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Provider: Camden and Islington NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 22-26 February 2016

During a routine inspection

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.

  • It is our view that the trust needs to take steps to improve the quality of their services and we find that they were in breach of three regulations. We issued three requirement notices which outline the breaches and require the trust to take action to address. We will be working with them to agree an action plan to assist them in improving the standards of care and treatment.

We found that the trust was performing at a level which led to a rating of requires improvement because:

  • We rated mental health crisis services and health based places of safety as inadequate. We rated acute wards for adults of working age and psychiatric intensive care units, long stay/rehabilitation mental health wards for working age adults, community-based mental health services for adults of working age, and substance misuse services as requires improvement. We rated wards for older people with mental health problems, community-based mental health services for older people, and community mental health services for people with a learning disability or autism as good overall.
  • There were a number of concerns about environments. In the health based places of safety the environment was not suitable. Patients in the health based place of safety at the accident and emergency department in the Royal Free hospital had to walk past other cubicles to use the toilet. The premises did not meet the guidance in the Mental Health Act code of practice or from the Royal College of Psychiatrist’s. The toilet also had ligature points in which could be used by a patient to self harm. The places of safety were housed in the acute hospital and were cleaned by their staff but the trust had not ensured the environment was clean and well maintained. Facilities at two of the three health based places of safety did not promote dignity, recovery, comfort or confidentiality for people using this service
  • We received limited assurance about safety. For example we identified ligature points in wards which had not been removed or measures put in place to mitigate risks. In some wards staff could not see all parts of the ward, there were blind spots and no mirrors to mitigate risk. Three staff on Garnet ward did not know where the ligature cutters (equipment to cut safely through materials used to self harm) were kept, other wards did not have any ligature cutters. There were multiple ligature points at St Pancras Hospital. The trust had completed ligature risk assessments; however, these did not always contain plans for how staff could manage these risks. At the Highgate Mental Health Unit, we found one ward had identified a new fitting as a ligature risk in an assessment, but other wards had not identified the same problem. Therefore, other wards had no plan in place to manage this risk and staff were unaware of it. The service had breached the eliminating mixed sex accommodation guidance at Highview, there were five bedrooms on the second floor, four used by females and one by a male, there was evidence that this male had used the female facilities on that floor. The trust had not completed urgent repairs on three wards, at St Pancras, in a timely manner.
  • Safeguarding was not always given sufficient priority. Safeguarding referrals for other services within the trust was being processed through community based adult mental health teams. The safeguarding referrals were being sent to email addresses within the community based mental health teams where the service was operating nine to five office hours. This meant referrals made out of hours were not being seen until the next working day. Staff were unclear how to make a safeguarding referral out of hours or at weekends. Staff did not always record safeguarding information appropriately and clearly.
  • Record keeping was disorganised in paper files which meant information was difficult to find and could lead to key information being missed. Confidentiality was breached in some teams where patient names on files in the office could be seen by others. Staff had not stored hard copy care plans and legal documents effectively. Some care plans were not person centred or holistic. Patients had not signed their care plans because care plans were completed electronically separately from the patient appointment. Staff did not always clearly document the level of involvement of patients in their care plan or reasons why patients had not been involved. Some patients had not signed their care plan to indicate agreement with it. There were gaps in records. In the learning disabilities service there were two electronic recording systems in operation in each team that did not link to each other at all, meaning that information may be entered twice on some occasions or being recorded on one system but not the other. In order to address this, the teams had a protocol that identified their social care system as their primary record where all information should routinely be stored, with defined information being up loaded to the trust system when the patient was in hospital or at risk of going into hospital.
  • In some services compliance with mandatory training for the service was below the trust target of 80%. In community adult services staff mandatory training rate was low, especially for safeguarding children training, safeguarding adults training and Mental Capacity Act and Deprivation of Liberty Safeguards training. This meant there was a risk staff were not trained sufficiently.
  • Compliance for Mental Health Act (MHA) and Mental Capacity Act (MCA) training were low with some staff not receiving any training at all in MHA or MCA. Some staff were not aware of their responsibilities under the MHA and MCA. The trust set a target of 80% for mandatory training.
  • Waiting times in some services were long. The waiting time for psychological support with the complex depression, anxiety and trauma service (CDAT) was one year. The assessment and advice team had a waiting list for routine referrals to be seen for an initial assessment of five weeks. North Camden recovery team had a patient waiting list for therapy of nine months, the personality disorder service had a waiting list to be allocated to a care coordinator of 16 weeks and a 12 month wait for therapy.
  • The arrangements for governance and performance management did not always operate effectively. The leadership, governance and culture did not always support the delivery of high quality person-centred care.

