All inspections: Pennine Care NHS Foundation Trust

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

Staff did not consistently monitor or document the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care Excellence guidance, especially when the patient was prescribed a high dose of antipsychotic medication and rapid tranquilisation.

The trust had not fully implemented the schedule 5 recommendations to prevent future deaths, for example providing psychological input as a critical treatment to all inpatient wards and to introduce one information technology system.

Staffing levels were insufficient to fully facilitate patients accessing their planned leave, one to one time and access to outside recreational activities. Blanket restrictions were also in place on all the wards we visited.

Staff did not always complete care plans that were personalised, holistic and recovery orientated. They did not always meet the needs for patients with protected characteristics. Psychological therapies were not available across all wards. The trust electronic record system was not fully accessible across all teams.

The information provided for patients with a learning disability was not always in a form accessible to them. The service did not always make adjustments for disabled patients.

Psychiatric intensive care unit beds were not always available within the trust when a patient required more intensive care. Female patients were unable to access a psychiatric intensive care unit bed within the trust.

Patients had access to outside space. However, on most of the wards the outside space was either locked or patients had to be accompanied by staff apart from Norbury ward where patients had access to a small garden freely. Patients and staff reported access to leisure facilities on all sites were restricted due to staff availability to accompany patients.

Although the trust had implemented audits throughout the adult inpatient wards the documentation audit was not effective to provide assurance that the collaborative care planning had been fully implemented and that care plans were produced to meet individual needs.

However:

The wards were safe and clean and the trust had implemented appropriate systems for managing the risks to patients belonging to the opposite gender. Risk assessments were in place for all the patient records we looked at apart from one on Taylor ward where specific risks had not considered nor assessed.

There were skilled staff able to deliver care and multidisciplinary and interagency team work was well established.

Patients were given a full physical health check on admission and at regular intervals thereafter. Physical health needs including referral to specialist services were completed in a timely manner and advice given to promote healthier lifestyles.

Feedback from patients and comments cards we received about the care and treatment they received were mostly positive. Our observations of staff confirmed staff treated patients with compassion, dignity and respect and involved them in making decisions about their individual care and treatment.

Staff planned for patients’ discharge, including good liaison with care managers/co-ordinators.

Consultation with patients, carers and staff had taken place to assist the trust in making future decisions about eliminating mixed sex wards.

There was a clear statement of vision and values displayed throughout the wards we visited. Staff were positive about the new management and proud about their work. Staff felt able to raise concerns without retribution.

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

We rated safe, effective and well led as requires improvement, caring and responsive as good. In rating the trust, we considered the previous ratings of the services we did not inspect this time in the overall rating.
Of the five services reviewed at this inspection we rated two as good, wards for older people with mental health problems and community dental services. We rated three as requires improvement community urgent care, mental health crisis services and health based places of safety and Acute wards for adults of working age and psychiatric intensive care units (PICU's).
Overall considering previously rated services and those undertaken at the inspection we rated one of the trust’s 17 services as outstanding, 10 as good and six as requires improvement.
Although several practice areas within the trust and service delivery had demonstrated improvement many of these quality improvements had not been in place for a sufficient time to demonstrate sustainability and assure the trust of the success of their implementation.
There was a risk of patients being harmed as there was limited assurance about safety measures in place to meet patient’s needs. There was an inconsistent practice throughout the organisation with lessons learnt not reliably shared with staff to support improvements in practice.
Staff did not consistently feel equality and diversity were promoted in their day to day work and when looking at opportunities for career progression. There had been a deterioration in the previous 12 months for black, minority ethnic staff (BME) staff in recruitment, experience of bullying and opportunity within the trust.
The leadership, governance and culture did not consistently support the delivery of high-quality person-centred care. There was a variety of practice throughout the trust with limited sharing of best practice when identified.
Whilst there were clear systems in relation to the implementation of the of the Mental Health Act 1983 and its amendments 2007 (MHA) and the Mental Capacity Act 2005 (MCA); these were inconsistently understood and adhered to throughout the trust.
There were four breaches identified in relation to the fundamental standards.

However:

The rating of effective, caring and well led in wards for older people with mental health problems improved from requires improvement to good.
There was a clear commitment from the trust that the priority was its service to the local population and a drive to improve the quality of services. There was evidence of a significant positive change in the culture within the trust led by the senior leadership team.
Patients were supported by staff, treated with dignity and respect and were involved as partners in their care.
Overall most patients’ needs were met through the way care was organised and delivered.
There had been an increase in support to the divisions to develop their own communication and engagement strategies and encouraged staff to get involved with projects affecting the future of the trust.

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

Staff did not manage medicines safely. There were different arrangements and processes for storing and administering medicines across the teams. Records were incomplete and staff were not aware of how to act on concerns.
Staffing levels meant that managers were providing clinical work, this had a detrimental impact on their managerial tasks including providing regular supervision to staff.
The service was not following the requirements of the Mental Health Act. Patients in the health based places of safety did not routinely have their rights explained to them or have an assessment from an approved mental health practitioner.
Oversight was not sufficient to ensure staff received regular supervision, the Mental Health Act was adhered to, learning and good practice was shared with managers in other boroughs.
The services did not meet the needs of all patients. Information for patients was only available in English. Patients we spoke with were not aware of any opportunities that they could feedback about the service or any examples of where their feedback had been requested. Not all patients were aware of how to complain about the service.

However:

Improvements had been made to the facilities since the last inspection. The health based places of safety had all been refurbished and regular maintenance checks took place including legionella checks.
Safety had improved with detailed risk assessments in place for patients and staff followed lone working arrangements. Staff were aware of the duty of candour and were open and honest when an incident occurred, learning was shared with staff at team meetings.
Records contained assessments completed in a timely manner with evidence of patient involvement.
Feedback from patients and our observations showed staff were caring, supportive and responsive to the needs of patients.

