was due to the fact that there were no controls for the heating; there was only the option to have it on or off with no temperature thermostat. Staff reported they had raised this as an issue before but nothing had been done about it.

Substantive staff frequently moved wards at short notice to fill shifts on Rose Ward, which required a full staffing complement due to the acuity of their patients. When this happened, there was a risk that the staff team on Rose Ward would not have the specialist skills necessary to care for patients with a personality disorder.
Compliance with mandatory training and supervision rates were a concern at our last inspection in July 2016. At this inspection, staff were still not fully compliant with all mandatory training in key skills. On four of the six wards we inspected staff compliance with clinical supervision was below 65%. Appraisal rates for two wards were also below 65%. This meant staff might not have the necessary skills or support to provide patients with safe and effective care and treatment.
Although the trust had systems and processes in place to assess, monitor and improve the quality of the service, they were not used to the full extent possible. Staff use of electronic systems for updating patients’ records was not always consistent with some information stored in different locations within the system. Rotas, low staffing levels and supervision records were not always adequately reported or updated.

However:

Each ward had a yearly environmental risk assessment. There were ligature risk management plans in place, which staff managed through observation to mitigate the risks. Patients we spoke with felt safe on the wards and felt staff provided appropriate levels of support.
Staff had training to recognise and report abuse. They understood how to protect patients from abuse and worked closely with the trust’s safeguarding team to ensure they referred concerns and alerts appropriately.
Staff carried out a comprehensive assessment to identify patients’ mental and physical health needs. Care plans clearly showed patients worked in partnership with staff in decisions about the care and treatment provision. Staff reviewed the plans regularly and involved other specialists when needed.
Activity co-ordinators and occupational therapy staff planned and organised a wide range of regular weekly activities. Patients were able to maintain links with the wider community and had access to educational, recreational and work opportunities.

We rated specialist community mental health services for children and young people as outstanding because:

Feedback from young people and carers who used the services and from those jointly working with the team was universally positive about the way the service responded to individuals.
Team members consistently tailored evidence based interventions to meet the specific communication needs of children, young people and their families.
The service delivered an extensive range of psychological interventions recommended by the National Institute for Health and Care Excellence to meet the needs of children and young people who used the service.
The strong research culture within the service further developed evidence based practice for deaf children, young people and their families.
Strong and respectful multidisciplinary working took place. Staff were passionate, enthusiastic and dedicated to working collaboratively.
There was a strong, visible, person centred culture of care and support that included access to advocacy for young people and their families.
Continuous professional development through training was embedded in the teams, this included sharing knowledge and positive practice across the service.
The senior management team offered clear leadership and the service committed to a shared vision.
Effective governance systems were in place to monitor appraisal, training, management and clinical supervision.

We rated the Yorkshire Centre for Psychological Medicine as good because:

Staff completed comprehensive patient risk assessments and risk management plans in a timely manner. They reviewed risk daily. This was essential as the ward had many ligature points and staff assured their patients were safe.
Patients were fully involved in their care plans, which were holistic, up to date and referenced best practice.
Staff tailored therapeutic interventions and the use of psychotherapy to meet patient’s individual needs, creating a bespoke package of care.

The ward achieved positive outcomes with the majority of patients reporting improvement in self-care and their ability to carry out their usual activities. This enhanced their quality of life. Carers confirmed that these improvements were sustained post discharge.
Carers and relatives felt involved in the patient’s care. Staff supported them, explained aspects of treatment and kept them up to date with the patient’s progress.

The service was patient led. All aspects of care and treatment took place at a pace comfortable for the patient.

Discharge plans clearly detailed the care and support the patient needed on their return to the community. Staff maintained good links with the community health teams supporting the patient on their discharge. Patients and carers knew they could ring the ward post discharge if they needed advice or had any concerns.
There was a programme of activities, groups, and exercises adapted to meet the needs of all patients. Some of the activities were innovative, for example the circus skills group, which addressed physical and mental health needs, and social interaction.

However:

The service did not comply with the Department of Health guidance on same sex guidance. Staff made patients aware of this before admission to the ward and endeavoured to protect privacy and dignity while on the ward.
Staff did not monitor the temperature in the clinic room where they stored medication. This meant they had no way of knowing if the temperature in the room ever exceeded 25 degrees Celsius. This was the maximum temperature recommended by the World Health Organisation for the storage of medicines.

Compliance with mandatory training was below 75% in several areas. This included essential life support, intermediate life support, moving and handling, and clinical infection control. Although the ward did not deal with acute admissions, the patients they did treat all had complex physical and mental health issues. Therefore, updates in this training were essential to ensure safe practice.
The ward compliance rate for supervision was 49%. This meant the staff were not receiving appropriate support to improve their skills and knowledge. The clinical operations manager had developed and implemented a robust action plan to improve staff compliance with this essential practice.

We rated community-based mental health services for older people good because :

The community based mental health services for older people were safe because teams had sufficient staff to protect patients from avoidable harm and abuse. Managers supported staff to be open and honest and carried out thorough investigations when something went wrong. Staff recognised and responded appropriately to identified risks to patient safety.

