Leicestershire Partnership NHS Trust

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

The trust needs to take steps to improve the quality of their services and we found that they were in breach of seven regulations. We have issued seven requirement notices which outline the breaches and require the trust to take action to address. We will be working with them to agree an action plan to improve the standards of care and treatment.

We rated the trust as requires improvement overall:

• Whilst there had been some progress since the last inspection in 2015, the trust was not yet safe, fully effective or responsive.

• We had concerns about the safety of some of the facilities where care was delivered. The environmental risks in the health based place of safety identified in our previous inspection remained. The trust had not met all the required actions to reduce and mitigate ligature points across wards following the previous inspection in March 2015. The trust had not fully addressed the issues of poor lines of sight in wards. Due to this staff could not observe all parts of wards due to their lay out and the risk had not been mitigated. The trust was not fully compliant with same sex accommodation guidance in two acute wards, the short stay learning disability service and rehabilitation services.

• Some facilities lacked essential emergency equipment. In the health based place of safety resuscitation equipment and emergency medication were not available and staff had not calibrated equipment to monitor patient’s physical health. The community therapy rehabilitation unit at Hinckley did not have a defibrillator in the unit for staff to use in an emergency despite staff having been trained how to use one.

• Some wards and community teams did not store or manage medicines safely. There were no pharmacy services within the community mental health teams or crisis team. This could have resulted in an increased risk of incorrect safe and secure handling of medicines and unsafe practice in relation to the administration and prescribing of medicines. We identified concerns around the storage of medicines in community hospitals, with missing opened or expiry dates across all hospitals. Patients’ own controlled drugs were not always managed and destroyed appropriately. We identified that in community mental health teams, wards and community inpatient hospitals, fridge temperatures were not recorded correctly; either single daily temperature readings were recorded rather than maximum and minimum levels or temperatures were not recorded on a daily basis. This did not demonstrate a consistent temperature, had been maintained to assure the safety and efficacy of the medicines.

• Some wards and community teams had low staffing levels, or an absence of specialist staff, and this had an impact on care.Staffing levels remained low at the Bradgate mental health unit. To ensure that safer staffing levels were met they used regular bank or agency staff to achieve the required amount number of staff for the wards to meet the needs of the patients. However, they did not always meet the required skill mix for the nursing teams. Despite considerable effort with recruiting new members of staff for community inpatient areas, staffing was the top concern for all senior nurses and there was still a significant reliance on agency staff to fill shifts which could not be covered internally. The majority of community mental health teams did not meet the referral to initial assessment and assessment to treatment times. The child and adolescent mental health (CAMHS) community team’s caseloads were above the nationally recommended amount, although young people had a care co-ordinator. The community adult team caseloads varied. People that were referred to the service were waiting for a care co-ordinator to be allocated. Due to the large caseloads in community health service, the number of visits that were required was not always manageable. The trust had identified the lack of psychological therapies for patients, and support and training for staff, on their risk register. This had been identified during the last Care Quality Commission inspection in 2015. We remain concerned that a significant period had passed and the trust had not improved access to psychology for patients and staff. At our last inspection we raised concerns that an insufficient number of nursing staff in community health services for adults had received appropriate statutory and mandatory training. At this inspection we found compliance levels with this type of training were still below the trust’s target.

• The trust was not meeting its target rate of 85% for clinical supervision. Sixty per cent of staff working in the mental health services had attended supervision and 64% of staff working in community health inpatient services.

• Record keeping was poor in some services. Within mental health services the quality of care plans was variable. Some care plans were not holistic, for example they did not include the full range of patients’ problems and needs. Care plans did not always consider the patient views, and were generic did and not all were recovery focussed. Patients in four services across the trust reported that they had not been involved in the planning of their care and had not received copies of care plans. Within the end of life service there were inconsistencies in the quality of completion for do not attempt cardiopulmonary resuscitation (DNACPR) forms, in the quality of admission paperwork within medical records and in the use of the ‘Last Days of Life’ care plans. This had been raised as a concern in the March 2015 inspection and had not been sufficiently addressed.

• Staff demonstrated poor understanding of some aspects of the Mental Capacity Act. We found that there were still errors within the staff’s application of the Mental Capacity Act. Staff did not ensure that mental capacity assessments and best interest decisions were consistently documented in care records. When staff deemed a patient lacked capacity there was no evidence that the best interest decision-making process was applied. There was little evidence that staff supported patients to understand the process, no involvement of family or independent mental capacity advocate in most mental capacity assessments. This meant that patients could have been deprived of their liberties without a relevant legal framework. Managers did not have oversight of these issues. Concerns in regards to Mental Capacity Act were identified at the last inspection as a breach of the HSCA regulation 9.

• Staff did not always maintain the privacy and dignity of patients. Staff in the community adult mental health teams did not protect patients’ dignity or privacy. During the depot clinic staff did not close privacy curtains when patients were receiving depot injections. On Bosworth ward patient privacy was compromised when staff and patients entered the clinic room during examinations because there was no privacy curtain in place. On Ashby ward, the shower rooms did not have curtains fitted. This was a breach of the patients’ privacy and dignity to patients as staff might be required to enter the shower rooms to check patients were safe. The trust confirmed that these were reinstalled after the inspection had taken place.