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

The wards were safe and clean. Staff ensured people were safe and their privacy and dignity maintained and provided support that was appropriate to their needs.
Managers were able to bring in extra staff when they needed to so that there were enough staff on each shift.
The multi-disciplinary team that cared for patients included a range of disciplines and specialists.
Overall, staff followed National Institute for Health and Care Excellence guidance. There was a range of psychological interventions available. The service had introduced topical sessions to promote healthy lifestyles.
Staff ensured care planning was holistic and patient centred and they undertook regular reviews of risks.
Staff encouraged relevant outside agencies and carers to attend multi-disciplinary meetings.
We saw many positive interactions between staff and patients, their relatives and carers. Staff respected patients’ personal and cultural preferences. They made efforts to involve patients, their relatives and carers in care planning as much as possible. They explained patients’ rights under the Mental Health Act in a way that they could understand. They gave carers information about the carer’s assessment.
Patients, their relatives and carers had opportunities to give feedback about the service. Staff reviewed complaints and compliments regularly and used the learning from this to help improve the quality of care.
The ward was accessible to older people with disabilities including those with a mobility impairment.
Staff understood the trust ethos and explained how they applied the vision and values in their work.
Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity.
Effective governance systems and audits provided assurance.
There were examples of innovative practice and staff felt supported to take opportunities to make changes.

However:

Not all staff had a clear understanding of blanket restrictions as defined in the Mental Health Act Code of Practice.
Not all staff followed national guidance in relation to medicines management consistently.
Frequency of staff supervision did not follow the trust policy.
There were no formal arrangements to monitor adherence to the Mental Capacity Act. Staff did not record best interest decisions in a consistent way.
Information was not always available in a format that was accessible by different patient groups.
Staff used a combination of paper and electronic records and they were expected to record information in more than one system. They said this did not cause them any difficulty in entering or accessing information on the ward. However, the records were not easy to navigate and information was held in different places. Staff said that using different recording methods meant sharing information was difficult.
Some staff said they did not have opportunity to be involved in discussing service strategy.
There was no forum for discussion or sharing good practice across the service.

This was the first rating inspection of the Urgent care services.

We rated it as requires improvement because:

The service had put some systems to manage risk so that safety incidents were less likely to happen. However, these were recently developed and were not yet embedded sufficiently to provide the service with assurance that can recognise risks and take appropriate action in a timely manner.

The leadership, management and governance of the walk-in centre did not always assure the delivery of high-quality and person-centred care. There had been a recent review of the governance arrangements which had brought about strengthening of the vision and strategy for the future development of the service.

Systems and processes to ensure staff learned from the incidents and complaints to improve their practice were not consistent to provide appropriate learning for staff. This issue was being addressed as part of an improvement plan.

Staff did not consistently receive suitable supervision or mandatory training to meet their job roles. There was inconsistency noted from staff in their involvement in meetings and awareness of support from senior managers.

Systems were in place to ensure patients were safeguarded from abuse and harm.

Staff involved and treated patients with compassion, kindness, dignity and respect.

Patients could access care and treatment from the service within an appropriate timescale for their needs.

The facilities and premises were appropriate for the services that were delivered.

The service took account of patients’ needs and choices.

There was now a focus on improvement and learning in the team.

This service has not been inspected before. We rated it as good because:

Staff had the qualifications, skills and experience to keep patients safe. They had access to training to support their roles.
Systems and processes were in place to deal with patients becoming acutely unwell.
Staff reported incidents and accidents, these were investigated and acted upon to reduce the chance of re-occurrence.
Infection control procedures were in line with nationally recognised guidance.
Staff were aware about issues relating to safeguarding and there were systems in place to refer children and vulnerable adults.
Staff provided care and treatment based on nationally recognised guidance.
There was an effective skill mix at the service to assist with the ever-increasing complexity of patient. Staff worked together as a team and with other healthcare professionals in the best interest of patients.
The service was proactive to improve the oral health of the local community.
Staff understood their responsibilities under the Mental Capacity Act 2005 and with regards to Gillick competence.
Staff cared for patients with compassion. We observed staff treating patients with dignity and respect.
Feedback from patients was positive. They told us staff were friendly, caring, informative and helpful.
The service considered patients’ individual needs. Clinics had been adapted to ensure they were accessible for all patients.
The appointment system met patients’ needs.
The service dealt with complaints positively and efficiently.
There was a clearly defined management structure. Managers had the right skills and abilities to provide high quality sustainable care.
There were systems and processes in place for identifying risks and planning to reduce them.
Staff engaged with patients and other healthcare professionals to continually improve the service.

However:

Recommendations from the routine test of an X-ray machine had not been identified or actioned.
Audits of X-rays did not reflect nationally recognised guidance and was not dentist specific.
Communication between teams was not consistent. Managers did not always know about risks relevant to the dental service.

We did not rate wards for older people with mental health problems at this inspection. This was a focused inspection, where we inspected part of the ‘safe’ domain. We checked whether improvements had been made following our last inspection and followed up information we had received about incidents. We rated safe as requires improvement at our last inspection in June 2016. The trust told us that it was still implementing its action plan to address this.