The community based mental health services for older people were effective because patients received care and treatment that met their needs. Staff were appropriately skilled, experienced and supported by managers to develop their practice. Staff used best practice guidelines to deliver effective care and treatment. Staff had regard for the Mental Capacity Act and ensured they protected the rights of patients detained under the Mental Health Act. Staff worked with a range of other teams and services to co-ordinate patients’ discharge and took patients’ needs into account.

The community based mental health services for older people were caring because patients and carers told us they felt supported by staff. Staff treated patients and carers with dignity and respect. Patients felt involved in their care and staff supported patients with kindness and compassion during their interactions.
The community based mental health services for older people were responsive because the service was reviewing the way it organised and delivered care. This focused on making improvements to meet the needs of older people in the local population. This was in response to recent feedback from people who used the services and analysis of the service following transformation to an ageless service four years ago. Patients had timely access to the service and the trust were meeting their targets to assess patients from referral.
The community based mental health services for older people were well led because staff were proud of the service they delivered to patients and their carers. The teams had a culture that focused on improvements to deliver high quality person-centred care. All teams were involved in individual projects and used a quality improvement methodology to share good practice across the localities.

However;

There were concerns that staff had high caseloads and this had an impact on staff morale. The service had caseloads outside of recommended guidance from the Department of Health 2002. The East, North East team could not always ensure their building was secure due to the length of time the electric door at the entrance remained open. The lone working procedures could not always ensure staff safety during community visits, which meant staff, could be left vulnerable.
Physical health monitoring and recording was inconsistent throughout the teams. Some teams were able to monitor bloods and electro-cardiograms more effectively than others were.
There were concerns that patients who were referred to the psychology service waited up to 20 weeks for psychological therapies. This meant that patients did not have timely access to specific treatments to meet their needs.
Staff were not up to date with their mandatory training and teams had not reached the trust target of 90% in areas such as Mental Health Act and Mental Capacity Act training. Appraisal rates had not met the trust targets and supervision rates varied across the teams.

We rated community mental health services for adults with learning disabilities or autism as good because:

Staff included patients and carers in their care and treatment. Patients and carers felt involved in their care. Leeds autism diagnostic service involved a patient in training videos which were used in staff training to show living with autism from an individual’s perspective.
Care and treatment was delivered in line with best practice evidence and guidance. Staff followed guidance and recommendations when prescribing medication and physical health monitoring was completed. A range of recognised psychological therapies were available.
Reasonable adjustments were made for people with learning disabilities or autism. We saw that teams were flexible in location and times of appointments, assessments were delivered in different languages to meet patient needs and adjustments were made such as, the time of fire alarms to reduce the impact and distress of patients attending clinics.
Teams worked with primary care community health services to improve physical health for adults with learning disabilities. Staff delivered training and supported GP surgeries in improving the uptake and quality of annual health checks and health action plans for patients with learning disabilities.
Staff participated actively and regularly in research to review, evaluate and improve services for adults with learning disabilities or autism.
Processes and systems were embedded to ensure reporting of incidents, completion of risk assessments and appropriate safeguarding of adults was in place.

We rated Leeds and York Partnership NHS Foundation Trust overall as Requires Improvement because:

The trust did not have robust governance arrangements in place in relation to staff training, supervision and appraisal, medication management and audit, application of the Mental Capacity Act, systems and guidance to support the application of the Mental Health Act, the delivery of seclusion, restraint and rapid tranquilisation in line with the trust policy, accurate and contemporaneous records, the timely reporting of incidents, the crisis assessment unit’s service provision, policies and procedures being sufficiently embedded. The trust did not have a systematic approach in place with regard to the documentation required to assure themselves, or the Care Quality Commission, that the directors met the fit and proper person requirement, regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
Systems and guidance were either not in place, not sufficiently embedded, or not operated effectively to ensure the delivery of safe and quality care. Incidents were not reported to the National Reporting and Learning System in a timely way and systems were not robust enough to ensure that incidents were reported to the trust from some services, including the supported living service and the forensic and secure inpatient services. The trust did not always meet its own targets or those agreed with the commissioners, for example the clustering targets. The trust did not return the data requested by the Care Quality Commission during the inspection in a timely way. Records were not always accurate and contemporaneous and did not always include all decisions about patient’s care and treatment within their care record.

The provider failed to ensure that all people receiving a service were protected from potential harm because the emergency equipment and medication checks were not sufficiently robust on some wards, including the inpatient wards for older adults and the long stay and rehabilitation wards, where items were out of date or missing and equipment like blood glucose testing meters were not being recalibrated. The trust compliance was low for training courses including essential life support, intermediate life support, and safeguarding children level two and three. The low compliance with essential and immediate life support meant that the service could not guarantee that all staff could respond to patients in a medical emergency.

We had concerns about the management of medicines in some settings. Medicines across the trust were not being stored at the correct temperatures to remain effective. Staff in many of the clinical areas throughout the trust were not monitoring ambient room temperatures and where they were, temperatures were exceeding the room temperature recommended by the World Health Organisation guidelines. Staff in clinical areas were either not recording the fridge temperatures or not always taking action when temperature readings were outside of the required range. The internal audit systems were not always sufficiently robust to identify missed doses or other medication issues and errors in some services.