However:

  • We observed staff interactions with service users and their families in a variety of settings, found that they were responsive, respectful, and provided appropriate practical and emotional support. Staff were committed to working in partnership with people to ensure that the service users felt supported and safe. Staff supported families and carers to be involved in the service users’ care. Staff offered families and carers access to psychological therapies.
  • Some wards were safe, visibly clean and well maintained. Clinical areas and ward environments were bright, airy and hygienic. Furnishings were of good quality and homely. Up to date cleaning records showed that the wards were cleaned regularly.Handrails helped patients to maintain their balance while walking around the wards. There were wheelchairs and bathing facilities specific to the needs of older frail people. The clinic rooms were fully equipped. Resuscitation equipment was accessible and regularly checked. Nurse call bells were in every bedroom, bathroom and communal area. Staff carried alarms to summon help.
  • Some services managed risks to patients well. There were clear lines of sight from the nursing offices. Where there were blind spots, a convex mirror was used to help staff observe the ward. There was a robust policy on the use of patient observations in place. Environmental ligature points (fittings to which patients intent on self-injury might tie something to harm themselves) were mostly addressed and the trust was taking steps to mitigate the risks from these by using the guidance of the trust observation policy.
  • Care plans in some services were personalised including patients’ views and staff wrote them in a way which met the patients’ needs. Patients had individualised risk assessments which had been commenced at the point of referral to the service and regularly updated thereafter. There were some good examples of crisis and contingency plans for each patient. Physical healthcare needs were identified and monitored during treatment. Staff used the ‘Modified early warning signs’ tool to monitor and assess physical health. Falls prevention plans were in place, all inpatient wards used the ‘Fallstop’ guidance. Pressure ulcer care was led by a tissue viability nurse.
  • There was rapid access to a psychiatrist when needed, and teams included staff from different disciplines with varied skill bases. Guidelines from the National Institute for Health and Care Excellence (NICE) for prescribing were being followed in all teams. There was an audit programme to monitor adherence to NICE guidance. A range of nationally recognised outcome tools were used.
  • Across the trust some teams used a balanced scorecard to monitor performance and quality of care. Some teams had a local risk register to identify and mitigate risks. Patients generally knew how to complain and complaints were logged. Learning from complaints was shared in team meetings in some teams.
  • Staff said that they felt supported by senior managers. Ward managers said they had authority to make changes to the ward staffing levels when needed. Ward Managers engaged well with their staff. Staff said they felt supported to raise concerns without fear of victimisation and told us that morale and job satisfaction was good.


CQC inspections of services

Service reports published 21 June 2016
Inspection carried out on 22 - 26 February 2016 During an inspection of Wards for older people with mental health problems Download report PDF | 295.57 KB (opens in a new tab)Download report PDF | 1010.5 KB (opens in a new tab)
Inspection carried out on 22 – 26 February 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 309.81 KB (opens in a new tab)Download report PDF | 1010.5 KB (opens in a new tab)
Inspection carried out on 22 -26 February 2016 During an inspection of Community-based mental health services for older people Download report PDF | 289.25 KB (opens in a new tab)Download report PDF | 1010.5 KB (opens in a new tab)
Inspection carried out on 22 - 26 February 2016 During an inspection of Community mental health services for people with learning disabilities or autism Download report PDF | 287.04 KB (opens in a new tab)Download report PDF | 1010.5 KB (opens in a new tab)
Inspection carried out on 22-26 February 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF | 345.76 KB (opens in a new tab)Download report PDF | 1010.5 KB (opens in a new tab)
Inspection carried out on 22 -26 February 2016 During an inspection of Long stay/rehabilitation mental health wards for working age adults Download report PDF | 290.62 KB (opens in a new tab)Download report PDF | 1010.5 KB (opens in a new tab)
Inspection carried out on 22 – 26 February 2016 During an inspection of Substance misuse services Download report PDF | 283.61 KB (opens in a new tab)Download report PDF | 1010.5 KB (opens in a new tab)
Inspection carried out on 22 – 26 February 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 442.74 KB (opens in a new tab)Download report PDF | 1010.5 KB (opens in a new tab)
See more service reports published 21 June 2016
Service reports published 27 November 2015
Inspection carried out on 12 - 13 August 2015 During an inspection of Community-based mental health services for adults of working age Download report PDF | 269.19 KB (opens in a new tab)
Inspection carried out on 3 August 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 274.44 KB (opens in a new tab)
Inspection carried out on 27-30 May 2014

During a routine inspection

The trust was well-led by the Board the executive team and senior managers. Their work was supported by strong governance arrangements and a comprehensive quality assurance process. This meant that they  were aware of the areas that needed improvement and were at different stages of addressing them.

People using the services were treated with dignity and respect. The majority of the service users and carers we spoke with said staff were kind and we observed many positive interactions. We also saw that the trust was supporting people to be actively engaged in their own care and also to be involved in the development of the services.

We saw many areas of good and innovative practice across a range of units and teams within each core services, and the trust had much to be proud of. We also found good collaborative working relationships with partner agencies such as social services. We saw that the trust genuinely wanted to put the people who used their services at the centre of their work.

There were, however, a few areas that could have an impact on the safety and effectiveness of the service being delivered. These were predominantly found in the inpatient, rather than the community, services. Although the trust had started to address these issues, there was still more to be done.

Our greatest concerns were in the acute inpatient services where ligature points were putting people’s safety at risk. In addition, the consistency of people’s acute inpatient care was sometimes being affected by ward moves, which were not based on clinical need. We were also concerned about the safety of older people, as procedures to reduce the risk of falls were not being fully used. At ward level, lessons from previous serious untoward incidents were not always being shared effectively to reduce future risks to people using the service.

Staff, mainly in inpatient services, were not always confident in using the Mental Capacity Act 1983 and Deprivation of Liberty Safeguards (DoLS). This meant that people might not be properly involved in decisions about their care. In some cases, it meant that they could be deprived of their liberty without the correct authorisations in place, which would contravene their human rights.

It is our view that the provider needs to take steps to improve the quality and safety of their services. We found that they are currently in breach of regulations.

We will be working with them to agree an action plan to help improve the standards of care and treatment.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.