All inspections: North Cumbria Integrated Care NHS Foundation Trust

We plan our next inspections based on everything we know about services, including whether they appear to be getting better or worse.

This report describes our judgement of the quality of care provided by this trust. We base it on a combination of what we found when we inspected and other information available to us. It includes information given to us from staff at the trust, people who use the service, the public and other organisations.

We rated well-led (leadership) from our inspection of trust management, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement.

Overall summary

North Cumbria Integrated Care NHS Foundation Trust (NCIC) was created in October 2019 following an acquisition of North Cumbria University Hospitals NHS Trust (NCUH) by Cumbria Partnership Foundation Trust (CPFT). During the acquisition the mental health and learning disability services were transferred out to another NHS trust.

When a trust acquires another trust in order to improve the quality and safety of care, we do not aggregate ratings from the previously separate trust at trust level for up to two years.

Our normal practice following an acquisition would be to inspect all services run by the enlarged trust. However, our usual inspection work has been curtailed by the COVID-19 pandemic and since that time we have maintained a risk based approach.

In our ratings tables we show all ratings for services run by the trust, including those from earlier inspections and from those hospitals we did not inspect at this time. The ratings shown are an aggregation of ratings from the original trust and those acquired by the trust which have been inspected since the acquisition as well as new ratings from this inspection.

The trust provides a range of acute hospital services based at the Cumberland Infirmary in Carlisle (CIC) and the West Cumberland Hospital (WCH) in Whitehaven. It also provides a midwifery-led maternity service at Penrith Community Hospital and community services covering the Cumbria region (adult and children's community services in north Cumbria and some which are whole county based). The trust has 536 inpatient beds across the acute hospital sites and 133 beds across six community hospitals. The trust employs over 5,400 members of staff.

The trust serves a population of approximately 320,000 in the west, north and east of Cumbria, in the districts of Allerdale, Carlisle, Copeland, Eden Valley and South lakes and Furness for some community services. It also provides services to parts of Northumberland and Dumfries & Galloway. The community is spread over a large geographical area, with 51% of residents living in rural settings. Over 65s make up a larger proportion of the population than the national average. Deprivation is similar to the England average and about 11,700 children (14.5%) live in poverty.

We carried out this unannounced inspection of North Cumbria Integrated Care NHS Foundation Trust as part of our continual checks on the safety and quality of healthcare services.

We inspected Emergency and Urgent Care and Medical care. We also inspected the well-led key question for the trust overall. We did not inspect maternity services, surgery, critical care, services for young people and children, end of life care, out-patients, or diagnostics at this inspection.

At our last inspection in 2020 we rated the trust overall as requires improvement. At that inspection we issued the trust with a section 29A warning notice in regard to the standards of care provided. At this inspection the trust rating has stayed the same. We did see improvements made as a result of our warning notice.

Our rating of services stayed the same. We rated them as requires improvement because:

We rated safe, effective, responsive and well-led as requires improvement, and caring as good
We rated 4 of the trust’s 17 services as requires improvement. In rating the trust, we took into account the current ratings of the 13 services not inspected this time
The service did not always have enough staff to care for patients and keep them safe. Not all staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service did not always control infection risk well. Staff did not always assess risks to patients, act on them and keep good care records. Pain relief was not always given timely when they needed it
The service did not always manage the safe storage of medicines and hazardous cleaning materials
The service did not always manage safety incidents well and although there was evidence of learning following safety incidents, there was further work required to manage environmental hazards and associated risks
Leaders did not always run services using reliable information systems. The trust’s vision and values were developed but did not have clear underpinning strategies

However:

Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers
The service planned care to meet the needs of local people, took account of patients’ individual needs and made it easy for people to give feedback

How we carried out the inspection

The team that carried out the inspection included two inspection managers, 10 inspectors, 5 specialist advisors, one assistant inspector and an inspection planner. In addition, there was an executive reviewer plus three specialist advisors experienced in executive leadership of NHS trusts. The inspection team was overseen by Sarah Dronsfield, Deputy Director of Operations.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Our rating of the trust remains the same as the previous inspection because:

This was a responsive focused inspection based on escalating risk, therefore we inspected specific elements of the safe and responsive domains. We did not inspect all of the key lines of enquiry as our concerns were related to specific risks. For the trust wide well led we inspected against all of the key lines of enquiry but did not rate at this time.

This means that the previous ratings for our 2019 CPFT inspection remain.

The service did not always have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave staff a full induction.
People could access the service when they needed it and received the right care in a timely way.

We rated 9 of the of the 14 core services provided by the trust as requires improvement overall. This takes account of the previous ratings of core services that we did not inspect this time.
We rated safe, effective, responsive and well led as requires improvement for the trust overall. Our rating for the trust took into account the previous ratings of services not inspected this time.
We rated well led for the trust as requires improvement overall.
The trust did not always have effective governance systems at service level in assessing, monitoring and improving care and treatment.
The trust board did not have effective systems in place to monitor operation and compliance of the Mental Health Act or its administration.
The trust had not ensured all patient care areas were suitable for the purpose they were being used for. In the health-based places of safety we found areas which did not comply with the Mental Health Act code of practice. Dova ward was not maintained to a reasonable standard. Oakwood and Kentmere wards provided dormitory style accommodation.
The trust had not fully implemented the role of the freedom to speak up guardian. Staff did not always know who the freedom to speak up guardian was or their role in the core services. Staff said that the guardian was not independent as they reported direct to the chief executive.
Medicines management arrangements were not effective in all areas of the trust.
Risk assessment and management were not always updated, individualised or updated in line with trust policy.
Blanket restrictions were not individually risk assessed or reviewed and there was no trust policy in place.
Not all staff were up to date with mandatory training.

However:

We rated caring as good overall.
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
Staff understood their roles and responsibilities under the Mental Health Act 1983, the Mental Capacity Act and their codes of practice.
Wards and teams had access to the full range of specialists required to meet the needs of patients. The staff worked well together and with partner agencies and stakeholders.
The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders and had active involvement in sustainability and transformation plans. The trust worked closely with local authority public health colleagues. There were good links with health and well-being strategy.

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

The systems and processes established were not operating effectively to assess, monitor and improve the safety and quality of the service or assess monitor and mitigate the risks relating to the health safety and welfare of patients.
The physical environment of the health-based place of safety at Kendal did not meet the requirements of the Mental Health Act Code of Practice.
There was not always a dedicated member of staff to observe patients in the health-based places of safety.
Some facilities in the health-based places of safety did not promote the privacy and dignity of patients.
Not all staff supporting patients in the health-based places of safety were trained in the prevention and management of violence and aggression.
There was not always a record on the electronic patient record system that patients had their section 136 rights explained when accessing the health-based places of safety.
Care plans were not always completed on the right documentation and a record of whether all patients received a copy of their care plan was not evident.
Staff managing patient care were not receiving supervision and appraisal in line with trust policy.
Staff did not feel supported by senior management.
Most staff did not feel respected, supported and valued. They did not feel able to raise concerns without fear of retribution. Not all staff were aware of the Freedom to Speak Up Guardian.