The trust did not ensure that staff received appropriate training, supervision and appraisal. The trust had not met its target of 90% compliance for appraisals and some services had low compliance. The trust compliance for clinical supervision was low across the trust except for the mental health services for children and young people.
Compliance in the mandatory level two Mental Health Act community and inpatient level two training was low and five teams or services had below 75% compliance in the Mental Capacity Act training, including Deprivation of Liberty Safeguards. The application of the Mental Capacity Act in some services was not in line with the trust policy or the Act and the trust did not always ensure that patients who did not have the capacity to consent to their care and treatment were detained using the appropriate legal authority such as by Deprivation of Liberty Safeguards. The systems and guidance in place did not fully support, or ensure, the application of the Mental Health Act across the trust and the code of practice was not sufficiently embedded across all the services or detailed in the trust policies.

Not all ward environments were safe or clean. There were concerns in relation to the trusts management of mixed sex environments and maintaining the patients’ dignity and privacy at three of the inpatient services we visited including the Yorkshire Centre for Psychological Medicine, Two Woodland Square and the crisis assessment unit. We did not accept that the Yorkshire Centre for Psychological Medicine met the requirements of the Department of Health guidance on same sex accommodation (2010), or the Mental Health Act code of practice at the time of the inspection. The provider had outstanding actions on the trust’s reducing restrictive interventions action plan and the use of seclusion; restraint and rapid tranquilisation were not always completed in line with the trust policy. In the community services systems were not in place in all services to manage risk effectively. This was in relation to supporting patients whilst they were on the waiting lists to access the service, managing the premises, and employing sufficient lone working systems to protect staff and patients. Also, there were delays above 20 weeks for patients to access some psychological therapies identified in the integrated community services for working age adults and older adults with mental health problems.

However:

The community services that supported deaf and hearing impaired children and young people, as well as children and young people with mental health problems whose family had hearing impairments, was rated as an outstanding service.
The trust was committed to improving and developing its services, using information from the local population and through working in partnership with the commissioners, other statutory, third-sector and voluntary organisations. Patient involvement appeared to be embedded in the trust’s approach to shaping its services and informing care and treatment. It had a well-established service user network and involved patients in research projects, delivering training and recruitment.

The trust had implemented a new recruitment strategy in 2016 and had implemented a number of measures to attract new staff to work in the trust. It had successfully recruited newly qualified and experienced staff through its recruitment events and its work with the universities, using values based recruitment. Whilst there continued to be regular use of bank and agency staff across the trust, the staff used were either substantive staff who worked extra shifts, or staff who worked regularly in particular areas but who chose not to take substantive posts to ensure the continuity of care for patients. Staff were respectful, caring and compassionate towards patients, relatives and carers and mindful of the best way to communicate with patients in order to support them.

The trust did not own all the premises it delivered care or treatment from. It had identified this as one of its strategic risks and was committed to improving working arrangements with its private finance initiative partners and NHS Property Services Ltd, to improve response times for maintenance and repairs and the overall management of its estate. The trust had completed a significant amount of work in relation to the identification and removal or mitigation of ligature risks across all its wards and services. They had robust systems in place to assess, report and communicate any ligature risks, supported by the trust’s ligature risk procedure.
In the majority of services and teams, comprehensive assessments were completed using recognised assessment tools, care plans were holistic and person centred, risk was assessed and addressed. Staff produced different versions of care plans in accessible formats, for example in the community services for deaf children and adolescents and the community services for learning disabilities or autism. Care and treatment was delivered by a multidisciplinary team and was reviewed regularly. Patients told us that they were involved in their care and most of the patients spoken to during the inspection told us they could have a copy of the care plan if they wanted one.

A range of information was available to patients in accessible and appropriate formats for the patients in the wards or services. The trust had a robust and effective complaints process and almost all the wards and services we visited during our inspection demonstrated a positive culture of reporting complaints and learning from complaints. Patients knew how to complain if they wanted to and were supported to do so.

We rated mental health crisis services and health based places of safety as requires improvement because:

The crisis assessment unit was admitting patients for reasons other than its stated purpose of providing extended assessments for people experiencing acute and complex mental health crisis. The unit was not intended and was not suitable for lengths of stay significantly above 72 hours. The unit was taking admissions due to bed management and other issues for which it was not suitable.
Compliance with mandatory training in immediate life support was 63% in the crisis assessment service. Compliance with mandatory training in essential life support and immediate life support was 64% and 44% respectively in the intensive community service. This meant in an emergency not all staff would be trained to assist.
The crisis assessment service and the intensive community service were below 75% compliance with staff appraisal targets.
The crisis assessment service was not regularly collecting and sharing data with other agencies to monitor compliance with all aspects of the crisis care concordat.
The crisis assessment service had significant gaps in section 136 documentation, including for example the time taken between detention and assessment.
The crisis assessment service and the intensive community service did not have effective governance systems in place to accurately monitor and share information about the service with the Care Quality Commission in a timely manner.

However,

Feedback was positive from current and former patients and their carers about both the crisis assessment service and the intensive community service.
The crisis assessment service operated 24 hours a day, seven days a week and was able to respond to high risk cases quickly.
The intensive community service provided a clear pathway from admission to discharge which stabilised recovery and reduced crisis symptoms.
The crisis assessment service had established several new approaches to multi-agency working. These included employing nurses to work in the local police control centre, establishing a team specifically to support the police with initial mental health assessments and forming a partnership with the local substance misuse services to secure early access for patients.

