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Provider: Mersey Care NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 27 June 2017

We rated the trust as good overall because:

  • The trust’s restrictive practice reduction programme was effective. There was a clear commitment to safeguarding. Almost all of the individual patient risk assessments we reviewed were thorough and up to date. The trust was compliant with duty of candour requirements and had taken potential risks into account when planning services. Trust buildings and clinical equipment were mostly clean and well-maintained. Security arrangements and environmental risk assessments were effective. Most teams had put measures in place to reduce the impact of low staffing, and staffing was discussed regularly at all levels of the trust. Overall compliance with mandatory training was good. Medicines management on most of the wards was good. Staff reported and learned from incidents.
  • Within high secure services, there was a clear aspiration to reduce the use of seclusion and long-term segregation. The trust had recruited an additional 19 psychology staff since our last inspection, which had improved access to psychological therapies in the local division. The quality and range of psychological and occupational therapies in learning disability and autism secure wards was excellent. Therapeutic intervention and treatment provided in most of the core services was in line with best practice guidance. Staff evaluated the effectiveness of their interventions using standardised outcome measures and clinical audit. Care planning and record keeping was mostly effective throughout the trust.  The majority of staff were experienced and skilled, and compliant with trust requirements for supervision and appraisal. Multidisciplinary meetings and handovers were patient-focused and effective. The majority of staff understood and applied the Mental Health Act and Mental Capacity Act.
  • Almost all of the patients and carers we spoke with were positive about staff and the service. Patients said that staff were supportive, helpful and kind. All of the interactions we observed in five of the six core services we inspected were caring and respectful. Staff involved patients and carers in the care they received. Patients were oriented to the wards on their arrival. There were many opportunities for patients and carers to give feedback and help develop services.
  • The trust’s services were planned and delivered to meet the diverse needs of the population. There were good escalation procedures in place for delayed discharges. Staff took active steps to understand and engage people from disadvantaged groups and those with protected characteristics under the Equality Act 2010. Food provided to patients had improved since our last inspection. Patients on all but two of the wards we inspected had access to at least 25 hours of activity each week. Services met people’s individual needs, including disability, spiritual and dietary needs. The trust listened to and learned from complaints.
  • The trust had a clear vision, values and strategy. Safety and quality were paramount. The trust was financially stable and secure. Non-executive directors and the council of governors were effective in holding the trust to account. The trust had an up to date risk register and there were clear risk identification and review processes in place for risks at corporate and divisional level. There were effective surveillance systems in place and each division had a clear governance structure. Leadership at all levels was visible and effective. The trust was committed to its goal of developing a fair and just culture. Staff were aware of the whistleblowing policy and felt able to raise concerns. Overall, staff morale was good despite service pressures. Staff and patients were engaged in all aspects of strategy delivery.

However:

  • There was an infection control risk in patients’ laundry rooms on four of the medium secure wards. On the STAR unit, staffing was not sufficient to manage the level of need. There was low compliance with training in basic and immediate life support on three wards for older people with mental health problems and one ward for people with learning disabilities and autism. Medicines were not always managed safely in wards for older people with mental health problems and on the STAR unit.
  • Five trust policies referred to the out of date 2008 Mental Health Act Code of Practice, which meant staff were not following current guidance. The trust had not notified CQC of authorised Deprivation of Liberty Safeguards applications. This is a requirement of their registration. At Wavertree Bungalow, care plans for patients who were not independently mobile did not include a detailed moving and handling risk assessment. Also at Wavertree Bungalow, there was insufficient information in care records to enable staff to safely support two patients with epilepsy.
  • We observed negative interactions on wards for people with learning disabilities or autism. On Wavertree Bungalow, we saw staff ignoring patients, talking about patients in front of other patients, and failing to provide verbal reassurance during moving and handling.
  • There was a lack of meaningful activity on wards for people with learning disabilities or autism. On STAR unit we found that staff did not always use patients’ communication aids and could not control the level of noise in the environment to make it suitable for patients with sensory needs.
  • Some ward staff told us that low staffing levels were affecting their morale and making it difficult for them to perform their roles safely. The proportion of staff who would recommend the trust as a place to work was worse than the national average for mental health trusts. Governance at local level was not always effective.
Inspection areas

Safe

Requires improvement

Updated 27 June 2017

We rated safe as requires improvement because three of the core services we inspected on this occasion, and two core services we inspected previously, were rated requires improvement for this key question.

  • Four of the wards in medium secure services included rooms that were used for patients’ laundry and disposal of dirty mop water. This presented a risk of cross-infection, which had not been adequately mitigated by the trust.

  • Staff vacancy and sickness rates were higher than the average for mental health trusts in England. Staffing on STAR unit, a ward for people with learning disabilities and autism, was not sufficient to manage patients’ level of need.

  • There was low compliance with training in basic and immediate life support on three wards for older people with mental health problems and one ward for people with learning disabilities and autism.

  • Staff did not always manage medicines safely in wards for older people with mental health problems and on the STAR unit.

  • Seclusion rooms on three wards in medium secure services had the potential to breach patients’ privacy and dignity due to the positioning of their windows.

