All inspections: Leeds Community Healthcare NHS Trust

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

The service was not providing consistently safe care. The unit continued to not meet national guidance and standards, and did not ensure that patients could be cared for safely at all times. Medicines and equipment were not managed safely. Restrictive interventions and observations were not recorded correctly. Staff had not recognised the implementation of blanket restrictions which were not based on individual patient risks.
The service did not have effective processes in place to ensure good adherence to the Mental Health Act and the Mental Health Act Code of Practice. We found a recent example of a patient who had been detained without the use of the Act. Paperwork in relation to Section 17 leave from the ward was incorrect.
The service was not providing care consistently in a way that was responsive to people’s needs. Staff did not plan for discharge well. The design, layout, and furnishings of the unit did not support patients’ treatment, privacy and dignity. The limitations of the unit meant that additional restrictions for patients were in place to manage safety.
The service was not well-led. Our findings from the other key questions demonstrated that governance processes did not operate effectively at ward level and that performance and risk were not managed well. The trust had not taken enough timely action when CQC and other organisations have raised concerns about the suitability of the building in which this service is located over a number of years. The trust did not effectively monitor key areas of risk and performance in mental health care and had not ensured that policies and procedures to support good care were reflective of national guidance.

However:

Staff were consistently caring. Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. Staff involved patients in care planning and supported patients to understand and manage their care, treatment or condition. Staff involved families and carers appropriately.
Except for adherence to the Mental Health Act, the service provided effective care. Staff assessed the physical and mental health needs of all patients and developed care plans which were personalised, holistic and reflective of identified needs. The unit team included the full range of specialists required to meet the needs of patients and staff were able to provide a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. Staff worked effectively with external teams and organisations.
The service had a positive culture. Staff knew the values of the trust and how these were applied in everyday practice. Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution.

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

Safe, effective, caring, responsive and well led were rated as Good
Sexual Health services were rated outstanding overall. The service was rated good for safe and caring, and outstanding for effective, responsive and well led. This was an improvement on our last inspection.
Children and young people’s services were rated good for safe, effective, caring, responsive and well led. This was an improvement on our last inspection.
Inpatient CAMHs services was rated good for caring, requires improvement for safe, effective and responsive. Well led was rated as inadequate This was the same overall rating as the last inspection.
Community CAMHs services were rated good for effective and caring, requires improvement for safe, responsive and well led.
Dental services were rated good for safe, effective, caring, responsive and well led. This remained the same as the last inspection
In rating the trust overall, we took into account the current ratings of the two services not inspected this time and the proportionality of the services to the overall business of the trust.

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

Staff did not consistently manage safety well. Staff had not ensured that clinical premises where patients received care and clinical equipment used to support care were safe, well equipped, and well maintained. Patient risks were not assessed and managed well. Patients on waiting lists were not monitored to detect changes in risk. Not all staff had received the basic training to keep patients safe.
The service was not consistently responsive to patients’ needs. Waiting times for interventions including therapy and specific assessments exceeded agreed targets.
The service was not consistently well-led. Our findings from the other key questions demonstrated that governance processes did not operate effectively at team level, but performance and risk were managed well. Managers had not ensured that clinical premises and equipment were safe. Not all staff had received their mandatory training or an annual appraisal.

However:

The service was providing effective care. Treatment and care for patients was in line with national guidance. The teams included or had access to the full range of specialists required to meet the needs of patients under their care. The teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
Staff were caring. Staff were attentive and treated patients and families with compassion and kindness. Staff involved patients and families in making decisions about their care and in shaping the future of the service.

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

The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
Young people were treated according to national guidance, including those from the National Institute for Health and Care Excellence (NICE) and Royal College of Paediatrics and Child Health.
Policies and procedures were based on national guidelines.
The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
The 0-19 service provided a wide range of health promotion activities for children and young people and their parents.
Managers monitored the effectiveness of care and treatment and used the findings to improve them.
Staff cared for patients with compassion. Feedback from parents confirmed that staff treated their children well and with kindness.
The trust planned and provided services in a way that met the needs of local people.
The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
We observed effective leadership at a local level, team meetings were professionally managed with engagement from staff attending.
There had been significant improvements in the areas we had previously identified as a concern at Hannah House. These included safe staffing, medicines management, evidence of competencies, safeguarding training and supervision and lack of oversight management.
At our last inspection we had concerns about the management oversight of Hannah House. We saw that at this inspection there was an interim manager who had worked in the unit for a significant time and had put into place actions identified previously.
Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

Community paediatric medical staff fell below trust targets for mandatory training.