However:

The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The mental health crisis service and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately.

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

The governance systems and processes in place were not always adequate. Bed management did not ensure beds were always available locally. Staff on Rowanwood were not assured of the effectiveness of the serious incidents reviewed. Staffing and recruitment was an increasing issue, despite measures already in place to eradicate this.
Staff did not do all that was reasonably practicable to mitigate risks to the health and safety of patients. Blanket restrictions were in place without being individually assessed. Staff did not always monitor patients’ physical health needs following use of rapid tranquilisation and repairs to Dova Unit were ineffective to ensure a patient room was suitable for use.

However:

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 ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. 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.

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

Medicines management arrangements on the ward were ineffective. We found two unlabelled medicines in storage. There was no risk assessment in place in relation to the use of sodium valproate to treat a female patient of child bearing age despite there being known risks of birth defects and abnormalities associated with the drug.
Staff did not carry out physical observations following the use of restraint and ‘as required’ medication was given after each of the nine restraint instances we reviewed without the rationale being recorded. Staff had not completed body maps for five of the nine incidents of restraint.
Patients did not have access to sufficient therapeutic activities. There was no activities co-ordinator on the ward. We saw little evidence of activities on the ward which was having a negative impact on patients’ morale.
Staff on the ward had not completed their local induction or mental health legislation training. The provider reported that only 57% of staff had completed their local induction and 12.5% had completed their mental health legislation training. Ten other modules were below the provider’s 85% compliance target.
Staff did not receive regular supervision. Since August 2018, out of the 24 staff members on the ward, nine had not received any supervision and 14 others had only received supervision between one and three times.
Governance systems for the ward were ineffective. Audits had failed to identify issues in relation to physical interventions, rapid tranquilisation, medicines management, confidentiality agreements, care records and a positive behaviour plan. The service had failed to address issues around mandatory training compliance that had been found during our previous inspection in October 2016.
Staff had not reviewed the care plan relating to a patient’s ‘as required’ medication since January 2018. A care record contained an incomplete positive behaviour support plan, lacked information about the patient’s strengths, goals, needs and problems and their epilepsy plan did not contain steps to support a safe bathing process. The care record also referred to the patient using the wrong gender.
We were told by staff that for physical healthcare emergencies during the night, staff used the NHS 111 system. However, we understood within the organisation that the agreed arrangements were to contact Cumbria Health On Call Limited when medical emergencies arose.
There were no confidentiality agreements in place for two patients who had been deemed as having mental capacity. There was no nurse call system on the ward which made it more difficult for patients to call for assistance.
Four members of staff lacked knowledge about the duty of candour and the role of the provider’s freedom to speak up guardian.
Two members of staff were unable to access suitable specialist autism training for their role and development needs.

However:

Staff treated patients and carers with kindness, dignity and respect and involved them in decisions about care and treatment. Staff used tools to communicate with patients with communication issues such as Makaton, flash cards, signers and translators. Staff undertook regular risk assessments of patients and put plans in place to mitigate risks. Staff ensured patients’ physical health needs were met and monitored.
Staff ensured patients had access to spiritual support and food choices to meet their dietary needs. The ward was accessible for wheelchair users.
Staff adhered to the Mental Capacity Act and Mental Health Act and there were systems in place to monitor how the Acts were used on the ward. Staff carried out capacity assessments and we saw evidence that best interests’ decisions were made appropriately if patients lacked capacity.

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

There were notable variations between the ward environments. Oakwood ward had not improved since the last inspection and dormitory accommodation was still in place. The ward was not fit for purpose and it was unclear when the relocation of the ward would take place.
There were vacant nursing posts on Ramsey ward which could not be filled. This meant that the ward relied on bank and agency. Feedback from carers was mixed about the care and treatment on the ward.
There had been a number of serious incidents on Ramsey unit. The trust had carried out investigations, but these continued to be areas of concern.
Section 17 leave forms on Ruskin and Oakwood were generic and not patient specific.

However:

There had been improvements since the last inspection in relation to the mental capacity act, the introduction of psychology onto Ramsey ward and staff supervision.
Ruskin ward provided a dementia friendly environment with a good balance between patient safety and ensuring patients were comfortable.
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 wellbeing diaries which were 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.
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 governance processes were in place to monitor the service.

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

Staff had varied knowledge of the Mental Capacity Act and audit information indicated there had been delays in assessing some patient’s capacity to consent to treatment. This had been highlighted as an issue at the previous inspection and did not appear to have improved. Some patients had care plans in place which stated that patient’s rights under the Mental Health Act should not be given as this caused patients undue distress or they lacked capacity to understand this information. It was not always clear if these were being regularly reviewed.
Staff had not completed all actions identified on the most recent ligature audit on Oakwood unit.
Patients on Ramsey unit did not have access to psychological therapies, and there were no immediate plans to address this. Patients on Ramsey were also experiencing longer delays in accessing speech and language therapy assessments, which had a negative impact upon patients.
Appraisal rates for non-medical staff had improved since our previous inspection but were still below the trust target. The lack of a centralised recording system for supervision made it difficult to be assured this was taking place in line with trust policy. Compliance rates for statutory and mandatory training for staff across the service were below the trust target.
Not all staff were confident in navigating the electronic case management system. This raised concerns that important information relating to patient care may not be accessible or missed.

However:

Staff knew patients very well and used this information to inform the delivery of person centred care. Patients and families had opportunities to provide feedback on the service and had been directly involved in the assessment of the ward environment on Ruskin unit which had resulted in improvements on the ward.
Ward environments were clean, well equipped and maintained. Patients had access to good facilities to support mobility issues.
Staff completed detailed assessments for patients using a range of validated tools. Risk assessments were regularly reviewed and informed the delivery of care. Staff had a good understanding of safeguarding procedures and made referrals where appropriate.
Patients had access to good physical healthcare on the wards and there was evidence that physical health was robustly assessed and monitored regularly.
There was effective multi-disciplinary working on the wards, with regular reviews of patient care and treatment. Clinical psychologists facilitated formulation meets to support the development of care and treatment plans on Ruskin and Oakwood wards.
There was strong and supportive leadership across the service. Staff spoke very highly of managers, who had a clear focus on providing high quality care. Staff felt valued, respected and supported by their colleagues and managers and worked well together.
Staff knew how to respond to and report incidents. De-brief sessions were held following incidents and changes were made in the service following lessons learned. Staff understood the duty of candour and family members were satisfied that staff responded appropriately and were honest when things went wrong.