  • The trust’s systems did not allow them to accurately report on all safeguarding indicators.

However:

  • The physical environment at core service locations was mostly clean and well maintained. Clinic rooms were well-equipped and staff ensured that all clinical equipment was checked and maintained according to manufacturers’ standards. All of the trust’s inpatient and supported living areas had a ligature point risk assessment completed within the last 12 months. (A ligature point is something to which a person at risk of self-harm could attach a cord, rope or other material for the purpose of hanging or strangulation.)

  • Security arrangements worked well. Staff managed alarms and keys safely. The trust had an effective restrictive practice reduction programme called No Force First. Use of prone restraint had decreased significantly since our previous inspection.

  • Most teams had put measures in place to reduce the impact of low staffing. Staffing was discussed regularly at all levels within the trust. Overall compliance with mandatory training across the core services was high at 89%.

  • The trust had a safeguarding strategy and a clear commitment to safeguarding. Almost all of the individual patient risk assessments we reviewed were thorough and up to date. There was evidence of good medicines management across all of the core services and most of the wards.

  • Staff reported incidents appropriately and in a timely manner. The trust had acted to reduce incidents and promote reporting since our last inspection. Learning from incidents was fed back to staff through team meetings, supervision and quality practice alerts. The trust had a ‘being open’ policy, which included duty of candour. The trust monitored adherence to duty of candour legislation.

  • The trust had an effective estates strategy and had taken potential risks into account when planning services.

Effective

Good

Updated 27 June 2017

We rated effective as good because four of the core services we inspected on this occasion, and all of the core services we inspected previously, were rated at least good for this key question.

  • We saw many examples of best practice being implemented across the core services. NHS England’s recommendation to ‘stop the overmedication of people with a learning disability’ was reflected in trust policy and practice. There was a clear aspiration across high secure services to reduce the use of seclusion and long-term segregation. Staff evaluated the effectiveness of their interventions by using standardised outcome measures and clinical audit.

  • The trust had recruited an additional 19 psychology staff since our last inspection, which increased the availability of psychological therapies. The quality and range of psychological and occupational therapies in learning disability and secure services was excellent.

  • Care planning and record keeping were mostly good throughout the trust. All patients with a learning disability or autism who presented with challenging behaviour had high-quality positive behaviour support plans. Staff could easily access the information they needed to be able to deliver safe and effective care. Staff assessed, monitored and met patients’ physical health needs,

  • Overall, staff were experienced and skilled. All had received additional training to support them in their role. The majority of staff in high secure, medium secure, low secure, learning disability and autism secure and substance misuse services were compliant with trust policy requirements for supervision and annual appraisal. The trust had a leadership development pathway that was open to all staff.

  • There were policies and support in place to address staff poor performance. The trust was in the process of implementing a ‘fair and just culture’ based on feedback from staff.

  • Multidisciplinary meetings and handovers were patient-focused and effective. All of the teams worked collaboratively with external organisations.

  • Most staff had completed Mental Health Act and Mental Capacity Act training. There were effective systems in place to ensure that the requirements of the Mental Health Act and Code of Practice were met. Most staff understood the application and principles of the Mental Health Act and Mental Capacity Act.

However:

  • Five trust policies referred to the out of date 2008 Mental Health Act Code of Practice, which meant staff were not following current guidance.

  • The trust had not notified CQC of authorised Deprivation of Liberty Safeguards applications. This is a requirement of their registration.

  • At Wavertree Bungalow, care plans for patients who were not independently mobile did not include a detailed moving and handling risk assessment. Also at Wavertree Bungalow, there was insufficient information in care records to enable staff to safely support two patients with epilepsy.

  • Psychological therapies and dementia-appropriate environments were not consistently available across all wards for older people with mental health problems.

  • Compliance rates for supervision and/or appraisal were low on three wards for older people with mental health problems and one ward for people with learning disabilities or autism.

  • Staff on the STAR unit (a ward for people with learning disabilities and autism) had not received training in autism, learning disability, epilepsy and communication skills.

  • Only 56% of staff on wards for older people with mental health problems had completed Mental Health Act training.

  • Only 30% of staff in medium and low secure services and 57% of staff in wards for older people with mental health problems had completed Mental Capacity Act training.

Caring

Good

Updated 27 June 2017

We rated caring as good because five of the core services we inspected on this occasion, and all of the core services we inspected previously, were rated at least good for this key question.

  • Almost all of the patients and carers we spoke with were positive about the staff and the service. Patients said that staff were supportive, caring, respectful, helpful and kind.

  • All of the interactions we observed in five of the six core services were caring and respectful. Staff were good at recognising and responding to patients’ needs.

  • The trust involved patients and carers in the care they received. Ninety-five per cent of patients who completed the trust’s patient experience survey reported that they had been involved in the development of their care plan. Trust policies and strategies were in place to ensure carers were meaningfully involved in care planning. Patients had been involved in many different projects across the trust.

  • Advocates and the patient advice and liaison service visited wards regularly to support patients and help facilitate community meetings. All mental health wards held community meetings at least monthly. High secure services and learning disability and autism secure services also held monthly forums attended by patient representatives. The patient representatives felt valued in their role and able to make changes on behalf of their peers.