On this inspection, we found the following areas where the trust needed to improve:

Staff were not fully managing the risks of providing mixed gender environments
There were gaps in records where staff had identified and assessed risks but not put plans in place to manage them. For example moving and handling, falls risks and antipsychotic monitoring.
At the time of our inspection, actual staffing levels at night on Saffron ward were not sufficient to meet people’s needs or keep people safe.
When patients received rapid tranquilisation to reduce severe agitation or aggression, staff were not always completing physical health checks to make sure that the risks to patients’ physical health were managed.
There were environmental issues including clinic rooms which were too hot, handwashing facilities that did not meet national guidance and temporary repairs to an electric plug that was a potential fire hazard.
There were gaps in the assurance process for risk management as senior managers were not always aware of significant incidents and risks were not always fully managed when they were identified.
There was poor access to falls risk equipment across some of the wards even when indicated on individual patient need.

However, we also found the following areas of good practice:

There was improved uptake of mandatory training of staff including improved levels of basic and intermediate life support training.
There had been improvements to the overall environment of Cedars ward.
We received good feedback from patients and carers who told us that they felt safe.
Staff completed ligature risk assessments and environmental checks to ensure the wards provided safe environments.
Apart from Saffron ward, there were sufficient staff to keep patients safe and ensure their needs were met and staffing levels at Oldham had been maintained to improve therapeutic engagement.

This was a focused inspection, where we inspected part of the ‘safe’ key question. We checked whether improvements had been made following our last inspection and followed up information we had received about incidents. We rated safe as requires improvement at our last inspection in June 2016. The trust told us that it was still implementing its action plan to address this. This was consistent with our findings, which showed improvements in some areas, but others that still needed to be addressed.

We did not rate acute wards for working age adults and psychiatric intensive care units at this inspection.

We found the following issues that the service provider needs to improve:

The trust was not effectively managing the risks of mixed sex accommodation. There were still occasions when patients had to sleep in a room other than a bedroom, because there was not a bed available.

Incident investigations were of a variable quality and learning was not always shared effectively.

The trust had a policy for nursing patients away from others, but as patients were not always able to leave when they wished, this appeared to be seclusion, without the necessary safeguards or monitoring.

There was a longstanding, persistent smell in the Taylor ward female lounge.

However, we also found the following areas of good practice:

The trust was now storing medicines safely.

Staff had completed most of their mandatory training. Most qualified nurses had completed immediate life support training, so there was always a suitably skilled nurse available in the event of a medical emergency.

The patients were spoke with were mostly positive about the staff and the service they received.

Risk assessments were carried out, and plans of care developed from these. The completeness and quality of the documentation of this was variable, but had improved since the last inspection.

Pennine Care NHS Foundation trust adult community provides services across six Greater Manchester boroughs or local authorities. Bury, Oldham, Rochdale, Heywood, Middleton and Trafford.

Adult services are commissioned by four clinical commissioning groups (CCG’s). Bury; Oldham; Rochdale, Heywood and Middleton and Trafford. Services are configured to match the CCG locations.

Adult nursing and therapies services provided by the trust includes:-

district nursing
palliative care
physiotherapy
audiology
podiatry
speech and language therapy
weight management service
wheelchair services
occupational therapy
nutrition and dietetics
tissue viability
community enhanced care services
services supporting the management of long-term conditions such as pulmonary rehabilitation, expert patients, vascular diseases and cardiac rehabilitation.

Overall rating for this core service Requires Improvement

We rated this service as requires improvement because.

Insufficient numbers of staff had completed Mental Capacity Act and Deprivation of Liberty Safeguard training.

Efforts to integrate Trafford services into the main body of the organisation were ongoing.

Staff said and minutes of meetings also indicated that at the time of the inspection Trafford staff felt isolated from the rest of the Pennine Care NHS Foundation trust.

However

The trust ensured care and treatment was based on best practice guidance.

The trust promoted and encouraged staff involvement with local and national patient outcome audits.

The trust frequently monitored the quality of the services provided.

Patients rated the trust highly and evidence indicated they felt involved in planning their care and were satisfied with the standard of care.

There were innovative services provided by the trust, for example the chronic obstructive pulmonary disease advisory service.

Processes and systems were in place to ensure lessons were learnt from incidents and complaints.

We rated substance misuse services as GOOD because:

The building was clean and well maintained. There was good provision of facilities including consultation rooms and group rooms. A range of information was available to clients in the waiting room.
Staff assessed clients’ needs and risk on admission to the service. Assessments were comprehensive and reflected in treatment plans.
The service employed staff and volunteers with lived experience of addiction. This was in line with the recommendations of the Strang report (2012).
There were strong links with external services and the local recovery community. Clients were encouraged and supported to develop recovery capital and access support.
Staff were knowledgeable around safeguarding and understood trust policies and procedures in this regard. There were good links with local safeguarding bodies.
Staff treated clients with respect and understanding. Feedback we received from clients was positive. Clients were actively involved in decisions about their care and treatment. Support groups were run for family members and carers of clients.
There was a process in place to report adverse incidents. Staff knew how to report incidents and there was a process to launch a formal investigation where required. There was evidence of learning from incidents.
Senior management was a visible presence. Performance monitoring was in place.

However:

The introduction of a new service model had caused low staff morale. The new model was in response to changed funding levels. Staff had been consulted and invited to submit their own proposed service models.
Compliance with clinical supervision and annual appraisal was either low or hard to evidence.

Overall rating for this core service Good lWe rated Community inpatients at Pennine Care NHS Foundation Trust as good.

This was because:

Incidents were reported through effective systems and lessons learnt or improvements made following investigations were shared.
The wards were visibly clean and spacious across both of the sites we visited.
Staff followed good hygiene practices and the trust had policies and procedures in place.

There were good systems for handling and disposing of medicines.
There was good evidence of multidisciplinary team working with regular meetings held to review patient’s ongoing development and needs.
Care provided was patient centred and patients were involved in their care and planning individual goals. Patients were observed receiving compassionate care and their privacy and dignity was maintained.
Staff were proud about their work and told us they felt supported and part of the team.
Staff had access to information they required, for example diagnostic tests and risk assessments.
Staff were aware of their role and responsibilities around the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards.
Best practice guidance in relation to care and treatment was followed.
Community inpatient service participated in National Audit of Intermediate Care audit and local audits and action plans formulated following the results of audits.