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

The environment in Whitehaven was poor and did not meet service users’ needs. There was a lack of space and no disabled access facilities. Furniture was old and worn.
Care plans and risk assessments were missing or not completed well. Risk assessments and care plans were often out of date and did not correspond to current information.
Staff supervision was not recorded or poorly recorded. Information about staff supervision was not shared with senior managers. It was not possible for senior managers to be assured that supervision was taking place.
Staff training and appraisal rates for non-medical staff were below the trust target.
There was a delayed response to items placed on the trusts risk register. There had been limited action regarding the poor environment in Whitehaven. This was affecting staff morale.

However:

Positive initiatives were encouraged and shared within the service. These included the virtual memory clinic and the delirium outreach support service. There were effective strategies to save time and costs.
Assessments were comprehensive and completed in a timely way. Service users were seen quickly from being referred.
Staff were kind and caring towards service users and carers. Staff were highly praised by service users and they were observed to be empathic and sensitive.
There were strong links with external services such as care homes and GP’s. Staff met regularly to discuss service users with complex needs.

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

Risk assessments were not present or incomplete in nine of the 19 records reviewed.
Care plans were not present in the records we reviewed, young people were copied into letters to GP’s which were described not being in an accessible format by patients and their carers.
Consultant psychiatrist posts had been filled by locums which had impacted on the continuity of care for people who use the service. The service was not meeting its target times from referral to initial assessment and then to appointing care coordination and intervention for routine referrals. Under the NHS constitution, no patient should wait more than 18 weeks for any treatment. The service did not monitor waiting times for specific conditions such as first episode psychosis or eating disorder waiting times in line with the national guidance.
The service did not have a methodology or tool to assess the services staffing requirements and it was unclear how staffing levels and skills mix were calculated.
The service did not have the staff with the necessary skills to provide the full range of evidence based interventions recommended by the National Institute for Health and Care Excellence and were unable to offer evidence based interventions to all.
Mandatory training and appraisal figures were not compliant with trust targets.
At the time of the inspection there was no comprehensive out of hours service provision for young people as the trust had not been commissioned to provide this service.
The waiting area for patients at Workington CAMHS service was shared with a GP surgery and did not promote the privacy and dignity of the young people who attended the service.
Staff morale was low with staff telling us they did not feel supported by senior members of the trust.

However:

We observed good interactions between staff and young people who used the service.
Staff had a clear understanding of safeguarding policy and procedures
Risk for young people on the waiting list was discussed and priority given to young people in crisis, the service met their target times for young people highlighted as a priority.

A summary of our findings about this service appears in the overall summary.

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

Services were well managed with good governance structures in place to ensure a good flow of information up and down the structure through the relevant forums.
The trust had acted upon our feedback from our last comprehensive inspection and made some improvements.
The trust’s vision and values were well embedded into teams. Staff knew and applied the trust’s values in their daily work.
Staff morale was good and team cultures were described as supportive, open and honest so staff were confident about raising concerns.
Feedback from patients and carers was universally positive. Patients said that staff had a good understanding of their individual needs and treated them with dignity and respect.
Patients were assessed quickly and comprehensively and prioritised according to needs and risks. If patients were placed on a waiting list they were regularly monitored by clinical leads.
Care records were up to date, personalised, recovery orientated and included evidence of ongoing physical care, informed consent and appropriate consideration of mental capacity.

However:

Not all premises had disabled facilities and so were not accessible for all patients.
There were inconsistencies in the storage and management of medicines at the three locations inspected.
Although mandatory training for the core service was just below the trusts target rate, some classroom based training courses were significantly below this target.
Supervision was taking place but not always 4-6 weekly and the templates used varied. There was also no central monitoring of supervision for senior management oversight.
The trust measures referral to assessment times but does not record or monitor referral to treatment for patients.

This was the first time we had inspected this service. We rated it as requires improvement because:

At the time of our inspection, there were 743 patients on the treatment waiting list for more than the 18 weeks notional target. Of this total figure, 278 patients were waiting for treatment under General Anaesthesia (GA), including 172 children, some of whom were likely to be in pain. Some of the patients had been on the GA waiting list for nine to twelve months.
The service completed risk assessments and audits and some of the results were stored centrally. The service did not have oversight of some of these documents and we observed action plans were not always completed.
The service did not have an effective system to ensure that all dentists in the emergency dental service and University of Central Lancashire, with honorary contracts, were up to date with continuing professional development and registration requirements issued by the General Dental Council.
The service and commissioners had developed a set of acceptance and discharge criteria so that only the most appropriate patients were seen by the service. The service had not taken steps in the last 12 months to work with referring dentists to identify inappropriate referrals and to review processes surrounding this to effectively manage the waiting list.

However:

Staff reported incidents appropriately. Incidents were investigated, the results of the investigation shared, and there was evidence of lessons learned.
Staff understood their safeguarding responsibilities and could describe the safeguarding policies and procedures. Staff had up to date safeguarding training at the appropriate level.
Staff stored, handled and administered medicines safely.
Staff maintained equipment well and it was fit for purpose.
Staffing levels were appropriate and met patients’ needs at the time of inspection.
Patients’ care records were comprehensive and included the information required to keep people safe. Relevant information was recorded appropriately and staff had access to the information they needed before providing care.
Standards of cleanliness and hygiene were generally well maintained. Systems were effective in preventing and protecting people from healthcare associated infection.
Mandatory training was provided for staff and compliance met or exceeded the trust targets in most topics.
Staff had the necessary qualifications and skills they needed to carry out their roles effectively. Further training and development opportunities were available for staff.
Appropriate systems were used to respond to medical emergencies.
Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
The service followed effective evidence based care and treatment policies which were based on national guidance.
There was evidence of good multidisciplinary working with staff. Teams and services worked together to deliver effective care and treatment.
During the inspection, we saw and were told by patients, that all staff working in the service were kind, caring and compassionate at every stage of their treatment.
People were treated respectfully and their privacy was maintained in person and through the actions of staff to maintain confidentiality and dignity.
Staffs were sensitive to the needs of all patients and were skilled in supporting patients and young people with disabilities and complex needs. We saw there were systems to ensure that services were able to meet individual needs, for example, for people living with dementia and learning disabilities.
Staff involved patients and those close to them in aspects of their care and treatment. Information about treatment plans was provided to meet the needs of patients.
There was an effective system to record concerns and complaints about the service. Complaints were reviewed and actioned appropriately with a view to improving patient care.
Staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.
There was a very positive and forward looking attitude and culture apparent among the staff we spoke with.

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

We rated safe, effective and well led as requires improvement. We rated caring and responsive as good.
Although staff had Mental Capacity Act and Deprivation of Liberty Safeguards training, not all staff had an understanding.
Patient care documentation was a mixture of electronic and paper. Records were not all up to date or contained completed risk assessment and reviews. The records were not individualised and updated to reflect patient’s needs.
Managers used a dependency and acuity tool to determine safe staffing levels and had a staffing escalation plan in place. However, on some wards they used additional health care support workers to maintain safe staffing levels. This meant that on some occasions registered nurses were not able to take a break away from the ward in line with the national working time directive.