• The trust could not always provide a bed locally for patients who required admissions to its mental health wards. Bed occupancy rates were above 85% for community health inpatient wards. Beds were not always available for people living in the trust’s catchment area. This meant patients had been placed outside of the trust’s area. We saw that patient numbers exceeded the number of beds available on wards. Therefore there were no beds available if patients returned from leave. To address this deficit the trust moved patients that required an acute bed to a rehabilitation bed which was not clinically justified or met the needs of the patients. The trust was not commissioned to provide female psychiatric intensive care beds. Therefore, if a female needed a psychiatric intensive care unit they were sent out of area.

• The trust did not ensure that they meet set target times for referral to initial assessment, and assessment to treatment in the majority of teams. This impacted on patients requiring care. Adult community health patients did not always have timely access to routine appointments. We found a total 40 breaches of the six week referral and seven breaches of the five day urgent referral. At the time of inspection, there were a total of 647 children and young people currently waiting to be seen in specialised treatment pathways. 87 of the total patients had been waiting over a year to begin treatment. The longest wait was 108 weeks for four patients to access group work or outpatients. In community based mental health teams for older people five of six services breached national targets from referral to assessment. The learning disability community team had not met the six week target for initial assessment on average it was six days over. The adult community therapy team did not meet agreed waiting time targets. Between August 2015 and July 2016 the trust had a total of 372 delayed discharges.

• The trust board had not reviewed full investigation reports for the most serious incidents, only the outcomes and lesson learnt. This meant board members were not able to monitor the trust’s assertions that there were strong systems and processes in place for identifying and reporting serious incidents, including deaths, or monitoring whether reviews and investigations were completed fully.

However:

• We rated the caring domain for the community health families, young people and children service as outstanding due to staff approaches to family and patient care utilising or creating tools to assist children to understand their condition or prepare for treatment. Feedback from those who used the families, young people and children services was consistently positive.

• The trust had made some improvements in response to the previous CQC inspection undertaken in March 2015.This included removing some ligature anchor points in the acute mental health wards.

• Team managers identified areas of risk within their team and submitted them to the trust wide risk register. Serious incidents were thoroughly investigated and outcomes and lesson learnt were discussed in a variety of clinical governance meetings. Managers shared the outcomes and lessons learnt from incidents, complaints and service user feedback at regular staff meetings, where meetings took place. Emails and the trust intranet also provided staff with this information. Lessons learnt were shared across the organisation via emails and the intranet. Staff had been trained with regards to duty of candour and in line with the trust policy. The trust had a major incident policy to deal with any major incidents or breakdown in service provisions. Potential risks were taken into account when planning community health services.

• In CAMHS community teams waiting times from referral to initial assessment was less than 13 weeks. The service was meeting its target in this area. This had improved since the last inspection in March 2015.

• Overall, the trusts compliance rates for mandatory training was 87%.

• We reviewed 267 case records and found that, generally, staff completed detailed individualised risk assessments for patients on admission. Care records showed that physical health examinations were completed upon admission and there was ongoing monitoring of physical health across the trust. The majority of care plans were up to date. Care and treatment was mostly planned and delivered in line with current evidence.

• Staff actively participated in clinical audits. The services used recognised outcome measures and monitoring measures to help assess the level of support and treatment required. The trust had well-developed audits in place to monitor the quality of the service. The trust used key performance indicators/dashboards to gauge the performance of the team. These reports were presented in an accessible format.

• Nursing staff interacted with patients in a caring and respectful manner. They remained positive when engaging patients in meaningful activities. Staff responded to patients’ needs discreetly and respectfully. Patients were positive about their care and treatment and said staff were caring and understanding and respectful. Patients told us that staff listened and empathised with them. Patients reported that they felt safe on the wards.

• The trust provided patients with accessible information on treatments, local services, patients’ rights and how to complain across all services. Patients we spoke with knew how to complain. Staff supported patients to raise concerns when needed. Staff received feedback on the outcomes on investigation of complaints via their managers. Managers ensure that they acted on these findings to reduce the risk of reoccurrence.

We rated end of life care services as good overall because:

• The trust had worked collaboratively with local partners to develop an end of life care strategy for the region as a whole which had incorporated a health needs analysis.

• Patients were protected from avoidable harm by sufficient staffing and safeguarding processes.

• Staff recognised and responded to the changing needs of patients with anticipatory medications readily available and care needs assessed and reviewed appropriately.

• Staff followed infection and prevention control practices and the community inpatient wards were visibly clean. Specialist equipment needed to provide care and treatment to patients in their home was appropriate and fit for purpose so patients were safe.

• Staff demonstrated commitment to delivering high quality end of life care for their patients. There was a strong, person-centred culture. Staff treated patients with compassion, dignity and respect. Patients and their relatives felt involved in the care provided. Patients’ social, emotional and religious needs were met and relatives valued the emotional support they received.

• Services were planned and delivered in a way that met the current and changing needs of the local population. The needs and preferences of patients and their relatives were central to the planning and delivery of care with most people achieving their preferred place of care. Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

• We saw evidence of multidisciplinary working, with staff, teams and services at this trust and external organisations working in partnership to deliver effective care and treatment.