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

Staff were encouraged to complete mandatory training relevant to their roles. Training rates were good. The clinics were clean, uncluttered and hygienic. Systems and processes were in place to help protect patients from abuse. There were sufficient numbers of staff to treat patients safely and effectively. The service had a good safety record and staff were familiar with the process for reporting significant events.
The clinicians provided care, treatment and advice in line with nationally recognised guidance. Staff were competent for their roles and had regular appraisal and supervision. The staffing skill mix delivered effective care, dental hygiene therapists and extended duty dental nurses were used to assist with the increasing complexity of patient need. Multidisciplinary working was well embedded within the culture of the service. The dental team worked with the trusts learning disability team to ensure the patient journey was as smooth as possible. Staff were aware of the importance of obtaining and recording informed consent and were fully aware of the principals of the Mental Capacity Act.
Staff treated patients with dignity and respect. Patients told us that staff were friendly, professional, polite and helpful. Staff provided emotional support to patients to enable them to receive dental treatment. The service had developed videos and leaflets to help children familiarise themselves with the dental environment prior to their first visit. Staff had sufficient time to discuss treatment and provide support to patients and made reasonable adjustments accordingly. Patients and / or their carers were fully involved in decisions about treatment.
All clinics which we visited were fully accessible. The service had access to hoists and a wheelchair tipper. Translation services were readily available for patients whose first language is not English. Patients individual needs were attended to, to ensure they were able to receive dental treatment.
There was a clearly defined management structure and systems in place to developed leadership. The service had a vision of what it wanted to achieve, and this was in line with the newly acquired contract. Staff morale was good across the service and they felt appreciated and supported by managers. There were governance arrangements in place to help with the smooth running of the service and manage risk. The service engaged well with staff and patients to help continually improve the service.

However:

The current waiting times from referral to assessment was 24 and 25.6 weeks for adults and children respectively. The waiting times from assessment to general anaesthetic was 8 and 16 weeks for adults and children respectively. Staff were aware that these waiting times required improvement and they had implemented consultant led assessment clinics that were supporting reducing the waiting times. Any patient who needed urgent attention would be prioritised.
Emergency medicines and resuscitation equipment did not reflect nationally recognised guidance. We raised this during the inspection and was also reiterated post-inspection. We were later advised that action had been taken to address the lack of buccal midazolam and masks for the self-inflating bags.
An audit of the quality of X-rays had not been carried out since 2011.

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

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided a holistic patient centred approach to planning and delivering care and treatment, proving high quality care. All staff were actively engaged in monitoring the effectiveness of the service to improve quality and outcomes for patients. Innovative and evidence-based techniques were used to improve the service. Staff development was a priority for the service and there was evidence of strong collaborative working.
Staff consistently treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. Staff recognised the importance of providing emotional support, health and relationship advice and this was routinely offered to patients, families and carers.
The service had the individual needs of patients central to the planning and delivery of care. Services were flexible and used innovative approaches to ensure the services met the needs of people needing them. There was active engagement with other agencies to support those most vulnerable to access services at the right time and there was a proactive approach to understanding the needs of those using the service. Significant work had been done and was ongoing to ensure people could access services in a timely way.
Leaders were passionate about the service, this was reflected in the highly motivated staff we spoke with. Staff were proud of the service they provided and felt valued and supported. There was a focus on staff development and continuous improvement. The service was clearly focused on the needs of patients using the service, feedback was proactively sought and used to inform service development. The service engaged well with patients and there was strong evidence of collaborative working with other teams and agencies.

When the community inpatients service at Leeds Community Healthcare NHS Trust was last inspected in November 2014, we rated the services as requires improvement overall.

We asked the provider to make the following improvements at that time:-

Ensure staffing levels and skill mix is suitable for staff to effectively provide the necessary support to patients.
Ensure emergency drugs can be accessed quickly in an emergency.
Ensure drug fridge temperatures are maintained appropriately.
Ensure equipment is appropriately maintained and fit for use.
Ensure resuscitation procedures and practice are reviewed and the use of best practice is implemented, for example Resuscitation Council guidance.
Ensure initial assessments are promptly undertaken and care plans are person centred on all units.
Ensure ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) forms are completed in-line with trust policy.
Ensure discharge-planning processes and decisions are more focused and time-stated.

At this inspection, we found the provider had made all of the improvements required.

We visited three locations.

the South Leeds Independence Centre (SLIC)
the Community Intermediate Care Unit (CICU)
the Community Neurological Rehabilitation Centre (CNRC)

We rated community inpatient services as good because:

Services were planned and delivered to meet the needs of all patients using them. There were systems to ensure patients were protected from avoidable harm and abuse. Safety performance was monitored, incidents were reported and lessons learnt.
The service managed staffing effectively and services had enough competent staff with the appropriate skills, experience and training to keep patients safe and deliver effective care and treatment. Staff were well motivated and knowledgeable. Staff teams and services worked together effectively to deliver good care.
Emergency medicines and equipment for use in a medical emergency were fit for use and quickly accessible in an emergency. Medicines management was effective.
Equipment was appropriately maintained and fit for use.
Patient care and treatment was planned and delivered in line with current guidance; patients had good outcomes because they received effective care and treatment.
Consent to care and treatment was obtained in line with current legislation and guidance. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were completed in-line with trust policy.
Patients were able to access the right care at the right time. Initial assessments and discharge-planning processes were promptly undertaken on all three units.
New care planning documentation had recently been introduced; care plans were person centred.
Resuscitation procedures and practice had been reviewed and were in line with best practice.
Staff involved and treated patients and their families with compassion, kindness, dignity and respect. People and their families understood the care and treatment choices available to them and were involved in making decisions about their care and treatment. Staff supported patients and their families to cope emotionally with their care and treatment.
Reasonable adjustments were made to ensure people with disabilities, or those in vulnerable circumstances, could access services on an equal basis.
The service had a low number of complaints and a high number of compliments; there was a complaints process and the service was proactive in dealing with any complaints received.
The leadership, governance and culture promoted the delivery of high-quality person-centred care. The new leadership teams, which had been put in place since the last inspection, were making effective changes.
The services had clear visions, values and strategies and staff in all areas were aware of these.
There were systems and processes in place for managing governance and risk, with a clear a focus on learning and improving. Appropriate actions had been put in place to mitigate identified risks in the services.