However:

Mental Capacity Act and Deprivation of Liberty Safeguard training was now compulsory for all staff. Compliance for the inpatient services in May 2017 was 100%, which exceeded the trust target of 80%.
All staff received mandatory training and had an appraisal.
Staff checked and ensured resuscitation and emergency equipment was ready for use.
Medicines management had improved since the last inspection.
Staff assessed patients who were at risk of falls are assessed and the occupational therapy staff used TOMS outcome measures.
Managers had introduced quality safety checks in inpatient services to assure themselves that quality was being monitored.
Managers shared learning from incidents and investigation was shared with staff.
The end of life document reflected national best practice guidance and contained a pathway for patients with mental health conditions.
There were strong multi-disciplinary team working relationships between therapists and nursing staff.

Some staff were concerned about the outcome of the service reviews and how that would affect the community wards and the forward strategy. However most staff we spoke with said that staff engagement and communication about proposals was positive.

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

We rated 8 of the 14 core services provided by the trust as requires improvement overall. This takes account of the previous ratings of core services that we did not inspect this time.
We rated safe, effective, responsive and well-led as requires improvement for the trust overall. Our rating for the trust took into account the previous ratings of services not inspected this time.
We rated well-led at the trust level as requires improvement. The trust was going through a period of significant change including the recent appointment of a new chair and chief executive. The roles and responsibilities of the executive team were under review to reflect the joint working arrangements with North Cumbria University Hospitals NHS Trust.
Managers did not review risk registers to ensure they were completed in line with trust policy. There was no direct link between the risk register and the board assurance framework.
Staff did not apply the Mental Capacity Act and Deprivation of Liberty standards were not consistently applied in services across the trust. The trust had not put in place a robust arrangement for monitoring compliance with the Mental Capacity Act and Deprivation of Liberty standards.
Risk assessments and care plans were limited within specialist mental health services for children and young people.
The service did not have sufficient numbers of appropriately skilled and qualified staff to deliver evidence based care in line with national guidance.
In some services waiting times for patients to receive assessment and then treatment were above local and national targets.

However:

The majority of patients and carers were positive about how staff provided their care and treatment.
The values of the trust were embedded throughout the organisation a positive and open culture. The majority of the staff we spoke to described a positive and open culture.
Staff across all services demonstrated a commitment to good patient care.
We rated caring as good and found it to be outstanding in community dental services and Wards for older people with mental health problems.
The senior management team were visible and engaged with staff in leading a significant change within the organisation.

We rated Cumbria Partnership NHS Foundation Trust as requires improvement because:

The recording of capacity to consent to treatment for detained patients could not always be found on the electronic care record system. It was unclear if responsible clinicians were completing capacity assessments at point of assessment.
There was not a robust system of psychiatric medical cover after 5pm or at weekends on Dova unit, Kentmere ward and Yewdale unit. There was not robust system of psychiatric medical cover after 12 midnight each day at Hadrian unit and Rowanwood.
Overall, mandatory training compliance was below the trust target of 80%.
There were missing signatures on medication charts on all wards.
A significant number of staff were not receiving an annual appraisal.
There was no dedicated psychology being delivered on two of the wards.

However:

There were clear processes to report and review incidents.
Staff used appropriate tools to assess risk and the needs of patients. Risk assessments were regularly reviewed.
Staff had a good understanding of safeguarding policies and procedures.
Patients felt well supported by staff and staff demonstrated a good understanding of the needs of patients.
Handovers and multi-disciplinary meetings were well structured and the introduction of the ‘acute admissions pathway’ was having a positive impact on daily practice.

Overall rating for this core service

Overall, we rated community health services for children, young people and families as good because:

The leadership, governance, and culture promoted the delivery of high quality person-centred care. Senior managers and staff had made significant improvements since CQC’s previous inspection, in November 2015. A strong, cohesive senior leadership team, supported by a proactive team of managers, had good oversight of risks and incidents, which they monitored and reviewed regularly.
Staff protected children and young people from avoidable harm and abuse, and they followed appropriate processes and procedures to keep them safe. The named nurse for safeguarding children had been instrumental in the establishment of a robust safeguarding supervision model, to ensure staff shared best practice and lessons learnt from serious incidents and serious case reviews involving children and young people.
Managers and staff managed caseloads well and there were effective handovers between health visitors and school nurses to keep children safe at all times. On a day-to-day basis, staff assessed, monitored, and managed risks to children and young people. This included risks to children who were subject to a child protection plan or who had complex health needs.
Children, young people, and families felt staff communicated with them effectively, kept them involved and informed about care and treatment, promoted the values of dignity and respect, and were kind and compassionate.
Services for children and young people were organised to meet the needs of children and young people. Managers and healthcare professionals from the team worked collaboratively with partner organisations and other agencies to ensure services provided choice, flexibility, and continuity of care.
Since the previous CQC inspection, in 2015, managers and staff had improved waiting times to ensure children and young people received the right care at the right time in community paediatrics, audiology, learning disability nursing, and physiotherapy. Although occupational therapy and speech and language therapy services waiting times were still outside of the required target, managers had taken appropriate action to reduce the time families had to wait.
Senior managers had developed a strategy that planned to introduce a new service delivery model, which included changes to the structure of the Care Group. Senior managers and staff had worked collaboratively with the local authority and commissioners and had proactively engaged with staff. The planned changes included the introduction of a dedicated team caring for the most vulnerable children and families across the county.

However:

Staff did not consistently complete care records within the required timescales recommended by the Nursing and Midwifery Council. Although staff had their own laptops, most did not use them to update patient records whilst away from their office base.
The trust did not provide a qualified specialist community public health nurse (SCPHN) for each secondary school in the county, which was in breach of Royal College of Nursing guidelines. Also, the school nursing service did not provide health promotion initiatives in local schools.
Morale was low amongst some staff due to the planned service changes. Although staff acknowledged senior leaders had shared information and provided regular updates, staff were unclear if their views had been included.

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

There was no clear process to review and learn from incidents. Staff did not feel they received constructive feedback following incidents.This had not improved since the previous inspection in November 2015.
Patients did not have access to occupational therapy support on the ward.
Compliance rates with some elements of mandatory training were below the trust target of 80% including training in Mental Health legislation.
Staff did not demonstrate a good understanding of duty of candour.

However:

Clinical practice had improved since the last inspection in November 2015, with the implementation of a positive behaviour support model.
There had been improvements in the quality of care plans, communication plans and discharge plans since the previous inspection in November 2015.
Staff used appropriate tools to assess risk and the needs of patients. Risk assessments were regularly reviewed.
Staff had a good understanding of safeguarding procedures and all staff had completed safeguarding adults training.
Patients felt well supported by staff and staff demonstrated a good understanding of the needs of patients, including their communication needs.