• There was strong local leadership on the community inpatient wards and in the community. Staff told us they felt supported by their line managers, ward managers and matrons.

However:

• There were inconsistencies in the quality of completion for do not attempt cardiopulmonary resuscitation (DNACPR) forms, in the quality of admission paperwork within medical records and in the use of the ‘Last Days of Life’ care plans. This had been raised as a concern in the March 2015 inspection and had not been sufficiently addressed.

• There was an unstructured, non-mandatory approach to formal end of life training for community hospital staff.

• Concerns were raised regarding the fast-track process and appropriateness of admissions to hospital by the out of hours GP service.

• We did not have assurance service leads had good oversight of the risks relating to this service as staff were not always recording incidents, the service was unable to identify incidents specific to patients at the end of life and concerns relating to the out of hours GP service were not formally recorded.

We rated families, young people and children services as good because:

• There were systems in place for reporting incidents and the service was able to demonstrate learning and sharing following incident investigations. However, staff told us they had little experience of incident reporting within the community children’s services.

• Safeguarding was a high priority with regular safeguarding reviews within each area of speciality and established systems for supporting staff dealing with distressing situations.

• Staff followed infection control practices and maintained equipment through regular servicing.

• Patient records were electronic, up to date and available to the multidisciplinary team to enable an integrated approach to care and treatment.

• Staff were trained appropriately within their speciality and new staff were supported to gain experience and skills.

• Children and young people felt listened to in a non-judgmental way and told us they felt respected. We observed positive interactions between staff and children and the use of age appropriate language. The school nurses used technology to communicate with young people.

• The service employed care navigators to help families and carers negotiate their journey through the various services provided.

• There was an established five year strategy and vision for the families, young people and children’s (FYPC) services and staff innovation was encouraged and supported. Staff expressed pride in their ability to work as a team and managers told us they were proud of achievements. Staff were included in service developments and involved in ‘listening into action’ projects for service improvement.

However:

• There was a lack of reporting and monitoring of informal complaints, meaning the service was unable to monitor and recognise themes of concern with the children’s service.

• The service is not appropriately commissioned to provide sufficient school nurses to meet the standard service recommendations of one nurse per secondary school and its associated primary schools.

• The medical and senior leadership provision within the looked after children service did not meet the professional requirements outlined in the intercollegiate document for this provision.

We rated community health inpatient services as requires improvement because:

• Despite considerable effort with recruiting new members of staff, staffing was the top concern for all senior nurses and there was still a significant reliance on agency staff to fill shifts which could not be covered internally. Senior nurses mitigated risk where they could which included switching an agency staff member with a trust member of staff if two agency staff worked together. However, we saw evidence this was not always achieved.

• Staff were open about their poor understanding around the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Our observations during inspection confirmed that staff knowledge and practical application of their knowledge was inconsistent despite training on their electronic learning systems.

• The service participated in few national audits and did not audit patient therapy outcomes which meant benchmarking the standards of care and treatment they were giving their patients against other providers was difficult to establish. The service did however, complete local audits and produced action plans for improvement in care.

• All hospitals were running at a high bed occupancy level of above 85% which national data has linked to increased risk of bed shortages as well as an increase in healthcare associated infections.

• The service had 175 delayed discharges between August 2015 and July 2016, which accounted for 43% of the trusts total delayed discharges. The most common reason for delayed discharges was due to family choices which were beyond the control of the trust. However, delay in paperwork completion was also responsible for a large proportion of delayed discharges.

• Staff were unaware of any service specific strategic direction. This had previously been identified on the CQC inspection in March 2015.

• Concerns about high bed occupancy, record keeping and delayed discharges were identified in the March 2015 inspection and had not been sufficiently addressed.

However:

• The electronic prescribing system which the trust had implemented supported the safe administration of medicines to patients, with staff reporting very few medication errors as a result of this.

• The feedback from patients and relatives was mainly positive about the staff providing care for them. Comments included terminology such as ‘marvellous’, ‘wonderful’ and ‘excellent’. All patients told us staff respected their privacy and dignity.

• The introduction of activities co-ordinators at Coalville Hospital had improved the patient’s experience on the ward and increased the activities that were conducted on a day to day basis.

• Staff told us they enjoyed working at the trust and thought they all worked well as a team. We saw evidence of good team working during our inspection.

We rated community health services for adults as requires improvement because

• The trust had not made sufficient progress in addressing the concerns raised at the previous inspection in March 2015. Following this inspection the trust were required to ensure teams were adequately staffed to prevent impacts on staff workload and ensure staff completed mandatory training in line with trust requirements.Insufficient progress had been made against these notices.

• The service had not delivered timely care to a significant number of patients. Service planning was not being managed in a systematic way. The high demand for services, high levels of staff sickness and staff vacancy rates had not been managed effectively. This had a negative impact on the delivery of urgent nursing care, continence services and non-urgent therapy care.

• Nursing staff had large caseloads. The number of visits was not always manageable. This impacted on the time available for staff development and training. In five of the six community nursing teams attendance on some mandatory training courses was below 70%.