However:-

There was no internal system to record delayed discharges from the South Leeds Independence Centre and Community Intermediate Care Unit until January 2017. This meant there was no way to know if discharges were timely or the reasons for any delays until this process was put in place.
Response rates for the friends and family test were low. One of the trust’s quality priorities was to increase patient survey response rates.
At the South Leeds Independence Centre, the call bell system and falls sensors were on a ‘linked system’. Senior staff told us the system was not fit for purpose.The falls sensors did not always trigger the audible alarm if patients stood up. This meant patients could be at risk of falling and suffering harm. Managers were aware of this and told us there were plans to replace the system. The call bell system relied on staff carrying a handset around with them. Staff then responded to patients who heard staff on a loudspeaker in their room. Staff told us this method of responding to patients usually caused more anxiety and confusion for patients.
There was no evidence to show that the recommendations identified in the most recent legionella risk assessments at all three locations had been followed up and appropriate actions taken. This included ensuring staff were appropriately trained in the control and management of legionella.
Staff caring for patients with dementia did not always have up-to-date appropriate training in dementia care.

We rated the child and adolescent mental health inpatient unit as requires improvement because:

Systems and processes were not operating effectively and sufficiently embedded to ensure the quality and safety of the unit. Issues identified included a lack of staff understanding in reporting safeguarding alerts and notifications to the Local Authority and the Care Quality Commission, protocols to support staff in the roll-out and the use of restraint new methodology were not in place, and procedures were not in place to monitor the use of prescription pads. Also actions identified in action plans and reviews for example the ligature risk assessment and the assessment of the lift were not completed in the identified timescales. Staff were unclear about key performance indicators and quality targets, and were unable to provide these relating directly to this service at the time of inspection. The systems for recording the training of temporary staff were unclear.

Staffing during evenings and weekends was almost entirely reliant on bank or agency staff. Some relatives and carers raised concerns that they had difficulty in communicating with the unit and in having questions answered by temporary staff. Not all temporary bank or agency staff, had completed the required mandatory training. The trust did not always recognise the needs of mental health practitioners, for example, the lack of specialist training and induction in the line with the national quality standards for this service, and policies and procedures relating to mental health services not being in place. Unit staff told us that at times they felt isolated from the main oversight of the trust.

There was a lack of regular therapeutic intervention for young people. At the time of the inspection, family therapy, art therapy and dialectical support therapy were not available, and the drama therapist was only able to hold one patient group session per week.

However:

Young people had updated risk assessments in place, which staff discussed at daily handover meetings. Support of young people with physical healthcare needs was accessible and of a high standard. Staff updated young peoples’ care plans and staff planned discharge from the point of admission. These were personalised, and holistic, young people were involved in the development of the care plans and discharge plans along with their family where appropriate. The service worked with partner organisations in the community to facilitate successful recovery and discharge. Young people had access to advocacy and were encouraged to get involved with the service via weekly community meetings and by involvement in activities such as the recruitment of staff.

The staff team were positive about their role and spoke about young people positively in meetings and discussions about their care. They were passionate about caring for the young people using the service and were kind, respectful and treated young people with dignity. Young people and their families were positive about the way staff treated them when they were admitted to the unit. Staff were positive about being part of the multi-disciplinary team within the unit, where they felt listened to and supported in their work. Staff knew the trust vision and values and linked them to their work. Systems and processes were operating effectively in relation incidents, complaint and staff supervision and appraisals.

Overall rating for this core service Requires Improvement

Overall we rated the service as requires improvement because:

The trust provided information highlighting that at the time of the inspection 16 out of 20 staff (80%) were trained to level 3 safeguarding or level 2 Leeds Safeguarding Children’s Board (LSCB) safeguarding training which the trust stated was equivalent to level 3 training against a trust target of 90%. The trust provided further information stating staff had received safeguarding training which was the equivalent to level 3 safeguarding. Not all staff had received child sexual exploitation awareness training with 66% of staff having received training in 2015/2016.
Medicines refrigerators temperature checks were not consistently carried out. However this had improved at the time of inspection.
Some mandatory training targets did not meet the target set by the trust.
Clinical supervision was not well embedded across the service, however there were plans to address this.
The service had capacity and demand issues, managers were aware of this and a project was planned to address these issues however most patient complaints related to long clinic waiting times.
The service operated a phone line, however due to the high volume of calls and reception staff vacancies, calls were not always answered and messages not returned within the target of one hour.
The risk register did not contain all risks that were known to the service however managers and the senior leadership team were aware of the issues such as long waiting times.