Overall we rated the end of life care services by Cumbria Partnership NHS Foundation Trust hospital as requires improvement. We rated safety, caring and responsive as good and effectiveness and being well-led as requires improvement. We identified areas where there was potential for improvement and these had been acknowledged by the trust. We saw evidence that work was in progress to address the shortfalls and improve the services. We have rated well-led as requiring improvement. This is due to the lack of monitoring of quality, lack of evidence of patient choice in treatment arrangements and the lack of measurement of the organisational performance against other similar services.

We saw good evidence that incidents were reported, investigated and outcomes were shared with staff and action taken to avoid it happening again.

Staff had a good understanding of the procedures for making safeguarding referrals. Patients and family members told us that they were satisfied that staff members respected their wishes and that they did not feel threatened or worried by them.

We observed staff adhering to the infection prevention and control policies when attending to patients. When visiting patients, staff carried with them hand gel and personal protective equipment and used them appropriately.

District nurses said that their jobs were challenging as they had high caseloads and also hadg to travel long distances when visiting patients in their homes. They said they prioritised and ensured patients with end of life care and palliative care needs were attended to. Community nurse specialists also got involved and worked alongside by delivering advice and treatment in the community.

Patients and families told us that staff continuously assessed the level of pain and administered appropriate pain relief. Although pain killers were in use, staff also introduced patients to other ways of relaxing and easing pain, such as aromatherapy and massage. Anticipatory medication prescriptions for pain relief were in use for people requiring end of life care and it was managed by district nurses or the community nurse specialists.

We attended two multidisciplinary meetings and found them patient focused, discussions were open, transparent and all attendees’ views were considered when decisions were made about the management of patients. At each meeting in-patients and community patients were discussed.

We observed examples where staff sought valid consent from patients and gave patients time to understand what was discussed. Staff did not hesitate to revisit discussions when they found the patient was having difficulty concentrating.

Patients and their family members told us that staff were sensitive to their feelings and able to support when they were distressed. They said nothing was too small for staff and ‘went that extra mile’ to help them resolve problems.

Part of planning and offering care for palliative and end of life care patients meant that patients after treatment had to travel long distances between treatment centres and their homes/ community hospitals. Although this could not be helped, patients and carers said this was distressing for them. They said a lack of choice and the lack of treatment centres near them made it difficult for everybody.

People who used the services told us that they knew how to make a formal complaint and said that they were confident to speak up if they were unsatisfied.

We received positive comments from patients and relatives which confirmed that end of life and palliative care patients received a seamless service between the hospital and the community. We saw that the trust governance arrangements included the local GPs; where agreement had been reached to work to Gold standard frame work.

Medical, nursing staff and managers were fully aware of the required improvements in the service and also the need for up-skilling staff to sustain good quality care. Further work identified were: end of life care Pathway was not established and this remained on their risk register, Care of the Dying Patient programme had not been implemented and a meeting with the acute trust was held to take this forward and there were plans to fund Care of the Dying facilitators and provide education for staff.

We found that the trust was performing at a level which resulted in a rating of Requires Improvement because:

In some services, the assessment of patients’ needs was not always holistic and there was limited evidence of the patients’ participation in developing their plan of care.

The trust has both electronic and paper care records in use across services. Not all staff had access to current, complete and contemporaneous care records to support the care and treatment of patients. The trust had a project in place to move to a single electronic care record across services. However, its implementation was delayed with the implementation taking place through 2016.

The trust did not have a named nurse for children’s safeguarding at the time of the inspection, although we were told that this post had been filled. A duty rota was in place to give advice and support to staff. The systems and frameworks for safeguarding procedures and safeguarding supervision were in early development. Safeguarding supervision had been incorporated into managerial supervison and training for managers was taking place.

The requirements of the Mental Capacity Act (2005), including deprivation of liberty standards, were not being met in some services. Patients’ capacity and ability to consent to their care and treatment was not routinely documented in care records.

Managers and staff did not have a clear understanding of Mental Capacity Act (2005) including deprivation of liberty standards. The trust did not have a system to monitor how they meet the requirements of the Act.

The trust did not have a restrictive interventions reduction programme in place to meet Department of Health guidance.

The environment of the health based places of safety in Carlisle and Kendal did not meet the expected standard to meet national guidance. This placed people who used these services at risk and did not provide an environment which supported good care and treatment.

On Kentmere ward, and Victoria Cottage hospital the environment did not meet all the requirements of the Department of Health guidance on same sex accommodation.

Mandatory training compliance in the trust was variable across services and 63% overall. This was below the trust target of 80%. The trust’s appraisal rate was 49% for non-medical staff. This was below the appraisal rate we would expect in an NHS trust.

The trust did not have a robust system in place to record staff training and appraisal. Individual and team records did not match centrally held trust records on training attendance. Therefore the trust could not be assured staff had received training to maintain their skills and knowledge to carry out their roles safely and effectively and were up to date with changes to best practice.

In some services, national best practice and guidance was not being followed in relation to the availability of suitably trained or skilled staff. In other areas, we found vacant posts within multidisciplinary teams such as consultant psychiatry and occupational therapy.

The trust did not have a robust process in place to ensure that trust policies and procedures were reviewed within agreed timescales. The meant that policies and procedures may not always reflect current good practice or changes in legislation.

Participation in clinical audit and the learning and improvement from these audits was variable across services.
Within community health services for children and young people, there was no paediatric resuscitation equipment in areas where children attended for treatment for minor injury and illnesses. In addition, there were no paediatric trained staff at these centres.

However:

The trust had a clear strategy, which established its long term vision and strategic goals, underpinned by the values of the organisation.

Staff treated patients and their relatives with kindness, dignity, respect and compassion.

Most patients shared positive experiences of care and treatment from the services they used.

There was evidence of good communication between professionals involved in providing care and treatment to patients through structured handovers and multi-disciplinary meetings in most services.

In community health services for adults, the referral to treatment times in relation to physiotherapy, diabetes and neuroscience were similar or better than the national target.

Overall we rated this service as requires improvement.

Staff across all locations reported incidents and the service had high rate of reporting of incidents. However we found there was limited evidence of learning from these incidents. Throughout the inspection we saw some care records were comprehensive but we found they were not always individualised and some care records lacked assessments and care plans. We saw the records were not standardised across the service.

Ward areas were very clean and tidy but there was insufficient storage space in a majority of the locations we visited. There was a lack of equipment for staff to use to help keep patients safe and some equipment was not properly checked or maintained.

People’s care and treatment was planned following assessment but this was not individualised. There was little evidence of current evidence based guidance being used and no outcome measures were available.

Staff were caring and respected people’s privacy and dignity but on occasions we found staffing levels to be low which increased the risk of harm to patients.