However,

Planned staffing levels on some of the units during the night were not always sufficient; however bank and agency staff were used on a regular basis to support safe staffing levels.
Overall compliance with mandatory training for the majority of staff was below trust target. The trust target was 95%.
A small number of staff across the units had attended Mental Capacity Act and deprivation of Liberties training.
Not all staff had access to clinical supervision provided by the trust.

We rated the community children, young people, and families services (the services) at the Pennine Care NHS Foundation Trust (the trust) as good.

This was because: -

Care and treatment across the children, young people and family’s services was provided in line with national and professional guidance and evidence based practice. Staff across all four of the boroughs (Bury, Oldham, Heywood Middleton and Rochdale, and Trafford) treated children and young people as individuals and involved them in their care and, when appropriate, in decisions about their care. Although not all services were open seven days a week, individual services worked flexibly to provide additional clinics in the evenings and weekends. To bring services closer to the local population clinics and appointments were provided in local children’s centres.

Staff were familiar with the trust’s incident reporting policy and understood their responsibilities to report safety and clinical incidents. People were told when things went wrong, and learning from incidents was shared at local levels within teams and boroughs, and across the organisation through emails, written bulletins and newsletters.

Reporting systems were in place to protect people from harm, abuse and neglect, and staff understood where they could obtain further advice on safeguarding issues. We saw evidence of referrals being made to other professionals and multi-agency teams when staff had concerns about children’s safety.

Staff were competent and passionate about the care and treatment they provided to children, young people and families, and there was effective multidisciplinary working within teams. However, some services we visited were experiencing capacity challenges, and longer waiting times, because of increased demand for their services. Plans had been put in place to improve waiting times in the affected services. Although we were told about one internal waiting list used in the children’s services in Heywood, Middleton and Rochdale, overall the plans put in place by services were showing evidence of improvement in waiting times as a result.

A new electronic computer system was being introduced across the trust, and there was varied progress towards the implementation of this across the services and boroughs. However, technology was used well to engage children, young people, and families with services. This included the introduction of Chat Health by the school nurse service, which enabled children and young people to book appointments with school nurses and ask health related questions. The Sugar3 (Sugar Cube) mobile phone app helped children with type 1 diabetes monitor and self-manage their condition. Plans were in place for all the services to develop a text messaging telehealth service called Florence (FLO). This was to help patients at home benefit from motivation and prompting; questions or education; or to report symptoms and home measurements.

Leaders of the services recognised the ethnically diverse population within each borough, areas of deprivation, and specific health issues affecting their communities. The services worked with the local community to ensure health visiting services met the cultural and religious needs of the local community. Although translation services were available throughout the services and boroughs, we saw little evidence of public health information being displayed in other languages in the treatment centres we visited.

There was good public engagement by the services through local patient forums and support groups. Carers and parents spoke positively about staff and the care provided to their children.

However,

There was a risk to the safety of people who used the school nurse service for vaccinations. This was because the service could not guarantee the ‘cold chain’ (ensuring an appropriate temperature range) for the storage and transportation of vaccines and medications as maximum and minimum storage temperatures were not recorded. Vaccines and medications stored outside the recommended temperature range may not be effective.

The Oldham children’s nutrition and dietetics service did not maintain accurate, complete, and contemporaneous records in respect of each service user. Records were of poor quality and did not always indicate what actions staff had taken following previous reviews of children within the service. This increased the risk that children were not kept safe because they may not receive continuity of care.

Care and treatment provided by the Heywood, Middleton and Rochdale speech and language therapy and occupational therapy services were not always provided in a timely way. This was due to high demand for the service and increasing caseloads, leading to long waiting times for treatment.

Staff understood and engaged with the trust’s strategy and vision; however, some staff were unsettled by the pace of commissioning and tendering changes, and were concerned about the future

Although some services were working towards agreeing consistent treatment pathways and procedures across borough boundaries, some staff told us they did not feel the boroughs worked together.

We rated Pennine Care NHS Foundation Trust as requires improvement overall because:

We rated six services as requires improvement, these were:

Wards for older people with mental health problems
Acute wards for working age adults and psychiatric intensive care units
Community based mental health services for adults of working age
Mental health crisis services and mental health-based places of safety
Community end of life care
Community health services for adults

The main areas for improvement were:

Department of Health guidance on same sex accommodation was breached in the wards for older people and the acute wards for working age adults and psychiatric intensive care units
Trust medicines management policy was not being observed in a number of the services we visited in recording, cancelling medicines, care plans for when required medicine and rapid tranquillisation. Temperatures for fridges and rooms were above the recommended guidance from the manufacture or the trust policy to safely store medicines. There were date expired needles and syringes in an emergency anaphylaxis kit in the Heywood, Middleton and Rochdale school nurse service at Milnrow Health Centre.
On Saffron ward, for older people, staff had not considered the need for a legal framework where people over the age of 16, who lack capacity, were subject to restrictions, which may amount to a deprivation on liberty. Consideration of best interest as detailed in the Mental Capacity Act Code of Practice, the Mental Health Act or the Deprivation of Liberty Safeguards. Patients’ capacity to consent to admission and treatment was not being assessed for patients admitted to Saffron ward. There were a number of patients on this ward who were not detained under the Mental Health Act, but lacked the capacity to consent to an informal admission. These patients were subject to restrictions, interventions and control without the safeguards of an appropriate legal framework.
In a number of the core services we visited we found that mandatory training was under the trust minimum. In some services less than 75% of staff had completed basic life support and intermediate life support. This would have a detrimental effect on patients of that service who required life support in an emergency.
Supervision policy was not being adhered to fully across the trust, in some files we could not find any records to show that supervision had taken place for up to two years and in some we could not find any record of supervision at all. Staff in Trafford Healthy Young Minds team were not receiving separate clinical and management supervision.
The trust had different recording systems across the trust, some of which do not link in with the trust electronic notes system. This meant that not all teams were able to access patient care records easily and some services used a mixture of paper and electronic records.
In two of the home care and treatment teams, there were missing care plans and risk assessments and physical health check recordings. One children’s nutritional and dietetics service did not keep contemporaneous, accurate and complete records, there were missing pages, unsigned entries and missing reviews and follow-ups.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