We rated community-based mental health services for working age adults good because:

The community-based mental health services for working age adults were safe because teams had sufficient staff to protect patients from avoidable harm and abuse. Managers supported staff to be open and honest and carried out thorough investigations when something went wrong. Staff recognised and responded appropriately to identified risks to patient safety.

The community based mental health services for working age adults were effective because patients received care and treatment that met their needs. Staff were appropriately skilled, experienced and supported by managers to develop their practice. Staff used best practice guidelines to deliver effective care and treatment. Staff had regard for the Mental Capacity Act and ensured they protected the rights of patients detained under the Mental Health Act. Staff worked with a range of other teams and services to co-ordinate patients’ discharge and took patients’ needs into account.

The community based mental health services for working age adults were caring because patients and carers told us they felt supported by staff. Staff treated patients and carers with dignity and respect. Patients felt involved in their care and we saw staff supported patients with kindness and compassion during their interactions.
The community based mental health services for working age adults were responsive because the service was reviewing the way it organised and delivered care. This was focused on making improvements to meet the needs of working age adults in the local population. The teams provided short term interventions as well as long term. This meant patients had better access to services and timely discharges. Patients had timely access to the service and the trust were meeting their targets to assess patients from referral.
The community based mental health services for working age adults were well-led because staff were proud of the service they delivered to patients and their carers. The teams had a culture that focused on improvements to deliver high quality person-centred care. All teams were involved in individual projects and used a quality improvement methodology to share good practice across the localities.

However;

The East,North East team could not always ensure their building was secure due to the length of time the electric door at the entrance remained open. There were concerns that staff had high caseloads and this had an impact on staff morale. The service had caseloads outside of recommended guidance from the Department of Health 2002. The lone working procedures could not always ensure staff safety during community visits which meant staff could be left vulnerable.

Physical health monitoring and recording was inconsistent throughout the teams. Some teams were able to monitor bloods more effectively than others were.

There were concerns that patients who were referred to the psychology service waited up to 20 weeks for psychological therapies. This meant that patients did not have timely access to specific treatments to meet their needs.

Staff were not up to date with their mandatory training and teams had not reached the trust target of 90% in areas such as Mental Health Act and Mental Capacity Act training. Appraisal rates had not met the trust targets and supervision rates varied across the teams.

We rated wards for people with learning disabilities or autism as requires improvement because:

We had a number of concerns about staff on the wards being suitably trained and supervised. Compliance with mandatory training was 75% or below in seven areas, including essential training for the service which is designed to reduce risk to patients: clinical risk assessment (54% at Parkside Lodge), Mental Capacity Act and Deprivation of Liberty Safeguards (75% at 2 Woodland Square), Mental Health Act Awareness (63% at Parkside Lodge), Mental Health Act Inpatients (67% at 3 Woodland Square and 70% at Parkside Lodge) high level personal safety training 68% Parkside Lodge), infection control (71% at 3 Woodland Square) and food safety (71% at Parkside Lodge and 68% at 3 Woodland Square. Staff did not receive supervision every four weeks in line with trust policy and not all staff had an annual appraisal.
The environment was not safe at 2 and 3 Woodland Square. The wards were not clean and repairs had not been completed when staff had reported them. This increased risk of infection to patients who were vulnerable due to long-term health conditions. 2 Woodland Square did not meet guidance regarding same sex accommodation because male and female patients shared one bedroom corridor and a communal bathroom and there was no female only lounge. However, the service mitigated this risk because most patients were not ambulatory and those who were, staff supported at all times moving through the ward.
Staff and carers raised concerns that patients at 2 Woodland Square were unable to attend activities that were not pre-planned and part of the patient’s normal routine prior to attending the respite service. They told us that this was due to staffing levels, the lack of a mini-bus driver, and the lack of access to specially adapted transport. The trust told us that activities were available for all patients and that appropriate transport could be arranged.
Governance structures did not always ensure the wards ran safely. Staff did not undertake audits of medication and equipment consistently. The inspection team found medication errors, which the service was not aware of. The service did not comply fully with guidance from the Department of Health, Mental Capacity Act and Mental Health Act. This placed patients at risk of staff not upholding their rights. 2 Woodland Square did not use performance indicators to ensure the service was high quality. Staff did not support patients to complain using easy read formats. Clear legal authority had not been obtained to care for patients who lacked capacity to consent to their care and treatment and were deprived of their liberty.

Staff had not consistently updated care and treatment records at 2 Woodland Square. Care plans, patient evacuation plans and risk assessments contained out of date information and best practice guidance. This placed patients at risk of receiving care, which could cause them harm. 2 and 3 Woodland Square did not always complete service specific risk assessments and care plans.

However:

We witnessed compassionate care and saw good practice such as communication profiles to assist staff to ensure sharing of patient views. The feedback from patients and carers was wholly positive about the way staff talked with, and treated them. Patients were involved in their care and staff encouraged patients to talk about their needs.
There were no waiting lists and the service offered emergency placements to patients when carers needed support. The service had an ethos of multidisciplinary working and the recording of incidents was good. Service level lessons learned were being shared and de-briefs took place after all incidents, which included the patient. At Parkside Lodge, professionals were working on outcome measures to improve patient recovery.