  • Staff oriented patients to the wards on patients’ arrival. Some wards gave patients an information pack that was specific to the ward. Patients from learning disability and autism secure services had been involved in making videos to help new patients know what to expect from admission.

  • The trust had employed seven peer support workers, who were people with direct experience of using trust services.

However:

  • We observed negative interactions on wards for people with learning disabilities or autism. On Wavertree Bungalow, we saw staff ignoring patients, talking about patients in front of other patients, and failing to provide verbal reassurance during moving and handling.

Responsive

Good

Updated 27 June 2017

We rated responsive as good because five of the core services we inspected on this occasion, and all of the core services we inspected previously, were rated at least good for this key question.

  • Patients in learning disability and autism secure services had ‘moving on’ care plans to prepare them for discharge. Trust staff had done exemplary work with local placement providers to ensure that transition to the community was as successful as possible.

  • Staff took a proactive approach to understanding the needs of different groups of patients. All of the wards provided access to separate rooms where patients could practise their faith. Wards were also able to cater for specific dietary needs. We saw good examples of compliance with NHS England’s accessible information standard.

  • All of the core services had a full range of rooms and equipment to support treatment and care. Trust premises were accessible to people who used wheelchairs or who had mobility difficulties. The trust’s patient-led assessment of the care environment scores for food had improved since our last inspection. Patients on all but two of the wards we inspected had access to at least 25 hours of activity each week. All patients were able to make private telephone calls (with limitations for some patients in high secure services).

  • All of the core services provided information on treatments, local services, patient rights and how to complain. The trust listened to and learned from complaints.
  • The trust’s services were planned and delivered to meet the diverse needs of the population. The trust’s three priorities for improvement were identified in consultation with stakeholders.

  • The trust had a five-year plan to integrate the community physical health services they were due to take over from 1 June 2017.

  • The trust took active steps to engage people who found it difficult to engage with mental health services.

  • There were good escalation procedures in place for delayed discharges.

However:

  • There was a lack of meaningful activity on wards for people with learning disabilities or autism.

  • On STAR unit, a ward for people with learning disabilities and autism) we found that staff did not always use patients’ communication aids and could not control the level of noise in the environment to make it suitable for patients with sensory needs.

  • The trust was not meeting its own targets for timeliness of response to complaints.

Well-led

Good

Updated 27 June 2017

We rated well-led as good. Four of the core services we inspected on this occasion, and five of the core services we inspected previously, were rated good for this key question. However, two of the core services we inspected on this occasion and two of the core services we rated previously were rated requires improvement for well led. We made a decision to deviate from our aggregation tool in this case because one of the core services rated as requires improvement for well-led (wards for people with learning disabilities and autism) represented only 14 of the trust’s 672 beds. We also found evidence that the trust overall was well led. It would therefore have been disproportionate for us to rate this key question as requires improvement.

  • The trust had a clear vision underpinned by four values. Staff knew and understood the vision and values. It was clear from the trust’s strategy that safety and quality were paramount. The trust had developed their overarching strategic goal following consultation with staff. Staff and patients were engaged in all aspects of strategy delivery.

  • The trust was financially stable and secure. The trust non-executive directors and council of governors were effective in holding the trust to account. The trust minimised the impact of pressures and efficiency changes on the quality of care.

  • Each division had a clear governance structure from ward or team level up to the board. There were thorough surveillance systems in place. There was evidence from the assessment of core services that the trust governance framework was effective, with some exceptions. The trust had an up to date risk register and there were clear risk identification and review processes in place for risks at corporate and divisional level.

  • At core service level, managers had access to ‘dashboards’ to monitor their team’s performance. The trust completed internal quality review visits to assess safety and quality at individual wards and locations.

  • Leadership at all levels of the trust was visible and effective. Leaders encouraged collaborative and supportive relationships among staff. Senior staff visited the core services. Staff were aware of the whistleblowing policy and felt able to raise concerns. Staff described the new ‘freedom to speak up guardian’ as visible and approachable. The trust was committed to its goal of developing a fair and just culture

  • Overall, staff morale was good despite service pressures. Many staff said that they enjoyed their work and felt valued by their teams. Staff in core services facing organisational change felt supported, and most said that communication was good. Staff were able to give feedback and suggest ideas for service improvement. The trust leadership development pathway was open to all staff.

  • Poor staff performance was addressed promptly and effectively. The trust had analysed the causes of staff sickness, and put plans in place to address it. The trust was compliant with the workforce race equality standard, and working to address shortfalls.

  • The trust had refurbished a popular local building to provide a well-used community hub. The trust offered volunteering opportunities to patients, staff, trust members and the public through its ‘people participation programme’. The trust had employed eight service users to help train staff and support patients through their recovery. The trust was also running a public campaign to encourage people to talk about mental health problems.

However,

  • Some ward staff told us that low staffing levels were impacting on their morale and making it difficult for them to perform their roles safely. The proportion of staff who would recommend the trust as a place to work was worse than the national average for mental health trusts. Staff sickness across the trust was high. Some staff expressed frustration about the lack of clarity for band 2 healthcare assistant roles, particularly in the local division.