However

There were systems in place to record incidents and staff we spoke with were aware of reporting incidents and how to report them. Managers investigated incidents and provided feedback to staff through team briefs. Managers had an understanding of the duty of candour and being open and honest with patients.
The environment was visibly clean and tidy in the areas visited. Records we looked at were found to be appropriately completed and securely stored on the electronic patient record system.
Staff were able to describe the relevant national guidance and local procedures. Staff could describe the British Association of Sexual Health and HIV (BASHH) guidelines and the Faculty of Sexual and Reproductive Healthcare guidance (FSRH). Audit programmes were in place and the service carried out local audits alongside the required key performance indicator monitoring.
The service was in the process of dual training staff to ensure they could provide contraceptive and genito-urinary medicine (GUM) services across all clinics. Staff we spoke with told us they would work within their competencies and seek advice where required. This training was ongoing and there were three dual trained staff during our inspection.
There was multi-disciplinary team working within the service. The integrated Leeds Sexual Health Service included sexual health registered nurses, medical staff, health advisors, healthcare assistants, outreach nurses, administration team and a research team.
Staff we spoke with were able to describe when they asked for consent and when they used written consent. Staff were able to describe their understanding of the Fraser guidelines and Gillick competence.
Patients we spoke with were mostly positive about the service. Staff provided patients with compassionate care and support and understood the needs of patients. Friends and family test data across the service was positive. Chaperones were available at the clinics for patients.
The service was an integrated sexual health service, formed in April 2015, and provided a main hub and spoke model of clinics to patients. Services were planned with local commissioners. The integrated service model meant that patients could attend any clinic and be seen for contraceptive and GUM services. The service offered appointment and walk in clinics.
Outreach services were provided outside of the clinics and in partnership with a number of different third sector organisations. Health advisors were available at the main hub to provide further support and advice to patients where required.
There had been a low number of complaints to the service.
The integrated service had a strategy in place and managers were able to describe their vision for the service. Risks were escalated through the partnership meetings between all the partner agencies where required.
Staff were passionate about their roles and work and the care they provided to patients. The service engaged with the public in a number of ways such as patient questionnaires and had a dedicated sexual health website, which provided advice and access to a live chat with the service.

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.

Letter from the Chief Inspector of Hospitals

We last inspected this trust in May 2014 and we rated the provider as ‘requires improvement’ overall. In reaching our judgement, we told the trust that they must make improvements to: staffing levels, quality of records particularly risk assessments, management of falls, planning and delivery of care, clinical supervision, governance and risk management processes and risks associated with unsafe or unsuitable premises.

We carried out an announced follow-up inspection of this trust between 31 January – 2 February 2017 and an unannounced inspection on 15 February 2017 to make sure improvements had been made. As part of the inspection, we assessed the leadership and governance arrangements at the trust and inspected the core services that required improvement at the last inspection. We inspected sexual health services, which had not been included at the last inspection, and because we had received a whistle blowing concern. We also included an inspection of Hannah House, part of the community services for children, young people and families because we had received concerns regarding medicines management. We inspected the following services:

Community health services for adults;
Community services for children, young people and families (Hannah House)
Community inpatient services;
Sexual Health Services
Child and Adolescent Mental Health Wards (Little Woodhouse Hall)

Whilst a number of individual services were judged good, Hannah House was rated as requires improvement, community child, adolescent mental health services (Little Woodhouse Hall) was rated as requires improvement and sexual health was also rated as requires improvement.

We have rated Hannah House at location level and not as part of the overall provider because we did not inspect the whole of the community children, young people, and families’ service.

The overall rating for the provider is good.

Our key findings were as follows:

In most areas, medicines were managed appropriately however; arrangements for the safe handling of medicines at Hannah House were not consistent showing omissions in recording.
There were high levels of staff sickness at Hannah House, which was affecting areas of the service to run effectively such as cancellation of short breaks. However safe levels of staffing were maintained.
Not all staff were clear about the level of safeguarding training undertaken or required particularly staff working with children.
Staff could access mandatory training however not, all staff at Little Woodhouse Hall were trained in restraint, and on some shifts there were not enough trained staff to carry out restraint if needed.
Not all services had consistent methods for monitoring environmental safety checks.
There remained some issues regarding the suitability of premises at Little Woodhouse, although the trust had mitigated a number of risks, not all of the actions were complete.
There was a lack of assurance and evidence of staff competence about specific skills needed to care for children and young people at Hannah House due to the lack of recording in competency assessments. Processes to ensure staff working at Little Woodhouse Hall to receive training specific to Child and Adolescent Mental Health services prior to starting work on the unit also required improvement.
Governance and assurance processes were in place to measure quality however; these arrangements were not as effective at Hannah House or in child and adolescent mental health inpatient services. As a response to the concerns raised at the announced inspection, an action plan was developed. This had ownership at senior staff levels with appropriate support by the quality lead and clinical lead for the Children’s Business Unit. They reported directly to the executive director of nursing providing assurance that concerns had been recognised at a senior level.
There were some inconsistencies in the approach and systems to meet the Fit and Proper Person requirements.
There was good staff engagement particularly in adult and inpatient services however staff engagement was variable with morale being lower at Hannah House and Little Woodhouse Hall where there was a feeling of disconnect from the rest of the trust.
The trust had a good incident reporting culture in most areas, and there was evidence of improvements following incidents, but systems for sharing information in some services was not as strong.
There were processes to ensure good and effective infection prevention and control.
Across community, services staffing levels and skill mix were suitable for staff to provide the necessary support to patients. Recruitment was continuing and additional funding for staffing agreed.
Patient feedback was good, and surveys confirmed this. Staff treated patients with dignity and compassion, and ensured that patients were involved in the development of their care. Services promoted independence and supporting patients to move to self-care.
Patients were able to access the right care at the right time. Services met the individual needs of patients and took into account patient preferences. There were some good examples of where staff met the needs of vulnerable people.
There was a stable leadership, which appeared cohesive and worked collectively. The leadership were aware of the challenges to provide a good quality service and identify the actions needed to address these.