• Staff morale in some teams was low, with high levels of stress. Some staff found there was insufficient time to complete their visits within the working day. There was limited time available for staff to attend specialist courses to enhance their knowledge.

• Data could not be relied upon to measure service performance or improvement.Data collection and interpretation did not include key pieces of information for example number of delayed or missed visits. The electronic data held by the trust was currently being validated with large numbers of visit records not closed on the database.

• The services did not have a strategy and there were no service plans. There was no process in place for learning from other organisations which provided similar services or to share this service’s best practice.

However:

• Patients were happy with the care they received and were very complimentary about the staff who cared for them. We observed care being delivered in a kind and caring way, by staff who demonstrated compassion and experience.

• Care and treatment was planned and delivered in line with evidence based guidance and standards, and systems were in place to ensure trust policies reflectedthe latest guidance

• The single point of access made contacting the service easy for both patients and health professionals and enabled referrals into the service to be triaged and assigned from one central point.

• The integrated therapy and nursing teams and the primary care coordinators in conjunction with the night service had clear focus on keeping patients safe and well in their own homes.

• Complaints were well managed to ensure a timely response and aid learning.

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

• Access to the service was delayed due to variable caseloads and waiting times.

• There was no medicines management input from pharmacy within the community based mental health services for adults of working age.

• A dual paper and electronic recording system meant that some information was not accessible to all of the staff that might need it.

• 56% of individual care plans were not up to date, personalised or holistic.

• The patients did not consistently have their physical healthcare monitored or recorded, unless there were identified problems.

• Not all of the patients felt involved in their care planning and not all had a copy of their care plans.

• Staff were not meeting targets for the assessment and assessment to treatment of urgent referrals and six week routine referrals.

• There were waiting lists of up to 18 months for psychology and up to 40 weeks for other treatment within the personality disorder service.

• Staff were not meeting the trust’s target compliance rate for annual appraisals and mandatory training.

However:

• Lessons were learned from feedback and complaints from patients. Managers changed practice because of this.

• Staff reported incidents, which were discussed and reviewed by line managers within the teams. Incidents were on the agenda at the clinical governance meetings. Staff were adequately supported and debriefed following incidents and could access further support if required.

• Staff held multidisciplinary team meetings weekly and these were attended by a range of mental health professionals. There was detailed discussion and consideration of patients and carers’ needs. Staff routinely referred patients to access additional support for employment, housing, benefits and independent mental health advocacy.

• Some patients told us that staff were polite and respectful and willing to go the extra mile in supporting them.

• There was evidence of leadership at local and senior level. Staff told us their managers were supportive and senior managers were visible within the service.

We rated Leicestershire Partnership NHS trust as requires improvement because:

• Environmental risks in the Health Based Place of Safety (HBPoS) identified in our previous inspection remained.

• The HBPoS had no designated resuscitation equipment and emergency medication and shared equipment with acute wards. We found out of date and non-calibrated equipment located within a cupboard in the health-based place of safety. The HBPoS did not have access to a dedicated clinic room.

• The HBPoS had poor visibility for observing patients.

• HBPoS and crisis resolution and home treatment (CRHT) team toilets were not visibly clean

• The HBPoS did not have designated staff provided by the trust.

• Risk assessments were completed during the initial assessment at the CRHT team. However, they were not updated regularly or following an incident.

• In all instances police transported the patient to the HBPoS. This does not comply with the guidance from the Royal College of Psychiatrists.

• The CRHT team did not have lockable bags to transport medication to patients’ homes; staff told us they transported medication in their handbags.

• Patients using the CRHT team had limited access to psychological therapies and there were no psychologists working within the CRHT team.

• Care records for patients using the CRHT teams were not holistic or personalised.

• Staff did not document physical health checks for patients detained under section 136 in the HBPoS.

• Records in the HBPoS did not clearly indicate if patients had their rights explained to them.

• Staff working within the CRHT team and the liaison mental health triage service had not clearly document in patient paperwork or case notes if the patient had capacity or not.

• With the exception of the liaison psychiatry service and the mental health triage car, managers were not supervising or appraising staff within the trust’s supervision policy.

• A new quality dashboard had been introduced in September 2016 after it was established that the previous system was incorrect, meaning all data submitted prior to September 2016 was incorrect.

• Mandatory training that fell below 75% included adult immediate life support, adult basic life support, safeguarding children level 3 and fire safety awareness.

However:

• Mental health crisis services and health-based places of safety had an overall mandatory training compliance rate of 82%.

• Lone working policies and procedures were in place for staff to follow to ensure patient and staff safety.

• Staff were de-briefed and supported after a serious incident; we saw that incidents were a standing agenda item for team meetings and were discussed with staff.

• Teams met assessment target times.

• Trust staff working within the had remote access to electronic systems used by the trust.

• Staff considered and supported patients with their physical health needs in CRHT and the liaison mental health triage service.

• Patients who accessed the CRHT team told us that they felt their wishes and needs were taken in to consideration, staff could be accessed quickly and they felt safe when visiting the Bradgate Mental Health unit.

• Carers told us they had regular contact with the CRHT team and they were kept involved with their loved one’s care.

• Staff were passionate about their roles and enjoyed working with the client group.

• Staff followed up on all people seen in by phone, post or face to face to help with any ongoing issues such as housing or benefits.