  • Governance at local level was not always effective. Learning from the specialist learning disability division (about care plans for patients with epilepsy) was not transferred for people with learning disabilities accessing inpatient beds in the local division.

  • Some patients felt that it was unfair that the trust did not pay volunteers for their work.

Checks on specific services

Acute wards for adults of working age and psychiatric intensive care units

Good

Updated 14 October 2015

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

Although the physical environment varied across wards, the trust had actions plans in place to ensure that any risks associated with the environment were addressed. The wards were clean and well maintained and there was good evidence that infection control was monitored. There were dedicated wards for men and women, and the mixed wards complied with gender segregation guidelines. Medication was managed safely in most areas. However, on the Broadoak Unit we found that staff had limited understanding of what constituted rapid tranquilisation and how the patient should be monitored afterwards, and there were errors in the controlled drugs register.

All patients were assessed on admission to the wards, which included an assessment of their mental and physical health and a risk assessment.

Staff treated patients with dignity and respect and were responsive to their needs. Patients were given information about the service and their care and how they could make comments or complaints.

Most of the care records we looked at were person centred and recovery orientated, but there were gaps on some of the wards. Patients had their basic physical healthcare needs met, but the trust was working to improve this further.

Staff reported and investigated incidents, action was taken and learning was shared with staff through supervision, meetings and bulletins. Most patients were admitted to a hospital within the trust when they needed a bed.

We found that services were well led and that staff were familiar with the vision and values of the organisation. They were aware of the trust’s initiatives that aimed to reduce the use of restraint within the trust, no force first and the zero tolerance to suicide strategy.

Managers of the service met regularly to review practices and areas of concern. They provided staff with regular supervision and appraisal and ensured that staff had under gone training, including being up to date with mandatory training.

Community mental health services for people with learning disabilities or autism

Good

Updated 14 October 2015

We rated this core service as good because:

•The service had developed clear, evidence based clinical pathways to support effective assessment, treatment and management of clinical needs. The teams worked effectively and collaboratively with other services to ensure continuity and safety of care across teams, including involvement of external agencies. We found that there were inconsistencies between the localities we visited, in relation to caseload management and service delivery. This meant that people may have a different experience of care or outcome of treatment, depending on where they receive their care. However, the community learning disabilities teams worked hard to meet the varied demands on the service despite challenges they faced at times with limited resources.

•People who used the service were treated with kindness, respect and dignity. Individuals were positive about the way staff treated them and were involved in the planning of their care. Clinician`s kindness, expertise and skills within the teams were highly regarded by all carers and patients we spoke with. The staff we met ensure  the people who use the service at the centre of what they did.

•The service operated an open referral system and had capacity to respond in a timely manner. The teams were confident that they all worked within the assessment targets agreed by the trust, however the systems in place to monitor compliance with waiting and response times did not appear to accurately reflect this. The teams worked flexibly to meet individual`s needs and worked closely with a number of different agencies to meet their needs, promote community involvement and social inclusion.

•The trust had a system to identify and monitor quality and safety of the services they provided. However, there were concerns with accuracy of recording and quality of data to monitor compliance with waiting and response times. There were not effective systems in place to monitor referrals, waiting lists, unmet need and the potential impact of gaps in service provision. There was a clear system in place to report incidents. However, we were concerned about the lack of comprehensive investigation into a serious incident affecting a member of staff last year.

• The community learning disabilities service was undergoing a comprehensive review of service delivery, local team performance monitoring and management structures, as part of the service re-design.Some teams, for example, both of the Asperger`s teams, and the administrative teams, did not have a line manager. Meeting structures were not in place which would support effective oversight monitoring across the whole service, for example, there were no management meetings or administration meetings in place. Most staff were concerned that there could be reduced learning disability representation within the senior management team with the restructuring.

•We saw good examples of local leadership from the team managers we met. Staff told us that they felt well supported by their team managers and were able to raise concerns and contribute to service development. The service manager and modern matron showed a good understanding of the current challenges for this service and staff.

Community-based mental health services for adults of working age

Good

Updated 14 October 2015

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

The CMHT’s at Arundel, Kirkby and Moss House had safe and clean environments. Clinical rooms were sufficiently equipped and the equipment was generally well maintained. Staff adhered to infection control requirements and good practices in medicines management. Staffing levels ensured people using the service received safe care. All the CMHTs visited, managed vacancies and sickness to ensure there was minimal impact for people using the service. Staff assessed and managed the risks of people. These were reviewed regularly. Staff discussed crisis plans with people and included them in their care packages. Staff were knowledgeable in safeguarding requirements. Staff reported on incidents and lessons learnt, were shared across the teams at location level and trust wide.

Peoples’ needs were assessed to enable staff to plan their care with a holistic and recovery focused approach. The CMHT’s had access to a full range of disciplines. Staff were well supported, appropriately trained and able to develop their roles. The CMHT’s held effective and regular multi-disciplinary meetings. There were good links with social services, inpatients settings and crisis provisions to ensure good care. Staff adhered to the Mental health Act 1983 (MHA) and the MHA Code of Practice and demonstrated good practice in applying the Mental Capacity Act (MCA) 2005.