Most people were involved in their care and treatment and also in any decisions made regarding their care and treatment. However, there was limited understanding of the implementation of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (2008) across the service. This led to poor recording of individual’s mental capacity and any decision making processes where a person lacked capacity.

The service worked actively with local health and social care organisation to ensure patients’ needs were met through the way services were organised and delivered but the service lacked an overall strategy and had not fully engaged with the staff regarding plans for the future.

Across the service we found a lack of assurance in governance processes. Many policies were out of date and there was a lack of senior management visibility to most front line staff across the service however the geography of the area covered by the service is very challenging There was a clinical governance structure, but there was limited evidence in the way the service robustly managed risks through action planning and dissemination of information to front line staff.

Some locations we visited lacked nursing leadership and mandatory training and staff appraisal rates were both below the Trust target.

Overall rating for this core service was good:

Staff were encouraged to report incidents and systems were in place following investigation to help rapidly disseminate learning.

The delivery of care and treatment was based on guidance issued by professional and expert bodies such as the National Institute for Health and Care Excellence (NICE) guidelines in the treatment of head injury.

Patients had self-management plans to help them to stay well and manage long-lasting respiratory conditions; therefore they avoided hospital admission. The response times to treatment in relation to restorative dentistry, physiotherapy, diabetes, and neuroscience were good.

Patients and their relatives were treated with kindness, dignity and respect, and we saw compassionate care being delivered.

The service was planned and delivered to meet patient needs. People with urgent care needs were prioritised for treatment and their needs were met in a timely way. Patients waited less than 18 weeks for a first appointment relating to physiotherapy, diabetes, and neuroscience. This was similar or better than the national target of 95% for a first appointment to attend these specialist services within 18 weeks.

Complaints were taken seriously, discussed with staff in their team meetings and included lessons learnt.

The service had a vision, mission and strategy which they clearly published for people and staff to see. Their values were known by staff. The chief executive and their team encouraged people and staff to have a voice and contribute to the way the service developed.

There was good local management and leadership. However, due to the recently restructure of the service some staff did not have confidence in the changes and told us they did not feel supported by middle management. They felt the changes in working practices relating to staffing, had not been fully discussed and they had not felt listened to.

The trust produced a ‘Trust Talk’ newsletter for patients, the public and members of staff. The newsletter kept people up to date with information about the services and included patient stories and challenges the trust needed to address.

We also found:

Work had commenced to review staffing levels in relation to caseloads and service provision. However, not all actions had been fully implemented or embedded in practice. In some areas there were shortfalls in staffing and although due to the goodwill of staff they continued to provide a service, they were not able to fully meet the needs of the patients.

Data showed mandatory training compliance across the teams was 75% with a trust target of 80%.

Training had been added to the risk register for the community teams in the north and south of Cumbria and the physiotherapy team in Furness. The service had an action plan, with a review date to address the concern and for staff to access training.

Information provided by the trust showed not all non-medical staff had an appraisal in the last 12 months. However, records held locally showed staff had received a 12 months appraisal, or they had a date booked when their appraisal would take place.

Record keeping was generally of a good standard. However, not all staff had been consistently recording in both electronic and paper care documentation when the information related to the same patient. Managers were aware of these issues and were implementing through a pilot, the use of mobile laptops in the community. Staff also reported they were in the process and being supported to use the electronic form of record keeping. This meant paper records would not be used which would address the inconsistencies in record keeping.

Several policies were past their review date. This could have meant staff did not always follow up to date guidance.

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

The service did not provide the full range of evidence-based interventions recommended by the National Institute for Health and Care Excellence (NICE).
Risk assessments were not present or not updated in seven of the 27 care records we reviewed.
There was no target time from assessment to first treatment intervention and no system in place to monitor or review risk for those people on the waiting list for first treatment intervention.
Care plans were not present in eight of the 27 care records we reviewed. Where care plans were present, there was no evidence the people who used the service had been given a copy.
There was no permanent consultant psychiatrist in the south team. A number of locums had filled this post. This had adversely impacted on continuity of care for people who used the service.
There was no tool to calculate staffing levels or skill mix to respond to increasing caseloads
There was no comprehensive out-of-hours CAMHS provision, or tier two service.
Mandatory training figures showed non-compliance with trust targets, particularly Mental Capacity Act training.
Appraisal rates for non-medical staff were below trust target.
Clinical audit was not widely undertaken in the service.
The majority of recommendations from the 2012 CAMHS review were still to be implemented.

However:
Premises were clean and well maintained.
Target times for referral to assessment were being met.
Staff demonstrated a clear understanding of safeguarding policy and procedures.
Prescribing was initiated and reviewed by appropriately qualified and competent staff.
Staff were participating in the children and young people’s improving access to psychological therapies programme, which would increase the range of access to evidence-based interventions.
The service operated within a multidisciplinary team framework with a wide range of skill sets.
We observed interaction between staff and people who used the service and noted that people were treated respectfully.
People we spoke to who used the service and their parents or carers were generally happy with the service they received.

We rated Cumbria Community Learning Disability Team as good because :

staff were caring and treated patients with dignity and respect
people had mostly been involved in the development of their care plans
staff responded quickly to changes in people’s health or level of risk and there were no waiting lists for initial assessment
complaints were listened and responded to appropriately
all staff had received safeguarding training and had a good understanding of how to raise and report safeguarding concerns or alerts
there were effective processes for managing staff caseloads
staff worked effectively to lone working practices and adhered to the trust policies and procedures

However:

Care records had inconsistencies and gaps that meant some people had incomplete risk assessment plans, reviews and recording of risks.
Care plans did not always demonstrate holistic, person-centred or treatment focused care in line with best practice guidance, such as positive behavioural support plans. Care records did not contain any evidence of advance decisions.
People did not receive care in accordance with their assessed needs. The service did not follow best practice and guidance in relation to supporting patients with communication difficulties and complex behaviours.
care records were difficult to navigate, this meant that important patient documents and information was not always easily found within the care records
the service had experienced continuing difficulties with staffing, including recruitment, retention and sickness, which meant that staffing, was not adequate to meet the needs of the people who use the service
some of the community teams did not have a full complement of professionals within their multi-disciplinary team which meant that people could not always access these professionals in a timely and effective way
staff appraisal figures were low with an average percentage of staff in the service that had received an appraisal in the last 12 months at 39% and non-medical staff appraisals averaging 30%
there was a lack of consistency across the service for people accessing treatment following assessment

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

The service was fully staffed, with a sufficient skill mix to meet patients individual treatment needs. The trust set target times for referral to triage/assessment of 15 days and all four teams were meeting this target. Staff knew what they had to do to keep themselves and patients safe.
Staff used evidence based tools and assessments to measure needs and risk. Outcome measures were used to assess the effectiveness of treatment and the services took part in audits to improve the quality of care. Staff had access to specialist training for their role and worked well with other services to meet all the needs of the patients.
Staff treated patients and carers with dignity and respect. Appointments were rarely cancelled and patients reported that staff were very accessible. Patients were given time to ask questions and felt supported by staff. All of the patients and carers we spoke with felt positively about their care and treatment. Carers were offered support with identified carers leads based in each team.
The CMHS had a commitment to quality improvement and innovation and was involved in research projects and innovative practices.