• We saw evidence of discharge planning in care plans written by CRHT staff.

• Staff working within criminal justice and liaison services and triage teams had good morale and worked well with internal and external colleagues.

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

• The trust had made improvements to the clinical environments but had not met all the required actions following the previous inspection of March 2015. Improvements to the inpatient wards included updating seclusion rooms, removing some ligature anchor points and replacing garden fencing. However, ligature points remained. Wards had high numbers of hydraulic style patient beds that were a risk to patients with histories of self-harming behaviour. The trust had begun the process of replacing some beds with more suitable options for the patient group. However, we were concerned that ligature risks remained in these bedrooms. Some wards and patient areas had blind spots, where staff could not easily observe patients. We found damaged fixings on one ward; that posed a risk to patients.

• The trust did not have seclusion rooms on all wards. This meant staff transferred patients to wards that had seclusion rooms when needed. This could pose a risk to patients and staff.

• The trust had high numbers of vacancies for registered nurses. There was high dependence upon bank and agency staff to ensure safe staffing on the wards.

• Patients did not have access to psychological therapies, as required by the National Institute for Health and Care Excellence (NICE).

• Staff were not in receipt of regular supervision in order to discuss training needs, developmental opportunities or performance issues. Ward teams did not hold regular team meetings. Ward matrons told us they shared outcomes from incident investigations in team meetings for shared leaning. Therefore, the trust could not be sure staff received information to support best practice and change in a timely manner. The trust had not ensured all staff had received training in immediate life support. The trust could not be sure that all staff

• Staff were not always recording room and fridge temperatures in clinical rooms and out of date nutrional supplement drinks had not been appropriately disposed of.

• The trust experienced high demand for acute inpatient beds. Patients could not always access a bed in their locality when needed and the trust moved patients between wards and services during episodes of care and following return from leave. Staff moved acute patients to the rehabilitation wards when acute beds could not be located. The trust could not ensure continuity of care for these patients.

• The trust had no psychiatric intensive care unit (PICU) for female patients. Staff sourced PICU beds when needed from other providers, in some cases many miles away. The trust was not commissioned to provide a female PICU and have identified the need with their commissioners. The trust admitted male patients to female areas of the mixed wards when male beds were unavailable. This was in breach of the Mental Health Act Code of Practice guidance on mixed sex accommodation. We noted, however, that staff maintained close observation when this occurred and considered this less stressful for patients than sourcing out of area beds.

• The acute service contained large numbers of beds in ‘bed bays’ accommodating up to four patients. Patients experiencing mental health crisis and distress did not have access to a fully private area in these environments. Curtains separated patients’ bed areas and the rooms were not secured to allow free access; meaning that patients could have their property removed by other patients. The provider supplied lockers on the wards; however, these were not large enough to contain all possessions and patients did not hold keys.

• On one ward, female shower rooms did not contain shower curtains. This did not protect the privacy and dignity of patients when staff undertook observations. On many wards, the trust had not supplied sufficient numbers of lounge and dining chairs to accommodate all patients and some wards did not have sufficient quiet rooms for care and treatment or for patients to receive visitors.

• Staff completed care plans for patients. However, staff did not consistently record patients’ views in their care plan or ensure they had received a copy. Patients did not have access to regular community meetings where they would discuss ward issues and concerns. When community meetings occurred, staff did not include details of outcomes to evidence change.

However:

• Senior managers were aware of the bed pressures in their acute and PICU service and had raised concerns with their commissioners.

• The trust had made improvements to the clinical environments since the last CQC inspection. For example, Ashby, Aston, Bosworth and Thornton Wards had been converted to single sex only accommodation to ensure compliance with the Department of Health and Mental Health Act 1983 guidance on mixed sex accommodation. The trust had begun replacing hydraulic beds on the wards and had agreed plans for the replacement of further hydraulic beds across the site over a four-year period. Improvements had been made to the seclusion facilities, and further improvements were planned across the service to improve patient experience and promote privacy and dignity.

• The trust had completed ligature risk assessments across all wards, detailing where risks were located and how these should be managed. Staff had access to quick guides in their clinical areas to ensure they were aware of how to manage risks. Wards employed additional healthcare support workers to meet patient needs when needed. Staff maintained a presence in clinical areas to observe and support patients.

• Staff received robust and detailed shift handovers, including information on patient risks, observation levels and physical healthcare concerns and how these were to be managed. Staff were provided with relevant information to care for patients safely.

• Staff completed detailed individualised risk assessments for patients on admission and updated these regularly and after incidents. Staff completed Mental Health Act 1983 (MHA) paperwork correctly and systems were in place for secure storage of legal paperwork, advice and regular audits.

• The trust employed registered general nurses (RGN) to assist with assessment and management of physical healthcare needs for patients. Wards had good evidence of multi-disciplinary team working, enabling staff to share information about patients and review their progress

• Staff were caring, compassionate and kind towards patients. We observed many examples of staff treating patients with care and compassion. We saw staff engaging with patients in a kind and respectful manner on all of the wards. Staff were visible in the communal ward areas and attentive to the needs of the patients they cared for. Overall, patients were positive about the care they received and had access to advocacy services on all wards. The trust had a dedicated family room for patients to have visits with children. This environment was pleasant and well equipped. Patients had the use of their mobile phones on the ward. The trust had a patient involvement centre, which was pleasant, well-equipped and supported involvement from friends and family.