Staff were kind and respectful to people using the services. Staff actively involved people in developing and reviewing their care and maintained people’s confidentiality. Staff also made sure that their families and carers were involved when this was appropriate.

Staff saw referrals within the trust targets. There was a clear process to discuss steps to be taken for people who found difficulty in engaging with the service. Inpatient discharges into the community and discharges from community services were planned and consultant led, with care co-ordinator involvement. Information was available to people and accessible in varying formats and languages as needed. People using the service knew how to complain and learning from complaints was discussed within staff teams.

Staff knew the trust’s vision and values and felt these were embedded into service delivery. Morale within teams was generally good and staff felt supported by management. Staff had opportunities to develop and were encouraged to do so. Managers had sufficient autonomy and support for their roles. Staff had attended trust wide events learning from incidents.

However,

  • The trust’s Lone Working Policy lacked detail on how regularly checks should be made to account for workers on community visits and who should conduct these checks.
  • People using the service had limited psychological interventions and with long waiting lists for psychotherapy.

  • Teams had not been subject to audits to ensure the MHA was being applied correctly in relation to community treatment orders (CTOs).

  • Some managers reported that systems for reporting training, supervisions and appraisals were not robust.

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Community-based mental health services for older people

Good

Updated 14 October 2015

We rated the community based services for older people as ‘Good' overall because:

  • People had their needs assessed, care planned and delivered in line with best practice.
  • Multi-disciplinary teams managed the referral process, assessments, on-going treatment and care. This included care navigators who support people with dementia.
  • Common assessments and pathways for post diagnostic support for people with dementia had been agreed across mental health, acute and specialist NHS trusts.
  • People who used services had timely access to care and treatment.
  • There were systems in place to triage referrals based on the individual needs of people who used the service. Services were planned and delivered to meet people’s needs in a person centred way, taking their cultural needs into account.
  • Each team was well led by committed managers.
  • Each team had team objectives which helped guide staff and teams.
  • Two out of three of the memory clinics were accredited as excellent, with the Royal College of Psychiatrists’ memory services network accreditation project.

We saw outstanding user involvement initiatives with significant service user involvement and community engagement, including by people with dementia. This was particular apparent in Central Liverpool. This included:

  • the work of the service user reference forum.
  • service users and staff working as partners to be involved in developing apps to assist their memory, reminiscence and daily functioning and working with businesses to make them 'dementia friendly'
  • partnership work with Everton Football Club.

People were exceptionally positive about the care they received.

However, there were vacancies within teams which meant that some staff had to manage caseloads greater than they usually would. Care navigators were managing large numbers of people. We did not see significant impact on patients from these; managers were looking to address these by recruiting staff and working with commissioners.

Some risk assessments for people using the service were over 12 months old. Lone working practices did not always fully ensure staff safety. Staff were not always proactive in following up on updates on safeguarding processes. There were minor issues with equipment in the clinic room at Central Liverpool older people’s CMHT

Forensic inpatient/secure wards

Good

Updated 27 June 2017

We rated forensic inpatient/secure wards (medium and low secure) as good because:

  • All wards had a ligature risk assessment in place. Security procedures that were in place for accessing the wards met the needs of each individual service and the level of security required.
  • Clinic rooms were functional; medical devices were checked regularly and serviced and calibrated annually. Physical health was monitored routinely, and patients had access to a GP twice weekly if this was required.
  • Risk assessments and care plans were in place for all patients. These were up to date and reflected the patients’ needs. The majority of patients told us that they had been offered a copy of their care plans.
  • Incidents were reported through the trust’s electronic incident reporting system. Staff received feedback on incidents and complaints through staff meetings and quality practice alerts.
  • Staff used National Institute for Health and Care Excellence guidance to guide their practice, and used recognised rating scales to monitor patient outcomes.
  • Staff received supervision and annual work performance appraisals. Staff felt skilled and competent to perform their role and had lots of opportunity for additional training should they wish to develop their skills further.
  • We observed positive and supportive interactions between patients and staff, which showed that staff treated patients with dignity and respect. Patients told us that staff were respectful and caring.
  • The independent mental health advocate was available on thewards, and supported patients in ward rounds and with their concerns. Community meetings took place monthly.
  • A referrals meeting took place weekly across the medium and low secure wards to review all referral, discharges and movements between the services.
  • Both diversionary and occupational activities took place on the ward seven days a week. The majority of patients told us that the food was good, and they had access to hot and cold drinks throughout the day and could have snacks. Both units had a multi faith room and could access spiritual leaders to support their patients’ cultural and spiritual needs. There was disabled access on both sites.
  • Staff were aware of the vision and values of the organisation. Staff felt that there was a high presence of the matrons within the low and medium secure services.
  • There were good governance systems in place for monitoring compliance with staffing sickness, mandatory training and appraisals. The ward managers felt that they had enough authority to perform their role and had access to key performance indicators, which helped to monitor the performance of their teams.
  • Staff morale was good and there was evidence of good team working. Staff were able to provide feedback on their services through team meetings. They were also invited to send any feedback to the trust chief executive.
  • All the wards were part of the quality network for forensic mental health peer review initiative.