However,

The main good points were:

Staff were on the whole responsive, respectful and caring and professional in their attitudes and worked to support the patients.
Staff had a good understanding of safeguarding and the trust had systems and policies in place to support the reporting of incidents.
The trust had business continuity plans in place across services for emergencies and staff were aware of them and in some instances had used them.
Staff we spoke to told us they were supported by their managers in accessing training opportunities that were suitable to their needs and development.
The trust had a well-structured governance pathway to monitor outcomes for patients.
My shared pathway was being used to promote recovery and positive outcomes for patients across the trust.
We found that multidisciplinary team working was well developed across the trust both internally and in developing links with external agencies.
The trust were working in conjunction with others when planning services for patients and had developed working relationships with other agencies.
The trust had a range of facilities that provided and promoted recovery, comfort, dignity and confidentiality to the patients and families in their care.
The trust had clear vision and values and staff were aware of these and could articulate their understanding.

We rated Pennine Care NHS Foundation Trust community mental health services for people with learning disabilities as good because:

A range of high quality, person-centred therapeutic interventions were being delivered to patients to support them to achieve improved independence and wellbeing.
Interactions between staff and patients demonstrated personalised, collaborative, recovery-oriented care planning.
Patients who had been assessed as being at risk of crisis had clear crisis plans.
All staff had a good understanding of the principles and application of the Mental Capacity Act
Staff attitudes and behaviours were responsive, respectful and caring.
Staff were using innovative methods to involve patients in their own care.
Services routinely supported patients to get involved in staff recruitment. This was underpinned by a detailed trust policy.
The Oldham service was facilitating a supported internship for a person with a learning disability.
Teams had made efforts to engage people from minority ethnic communities. The team in Oldham had developed a set of easy-read pictures and symbols for patients from a South Asian background.
Teams had a strong identity and were committed to helping people with a learning disability achieve improved independence and wellbeing.
Managers attended directorate governance meetings, and received regular feedback on their teams’ performance.
Two of the teams had audited themselves against the National Learning Disability Professional Senate specification for learning disability teams.
The learning disability directorate participated in the Greater Manchester plan to transform care for people with learning disabilities.
Teams had been able to raise their concerns about confidentiality in the bases to their senior managers.

However,

Seven of 32 case records checked did not include a risk assessment, and 15 others did not include a full risk assessment.
In two of the locations, patients and carers needed to walk through or past staff desks to get to the interview rooms. This made it difficult to protect confidentiality.
Interview rooms were not soundproofed.
The joint protocol between mental health and learning disability services in Stockport did not cover the home treatment team and on-call psychiatrist. This meant that patients may need to go to accident and emergency to access a mental health crisis service.
Learning disability, psychiatry and mental health teams kept separate care records. This meant that staff did not have easy access to all of the information they needed to be able to deliver safe and effective care.
An audit of antipsychotic prescribing in people with a learning disability identified that there was no documented evidence of side-effect monitoring in around half of care records.
Two of the teams did not employ the full range of professional disciplines recommended by the national specification for community learning disability teams.

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

Three wards did not comply with the Department of Health’s guidance on eliminating mixed sex accommodation.
The layout of the wards did not allow staff clear lines of sight of patients. These were not mitigated by the use of mirrors to cover all areas of the ward.
Overall compliance for mandatory training did not meet the trust’s set targets.
The trust policy on seclusion did not safeguard patients around nursing, medical and independent review as per the requirements in the Mental Health Act Code of Practice.
Most patients on Saffron ward were being cared for and treated in their best interests but there were no formal considerations of these best interests and no consideration whether the restrictions faced by patients on Saffron ward amounted to a deprivation of liberty.
On most other wards, where significant decisions were made, these decisions were not always supported by staff fully considering the best interests of patients and recording those decisions.
Patients on some wards did not have meaningful activities because there was limited occupational therapy input and nursing staff were too busy attending to patients’ basic care needs.
On some wards, the quality of care provided for patients who had difficulty communicating was poor.
Outside space was not always accessible due to the doors being locked.
Dementia friendly signage on the wards was limited.
Managers had not taken sufficient action to resolve issues with mixed-sex accommodation, ward layout, implementation of the Mental Capacity Act and quality of patient care.
The shortfalls we found on our inspection highlighted some gaps in the governance arrangements.

However:

The wards were clean, tidy and well maintained. Ligature risk assessments and environmental checks were in place.
Patient risk assessments had been completed.
Staff completed life story work with patients with dementia to enable them to provide person centred care.
Staff considered patients’ physical health needs on admission and on an ongoing basis.
There were good systems in place to ensure the Mental Health Act was followed.
All patients told us they were treated in a kind, caring and respectful manner.
While the bed occupancy levels were high on most wards, most patients were admitted to their local catchment area or where this was not possible repatriated to the local area as soon as practicable.
Patients’ discharges were planned and involved multidisciplinary teams, families and carers.
There were systems in place to manage complaints.
Information leaflets were available in other languages should these be needed.
Whilst Cedars ward was small and crammed, the trust had developed plans to address this.
The trust were developing an older people’s mental health strategy.