The ward managers were innovative and looking at ways to improve the service.
Staff morale was good and staff told us that they felt supported.

We rated wards for older people with mental health problems as good because:

Staff completed comprehensive assessments of patients’ needs, incorporating any specialist care needs. Assessments included nutritional screening and physical health checks. We saw that patients had detailed risk assessments and corresponding management plans for how to manage any risks. Staff reviewed care plans and risk assessments regularly and updated them in response to patients’ needs. Patients and relatives were involved in these reviews.

Wards one and two were undergoing refurbishment to improve the environment in line with good practice for dementia environments. Wards were clean and tidy. Staff completed a number of environmental checks including infection control and health and safety. There were many different rooms and areas for patients to spend time on the wards. Patients had access to an outside garden area via ward on the ground floor. Patients and their relatives felt the environment was safe.
Staff were knowledgeable about what incidents to report and felt confident in reporting. Incidents reports were detailed and contained clear information about actions that had been taken in response to each incident. Staff reported any safeguarding concerns as necessary to help ensure patients were protected from harm.
Patients spoke highly of the staff and said they were treated with kindness and respect. Relatives were also complimentary about the staff and said theysupported them in their role as carers. We saw positive and caring staff interactions with patients. Patients and relatives were able to give feedback via community and carers meetings that took place. Patients had access to advocacy support on the wards.
Although there were times when staff were pressured, there were suitable amounts of staff at the service to meet patient’s needs. Patients and relatives said staff were always present and visible. Our observations supported this. We saw activities took place which staff encouraged patients to participate in.
Staff felt positive in their roles and spoke highly of the support they received from colleagues and managers. We saw managers were visible on the wards. Staff were knowledgeable about the patients they supported and their needs. Managers praised staff attitude and resilience.
There was useful information on display for patients, relatives and visitors about the service. This included information about how to make complaints. Patients and relatives said they would feel comfortable speaking with staff if they had any complaints to make. Relatives said any issues had been resolved in the past where they had raised them. We saw complaints were dealt with thoroughly.
Governance meetings took place regularly for senior staff to discuss relevant information about the service. This included learning from incidents. Information from these was fed down to ward based staff in team meetings. Staff participated in clinical audits and we saw that any shortfalls were rectified where identified.

However:

Staff did not always keep robust records in relation to patient care. There was incomplete and omitted information in relation to patients who required their dietary intake to be monitored. Also, because bank and agency staff did not have access to the trust’s electronic system, in some instances temporary staff had recorded details of care interventions separately to the patient’s main care records.
There were shortfalls in some mandatory training compliance and the service had not met the trust target. The areas with lowest compliance were the Mental Capacity Act training, Mental Health Act legislation training and safeguarding children. Three wards were short of the trust target for appraisals and not all wards had met trust supervision targets.
Staff demonstrated a good understanding of relevant legislation such as the Mental Capacity Act and the Mental Health Act. However, nursing staff deferred to doctors to make formal assessments of capacity. Capacity assessments did not always show what attempts had been made to support patients with making informed decisions before assessing capacity.
Staff did not always undertake the necessary checks to ensure patient safety. They did not take the appropriate action in response to excessive temperatures of fridges where drugs were stored. We found some omissions in prescription charts which staff had not identified. Although staff regularly checked emergency equipment, action was not always taken when shortfalls were identified.
From information available, we could not always be clear how results from clinical audits were used to drive improvement at service level.

We rated child and adolescent mental health wards as good because:

Staff carried out comprehensive assessments of a patient’s needs on admission. This included risk assessments, which staff regularly updated. They treat patients with kindness, respect and compassion and engaged with them at an age appropriate level. Staff were knowledgeable about safeguarding patients from abuse.
Patients and their relatives or carers were involved in the patient’s care. Care plans were up to date, personalised and holistic. There was a full range of mental health disciplines providing input into a patient’s care and treatment; this included structured therapeutic treatment and other activities to promote the patient’s wellbeing. There was a full activities programme including weekends and evenings.
There was an effective governance structure to monitor the unit’s performance. Managers supported staff and provided appropriate training.
Patients and relatives were able to give feedback on the service they received and input into the daily running of the unit.

However:

Staff did not have a full understanding of what constituted seclusion and the procedures they needed to follow to ensure patients were protected by the safeguards of the Mental Health Act Code of Practice.
Temperatures for the fridge used to store medications requiring refrigeration were sometimes outside the required range. It was unclear what actions staff had taken, if any, to ensure the medicines remained effective.
Staff had not identified missed medication doses in their medication management processes.
Patients did not like the food. There was limited choice for patients requiring food to meet their religious requirements.
Staff did not update the information board for patients to see the staff members due on shift during a night time.
The advocacy provided by the trust was not specifically for children and adolescents.

We rated forensic inpatient secure wards as requires improvement because:

Compliance with mandatory training was poor, especially training in clinical risk, intermediate life support, and the Mental Health Act. Staff knowledge and understanding of these legal requirements in relation to the Mental Health Act was variable across the service. Rates for clinical supervision were low and appraisal rates did not meet the trust target.
Restrictive practice was not based on individual risk or need and was not proportionate or person-centred.