We saw several areas of outstanding practice including:

The speech and language therapy team had developed an award-winning choir, which helped patients in their speech and language skills and provided social opportunities.
Senior therapists saw musculoskeletal (MSK) and rehabilitation patients at the initial assessment. The MSK service in Leeds was trialling alternative models of care both to support increasing demand and support capacity in Primary Care.
There was a project to improve patient flow. This involved looking at patient pathways and journeys through the inpatient unit and identifying any delays and ‘blockages’ in the current system which could reduce patient’s length of stay and improve patient flow.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

Ensure that processes are in place for the safe handling of medicines at Hannah House.
Ensure that staff receive appropriate training and development of their competencies, skills and experience at Hannah House.
Ensure bank and agency staff working in child and adolescent mental health are trained in the use of restraint.
Ensure staff working in child and adolescent mental health receive specialist training in working with young people, in line with quality standards for this type of service.
Ensure that governance processes and quality measures are strengthened at Hannah House and the child and adolescent mental health ward.
Develop a seclusion policy for young people in crisis.
Ensure that all staff are trained in the appropriate level of safeguarding children and adults for their service.

Community Health Services for Adults

Ensure systems are consistent to monitor environmental issues in community clinics.

Community Inpatient Services

Replace the patient call system and the falls sensor system at SLIC.
Introduce audits to assure the quality of patient records.
Continue to review systems to improve response rates for patient feedback.
Improve patient participation in self-medication at CICU and SLIC.
Consider improving the variety of food and timings of meals at SLIC.
Ensure processes are consistent to complete mental capacity assessments for patients who require these.
Continue to address the recommendations in the Legionella Risk Assessment.

Sexual Health Services

Ensure daily checks of the emergency oxygen bag and areas in the management of medicines.
Continue to address the provision of clinical supervision for staff in sexual health services.
Ensure key performance indicators are improved to avoid long waiting times in clinics.
Consider communicating waiting times in clinics.

Hannah House

Ensure processes are in place for environmental safety checks.
Ensure learning from incidents and complaints is shared with staff.
Ensure daily records of care are completed.
Consider Wi-Fi access for children during their stay at Hannah House.
Consider how the service engages with families to enable them to contribute to service development.
Reduce the number of cancelled short break stays and review the reasons for cancellations.

Trust-wide

Review systems to ensure consistency in meeting the Fit and Proper Person requirements.
Ensure consistency in recording risks on the risk register in all services.

Ellen Armistead

Deputy Chief Inspector of Hospitals

We rated adult community services as good overall and caring as outstanding.

We found that there was good incident reporting and learning from incidents was shared.
We saw that record keeping was of a good standard and that information was stored securely.
Staffing issues were acknowledged and mitigating actions put in place.
Business continuity plans were in place and consistently reviewed.
There was a good understanding of the duty of candour regulation and major incident policies amongst all levels of staff.
There was evidence care and treatment was based on current guidance, standards and best practice
We observed good patient outcomes for example in the significant increase of patients wishes to die at home being facilitated.
There was participation in external and internal audits and the results of monitoring were used to improve quality of care.
We observed excellent care being delivered by highly motivated staff.
Patients were treated with dignity, respect and kindness and were supported in decision making
People’s needs were met through the way the service was organised and delivered.
Services were planned in line with the needs of the local population offering flexibility, choice and continuity of care.
The leadership, governance and culture supported the delivery of person centred care and staff were committed to the delivery of high quality patient care.
Staff felt supported and valued in adult community services; there was an open and transparent culture.
The vision and values are well developed and encompassed key elements such as compassion, dignity and equality. The vision and the strategy were aligned.

However, the trust should:

Ensure dementia awareness is incorporated into mandatory training.
Clarify in safeguarding children training records which level has been attained.
Continue to monitor environmental issues in community clinics

Overall we rated Hannah House as requires improvement because:

There was limited documented evidence of sharing of learning from incidents. Eleven staff we spoke with were unable to provide examples of learning or changes in practice in response to an incident. The trust said that learning from incidents took place during clinical supervision and safeguarding supervision within the unit
There were concerns over safeguarding training; there was a requirement for staff to be trained to level three and not all staff had received this traininig. Safeguarding supervision levels were 82% this was below the trust target of 90%.
Not all medicines were being transcribed correctly and some medication being used had past its expiry date. Following a discussion with the trust an action plan was developed. This outlined areas for improvement with leads identified and clear timescales for actions to be competed.
Staff sickness levels were high at 22% and as a result some short breaks had been cancelled. However, safe staffing levels were being maintained at all times.
Staff appraisal rates were 75% this did not meet the trust improvement trajectory target of 85%.
There was a lack of evidence in relation to staff skills and competence. The competency documentation was incomplete and some staff expressed concerns over this.
The bed occupancy targets of 85% had only been met in four out of ten months. This had been impacted by the transition bed being occupied which required a staff to child ratio of 1:1. The unit was also closed on two occasions on the advice of the infection prevention and control team.
Data was not collected on how many allocation requests were given to individual families and carers. Therefore the trust could not provide evidence that they were fair and equitable in the allocation of short breaks.
Risks to the service were not clearly identified and escalated. There was a lack of management oversight in the unit because of sickness and vacant posts. There was an interim manager in post at the time of inspection.

