The Care Quality Commission
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Archived: Calderstones Partnership NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

5 to 8 October 2015

During an inspection of Forensic inpatient or secure wards

We rated Forensic inpatient/secure wards as good because:

All of the wards were clean, tidy and well maintained. Staff completed regular checks on the ward resuscitation equipment. These checks were recorded.

Staff managed physical, relational and procedural security well. The outdoor areas met the secure service standards set out by the Department of Health in its Environmental Design Guide (2011). The wards had airlock systems at their entrances and a central office managed keys and alarms so that staff collected these on their way in and left them on their way out. Staff used the ‘see think act relational security explorer’ during handovers. Staff knew how to access the security policies that were available on the trust intranet. These were all in date.

Care plans focused on recovery. Ward staff understood the principles of positive behavioural support and applied these when developing care plans.

All of the care records we reviewed showed that staff checked the physical health of patients regularly. The trust ensured that patients had good access to a range of physical healthcare services including GP services, opticians, dentists, dieticians and podiatrists.

The staff worked well together as multi-disciplinary teams.

Staff at all levels were kind and respectful when speaking to patients. They respected patient privacy and dignity and maintained confidentiality. Staff involved patients in all aspects of care planning, including in the development of positive behavioural support plans.

The trust ensured that advocacy services were available and present on the wards. Patients told us that they had good relationships with advocates.

The trust made a wide range of therapeutic and social activities available to patients on all of the wards. Patients could use the outdoor areas at any time. There were good facilities for children to visit away from the ward areas.

The care was discharge-oriented. Staff actively planned for discharge to appropriate alternative placements, taking account of patient needs and risks. The ward teams worked collaboratively with community teams mental health and learning disability teams that would support patients post-discharge, and with commissioners.

Staff at all levels understood and supported the trust’s vision for the service. Ward staff knew who the members of the trust board were and told us that they saw them regularly. The trust ensured that there were systems in place to monitor quality and to give feedback on performance to staff throughout the organisation.

However:

Managers had not undertaken an appraisal of all ward staff in the previous 12 months.

On Maplewood 1 and 2, the managers had not put in place a system that allocated staff to respond when an alarm was activated.

6-8 October 2015

During a routine inspection

We found that the trust was performing at a level that led to a rating of ‘Good’ because:

  • Since our last inspection of the trust in July 2014, the trust had made significant improvements in the care and treatment that staff provided to patients and the environments in which this was delivered. The trust had developed an action plan following our last inspection and worked with external stakeholders to address the issues we had raised.
  • The executive team had reviewed and strengthened the trust's governance structure. The trust had implemented reports which provided ‘real time’ information about a number of clinical key performance indicators which could impact on the quality of care provided. These included staffing issues, incidents, complaints and episodes of restraint and seclusion. This allowed the service managers and the board to monitor trends and possible gaps in service provision to enable them to take timely action.
  • The trust’s vision and values were fully embedded throughout the organisation and all of the staff we met with were aware of these and explained how the values underpinned their work. Staff were satisfied with the support they had from their managers and were proud of the work that they were doing.
  • The trust had implemented a new model of working called ‘safe wards’ which focussed on reducing restrictive practices and improving patient outcomes. All staff had been trained in the new way of working and were committed to improving the care they provided to patients. All patients had a comprehensive risk assessment, positive behavioural support plan (PBS) and ‘moving on’ plan in place. The quality of the PBS plans was exceptional and there was evidence of patient involvement in the formulation of these.
  • The implementation of the new model had significantly changed the culture within the trust and enabled staff to reflect on their practices to identify areas of improvement. The board was the driving force behind the changes and they had supported staff whilst maintaining good oversight regarding the monitoring and implementation of the changes.
  • The most significant improvements noted was the reduction in the number of episodes of restraint, seclusion, the use of rapid tranquillisation and the eradication of the use of emergency response belts within the trust.
  • This had been achieved despite the uncertainty regarding the future of the service. NHS England had recently announced that Calderstones Hospital would close as part of the Government’s transforming care agenda. This uncertainty had led to the trust experiencing some challenging staffing issues over the previous year. The trust had managed the staffing issues proactively and we were satisfied that there were sufficient numbers of staff to deliver the care and treatment that patients needed safely and effectively with the appropriate use of bank and agency staff.
  • Within the learning disability service, we saw some outstanding examples of staff adapting their interactions with patients based on their individual needs. The staff accepted and embraced the unique communication methods of patients who did not use speech to communicate, including individual sounds and gestures. All of the care plans we reviewed were person centred, and patients all had their own copy and reported their involvement in the care planning process where their capacity allowed. These plans clearly demonstrated that staff had a good understanding of patients’ needs, their hobbies and interests, likes and dislikes. The patients who were able could describe their discharge plans and were animated about their future opportunities. We also found numerous examples of how the trust and staff engaged with patients and their carers and provided opportunities for them to be involved in service development initiatives.

However:

  • We identified some inconsistencies across services in relation to staff training, supervision, de-briefs and staff understanding around the Mental Capacity Act.
  • The number of staff trained in basic life skills was low within the learning disability services which could expose patients to a preventable risk within these services.