The trust had not investigated incidents in a timely manner or taken adequate and effective actions to prevent further incidents in some cases. Systems in place were not utilised effectively to ensure lessons learnt were shared across the service. Not all the governance arrangements in place provided assurance that systems were effective.

However,

• Overall, patient experience of the forensic service was positive. Staff treated patients with kindness, dignity and compassion. Patients felt safe and relationships were built on mutual respect. Opportunities for patient and carer involvement were evident.

• Patients’ individual needs were met through the effective assessment and monitoring of both mental and physical health. Patients were at the centre of their care and supported to contribute to multidisciplinary discussions. The service was responsive to the needs of patients. Allied health professionals and clinical staff worked collaboratively to ensure patients’ individual needs and interests were met through a range of psychological and occupational therapies.

• Complaints across the forensic service were low.

We rated Long stay/rehabilitation mental health wards for working age adults as good because:

Staff treated patients with kindness and respect. Interactions between staff and patients were warm and supportive. Patients were actively involved in the development of their care plans. Patients and staff told us that there were good links with the advocacy service.
Staff ensured that patients engaged in meaningful activities whilst on the wards. Patients had a range of activities they could participate in and some patients were able to cater for themselves. Staff provided a range of activities and were instrumental in applying for local community grants that were available for groups wanting to encourage people to walk more.
Medication was prescribed in line with best practice and National Institute for Health and Clinical Excellence guidelines.
The service had introduced individual digital tablets to patients. The tablets contained an app called U- Motif and allowed patients to take more control over their care through a platform that enabled communication with their clinician.
Staff were knowledgeable in the application of the Mental Health Act. They received support from the central Mental Health Act administration team where appropriate. Staff also understood the principles of the Mental Capacity Act.
Staff were skilled in de-escalation techniques and this meant there was a low level of restraint used in the service.
The service provided a pathway for unregistered staff to gain a national vocational qualification level 3 in health and social care.
There was strong local leadership across the wards, which staff and patients confirmed. All staff we spoke with felt supported by their colleagues and held them in positive regard. The ward managers had enough autonomy to run their wards.

However

Compliance with mandatory training was below the trust requirement of 90% for the long stay and rehabilitation services.
Capacity assessments for treatment for detained patients were not always recorded in their file.
Supervision was not always provided in line with the trusts policy.
Oxygen cylinders were not checked regularly and replaced when they had been used.

We rated acute and psychiatric intensive care services as good because:

There were sufficient numbers of staff to keep patients safe. The trust had upgraded patient areas and had made a start in replacing fixtures and fittings that had been identified as a ligature risk. Where ligature risks remained, staff managed them through completing risk assessments and using appropriate patient observation levels.

The wards we inspected were effective. Staff had a good understanding of the Mental Health Act and the trust had a central office that staff could contact if they had any queries. Ward staff had regular supervision, appraisals, training, staff meetings and weekly reflective practice meetings.
Staff on the wards were caring and responded to patients’ needs. Patients said that they felt involved in their care and treatment and they had the opportunity to comment on the service through weekly ‘your views’ meetings. Patients knew how to complain and they said they thought staff would take their complaints seriously. Staff offered various activities to patients and on some wards there was good access to activities over the weekend. Patients could attend group sessions and were able to spend time with their keyworker. Wards had communal lounges, activity rooms, rooms for interviews, and areas where they could spend time with their visitors, and patients told us the food was good and met their dietary and cultural requirements.
Staff felt supported by their managers and morale was good on most wards.

However:

Staff at the Becklin Centre did not manage some risks well. Staff at the Becklin Centre did not always monitor the temperature of the medicine fridge. Also, when the maximum temperature was exceeded, they did not act to ensure that medicines were stored safely. Patients smoked in the hospital grounds and on wards at the Becklin Centre despite the trust’s commitment to a smoke-free environment. On ward three at the Becklin Centre, a patient was smoking cannabis in their bedroom. This put staff and patients at risk of passive smoking. Following the inspection the trust confirmed that this patient was seen by the psychologist and their care and treatment reviewed. Staff at the Becklin Centre told us that all patients were subject to 15 minute observations when admitted to wards. However, information provided by the trust after our inspection evidenced that this was not the case. We were concerned that this meant staff did not appear to have a good understanding of the trusts policies and procedures in relation to patient observation levels.
Wards at the Newsam Centre were not visibly clean in some areas.
Staff did not always follow the requirements of mental health legislation. They did not always store Mental Health Act documentation about medication correctly.
The e-prescribing and medication administration electronic flag did not always accurately reflect the most up to date authorisation certificate. This meant staff could not be sure the correct medication had been authorised. Staff were not clear about their responsibilities under the Mental Capacity Act. All mental capacity assessments were carried out by consultants. The wards at the Becklin Centre did not display a poster to inform informal patients of their right to leave the ward.
Managers were unable to describe what key performance indicators were used to ensure the service delivery was safe and high quality and the mandatory training compliance for staff did not meet the trust target of 90%. There was low compliance with 11 of the trusts identified mandatory training courses, including training in clinical risk, essential life support, intermediate life support and personal safety with breakaway techniques. These are essential training courses for ensuring that patients and staff are safe.