However:

There were detailed and clear escalation plans in place for each child if they became unwell whilst at Hannah House.
There were clear plans in place to ensure the nutritional and hydration needs of children and young people were met.
Children and young people’s needs were assessed and care was delivered in line with current legislation, standards and recognised evidence based guidance.
Staff were passionate about the care they provided. Parents gave positive feedback and felt confident their children were safe whilst at Hannah House.
Emergency access was always available for families if a crisis occurred.
There were clear vision and values within the organisation and staff were aware of them.
Staff reported good support from their line manager.

We rated the service as good because,

The service had good provisions and clinic facilities for children, young people and families.

The trust were using an electronic system to store patient records. Staff had completed patients risk assessments in a timely manner and they contained all the relevant information. This had been an improvement from the last inspection.

The teams had a sufficient number of staff to meet the needs of the patients. They did not have to rely on bank or agency staff to fill clinical roles. There were a high number of experienced band seven and eight staff within the teams.

Staff were aware of their responsibilities in adult and child safeguarding, this was reflected in the high training figures throughout the teams.

Children and young people experienced shorter waiting times for assessment and treatment than at the last inspection. The teams had mechanisms in place to monitor wait times and were continuously aiming to improve them. Staff were able to offer immediate short term interventions which meant children and young people discharged from the service sooner. The trust were meeting their target for emergency assessments within four hours and urgent assessments within a week.

However :

The service was not assessing children and young people for autism and attention deficit hyperactivity disorder (ADHD) within the trust’s 12-week target. The trust had a recovery plan to reduce wait times to 12 weeks for assessment by the end of March 2017. The average waiting time for an autism assessment had reduced from 40 weeks to 20 weeks since the last inspection.

Some specialist treatments had wait times of above 18 weeks; these were cognitive behavioural therapy and play therapy. The average wait time over the year for both treatments was around 20 weeks.

We only inspected the safe domain of Little Woodhouse Hall.

We found there had been a significant reduction in staff, within each of the CAMHS teams and this had affected services. Some of the changes had been due to influences outside of the trusts control. The staff had responded to the reductions by implementing a triage and priority appointment system to make sure people were seen promptly if needed. However this had reduced access to the service and had increased the wait for appointments. In addition the trust had started to respond to the long waiting lists and was aware of the impact of reducing access through use of the risk based approach. They were now engaged with and working with the local clinical commissioning groups (CCGs) to make improvements. But the long wait for appointments and the reduced access to the services had the potential to impact on people’s mental health.

The staff had followed the local safeguarding procedures for children and incidents were reported. Staff had assessed the potential risks to people and staff. However we found some staff had failed to record peoples initial risk assessments on the electronic records.

We found the CAMHS teams provided people with the care, treatment and support they need based on the best available evidence. Information about people’s care and treatment, and their outcomes, was routinely collected and monitored. Staff had the supervision and training they needed to carry out their roles effectively, although this was not always recorded on the computer data system. All of the multi-disciplinary staff team were involved in the assessment and planning of peoples care and treatment.

We found the service offered to young people, children and families was compassionate, kind and respectful. Young people, children and families made extremely positive comments about the service and the staff that had supported them. Young people, children and families were asked about their views of the service and were informed about and involved in decisions about their care and treatment.

Staff were motivated and dedicated to give the best care and treatment they could to young people and children. We found that within the parameters of the resources and increased demands on the service at local level; the teams were well managed and had good governance. Staff described strong leadership at team level and felt respected, valued and supported. However, staff said the reduction in staff and the constant reviews of the service had affected their morale. The staff were committed to the service’s quality, improvement and innovation.

There were some good practices in place, for example reporting and responding to incidents, the management of medicines, safeguarding children and adolescents and ensuring the staffing levels and skill mix were appropriate.

Improvements were needed to ensure patients were protected from avoidable harm. For example:

The trust was a tenant at Little Woodhouse Hall and therefore could not make changes to the fabric of the building. They had identified that the design and layout of the ward, where patients were cared for was not safe or suitable and they were looking for other premises. However there was no agreed timescale for any move to happen.
The local environmental health and safety register did not include any potential risks to patients from objects which could be used by patients to self-harm by hanging. This meant staff may not have been aware of all of the potential environmental risks to patients or have considered ways to remove them.
Staff were specially trained to use the least form of restraint possible. Staff recorded the incidents of restraint in the patient’s notes. However, no-one collated the number, type and staff involved with a restraint incident to enable patterns or triggers to be identified and to reduce risks to patients.
The hospital had an arrangement that Leeds General Infirmary security guards would assist on an evening if a patient became violent. However, we found the agreement was not clear whether security staff had completed the appropriate training to restrain a young person or child.

We found Little Woodhouse Hall provided patients with the care, treatment and support they need based on the best available evidence.

Information about patients’ care and treatment and their outcomes, was routinely collected and monitored. Staff had the supervision and training they needed to carry out their roles effectively, although this was not always recorded on the computer data system used for recording training. All of the multi-disciplinary staff team were involved in the assessment and planning of patients’ care. Staff had followed the Mental Health Act 1983 code of practice.

We observed how patients were cared for and found patients were spoken to in a dignified and caring manner. Patients spoke positively about those who cared for them. Patients and relatives were informed about and involved in decisions about care and treatment. External agencies had been accessed by the service to support patients’ needs and where patients chose, access to an advocacy service.