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

Staff managed patient’s risks. There was a proactive approach to managing patients on waiting lists. This meant staff were able to identify changes in risk and prioritise urgent cases.
There were processes in place to support safeguarding and the management of patients at risk. There were good links with local safeguarding bodies.
Patients had access to a range of psychological therapies in line with National Institute for Health and Care Excellence guidance.
There was a multidisciplinary approach to the delivery of care. Staff groups worked together to meet the needs of patients.
Patients and parents were involved in decisions about their care and treatment. Feedback from patients was positive. We observed patients being treated in a respectful manner and with a caring and empathetic approach.
Patients and parents were able to give feedback on the care they had received and input into decisions about the service.
There were processes in place to manage adverse incidents and complaints. There was evidence that learning from incidents and complaints were shared across the service.

However

Not all staff were receiving regular managerial supervision. The service did not collate information on compliance with supervision. This meant that the service could not be assured that staff were supported in their role.
There were waiting lists in place in two teams. Some patients had not been seen within the 12 week to assessment and 18 week to commencement of treatment targets.
Whilst morale in the Bury and Oldham Healthy Young Minds teams was good. Staff told us that morale at Trafford Healthy Young Minds was mixed. The Trafford team was going through a process of organisational change. Some staff told us they did not feel engaged with the trust or with the change process.

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

The wards provided safe, secure environments. There were effective systems to maintain safety and security.

The Royal College of Psychiatrists’ quality network for inpatient child and adolescent mental health services review team had assessed the service in 2015 and both wards were accredited, Horizon as excellent.

Staff respected and valued patients as individuals and empowered them as partners in their care. There was a strong, visible person-centred culture. Putting patients at the centre of the service, involving and empowering them was clearly embedded. Staff treated patients with dignity, respect and kindness and the relationships between them were positive. These relationships were highly valued by staff and promoted by managers.

The emphasis on patient involvement was obvious across the service. There was a genuine commitment from all staff. Patients were involved in recruiting staff and the young people’s council had a voice in governance. Through the council, patients were actively involved in plans for service developments and improvements.

There was a strong recovery focused ethos. Staff worked within the principles of the ‘my shared pathway’ model. They focused on helping patients to concentrate on their goals for recovery and the progress they had made towards the outcomes they wanted to achieve. This meant that staff ensured patients did not stay in hospital longer than necessary and promoted patients’ early discharge.

There was a large, outdoor therapeutic space called the woodland retreat that was used by patients for time off the ward in a safe environment.

There was a good governance structure to drive the delivery of high quality person-centred care. Managers prioritised safe, high quality, compassionate care and promoted equality and diversity.

Managers encouraged continuous improvement and there was excellent commitment to quality improvement. There was a culture of collective responsibility across the service.

However:

There was a blanket restriction on the use of mobile phones.

We found that on one occasion when a patient was cared for in the extra care area, staff had not adhered to either the Mental Health Act Code of Practice or the trust policy and did not provide the necessary safeguards to the patient.

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

The health-based place of safety at Stockport was particularly dirty, especially in the en-suite room which made it not fit for use. The en-suite did not have toilet paper, towels or soap readily available for patients to use. There was no evidence that monitoring of the cleanliness of this room took place or monitoring of the water system in line with trust policy to prevent the risk of legionella disease. This posed an avoidable risk to the health of patients. The health-based places of safety at Stockport and Tameside were not in good decorative order and the chairs were stained. The rooms were sparse, not welcoming and resembled a seclusion room. The rooms did not contain a bed where patients could comfortably lie down. There were no sheets, pillows or blankets in the rooms. At Stockport there was not a clock to orientate patients to time in line with national guidance.
At Tameside, there was a window which could be overlooked from the outside. Although the window faced the wall of another building, it was possible for a person to access the outside of the window and see into the room. The window did not have a blind which could impact on a patient’s privacy and dignity.
Patients using the health based places of safety were unable to see staff in the staff room through the one way mirror. There was no intercom system, or other way for a patient to directly communicate with staff or know that staff were present in the staff room. The rooms had CCTV monitoring systems but no notices informing patients of this. If a patient wanted to communicate with staff or summon assistance, they would need to do so via the CCTV camera.

Compliance with mandatory training, appraisals and supervision was inconsistent across the service and much lower than the trust’s target in some teams.

The quality of assessments, risk assessments and care plans was inconsistent across the service. Patients’ allergies, physical health needs and medication were not routinely recorded. Some patients did not have up to date risk assessments or care plans in their care records.

Staff did not always have timely access to the care records of young patients detained under section 136 of the Mental Health Act.

There were inconsistencies across teams regarding staff skill mix which meant that not all teams could provide the same level of service to patients.
There was a lack of evidence to demonstrate effective use of performance indicators and audits to drive improvement in most teams.

The quality and effectiveness of the local governance arrangements within each team was inconsistent. The issues we found regarding the health based places, care plans and risk assessments had not been identified through existing monitoring arrangements.

However:

Staff morale was good and staff turnover was low. The teams had enough staff to meet the needs of patients.
The teams had developed and maintained good working relationships with the acute wards, acute trust and other external stakeholders such as the police.
There was effective, embedded monitoring in relation to the use of section 136 of the Mental Health Act.

Two home treatment teams had recently begun supporting patients with Clozapine initiation within the community. This meant that patients did not have to be admitted to hospital because staff carried out monitoring in the patient's own home.
Staff ensured patients knew how to access help including out of hours.
The feedback from the friends and family test questionnaires and patients we spoke with was extremely positive.
Staff were responsive to patients’ needs. Staff ensured patients knew how to access help including out of hours.