However:

  • At the Scott Clinic, the sluice on four of the wards was located within the patient laundry room. This did not apply good infection control principles for clean and dirty areas.
  • Patients that were secluded at the Scott Clinic could potentially see the computer screens in the staff office which could cause a breach of confidentiality.
  • The ward staffing levels meant there were not always enough staff on duty to meet the needs of the patients; patients and staff told us that leave often had to be rescheduled.
  • The drug detection dog attended all the wards on a frequent basis. We felt that this practice was overly restrictive on low secure wards.

Long stay/rehabilitation mental health wards for working age adults

Requires improvement

Updated 14 October 2015

We gave an overall rating for long stay/rehabilitation mental health wards for working age adults of requires improvement because:

  • The ligature assessment on Rathbone Rehabilitation was out of date; actions from previous years did not appear to have been completed. Previous assessments did not take into accounts the risks in the garden such as the gym.
  • Brain Injury Rehabilitation Ward did not have access to ligature cutters for all staff. These were locked in the clinic room in a cupboard that only certain staff could access.
  • There was an average of 2 shifts per week left on Rathbone where staff numbers were below what was clinically required. There was also a high level of sickness.

  • 1:1 supervision rates of staff were not in line with trust policy.
  • Mandatory training records showed that staff at Rathbone Rehabilitation Ward, were not up to date with required training, which was set at 95%.
  • Staff were not appraised in line with trust policy, 3 staff had not been appraised for 2 years.
  • Knowledge and access information for IMHA and IMCA services was out of date.

However:

Wards were clean, tidy and well maintained. There was good medical cover from doctors and a nurse practitioner to take the lead on physical health assessment. Staff carried out audit of patients care plans and of infection control risks. Safeguarding training was up to date and there was generally good knowledge around safeguarding procedures. NICE guidelines were followed for prescribing and offering therapies such as Cognitive Behavioural Therapy. Staff were observed to have a caring attitude towards the patients and the interactions were positive.

Patients reported feeling safe on the ward and they were supported after being discharged through follow up groups. There was a comprehensive range of disabled equipment and wards were adapted to have very good disabled access. Wards had activity timetables that were generic but also produced individualised activity plans that were of a multi-disciplinary approach. There were procedures in place to listen to and escalate complaints, the services showed they listened to and adapted according to patient feedback. Morale of staff was reported as good and staff felt free to raise concerns. Rathbone Rehabilitation Ward was AIMS accredited whilst Brain Injury Rehabilitation was accredited with Headway meaning that they were providing a service that was of a high quality and measured against national standards.

Mental health crisis services and health-based places of safety

Good

Updated 14 October 2015

We rated the health based places of safety as good overall because:

  • There was evidence of good inter-agency working including shared forums for reviewing issues, strategic meetings, addressing continued service improvements and positive relationships within the operational services.

  • Joint protocols were in place across Merseyside police, Mersey Care NHS Trust, the acute hospital trusts, local authorities and ambulance services involved in the detention, assessment and conveyance of people detained under section 136 of the Mental Health Act.

  • Joint procedures included a 10 step pathway for all involved in the process of section 136 to follow. The police used a traffic light rating system to support joint decision about remaining at the assessment or leaving.

  • There was a designated health-based place of safety in the city for children under the age of 16 years.

  • There had been no detentions of anyone subject to section 136 to police cells within Merseyside in the previous 12 months.

  • There was a culture of continued development. This included the street car initiative and the development of a heath-based place of safety within adult mental health inpatient services. There was also the implementation of employing health care assistants within accident and emergency services to provide one to one support for people detained under section 136.

However

  • The section 136 room at Aintree University Hospital did not provide a safe and a suitable environment for the assessment of patients detained under section 136 of the Mental Health Act (MHA) 1983 and there was a privacy and dignity issue at the Royal Liverpool University Hospital as the toilet door had been removed for safety reasons.

  • There were some considerable waits for section 136 assessments to be concluded. The reason was not clearly recorded in all the instances.

  • All of the forms that we reviewed required multi-agency input to record each stage of the 10 step care pathway retained within the A&E departments were incomplete.

Substance misuse services

Good

Updated 27 June 2017

We rated substance misuse services as good because:

  • All the services we visited were tidy and well maintained. The furniture was in good repair and the clinic areas were clean and well organised. Staff understood infection control procedures.

  • Staffing levels and skill mix were planned and reviewed to keep patients safe and meet their needs. There were effective procedures for escalating concerns about staffing levels. There were effective handovers to ensure staff were aware of the risks to patients.

  • There were clearly embedded systems, processes and standard operating procedures to keep patients safe. The staff knew how to look for signs of abuse and how to make a safeguarding alert if necessary. This meant that patients were protected from avoidable harm.