We found that the learning disability services had safe staffing levels, there was a shortage of permanent staff and there were vacancies, however there was no impact on care or patient safety.

We found that learning disability services assessed and managed risk to patients and staff and staff were aware of the incident reporting system and learned when things go wrong.

We found that the learning disability services assessed the needs of people and planned care and followed best practice in treatment and delivery of care.

We found there were skilled staffs and multi-disciplinary team working was evident.

There was adherence to the MHA and the MHA Code of Practice.

Medication was stored, handled, administered and disposed of correctly.

All wards were able to describe the complaints policy and how these were dealt with at local level

We found that all patients had a physical health check on admissions and there were specialised care pathways developed for some patients. Each patient had their own activities timetable and there was evidence of occupation and engagement.

The services we reviewed used “TOMS” (Therapy Outcome Measure Scale) and also engaged in regular audits.

Staff training attendance was variable across the learning disabilities services. Whilst some figures were low, There were plans to increase compliance with mandatory training and some of these staff already had dates identified to attend the training.

We found that there were some issues around adherence to the supervision policy, however this was being addressed.

We found that the learning disability teams and involved people in the care they received and treated them with kindness, dignity, respect and support. we saw a number of ways that this was done

We found that generally the learning disability services had good governance procedures in place and staff were aware of the Trusts vision and values. Strong leadership was evident within the learning disability services.

All wards were able to describe the complaints policy and how these were dealt with at local level.

The low secure services were safe; effective systems were in place to assess and manage risks to individuals. The newer women’s wards at Clifton House provided a safe environment. There continued to be some environmental safety and ligature risks especially at the Newsam Centre but the risks were mitigated. There were appropriate actual and relational security arrangements within the low secure environment.

Whilst there were examples of good practice, we found that the low secure services were not always as effective as they could be. Many patients commented that activities, leave and access to fresh air was cancelled or curtailed due to the high levels of vacancies and sickness levels. We found good Mental Health Act adherence but there were issues with capacity to consent and seclusion recording; as well as one incident of mail being withheld inappropriately. Staff at Field View were not fully supported to provide effective care.

Overall the trust was providing a caring service for patients across the low secure wards. Throughout the inspection we saw examples of staff treating patients with kindness, dignity and compassion. Patients commented favourably on the quality of care and support they received. The service had outstanding examples of how it involved patients in their care and engaged in how the services were designed.

The service was responsive to patients’ needs. Restrictions were usually kept to a minimum. Patients’ individualised needs were met. Complaints were managed locally, but there were no systems in place to monitor these complaints held at local level.

We found that the service was well led with effective management of the service through regular audit and a commitment to provide high quality care and continuous improvement in line with the trust’s stated values and strategy.

We found a breach of regulations relating to staffing levels. We have issued a compliance action. This was because nursing staffing levels at one location, Field View which provided four beds for patients to step-down to lesser restrictions, were not maintained at expected levels at all times and therefore detained patients were not safeguarded. We were given assurances after the inspection promising improvements.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence. This statement should be in all provider level reports.

Bootham Park Hospital, despite significant work having been taken around ligature points and further work planned is not fit for purpose as a modern inpatient setting. The building no longer meets the needs of psychiatric patients in acute distress. Staff could not observe all parts of the wards due to the layout and design of the building. Bedrooms were large and airy, but doors opened out into corridors. There were sash windows in bedrooms and bathrooms. There were other features of a building that was built in the 18th century meaning that ligature points could not be fully eliminated.

In York specifically, the facilities and premises at Bootham Park Hospital were not appropriate for the services being provided. The trust during and subsequent to the inspection provided documents that outlined their engagement and documented concerns about the premises with the relevant parties from July 2013 to find a solution, including Vale of York commissioning group, the NHS area team and NHS property services. Solutions were put in place and included English Heritage, but have not as yet been implemented.

We saw that this had been the case with Lime Trees child and adolescent unit but that the trust had worked collaboratively with the specialised commissioning team and NHS England to make immediate changes and move the service to another location.

Staff did not always identify safety concerns about ligature points quickly enough. We identified ligature points across the Leeds’ inpatient areas that were not all recorded on the trust risk register.

We found the use of patient group directions was unlawful in the crisis assessment service in Leeds. The trust suspended their use before the end of the inspection.

Staffing levels were usually maintained at the level set by the trust. The expected qualified nurse staffing levels at Field View were not maintained on the week of our inspection. There was limited medical cover in some locations in the trust and this meant that it could be difficult to get medical assistance in an emergency.

Safeguarding vulnerable adults, children and young people had a raised profile in the trust as they had just appointed a non – executive director lead. Training for all staff was in place. Policies and procedures were easily accessed and staff understood them.

The trust did not meet the Department of Health guidance on same sex accommodation and did not comply with the Mental Health Act Code of Practice. Four wards including one rehabilitation ward, Acomb Gables and three older people’s wards Meadowfields, Worsley Court and ward 6 did not comply. These were all wards in York. We concluded that the trust was not promoting sexual safety and not ensuring patient privacy and dignity was being maintained at all times.