• Staff consistently demonstrated good morale. There was highly visible, approachable and supportive leadership.

We rated community based services for people with learning disabilities or autism as good because:

• Staff worked well as a team and morale was high. Multi-disciplinary team meetings took place on a regular basis. 89% of staff had attended their mandatory training; 92% of appropriate staff had received training in safeguarding adults and 90% of staff had completed safeguarding children training.

• There were good systems for lone-working which included a code word that staff used when they required assistance. Staff said this made them feel safe whilst visiting patients at home or whilst undertaking activities with patients in the community.

• Staff undertook comprehensive assessments and developed high quality care plans. The assessment and resulting care plans were personalised, holistic and recovery focussed. Staff made individualised risk assessments which were regularly updated and followed best clinical practice. Staff managed their caseloads effectively; they discussed their caseloads during multi-disciplinary team meetings as well as in supervision. The teams did not have waiting lists for care coordinators at the time of inspection.

• Staff treated patients with kindness, dignity, and respect. Staff allowed patients time to respond to questions and did not try to hurry them. We spoke with six patients who all told us that the staff were very kind and looked after them well.

• The teams were able to respond quickly when patients or carers telephoned with problems. We spoke with carers; they all stated that staff responded well when they contacted the service.

• Staff were given opportunities to expand their knowledge and develop their roles. They could undertake both internal and external training and were able to give feedback on service development.

However:

• Three out of 18 staff interviewed said that supervision was irregular.

• All the team leaders we interviewed said there were internal waiting lists for patients who had been initially assessed to access profession specific treatments.

• The service had not met the six week target for initial assessment, on average patients were seen six days over the target date.

• Access to rooms to undertake activities in the community for people with autism had been reduced.

• Patients were not always involved in the planning of their care. Five out of 25 care records showed that patient involvement had not been recorded.

• The walls in patient areas at the child and adolescent mental health team were visibly dirty in places and rooms were sparsely furnished.

We rated specialist community mental health service for children and young people as inadequate because:

• Staff managed high caseloads and reported low morale.

• Care plans reviewed were not personalised, holistic or recovery orientated.

• The trust reported a 10% increase in the number of referrals received into the CAMHS service.

• There were delays in staff delivering treatments to young people and young people following assessment. We found multiple internal waiting lists where the longest wait for young people was 108 weeks. There were significant waiting times for a range of further assessments and treatments including psychology, school observations, psychiatric opinion and group work.

• Four young people told us they felt involved in developing their care plan however, they had not received a copy.

• Staff did not always record or update comprehensive risk assessments.

• Cleaning products in a cupboard in the waiting area was unlocked, which posed a risk to the young people.

However

• Environments were visibly clean and welcoming.

• Staff reported they felt supported by their colleagues and managers.

• Young people and their carers spoke positively about the CAMHS service.

• Staff had received specialist child safeguarding training and were able to make referrals when appropriate.

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

• The wards complied with the Department of Health 2015 guidelines on single sex accommodation.

• Patients reported that they felt safe.

• The use of restraint was low and staff used it as the last resort and if verbal de-escalation had not been successful.

• Managers had a system in place for tracking and learning from safeguarding incidents and other reportable events.

• Managers used a tool to identify and review staff numbers in accordance with need.

• Staff completed detailed risk assessments for patients on admission and reviewed them regularly after incidents.

• Staff were observed to be caring and responsive to patients.

• Staff monitored patients’ physical health regularly from the point of admission.

• Care records were up to date and holistic.

• There was a range of treatment and activity delivered by skilled and experienced staff.

• Patients and carers knew how to complain.

• Staff described managers as supportive and approachable.

• Staffs were dedicated, passionate and patient focused.

However:

• Managers did not ensure that staff completed Mental Capacity assessments in line with the Act.

• On Kirby ward there was no evidence of Section 132 rights read on detention in 54% of records reviewed.

• There was minimal evidence of patient involvement in care plans.

• Between August 2015 and July 2016, there were 60 delayed discharges across the service.

• There were no dedicated visiting rooms.

• At times, there were insufficient qualified nurses on shift.

• Clinical supervision was not taking place regularly across the service.

We rated community based mental health services for older people as requires improvement because:

• When we checked care records, we found variable implementation of the Mental Capacity Act. Staff did not record consent to treatment, and capacity to consent and best interest’s decisions when these were needed. Staff received Mental Capacity Act 2005 and Deprivation of Liberty Safeguards Some staff did not demonstrate a good understanding of the Mental Capacity Act.

• Staff did not assess and record the risks posed by medicines stored in patents’ homes. For example, for adepot injection,a slow-release slow-acting form of medication. Not all medicine records included allergy information.

• Care plans were generalised, not person centred or recovery focused. Risk assessments were brief, did not always contain sufficient information and were not updated regularly.

• At West Leicestershire there was a lack of psychology input.

• Patients and their carers were not involved in care planning and care programme approach (CPA) reviews. Staff told us they involved patient’s carers but there was little evidence of this in care records. Patients told us they did not have access to a copy of their care plan.