The needs of the different patients was taken into account when planning and delivering services. Care and treatment was co-ordinated with other services. Patients could make a complaint or raise a concern. There was evidence these were taken and responded to in a timely way and listened to. Improvements had been made to the quality of care as a result of a complaint.

Little Woodhouse Hall local management team were knowledgeable about quality issues and priorities, they understood what the challenges were and took action to address them. Performance information was used to hold management and staff to account.

Overall rating for this core service Good

The community dental service at Leeds Community Health Services NHS Trust met the needs of patients and overall we rated the service good.

At the time of the inspection, we judged that the service was safe and people were protected from abuse and physical harm. We judged he service was effective and that people’s care, treatment and support achieved good outcomes for them. Treatments were based on the best available evidence and the service provided good health promotion.

We judged that people were involved in their care, and were treated with compassion, kindness, dignity and respect. The service was responsive to people’s needs, specifically meeting the needs of patients who were vulnerable and /or suffered from very poor oral health. The service was well-led in that the leadership and management of the service provided a platform on which a holistic pattern of oral health care could be provided.

In coming to these judgements we spoke with patients and carers, and staff who worked in the community dental clinics. We also inspected the facilities in three clinics (50% of the trusts dental locations) at Seacroft Clinic, Yeadon Health Centre and Armley Moor Health Centre, and observed treatments and care being undertaken, as well as examining clinical records. We spoke with eleven patients and relatives, and observed eight patients receiving dental treatments. We also examined eleven clinical patient records. We spoke with twelve members of staff.

There was a system in place to report incidents however we saw learning from incidents was variable.

Staff were competent to carry out their role, identified and responded to patient risk that ensured patient safety. There were vacancies across the service, which meant caseloads were high for some nursing and therapy teams. Managers and staff within the district nursing service did express concern regarding staffing levels and these had been on-going for some time. Some staff told us they felt under pressure due to staff shortages.

A range of audits had taken place however some services had limited audit activity in relation to the outcome and impact of the services they provided.

The service was caring; care and treatment was evidence based and staff followed current best practice recommendations. There were positive examples of multidisciplinary working across internal services and between local healthcare organisations. All patients and carers spoke positively about the care provided and we observed staff deliver compassionate care.

The service was responsive to patient need and patients were treated in their own homes or community clinics where possible. Services engaged with patients to gain feedback and improve services.

There were notable examples of innovation.

Overall rating for this core service Good

Community health services for children, young people and families included a range of services. During our inspection we reviewed the health visiting service, the school nursing service, children’s audiology, community paediatrics, the children looked after team, the family nurse partnership service, therapy services, Hannah House, sickle cell and Thalassemia service and the stammering centre.

We spoke with 105 members of staff across children’s services and reviewed 24 health care records. We spoke with 33 parents who were either accessing services during our inspection or by telephone. We accompanied staff on three home visits. We received 4 CQC comment cards which had been completed by parents prior to or during the inspection.

We rated children’s and young people’s services as good for safety. There were systems in place to report incidents. Staff reported they knew how to report incidents and usually received feedback from these. However we found learning and actions from a serious case review were not shared with other relevant services. The school nursing service was working within the DH recommendations from Choosing Health or CPHVA guidance of one qualified school nurse for every secondary school and their cluster of primary schools. Maximum health visitor caseloads were within the trust’s caseload weighting tool but did not meet the recommendations of Lord Laming or the CPHVA. Medical staff within the Child Development Unit (CDC) told us they were concerned that the community paediatric service had been partially staffed over a number of years by locum medical staff.

Overall children’s and young people’s services were rated good for providing effective services. The Healthy Child Programme was delivered through skill mixed child health teams. The teams consisted of health visitors, school nurses, community staff nurses, nursery nurses, assistant practitioners and health care assistants. Initiatives such as UNICEF baby friendly were in operation. We reviewed evidence which demonstrated patient outcomes and performance information was closely monitored and reported by children’s services in the trust. For example we saw performance data which monitored compliance with the key contacts within the Healthy Child Programme for the 0-5 age group. Although managers and staff told us supervision occurred on a three monthly basis the trust’s systems were unable to demonstrate this happened. This meant the trust did not have an effective system to record supervision.

Overall we rated children’s and young people’s services good for the quality of care. As part of our inspection we observed care in patient’s homes, clinic settings and observed staff speaking to clients on the telephone. In order to gain an understanding of people’s experiences of care we talked to 33 people who used services within children’s services. Throughout our inspection we found members of staff treated children, young people and families with dignity and respect. Staff we spoke with told us they were passionate about delivering a quality service. People who used services told us they were happy with the care they and their child received.

Overall we rated children’s and young people’s services as good for providing responsive services. The trust had a range of specialist services to meet the different needs of people which included the stammering centre, sickle cell and thalassemia service and Hannah house. Children’s services were provided in a number of settings including the patient’s home, health centres, children centres and the child or young person’s school. Children’s services within the trust followed the trust’s NHS complaints processes. The main themes from the complaints were communication, staff attitude and treatment. Staff within children’s services told us themes from complaints were shared at monthly team meetings.