Patients had access to advocacy.

We rated Pennine Care NHS Foundation Trust as good because:

Patients had an ongoing risk assessment and a comprehensive assessment of their needs. Patient involvement in their care planning was variable. However, this was improving following the introduction of “My Shared Pathway”, a nationally recognised person centred care planning tool developed collaboratively by patients and professionals.

The multidisciplinary team routinely reviewed patients’ care. Patients had a care programme approach (CPA) meeting every six months.

There were rehabilitation and discharge care pathways for patients that lasted from two to five years. Some patients with complex or treatment resistant illnesses were in hospital for longer. However, staff continued to engage with them to work towards moving on from the service, but outside the pathway timeframes.

Patients had their physical healthcare needs met.
Staff were familiar with the principles of least restrictive practice. This was an ongoing piece of work, but restrictions within the service were under review. These balanced least restrictive practice against risks presented to patients and other people.

Medication was managed and administered correctly. Some patients administered their own medication and there were clear stages for patients to work through at their own pace.

The environment was clean and maintained. Environmental risk assessments had been removed, and risks to patients had been removed, or were mitigated against.

Managers and senior clinicians met regularly and reviewed information about the safety and quality of the service. This included reviewing incidents and complaints, in addition to new initiatives and guidance. When actions were required, action plans were followed up at the meetings. Information was passed to ward staff through team meetings, emails and supervision.

Staff had completed most of their mandatory training.

The Mental Health Act and Mental Capacity Act were implemented effectively.

Psychology input was provided on all the wards, but was a limited resource so focused on providing support and advice to staff, with one or two sessions with individuals and groups.

There was an occupational therapy or technical instructor on all the wards. They provided an activity programme, and the occupational therapists carried out assessments of patients.

There were nursing and health care assistant vacancies. These were filled by bank and agency staff, and there was ongoing recruitment.

All patients had their own room. Some wards had ensuite bathrooms and others had shared facilities. Patients had access to food and drink, and some patients prepared their own meals.

However:

Patients had an ongoing complaint about the lack of choice and poor quality of the food on some of the wards. External companies supplied meals.

We rated acute wards for people of working age and psychiatric intensive care units as requires improvement because:

Three of the wards did not comply with same sex accommodation guidance which meant that patients’ privacy and dignity may have been compromised.
The layout and access to outside space on Northside and Southside wards did not ensure the safety, privacy and dignity of patients. Patients from Northside ward were only able to access outside space via Southside ward.
We found that medicines practice was not always in line with current National Institute for Health and Care Excellence guidelines. There were three out of five rapid tranquilisation forms which we found to be missing or incomplete which meant that patient’s physical health may not have been monitored. On two wards there were issues with the safe storage of medicines. The clinic room temperature on Cobden unit exceeded recommended guidelines and the fridge temperature on Southside and South ward was not monitored properly. Doctors did not always cancel medication records in line with trust policy.
Patients were not always afforded privacy when receiving their medication.
We found that training in basic life support and immediate life support did not meet trust targets on some wards.
The trust had used the safer staffing tool to look at the staff required on each ward and to ensure patient safety. However, staff and patients told us that although there were enough staff they often had to deal with other tasks which sometimes took away time from their nursing role.
There was a blanket restriction in place on all wards relating to cigarettes. These were removed from patients when they were admitted to the ward.

We found that staff were not receiving supervision every four to six weeks as per trust policy. Not all members of staff had received an appraisal on a yearly basis as per trust policy. Staff sickness was above the national of average of 5% on eight of the wards which meant that bank and agency staff were used on a regular basis.
There was very limited access to psychological therapies on wards and only Cobden unit had a ward based clinical psychologist. Moorside ward had a trainee clinical psychologist.
Most of the patients we spoke to gave negative reports about the quality of food on the wards.
We found some issues regarding Mental Health Act documentation. Recording of patients section 132 rights under the Mental Health Act was not always recorded and reviewed. In a small amount of files, we found that original Mental Health Act documentation was missing and capacity to consent to treatment was not recorded.
There was high bed occupancy across all of the wards which led to patients waiting a considerable amount of time for their needs to be met. Patients told us that requests were not responded to quickly because the staff were so busy. On Norbury ward, the office door was closed and we saw that patients were queuing outside the door with requests which were not responded to in a timely manner.
Patients did not always have a bed to return to upon return from leave. Continuity of care was disrupted as patients were sometimes admitted to a bed in other parts of the trust or out of area. This meant that patients were cared for by a different nursing team on a different ward.

However:

Incidents of restraint and seclusion were low across all wards and we saw that there was good use of de-escalation techniques used across all wards. The trust had implemented the ‘Safewards’ model of care on all of the wards, which aimed to minimise conflict and maximise safety and recovery. The implementation of this approach had contributed to low levels of restraints and seclusion across all of the wards.
Patients felt involved in their care and attended weekly community meetings on the ward as part of the ‘Safewards’ initiative. They felt they were listed to in multidisciplinary meetings and were given choices in treatment options.

The majority of staff treated patients with kindness, respect and dignity. Patients were oriented to the ward when they first arrived. There was good access to local advocacy services across all of the wards we visited and we found that advocates played an active role in patient care. Patients knew how to complain and were supported to do so. There was a full range of information leaflets available to patients and carers and these were displayed clearly on wards. Leaflets were available in different languages upon request.
We were told and we observed good multidisciplinary working on all wards. Handovers and multidisciplinary meetings were detailed and comprehensive.

Lessons learnt from incidents were shared with staff in variety of different ways including via emails, multidisciplinary team meetings and on an individual basis.