  • Managers encouraged openness and transparency about safety. Staff knew what to report and how to report it. They understood their responsibilities relating to the duty of candour.
  • In most cases, patients’ needs assessments included consideration of clinical needs, physical and mental health and wellbeing, and nutrition and hydration needs.
  • Staff planned care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Links to best practice guidance were available on the trust’s website.
  • Patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.
  • Staff respected patients’ diverse needs. Patients were supported, treated with dignity and respect, and involved as partners in their care. There was a visible person centred culture.
  • Patients were involved and encouraged to be partners in their care and in making
  • decisions, with any support they need. Staff spent time talking to patients so that they understood their care, treatment and condition.
  • Staff took into account the needs of different groups so that they met patients’ needs.
  • Patients understood how to complain or raise a concern. Staff took complaints and concerns seriously. They listened and responded to in a timely way.
  • The service was transparent and open with stakeholders about performance. Information was used to support effective decision-making and drive improvement. Staff reported and reviewed information on patients’ experiences alongside other performance data.
  • Staff felt respected, valued and supported. They were committed to their roles and enjoyed working with the patient group. They described a strong and supportive team.
  • Managers supported staff to work in innovative ways. They encouraged staff to discuss issues and ideas for service development.

However:

  • At the Windsor Clinic, the fire risk assessment was out of date and actions had not been completed.
  • Not all patients had a comprehensive risk management plan that staff reviewed regularly.
  • Care records were not always comprehensive and holistic. They did not always take account of patients’ views. Some were not recovery focused and were not reviewed regularly.
  • Systems for audit and review in relation to care records were not always effective.
  • Some care records did not contain individual plans for unexpected exit from treatment.

Wards for older people with mental health problems

Requires improvement

Updated 27 June 2017

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

  • The service was not providing safe care and treatment in relation to medicines management. Allergies were not being recorded on medicine cards, which meant there was a risk of a patient being prescribed medicines they were allergic to. On Irwell ward, there was no guidance to staff of how to administer medicines to a patient covertly and medicine administration cards had several administration boxes left blank. We noted delays in treatment starting for up to three days.

  • Training was a concern. Training levels for basic life support, immediate life support, Mental Health Act and Mental Capacity Act were low across the wards. Dysphagia training (to assist patients with swallowing difficulties) was not available to staff; this had been identified as being required in an action plan following the death of a patient.

  • Staff were not receiving supervision and appraisal in line with trust policy. Staff reported morale as low, particularly following the closure of one of the wards caring for patients with dementia.

  • Patient access to a variety of staff from different disciplines varied across the wards, especially in relation to psychology, occupational therapy, speech and language therapy and gerontology(a doctor specialising in old age and ageing).

  • Accessible information was not available to patients to assist with orientation to the ward at admission.

  • The service provision in some of the wards did not reflect national guidance in relation to the environment and activities available.

  • There was no evidence that staff followed legal advice to review a patient’s capacity pending the outcome of a Deprivation of Liberty Safeguards Application. Only one of the five wards notified CQC of authorised Deprivation of Liberty Safeguard applications.

However:

  • Feedback from patients and carers was positive in relation to the care provided and we observed respectful, responsive and encouraging interactions from staff.

  • Incidents and complaints were managed well and learning was shared with staff via team meetings.

  • Staff had a good understanding of safeguarding and how to respond if safeguarding concerns were raised.

  • Physical health was managed well, with assessments taking place on admission. Frailty reviews took place for all patients, which were multidisciplinary in nature and clear actions set and reviewed. The service provided ongoing physical health care.

Wards for people with learning disabilities or autism

Requires improvement

Updated 27 June 2017

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

  • We were concerned about staffing levels at the STAR unit and the impact of this on patients and staff.

  • Staff had not had sufficient training in a range of areas essential to this core service, including autism awareness, learning disability awareness, epilepsy and communication skills.

  • At Wavertree Bungalow, not all patients with epilepsy had an epilepsy care plan. Patients who required moving and handling assistance did not have written assessments or plans for this.

  • We undertook short observations at both services and noted negative interactions with patients at times and that staff did not always follow support plans.

  • At the STAR unit and Wavertree Bungalow activities were not always taking place as planned.

  • We noted observation records were not fully completed, with gaps where staff had not recorded observations.

However:

  • Wards were clean and well furnished.

  • Infection prevention practice was good.

  • Positive behavioural support plans and risk assessments were well completed and comprehensive.

  • Patients and carers gave positive feedback about staff at the services.

  • At the STAR unit, a well equipped sensory room was available on the ward and well used.

High secure hospitals

Good

Updated 19 October 2017

We rated high secure services at Ashworth Hospital as good because

:

  • Wards were clean and well furnished. Mirrors and closed circuit television cameras were used to ensure that patients and staff were safe and monitored on every ward. Staffing was being managed by ward managers and matrons, using a safe staffing system, and we were informed that 53 new staff had been recruited to the trust and would soon be ready to join the teams. National policies relating to night time confinement and long term segregation were being followed. Medication management followed guidance, and the introduction of an electronic prescription system had improved monitoring. Incidents were reported and appropriate actions were taken to deal with these incidents.