Prior to our inspection, we heard that patients, carers and relatives did not find it easy or worried about raising concerns and complaints. We found during our inspection that when issues were raised locally, they were dealt with at ward/team level. However, corporately there was a backlog of complaints. Patients’, carers’ and relatives’ were in receipt of unsatisfactory responses after waiting for a response for a long time. The trust was not meeting its own targets for response times. Information on how to make a complaint was not displayed in all ward areas or areas of public access. We concluded that patients’ concerns and complaints do not always lead to improvements in quality of care.

Staff had access to learning and development opportunities. The learning opportunities offered to staff did not fully meet their needs. Mental Capacity Act training was not in place. The trust did not monitor the number of people who had undertaken Mental Health Act training. We concluded that the trust cannot be assured that the relevant staff had up to date knowledge regarding Mental Capacity Act, Deprivation of Liberty Safeguards and Mental Health Act legislation. Specialist training was limited in York. Training programmes were held both in Leeds and York although staff in York told us they found it difficult to attend.

Representatives from the York commissioning groups told us that the trust did not engage positively with them and did not involve the local communities or other organisations in how services were planned or designed. The trust also told us that the relationship between them and the commissioning groups in York was a difficult one. We were concerned that this might adversely affect the provision of high quality patient care.

After the inspection, the York commissioning groups informed us that there had been improvements in the three months post inspection. They identified that the context of their discussions with CQC had all previously been shared with the trust. This included their view that the trust had been the provider of services for over two years but had not progressed key estates issues including actions relating to ligature points despite the resource being identified prior to the trust taking over the contract.

The trust submitted documents after the inspection that showed a timeline of partnership and engagement within the York localities of which the first dated evidence is January 2013. There were a number of pieces of evidence that supported the trusts view that they had actively engaged with the clinical commissioning group through a variety of different groups and meetings. They also included several pieces of evidence demonstrating how they had engaged and involved local communities in how services were designed and planned. The trust included a document that detailed the different partnership groups that members of the trust attend. Minutes were provided that demonstrated that the trust had engaged in a board to board meeting with the Vale of York commissioning group in February 2014 followed by an executive to executive meeting in April 2014. These meetings included discussions on the way forward with Bootham Park Hospital and the respective roles and responsibilities going forward.

The arrangements for governance and performance management did not always operate effectively below senior management level. As a result it was not clear that the trust had the full range of information from the care teams to manage current and future performance. However the structures had been seen to be working well and embedded at senior management and board level. We saw that performance issues were escalated to the board through the relevant committees. Financial pressures were not compromising the quality of care.

Staff planned and delivered care and treatment in line with evidence based practice. They undertook comprehensive assessments of needs. However they did not always collect or monitor measures or outcomes of patient care and treatment regularly or robustly. The eating disorder service was an exception to this. Participation in external benchmarking was limited, although we could see that plans were in place to develop this approach. The trust had undertaken national benchmarking for the first time in 2013.

Overall the application of the Mental Health Act was good. However we found some practices did not always meet the Mental Health Act Code of Practice. We raised these at the time with the ward staff. Staff appeared to be knowledgeable about the application of the Mental Health Act. We found mail being withheld for one patient contrary to the rules in the Mental Health Act. There was inconsistent practice in giving people copies of section 17 leave forms and some evidence of scrutiny of documents not always taking place, in as short a period of time as possible, following the application for detention.

Staff understood and fulfilled their responsibilities to report incidents. When things went wrong, there was a thorough investigation that involved all the relevant staff, patients’ and their carers’. Lessons were learnt, however it was not clear from the investigation reports how widely they were communicated.

Despite the lack of available training, we saw that the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards were met where its use was required. However we found inconsistencies in staff understanding of the application of the Mental Capacity Act.

Patients were supported, treated with respect and were involved in their care and treatment. Prior to the inspection, we were told that patients were not always involved with or have their care plans reviewed, however during the inspection the majority of patients told us they had been actively engaged in reviews of care. There was variation between services in Leeds and York, with Leeds services engaging patients, carers and or relatives more proactively. Staff had a good understanding of the different needs that patient’s had on the basis of gender, race, religion, sexuality, ability or disability within services.

Patients could access the right care at the right time. Bed occupancy was marginally higher than that of the national average. The introduction of single point of access had improved response times to referrals. Patients did not have problems contacting services when they needed to.

In Leeds, we saw and heard that other organisations and the local community were involved in planning and delivering services to meet patients’ needs.

A clear statement of vision and values had been developed through engagement with internal and external stakeholders including patients and governors. A strategy had been developed with clear objectives that were reviewed regularly. The board and the non-executive directors had the experience and capability to ensure that the strategy was delivered. Staff understood the vision and values but did not always understand how that related to them at a more local level.

We heard that not all of the managers and clinical leads in York had the necessary experience, knowledge, capacity or capability to lead effectively. As a result, the trust had recently moved a number of senior managers across from the services in Leeds to address some of the challenges that this had created.

Staff felt supported and valued. We saw that there was good collaboration between teams.

There had been the introduction of the Mental Health Act committee in the preceding 12 months. This meant that CQC Mental Health Act reports were reviewed by non executive board members and the board was made aware of any outstanding actions. Statistical information on the MHA was being monitored.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.

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