• The trust set target times from referral to initial assessment against the national targets of 28 to 42 days. Five of the six services in this core service were in breach of these targets.

  Managers identified the breach in these targets and had plans in place to reduce them and had highlighted this risk on the risk register.

• Staff received supervisions and appraisal. However at South Leicestershire clinical supervision take-up was low at 73%.

• There were not enough registered staff at City West and this was identified as a risk on the service risk register. However, managers had identified funding for two agency nurses to start work the week following the inspection.

• Staff told us there were no service information leaflets available. We saw information in the service reception areas about older people’s care. Patients occasionally attended the service. Staff usually met patients in their homes or in the community.

• At Melton, Rutland and Harborough and Charnwood there was a lack of audits and little focus on quality and improvement.

However:

• The waiting areas and interview rooms where patients were seen were clean and well maintained.

• Staff were up to date with mandatory training. Staff had a good knowledge of safeguarding.

• There were appropriate lone working procedures in place.

• There was a duty worker system in place which meant the service was able to respond quickly to escalating risks if necessary.

• Some staff used tools and approaches to rate patient severity and monitor their health.

• Staff received appropriate induction.

• There was good multi-disciplinary working within the teams and good communication with other organisations.

• Staff treated patients with kindness, compassion and respect.We saw staff spend time talking to and their carers. Patients told us that appointments usually run on time and they were kept informed when they do not. Staff provided patients and carers with information in a way that they understood.At City West, City East, and South Leicestershire patients and their carers reported “outstanding” and “good care”.

• There was access to interpreters and staff were aware of how to access them.

• There was good staff morale. Staff felt well supported and were able to raise concerns with their line manager and were listened to.

• At Melton, Rutland and Harborough, City East and City West CMHT’s m

• At City West in conjunction with the young onset dementia assessment service staff developed a digital app for younger who were developing dementia.

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

• The environment in some areas was very poor, particularly at Stewart House. There was a lack of storage at Stewart House, the utility/laundry room was used to store cleaning equipment. Clinic room temperatures were very hot, although one thermometer was above a radiator so would not give an accurate reading. The room used to administer medication on Arran ward at Stewart House was not appropriate; the room was a bedroom and still had a toilet in. There was no fridge to keep medicines cool when required. The old kitchen at the Willows was not fit for purpose and poorly equipped but was being used by occupational therapy. The ovens were old and the dials were not visible and cupboards were broken. There were no vision panels on patient bedrooms. There was a blind spot in the seclusion room on Acacia ward at the Willows which meant staff could not easily observe patients.

• Men using the laundry had to pass women’s bathroom and bedrooms. The 30 bed unit at Stewart House was mixed sex and there were no doors to lock between the male and female sections.

• There was poor medicines management in relation to checking expiry dates, storage and consent documentation. Staff who were unclear of the process for rapid tranquillisation did not have a reminder of the process to follow. Wards did not have a list of stock items.

• There had been periods of understaffing. Staffing levels were not consistent across the two sites. There were high vacancy rates.

• Record keeping at Stewart House was disorganised. Staff used a mixture of paper and electronic records which were not easy to follow. We found loose papers in records. There were problems with access to the electronic system owing to ongoing building works. There was no evidence of patient involvement recorded in some of the notes.

• Mental Health Act documentation was not always up to date on the electronic system. The paperwork was difficult to find and not consistent. Staff were confused about Deprivation of Liberty standards and paperwork was incomplete. Capacity assessments were unclear. Detention renewal paperwork had been signed by a doctor prior to them seeing the patient.

• Local audits were not completed regularly. Team managers could not be assured of local performance around record keeping, care planning and patient involvement.

• Acute patients had been sent to rehabilitation wards inappropriately.

• Staff were not aware of the trust’s visions or values.

• There was a high staff sickness rate reported and managers did not always follow the managing sickness policy.

However

• Recruitment was in progress for 10 new healthcare support workers. The senior occupational therapist was trying to recruit to vacant occupational therapy posts. Support workers were being trained in phlebotomy to improve timely blood testing. There was a floating qualified unit coordinator to oversee the service requirement at the Willows. Staffing numbers were met but not always the right skill mix.

• Patients felt safe and said they were checked regularly by staff. Patients described being cared for, respected and treated with dignity. Notes reflected caring and compassionate view of patients. Staff were quick to sort out requests and problems for patients. We observed positive interactions between patients and staff

• There were low levels of restraint and staff tried other methods to de-escalate before restraining patients. There was an effective incident reporting system.

• Staff carried out physical health checks on admission.Ongoing physical healthcare was provided by a local GP who visited two days a week and was available in case of an emergency.

• There was a range of large therapeutic areas and rooms for art therapy plus other interventions.

• Leadership had been strengthened at Stewart House. Staff acknowledged directors’ visits.