5 to 8 October 2015

During an inspection of Wards for people with a learning disability or autism

We rated wards for people with learning disabilities or autism as good overall because:

  • the wards were clean and well kept and had up-to-date environmental risk assessments

  • patients told us they felt safe on the wards and that staff handled incidents well

  • the wards managed staffing pressures and it was unusual for them to be below their required number of nurses on duty

  • risk assessments and care plans were recovery focused and person centred, patients all had their own copy of their care plan and reported their involvement in the care planning process where their capacity allowed

  • some of the wards were located within residential houses that were well integrated in the local community and complemented the step-down philosophy of the services

  • patients had ‘moving-on’ plans and there were discharge plans in progress

  • there was good multidisciplinary working, in particular occupational therapists and psychologists worked in each of the inpatient wards

  • there were good examples of staff working hard to enhance communication and understanding of patients’ needs and individual communication methods

  • patients reported that staff were friendly, caring and respectful

  • staff had a good knowledge of the individual needs and preferences of patients, and were highly responsive to patients with complex needs who did not use speech to communicate

  • we observed caring, respectful and professional interactions between the staff and patients on the wards

  • family members told us they felt included in the care of their relative, were asked to share their views and opinions, and felt these were taken into account by the service

  • information for patients was available in a range of formats including easy read and pictorial

  • there was a wide range of activities for patients, which were appropriate to their needs

  • staff spoke positively about the teams they worked in and there was good communication between the wards and senior managers.

However:

  • staff did not always receive a debrief after incidents

  • staff at 2 and 3 West Drive did not receive regular supervision

  • staff had limited understanding of the Mental Capacity Act and how this related to their role

  • staff could not describe the key performance indicators that were monitored to drive improvements

  • staff training attendance for life support and prevention and management of violence and aggression was below the trust target of 80%.

8 - 11 July 2014

During a routine inspection

Calderstones Partnership NHS Foundation Trust is a unique organisation.  It is the only NHS trust that provides care exclusively for people with learning disabilities.  It is also unusual in that all of its patients are cared for in a hospital ward and almost all detained under the Mental Health Act.  At the time of our visit 42% of the 216 patients were subject to a restriction order; which meant that they could not be discharged from hospital without authorisation from the Ministry of Justice.  The great majority of people admitted to Calderstones stayed in the hospital for a long time.  At the time of our inspection, 92 of the patients (43%) had been at Calderstones for more than five years.

We found that some of the wards and seclusion rooms at Calderstones were dirty and that effective infection control procedures were not in place.  This is never acceptable in a hospital setting but it is of particular concern for wards that are, in effect, a person’s home.  We also found that some of the rooms used to seclude people at times when they were disturbed or distressed were neither clean nor safe.

The people who are admitted to Calderstones have severe mental health problems and complex needs.  Many have behaviours that put themselves at risk and that sometimes put others at risk.  As a result, some patients are cared for in single bed wards for long periods of time.  Also, staff at Calderstones frequently seclude people for short periods of time and/or use physical restraint to protect people from harming themselves or from harming others.  In light of this, we were concerned that not all staff were familiar with the trust policy on seclusion and segregation.  

The trust frequently restrained people in the prone (face-down) position as a planned intervention.  Recently published national guidance states that people should not be restrained in the face-down position because it is less safe than other methods of restraint.  At Scott House, one patient had been repeatedly restrained in a face-down position.  The care records of this patient showed that staff had not followed trust policy, which states that a doctor should be summoned to attend a prolonged episodes of restraint.  Furthermore, the arrangements for medical cover to Scott House did not permit the prompt attendance of a doctor when required.

The trust has had difficulty recruiting nursing staff and many posts were vacant.  As a result, it relied heavily on the use of agency and bank nurses.   We had a specific concern about the safety of night-time cover to wards at 5 Chestnut Drive, North Lodge and 14/16 Daisy Bank. 

Although the trust was good at providing and monitoring mandatory training for its staff, we concluded that it was less good at providing the training required to meet the care needs that are particular to the specific problems of the patient group admitted to Calderstones.  In particular, too few staff had completed training in how to manage epilepsy, in eating and drinking difficulties in adults with a learning disability and in Makaton communication training. 

Our findings about the quality of care were consistent with our conclusion about the relative lack of specialised training.  The clinical staff made good assessments of people’s general mental and physical health needs and had arrangements in place to provide medical care for people’s physical health problems.  However, few care records contained health action plans or communication passports and not all wards were following modern and best practice in managing challenging behaviour or in recovery-focused care. 

We found many instances of failure to meet the requirements of the Mental Health Act.  This is of particular concern given that nearly all of the patients in the learning disability services at Calderstones are detained.

We heard about, and observed numerous care interactions that showed that staff were caring and compassionate, and we found that most of the people who use services were active participants in their care planning.  Staff told us that they felt able to raise concerns when they needed to and most patients told us that they would feel confident about making a complaint.

In response to the discovery of the abuse of people with learning disabilities at Winterbourne View hospital in 2011, the Department of Health had decided that people with learning disability should not be cared for in hospital wards for any longer than is absolutely necessary.  Although the clinical teams at Calderstones held regular care programme approach meetings at which discharge was discussed, the trust had not yet implemented its formal approach to managing the discharge care pathway.  Furthermore, some of the wards had ‘blanket restrictions’ in place, which limited patient autonomy, and were not consistent with a care approach geared towards rehabilitation and recovery.  Although our overall conclusion was that Calderstones could have done more to facilitate discharge, we recognised that there were other factors that mitigated against this.  These included the fact that many patients required authorisation from the Ministry of Justice for discharge, and that discharge was dependent on the availability of suitable accommodation and community services in the patient’s home area.

Although we concluded that some of the governance arrangements were deficient, the trust senior leaders were visible to front-line staff who reported being engaged in work to develop and implement the trust’s longer term strategy.

Mental Health Act Commissioner reports

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.