  • Care plans were comprehensive and holistic across the service. Staff involved patients in the development of their care plans and gave copies of care plans to patients when the patient agreed to accept them. Staff were able to access further specialist training from external bodies, up to and including masters level qualifications. The care records indicated that staff paid as much attention to patients’ physical healthcare as they did to patients’ mental health. The provider had recruited psychologists to the service.This improved the patients’ access to effective psychological therapies. All patients were detained under the Mental Health Act.Staff across the service adhered to the guidance in the Mental Health Act Code of Practice. However, the trust Mental Health Act policy referred to an out of date Code of Practice; the trust was using the current Code of Practice. The Mental Capacity Act was applied across the service, and we saw evidence of capacity assessments in care records.

  • Interaction between patients and staff was seen to be of a high standard, empathic and professional. Patients told us that staff treated them with kindness and respect. We observed a patient forum and saw excellent interaction between staff and patient representatives, with matters discussed openly and with due consideration for all. We spoke with carers of patients and were told that, generally, they were positive about the service. Some carers raised points that we looked further into, and were assured that the service was acting in the best interest of patients. Patient viewpoints were listened to and helped to define the service.

  • The service was adhering to national recommendations regarding times for referral and assessment of patients. Wards were updated and refurbished on a rolling basis, as older wards were redecorated and improved. Forster ward had recently closed and re-opened as Newman ward, the new ward being appreciatively more modern than the old ward. The service had plans in place for patients from different cultures and countries, considering food, treatment and religious aspects.

  • The trust visions and values were embedded in the service. All staff knew of the values of the trust, and the direction the trust wanted to move. We saw evidence of senior staff involvement in the service, including at chief executive level. Staff were involved in clinical audit; the service itself had been involved in a number of audits in the 12 months prior to the inspection. Ward managers felt they had the authority to do their job. Staff told us that morale on the ward was quite high, but it would improve more when new staff joined the teams.

Other specialist services

Outstanding

Updated 27 June 2017

We rated learning disability and autism secure services as outstanding because:

  • Staff were highly skilled at anticipating and de-escalating behaviour that might have led to violence or self-harm.The trust had trained its staff to use effective de-escalation techniques. Staff developed, applied and reviewed good positive behavioural plans; especially for patients who were individually nursed. As a result, staff used physical restraint and other restrictive interventions on many fewer occasions than in the past.

  • Person-centred therapeutic interventions were being delivered to patients to support them to achieve improved independence and wellbeing. There was a wide variety of activities available to patients both on and off site. Information in a variety of formats had been developed to ensure that it was easy for patients to communicate and to express their needs. All patients had access to a wide range of social, recreational, therapy based interventions, and a recovery college called ‘our shared college’. Individualised care had been adapted to meet patients’ specific communication needs. All patients had received input from speech and language therapists where necessary to ensure their communication needs were met.

  • Staff ensured patients and relatives were engaged with assessments, care plans and discharge arrangements. Patients were involved in developing their own care plans and staff provided them with copies which were in an ’easy read’ format to meet their needs.

  • The service was proactive in promoting equality and diversity and meeting the specific needs of vulnerable groups of patients. The service had introduced a health awareness and improvement initiative called ‘Dr Feel Well’. This project aimed to improve patients’ physical health by the use of patient education, guidance and encouragement.

  • Interactions between staff and patients demonstrated personalised, collaborative, recovery oriented care planning and involvement. All patients had a moving on plan, which the individual and other stakeholders had developed collaboratively. Some patients had been involved in filming a number of short videos about the wards with the trust’s patient led media crew.These videos were available online to help new patients know what to expect from admission and the transforming care agenda.

  • Comprehensive risk assessments for patients were completed and reviewed. Patients’ individual care and treatment was planned and best practice guidance was implemented, ensuring outcomes were monitored and reviewed.

  • Staff had an understanding of the Mental Capacity Act 2005 and the Mental Health Act 1983. They assessed mental capacity and enabled patients to make decisions where possible. Staff routinely referred patients for advocacy support if they lacked the capacity to do so themselves.

  • Staff received mandatory training, specialised training, supervision and appraisals. Staff had knowledge and skills to deliver effective care and treatment. Staff received support, appraisals, mandatory, specialist training, and supervision from their managers and peers. There was an ongoing recruitment programme to fill vacancies and managers ensured that bank and agency staff were familiar with the service and patients. The division monitored and adjusted staffing levels daily in response to risk on the wards and monitored and reviewed their divisional risk register.

  • Patients were protected and safeguarded from avoidable harm and incidents were appropriately reported to the local authority. Staff had received training in safeguarding and mandatory training compliance levels for staff were good.

  • Patients and their carers were positive about the care and treatment they received and staff behaviours were responsive, respectful and caring. Staff involved patients and their carers in the care and treatment they received.

  • The autism risk group provided a proactive, creative and dynamic approach based on best practice guidance and psychosocial approach to risk, engaging all patients that attended in self-discovery. There was an established championing recovery meeting co-produced with patients and facilitated monthly. Patients attended as designated recovery champions for their wards to share ideas and plan new recovery focused activities from their perspective. Staff empowered patients to have a voice. Patients reported their opinions and views were listened to and considered by staff in all aspects of their care.

  • The management and governance arrangements within the division were effective.

  • Managers were able to provide information into the governance meetings and staff received regular feedback from these meetings. They were kept up to date about the trust and wards’ performance.