Overall we rated children’s and young people’s services as good for being well-led. Staff within the different children’s services were clear about the vision of their individual service and the trust’s vision and values. However a strategy between health visiting and school nursing which supported how both services worked together to support children, young people and their families needed to be developed.

Governance arrangements were in place and learning took place, however some medical staff in CDC did not always receive timely feedback from clinical incidents or concerns they had raised.

There was an open culture, and whilst not all staff had regular formal meetings with their managers outside of their appraisals, they told us they felt well supported and could access their managers when they needed to.

Staff across services told us they felt the service reviews had not been well communicated and they did not feel listened to. They told us the trust had held consultation events and meetings but the information provided had not been sufficient. The majority of staff we spoke with told us they understood the reasons for the reviews but felt the communication of change was not always as good as it could be.

Overall rating for this core service. Requires Improvement

The units we inspected were South Leeds Independence Centre (SLIC) and the Community Intermediate Care Unit (CICU) based at St James’s Hospital. Both of the units provided rehabilitation and hospital avoidance services in the community.

In terms of safety, we found there were areas for improvement around staffing levels and skill mix, particularly at SLIC. Other aspects of safety were more positive particularly in terms of incident reporting, records, medicines management and infection control.

The effectiveness of the services provided by the units varied. Care plans were in place for all patients at each unit and care plans on CICU were appropriately patient-centred but those on SLIC were more generic and impersonal. Evidence-based documents were in place at both units but these weren’t always fully completed. For example, with some forms, staff signatures and dates were missing and certain sections were blank, such as identified goals, time-frames and outcomes. Such sections should have been completed before moving on to complete later sections of certain documents; this was confirmed by staff we spoke with.

Staff worked together well across the two units and between disciplines and appraisal rates were suitable on CICU at 87% but were slightly lower on SLIC at 73%, although this was recognised by the trust and efforts were being made to increase this figure. There were good examples across both units where consent was gained before treatment but, on SLIC, there were issues with do not attempt cardio pulmonary resuscitation (DNACPR) forms.

We found staff, at both SLIC and CICU, to be caring in their approach to patients and their relatives. We observed numerous interactions between staff and patients and staff showed compassion, respect and understanding.

In terms of responsiveness, there were positive aspects and this included equality and diversity and meeting the needs of vulnerable people. Average length of stay data, on the whole, for both units was encouraging but there were some outliers on SLIC in relation to some long term nursing patients. Both units were able to admit referred patients within acceptable time-frames but there was no formalised process for ensuring patient's needs could be met as judged against the needs of existing patients and available resource. A care needs dependency tool was being piloted in November 2014 to help to clarify and understand the process.

In relation to well led, there were some leadership challenges on SLIC and staffing skill mix was not well balanced and staffing had been struggling to meet the full needs of all patients for a relatively long period. There was however a clear vision and detailed strategy for the services and leadership was seen by many staff as supportive and there was open culture.

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.

Whilst a number of individual services were judged good, concerns within community inpatient services, and community child and adolescent mental health services, means that overall we have judged the trust as requires improvement.

The provider was not meeting regulation 15 premises and equipment at Little Woodhouse Hall, and regulation 17(2)(d) good governance within the community children’s and adolescent mental health service. There were concerns with regards to staffing levels across a number of services, and concerns regarding the transcription of medication in district nursing services.

The trust had a good incident reporting culture, and there was evidence of improvements following incidents, but these were not always shared across teams. Staff were positive regarding informing patients if there had been an incident and some were aware of the recently introduced Duty of Candour. Staff could access mandatory training, and the majority of premises were suitable with the exception of Little Woodhouse Hall.

Staff were aware of and used national guidance in the delivery of their care, though there was an inconsistent approach to assessment within the South Leeds Independence Centre (SLIC). Pain relief was effective and patients nutritional and hydration needs were effectively assessed where appropriate. Multidisciplinary team working was effective, as were consent processes with the exception of some do not attempt cardiopulmonary resuscitation (DNACPR) consent at SLIC.

Whilst some audit activity took place, overall the trust needed to improve its plans and overall approach to audit. Some services utilised outcome data, but there were other services particularly in the community where there was limited data to demonstrate the impact of service provision.

Patient feedback was good, and surveys confirmed this. Staff treated patients with dignity and compassion, and ensured that patients were involved in the development of their care. On the whole services promoted independence and supporting patients to move to self care, though this could be developed further on the SLIC.

There was variation in the planning and delivery of services, in particular some length of stay on the SLIC, and waiting times for community children’s and adolescent mental health services. Staff ensured that services met the individual needs of patients and took into account patient preference in most circumstances, and there were some good examples of where staff had looked to meet the needs of vulnerable people.

Locally many staff felt they had good support from their immediate line managers; however morale was low and many staff were uncertain regarding their and their services’ future. There was inconsistency in how and when staff were communicated with regarding changes to their roles and services. Governance of the organisation, whilst improving had been reliant on reassurance, not assurance, and we identified examples of incidents and risks that had not been investigated in a timely fashion, and risk registers which were not effectively produced to afford the necessary controls to reduce or remove risk.

The culture of the organisation whilst reported as open and supportive to learning from incidents reflected a change weary staff group, with above average levels of sickness, including stress related long term sickness.

Leadership was improving; the new chief executive was affecting change to improve access to executive and non executive staff. There were examples of innovation across different services, and numerous examples of staff being recognised for their work and endeavour at local and national award ceremonies.

All Inspections