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

• The short stay services did not comply with the guidance on the elimination of mixed sex accommodation. There were no separate female bedroom areas and no gender specific toilets or bathrooms. Bathrooms and toilets were specified for which gender depending on who was resident at the unit at the time. This was done by sliding signs to the door as needed.
• Shifts were not always covered with sufficient staff, or with staff who had the appropriate qualification and experience for the role.
• Staff were not supervised in line with the trust's policy. The overall average compliance rate for supervision of staff in the learning disability wards was 46%.
• Staff did not adhere to the Mental Capacity Act Code of Practice and the five principles of the Act. Capacity assessments were not decision specific. Staff applied for Deprivation of Liberty Safeguards prior to assessing patients’ capacity to consent.

However:

• Staff completed and regularly reviewed and updated comprehensive risk assessments.

• Staff completed extensive and detailed care plans. Patients were involved in the writing of their care plans and their views were reflected in the plans. Staff used "my care plan" documents to obtain patients’ views on their care. Plans were shared with family and carers.

• Staff were kind, caring and compassionate and treated patients with dignity and respect. Patients felt safe.

• Staff reported morale was good, they worked well together and supported one another.

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

• The ward had clear lines of sight in the main areas of the ward. In the dormitories, observation mirrors were situated so that staff could observe patients without having to disturb them.

• The ward had an up to date ligature risk audit, staff mitigated the risks on the ward by observing patients. Staff mitigated the risks posed in the garden area by accompanying patients when they wanted to access the garden.

• The ward had sufficient staff to provide care and treatment to patients.

• Staff followed the trust policy on seclusion. Data provided by the trust showed there were four episodes of seclusion from February 2016 to July 2016. Staff monitored the ongoing condition of any secluded patient.

• 100% of staff were trained in how to safeguard children from harm. Staff informed us there was a safeguarding lead to refer to when guidance was needed.

• Staff updated risk assessments and individualised care plans regularly. Patients had their own copies of care plans and were involved in their care plan reviews.

• A psychologist led weekly reflective practice sessions to help staff think about the best way of helping the patient on the ward.

• Patients’ reported staff treated them with dignity and respect. Staff interacted with the patients’ in a positive way and was respectful to them.

• Patients knew how to formally complain and could attend daily community meetings where they could raise any issues of concern.

• Staff said morale was good and they felt supported by their managers.

However:

• The service used a computer record system that differed from the rest of the trust. Other professionals within the trust could not access this system. Staff said the system was difficult to use and this had affected the information recorded in patient’s notes.

• Staff and carers said that when a patient was discharged, it was difficult to allocate them to a community CAMHS worker.

• Patients said they got bored at the weekends, as there were fewer activities on offer.

We rated the forensic inpatient/secure services as good because:

• Phoenix ward had clear lines of sight for staff to observe patients. However, Griffin did not. Managers had plans in place to address this issue. However, no time frame was set for the work to be completed. Managers completed ligature audits which highlighted what mitigation was in place to reduce the risk for patients.

• Staff completed comprehensive assessments which included physical health checks and the majority of patients had completed risk assessments. Staff ensured that these were updated regularly.

• Staff used the mental health clustering tool, which included Health of the Nation Outcome Scales (HoNOS) to assess and record severity and outcomes for all patients. Advanced Directives had been introduced to enable patients to make decisions now about their long term care.

• Managers had a recruitment plan in place to increase the number of substantive staff for the service. Managers ensured they used regular bank staff to achieve the required safer staffing levels and to promote continuity of care of patients. 83% of staff received mandatory training. Managers ensured they monitored their staff’s compliance with mandatory training using a tracker system. 78% of staff had completed their annual appraisal. Managers ensured they monitored the reporting and recording of incidents and complaints. They provided feedback to staff via monthly ward meetings, MDT meetings supervision and handovers.

• Patients gave positive feedback regarding the care they received. Patients were able to access hot and cold drinks any time during the day. Patients could approach staff at night to request them. Staff interacted with patients in a caring and respectful manner. Staff we spoke with demonstrated their dedication to providing high quality patient care.

• Wards had well equipped clinic rooms with appropriate equipment which staff regularly checked.

• The average bed occupancy was low. The service did not have any out of area placements, readmissions or delayed discharges. Staff worked with both internal and external agencies to coordinate care and discharge plans.

• The trust had a range of information displayed on the ward and the hospital site relating to activities, treatment, safeguarding, patients’ rights and complaint information.

However:

• The service had seven vacancies for qualified nurses and three for non-registered nurses.

• There was a blanket restriction. On Phoenix ward patients were not allowed access to the garden. However, this was a temporary restriction due to the building works and patient safety.

• Clinical supervision rates were low. 42% of staff on Phoenix ward and 27% Griffin ward had received clinical supervision. Managers did not ensure that the staff were receiving regular clinical supervision and had not met the trust target compliance rate of 85%. Staff morale on Griffin ward was low due to the announcement of the ward’s closure upon the completion of works on Phoenix ward.

• Staff explained to patients their rights under the Mental Health Act on admission and routinely thereafter, although we saw this was not always documented in the patients’ care notes.

• Clinic rooms were overstocked with medications. Nursing staff did not have a stock list to randomly check medication which meant they could not reconciliation check.

• The phones on each ward were in communal areas; the phone on Griffin ward had not been moved since the last inspection, although it had a privacy hood installed. There was a mobile phone in the ward office that patients could use for private calls, for example to a solicitor.

• Patient views on the quality of the food were variable.