However:

Patients’ records were not always complete, accurate and up to date. They did not always reflect the involvement of the patient in planning their care and treatment.
Staff had a variable understanding of the Mental Capacity Act in practice. Patients’ records did not always evidence that a capacity assessment had been completed where required, or that consent to treatment had been sought.

we rated community based mental health services for adults of working age as good because:

the environment at the team bases were clean and there were systems in place for reporting required estates work
staffing levels were safe, bank and agency staff who knew the service were used and recruitment was in progress for vacancies. The teams were multi-disciplinary consisting of psychiatrists, psychologists, nurses, social workers, occupational therapists and support workers

risk assessments were recorded and updated regularly. Physical health care needs were considered and comprehensive assessments were completed in a timely manner. Records showed care was recovery orientated and personalised. Confidential information was stored and moved securely

all staff had a good understanding of safeguarding and understood their responsibilities in reporting concerns. Safeguarding champions had been identified in teams. CMHTs had good arrangements for the management of medicines

there was an effective incident reporting system in place and staff knew how to report incidents. De-briefs were offered and there was shared learning from serious incidents. Staff were aware of their responsibilities in relation to the duty of candour and formal complaints from patients were received and monitored by the patient experience team

all newly recruited staff received corporate and local induction. Role specific training needs were identified and staff had received training such as cognitive behavioural therapy and physical health care. Supervision protocols were in place and staff attended regular team meetings. Staff were aware of and followed National Institute for Health and Care Excellence (NICE) guidance. Outcome measures were used to evaluate the effectiveness of care and treatment
staff were respectful and caring when they spoke with people and there was positive feedback from people who used the services. People said they felt staff listened to them and they were involved in their care planning and treatment.Staff offered carers assessments and provided support
patients were assessed in a timely manner and teams took active steps to engage with people who used the service. Patients could access help outside normal working hours from the crisis team. Teams were recovery focused and decisions to discharge patients were agreed within the multi-disciplinary team. Rooms were accessible for people with disabilities and available for confidential discussions. Information was displayed such as advocacy services and how to complain
managers used key performance indicators to gauge the performance of their teams such as time from referral to assessment and contact with general practitioners. There was sufficient administrative support available to team managers
managers were able to use the trust absence policy to support staff in their return to work. Staff reported a supportive team culture and were confident about raising concerns without fear of victimisation.

However;

staff identified that the transition of young people from the community mental health services for children and young people (CAMHS) did not always occur from the age of 17 and a half as stated in the trust policies.The trust recognised improving transition from children’s services as a priority for 2014-15. This meant that staff did not always work together to assess and plan ongoing care and treatment in a timely way when people move between services or teams
the mandatory training rate across the teams was 67% which was below the 80% compliance level expected by the trust. Adherence to the trust Mental Health Act and Mental Health Act Code of Practice mandatory training was 55%
teams were using a combination of paper and electronic records in order to maintain a complete record in respect of each patient. Staff regarded the paper record as the primary record of patient care and treatment however, paper records were not always complete and contemporaneous. Transfer of paper records between teams were delayed whilst awaiting typed notes to be filed
a list of patient names were visible from the reception area at one team base. This meant patients’ confidentiality was not being maintained and we requested this be removed immediately
staff did not routinely participate in clinical audit and were not aware of any trust wide audits that had taken place involving their services. This meant staff were not involved in activities to monitor and improve people’s outcomes
the trust reported 38% of non-medical staff had an appraisal in the past 12 months for the CMHTs. Individual clinical supervision was not fully embedded in all the teams we visited
there were no trust targets to measure waiting times from assessment to treatment or allocation to a care co-ordinator. The waiting times across the teams we visited were varied and patients told us they were waiting too long for treatment
we did not see any evidence of how patient feedback was being routinely collected or used by the services we visited.

We rated mental health crisis services and health-based places of safety as good because:

There were sufficient staff within the crisis teams to ensure that patients received appropriate support.
The environment of the health based place of safety (HBPoS) at Barrow was good.
There was good multidisciplinary working in the crisis teams and good interagency working with the police around the crisis concordat work.
Staff were skilled with good levels of experienced Band 6 nurses within the crisis teams.
Crisis teams proactively attended the wards on a daily basis to facilitate patients’ discharge.
We saw staff providing person centred care to patients in a crisis.
Staff we spoke with demonstrated a caring attitude.
Crisis teams saw patients quickly, within two, four and 24 hour targets.
There was a single referral protocol to ensure referrals into the service were co-ordinated to ensure all key information was captured.
There were low numbers of complaints.
Staff were committed to providing good quality care in line with the trust’s vision and values.
Managers provided good leadership, were aware of the shortfalls and were working to address them.
There was good auditing of the use of section 136 activity.

However:

We found that the HBPoS at Kendal and Carlisle were not fit for purpose. There was a lack of washing or toilet facilities in these HBPoS and no risk assessments were used when patients in the HBPoS accessed the public toilet. The rooms were used for multiple purposes so may not be immediately available in an emergency. The furniture in the HBPoS was not suitable for its purpose.
Mandatory training levels of staff within the crisis teams were below trust targets.
The majority of staff from the ALIS teams who attended the HBPoS did not have the appropriate training to deal with episodes of violence or aggression.
Some patients had to wait more than nationally recommended three hours within the health based place of safety but the delays were beyond the trust’s control because of the lack of staff external to the trust. Delays were monitored and fed back to appropriate agencies through the audits of section 136.
Patients detained using section 136 of the Mental Health Act weren’t always informed of their rights in a timely manner and there were minor gaps in the recording of episodes of section 136, such as times of key events.

We found that the environment of the HBPoS breached regulations about premises and equipment. We have issued a requirement notice to the trust. We have asked for an action plan telling us how they will improve the environment of the HBPoS.

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

There were enough staff for people to receive the care and treatment they required
staff identified ligature points (places where someone intent on self-harm might tie something to strangle themselves) and took action to remove or minimise risks
the ward was clean and tidy and was maintained to a high standard
the staff were caring and treated patients in a respectful and dignified manner
there was good multidisciplinary team working and staff engaged well with community teams as well as outside organisations
there were no complaints about this service in the last twelve months
the clinical leadership on the ward was clear and all staff said that they felt supported and listened to
staff were aware of the trust vision and values and were committed to providing good care in line with this.