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

There were safe lone working arrangements in place when staff visited patients’ homes. Staff had reasonable caseloads so staff could keep patients safe. Referral information was coordinated and actioned quickly. Care plans had crisis care plans to inform patients and carers on what to do in crisis. Patients’ records contained comprehensive risk assessment. Staff were kept up-to-date with good mandatory training uptake.

There was effective multidisciplinary working in most teams. Staff completed life story work with patients with dementia to enable them to provide person centred care. There was good interagency working including with voluntary and third sector organisations. Staff took action to ensure that patients’ physical health needs were monitored and treated. There were good systems to ensure the Mental Health Act was followed where patients were on a community treatment order. Staff had a good understanding of the Mental Health Act and Mental Capacity Act despite this not being required mandatory training.

Patients were highly complimentary about the care they received. Records showed support workers going the extra mile to support patients. There was significant service user involvement and community engagement in Stockport, including people with dementia providing peer support and post diagnostic support to people with a recent diagnosis of dementia as well as being involved as partners in staff training.

Access into the services was coordinated through a single point of entry in each locality. There were no waiting lists to receive an assessment or receive treatment. The teams were meeting the targets expected of them. There were specialist workers within some teams such as an early onset dementia team in Stockport and a specialist vascular dementia worker in Bury. There were proactive contact with Black and minority ethnic communities to promote the work of the teams, improve referrals and for health promotion. There were low numbers of complaints and these were well managed.

Staff understood the trust’s vision and values. Teams were well-led by committed managers and staff felt respected and supported by managers. Effective managerial operations meetings took place where incidents were discussed, team performance was reviewed and staffing and sickness in teams was considered. There was a commitment to service improvement and extending services to meet the needs of different patient groups.

However:

There were unsecure records at the offices in Bury which was a shared building with non-trust staff working in the building. The trust took action to address this immediatley following the inspection.
There were issues with informing patients on a community treatment order about the availability of the independent mental health advocacy service and ensuring the legal certificate to provide treatment to a community patient was kept with the medication card.
Records did not always contain full details of the legal safeguards when decisions were made on behalf of incapacitated patients such as the extent of any lasting or enduring power of attorney decisions and the conditions and Deprivation of Liberty Safeguards authorisations.
Staff in the Bury team did not always request interpreter involvement for more routine appointments when the patients’ first language was not English.
The trust did not provide any steer around how each team could evidence or develop services in line with the trust’s three quality priorities for 2015/16.

We rated community-based mental health teams for adults of working age as requires improvement because:

Information relating to the risks of patients were not included in patients’ care records.
Staff did not maintain an accurate, complete and contemporaneous record that included a plan of care. This meant that information needed to deliver care was not available to staff when needed.
Staff were not up to date with basic life support and fire safety training.
Copies of forms showing that patients had the capacity to consent to treatment were not attached to medication charts at any of the teams we visited.

Patients were not involved in making decisions about the service. There were no formal meetings for patients to attend to give feedback on the service.
Some teams did not have a target time for referral to assessment and treatment. We found little evidence of staff routinely planning discharges with patients.
Staff did not receive regular clinical supervision and there were no records of clinical supervision taking place. Staff at Bury early intervention team did not have access to regular team meetings.

However:

Caseloads within the teams were manageable. Cover was provided when staff were off work. Agency staff were employed to cover long term sickness.
Regular multidisciplinary meetings were held to discuss patients. Staff communicated effectively within the team and with other teams and organisations.
Patients told us they were actively involved in discussions about their care and treatment and were happy with the treatment provided.
We observed staff being supportive, caring and respectful towards patients who used services.
Staff made attempts to engage patients who had failed to attend their appointment. Staff also made efforts to engage with patients who were reluctant to engage.
Staff felt able to raise concerns and were supported by managers and their teams.

We rated forensic inpatient/secure wards as good because:

the wards were bright, clean and well equipped.Patients’ rooms were en suite and they had ample space to store their belongings.
There were good security systems in place and these were appropriate for a low secure inpatient environment.
The trust were continuing to address least restrictive practice and were regularly reviewing rules and blanket restrictions on the wards.
Patients had multidisciplinary team involvement and access to evidence based interventions. Staff had the right qualifications and access to a range of training.
Care plans were comprehensive and reviewed regularly.
All the wards had a range of activities available seven days a week and including some evenings. Many of the activities took place within the local community and included access to education and training.
There was clear leadership in the service. Managers knew what was going on within the wards and were known to both staff and patients.
Staff engaged in a range of audits and were using the outcomes of these to review how effective their service was and to look for ways to improve.

However:

There were staffing pressures at Prospect Place. Managers were not meeting with staff to undertake an exit interview.
Many patients expressed dissatisfaction with the choice of food that was provided. Patients told us this made the food choice boring and did not offer much real choice if someone disliked the main meal options that were repeated regularly
Staff facilitated garden access every two hours at the Tatton Unit. Staff were unclear why there was no unrestricted access to the outdoor area.

Overall rating for this core service Requires Improvement

We have rated this service overall as requiring improvement. This is because:

Bury specialist palliative care nursing team did not have sufficient staff to provide a timely service to patients at the end of their life. There was no consultant in specialist palliative care, which meant that highly specialist advice and support regarding complex symptom control was not available throughout the trust.
Systems or processes were not sufficiently established and operated to effectively ensure the trust was able to assess, monitor and improve the quality and safety of end of life care.
There was no trust wide method of categorising end of life care incidents and complaints to monitor themes and share learning across the trust.
The trust had not implemented individual plans of care for end of life patients in each of its geographical location at the time of the inspction.
There was no structured end of life care training plan or register of training to ascertain the skills of staff in different roles and teams.
There was no trust wide strategy or vision for end of life.

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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