However:

Patients’ bedrooms were on the first floor of the building except two bedrooms on the ground floor. There was no nurse call system or alarm system in patients’ bedrooms. There were blind spots on the first floor, these were mitigated by the use of parabolic mirrors. However, staff did not routinely work on the first floor, the only staff presence was during hourly observations. This meant there patients had no means of summoning staff help or support in an emergency. This is a breach of regulation 12 of the Health and Social Care Act 2008.

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

Staff had limited access to specialist training to ensure patient needs could be met effectively.
There was no formal process for learning when things went wrong or when incidents occurred.
The ward did not have any plans in place to evaluate and minimise the use of restrictive practice.
Management of medication required some improvements.
Care and treatment was not planned and delivered in line with best practice guidance.
Care plans were not holistic, person-centred or treatment focused.
There was limited assessment of patients communication needs across the ward.
None of the patients had a discharge plan in place.
The clinical leadership on the ward was not clear and all staff reported that they felt the ward felt disorganised and chaotic.
Only 11% of non-clinical staff had received supervision and appraisal
Only 71% of staff had received mandatory training.

However:

There was sufficient staff on duty to ensure the safety and well-being of patients.
Each patient had a comprehensive risk assessment in place that was up to date.
The service carried out audits of ligature points (fixed objects/fittings where someone might tie something with intent to strangle themselves) and where they were identified action was taken to minimise the risk of harm.
The ward was spacious, clean and safe.
Staff were caring and treated patients with dignity and respect.
Complaints were listened and responded to appropriately.
Patients had health action plans in place, and medical needs were responded too.
Staff were aware of the trust vision and values and acknowledged the service required improvements but were committed to providing good care to patients.

We rated Cumbria Partnership NHS Foundation Trust as requires improvement because:

The trust did not have robust arrangements for psychiatric medical cover out of hours.
Staff had a varied understanding of the Mental Capacity Act. Patient records did not always show that staff sought consent for treatment or completed required capacity assessments.
Dormitory-style bedrooms on Oakwood unit did not promote patient privacy and dignity.
Staff appraisal rates were low. Only 34% of staff on Ramsey unit had completed appraisals, 5.13% on Ruskin and 12% on Oakwood unit.
Mandatory training rates among staff were below trust requirements.

However

The wards were clean, spacious, safe and secure. They were also patient and age friendly and offered pleasant outdoor areas as well as various rooms and activities.
Staff used evidence-based tools to assess, monitor, and manage individual patient needs and risks. Staff also used outcome measures to assess treatment effectiveness.
The trust provided staff with access to specialist training for their roles. It also supported clinicians to attend further training for career progression and to improve their clinical effectiveness.
Staff treated patients and carers with dignity and respect. They gave patients time as necessary, were enthusiastic and positive, and had a good understanding of patients’ needs and how to meet them.
All patients and carers we spoke with were positive about the service’s care and treatment, and patients said they felt well supported. The service had a carers’ support group.
The wards participated in an innovative pathway-wide project called ‘#seethe person’. The project moves the focus of care away from a patient’s diagnosis or symptoms and onto their individual needs. Staff had a commitment to quality improvement and innovation. Clinicians took part in audits to improve the quality of care.

We rated this core service as requires improvement because:

There was no psychiatric junior doctor medical cover after 5pm or at weekends on Dova unit, Kentmere ward and Yewdale unit. There was no psychiatric junior doctor medical cover after 12 midnight at Hadrian unit and Rowanwood.
Privacy, dignity and safety had been compromised on Kentmere ward. A female patient occupied a side room where male patients passed in order to access the bathroom. The female patient needed to pass the male dormitory in order to access the female bathroom and toilet.
Staff did not always demonstrate application of the mental capacity act in practice.
There were issues related to recording compliance with the Mental Health Act 1983.
There was a restrictive practice of locked doors operating across the acute wards without clear justification.
Overall compliance with mandatory training was low and did not meet the Trust target of 80%.
All wards used restraint and compliance with basic life support with defibrillator training was below the trust target of 80%

However:

We saw consistently kind and appropriate interactions between staff and patients. Multidisciplinary working was evident across all the wards. Handovers and ward rounds were well-structured and comprehensive, with team members sharing the relevant information.

A daily bed management teleconference call helped to ensure there were sufficient beds available for people requiring acute care or psychiatric intensive care.

There were highly visible, enthusiastic and innovative ward managers on each ward.

Overall, we rated the service as inadequate.

The trust did not have robust safeguarding systems and processes in place. There was no senior children’s safeguarding lead to provide leadership and oversight of safeguarding systems or support for staff. The trust had recently appointed a named nurse for children’s safeguarding but this post remained vacant at the time of the inspection. Staff did not have access to a framework for safeguarding supervision in line with national recommendations.

There was no paediatric resuscitation equipment in two locations where children attended for treatment for minor injury and illnesses. There were also no paediatric trained staff at these nurse led treatment centres, and staff did not take part in paediatric life support training. This posed a risk for children whose health may deteriorate whilst at a minor injuries unit. Data provided by the trust showed that children and young people under the age of 16 accounted for 21.4% of attendees across the five minor injury units.

Some policies were out of date for review for example, infection control. It was not clear who had responsibility, in the service, to ensure policies were up dated in a timely way and ensure they reflected evidenced based practice. The children’s community nursing service could not show us any specific policies on which they based their care, but said they were in the process of looking at NICE guidelines.

The trust was not achieving the national target of 95% of children being seen within 18 weeks in out-patients departments, across the services provided. The trust had its own target of 92% of children receiving an out-patients appointment from the time of referral: - however, services were still not achieving this. In the speech and language therapy service, only 50% of referrals were seen within 18 weeks. The trust had a recovery plan in place to reduce waiting times for children: however, the trust trajectory report showed waiting times would increase over time, due to lack of appointment times commissioned.

It was not clear from the trust’s strategy for children, how young people contributed to the transformation and shaping of services, or how the trust embedded the voice of children in its strategy and vision to ensure their rights and views were promoted.

There were 96 risks reported between 1 July 2015 and 31 October 2015 on the trust wide risk log for children’s community services. The risk register had gaps in review dates and control measures to mitigate risks. There was a clinical governance structure in place, but there was limited evidence in the way the trust robustly managed risks through action planning and dissemination of information. Recommendations from audits and service reviews were not acted upon, to improve services and the safeguarding of children.

There was not a culture of sharing best practice across the teams in the county: staff expressed a lack of cohesiveness in the services provided. However, staff talked about a change in culture since a change in management at trust board level. They felt that the culture had moved from one of blame, to a more open and trusting culture, where they could raise their concerns and feel listened to.

Parents and carers were positive about the care they received from the community children’s services. People we spoke to told us they were treated with compassion, dignity and respect. They were provided with information about their child’s care, in a way they could understand, and were given the opportunity to contribute to their care plan and treatment.

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.

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