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Child and Adolescent Mental Health Services (CAMHS) Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 December 2020

The Child and Adolescents Mental Health service is now based in Smyth House, a refurbished building situated on St Andrew’s Healthcare Northampton site. Smyth House has three ten bedded wards.

At the time of inspection, the service was still based in Fitzroy House and we inspected seven wards. We completed a follow up visit to Smyth House and inspected one ward. Further details can be found later in the report.

This service was last inspected in December 2019. The service was rated inadequate overall and continued to be in special measures which they were placed in July 2019. We issued an urgent Notice of Decision under section 31 of the Health and Social Care Act 2008, imposing conditions on the provider. We told the provider it must make immediate improvements to ensure young people were kept safe through ensuring staff only use approved restraint techniques, that seclusion practice complies with the Mental Health Act, that incidents are investigated in a timely manner, that safety checks and observations are carried out robustly and that staff treat young people with kindness and adopt practices that are least restrictive and not punitive. In addition, we told the provider it must ensure it fosters a positive culture and that the service is overseen by effective leaders who have appropriate processes in place to always ensure oversight of the service.

At this inspection we rated St Andrew’s Healthcare Child and Adolescents Mental Service as requires improvement because:

  • Whilst the service had made several improvements senior leaders had not yet achieved consistency of standards across all wards. Governance processes and aspects of practice were inconsistent across all wards and not yet fully embedded.
  • There were inconsistencies in safety practices across the wards. Staff on Meadow, Maple, Brook and Bracken wards (four out of eight wards) did not always ensure a safe environment. On Maple and Bracken ward we found plastic rubbish liners in children and young people’s toilets which could be used to self harm. We did not find this issue on the remaining six wards. Five staff across Meadow, Brook and Bracken wards did not wear protective masks correctly and we identified issues relating to infection risks for two young people on Acorn and Berry wards. However, we raised this with the ward manager who implemented new infection control processes for both young people whilst we were on site.
  • Not all staff managed risks to children and young people and staff effectively. Staff on Bracken, Brook and Maple wards did not always follow the provider’s policy and procedures on the use of enhanced support when observing children and young people assessed as being at higher risk harm to themselves or others. This was managed effectively on all other wards. We found one example of staff observing the same young person for 11 hours of their shift on Brook ward. Staff routinely observed for periods of four hours and above on Brook ward. Staff did not always record children and young people’s presentations and risk factors correctly on Bracken and Maple wards. The provider reported 249 incidents of children and young people self harming, across seven wards, whilst on enhanced observations between 1 May 2020 and 31 August 2020.
  • Levels of staff restraint of children and young people, including prone restraint and use of rapid tranquillisation had increased on Acorn, Meadow and Maple wards since the last inspection, although had reduced more recently. Staff on Maple ward did not always follow National Institute of Clinical Excellence guidance or the providers policy when using rapid tranquillisation. In one example they did not monitor a young person's physical health after rapid tranquillisation. We did not find this issue on the remaining seven wards.
  • Not all staff followed systems and processes when safely prescribing, administering, recording and storing medicines. There was missing medication on Brook ward. Staff had not always recorded medicine fridge temperatures on Bracken and Maple ward. Staff had not disposed of expired medical equipment on Maple and Bracken wards.

However:

  • The provider had made a number of improvements that we told it needed to be made following our inspection in December 2019. There were new hospital leaders in place who had taken action to change the culture of the service and staff reported a shift to people taking responsibility and raising issues in an open and honest way. Leaders displayed the values of the service and ensured staff worked with children and young people in ways which were supportive and not punitive. We saw an overall improvement in seclusion and restraint practice, safeguarding investigations and staff had stopped using punitive language in children and young people’s records. Leaders implemented new governance systems, improved their processes and acted to address poor staff conduct quickly.
  • Generally, we found that staff went the extra mile for children and young people; carers told us staff hired a soft play centre out of hours for a young person's birthday and staff supported a young person to cook with his mum via video calls during the coronavirus pandemic. Staff treated children and young people with kindness, dignity and respect on seven of the eight wards inspected. We observed positive and relaxed interactions between staff and children and young people. We observed care delivered by staff that demonstrated staff knew the needs of the children and young people on the ward. Young people told us staff were kind and supportive and good at helping them stay calm. Carers spoke positively about staff and told us staff supported them to keep in contact with their relative throughout the coronavirus lockdown.
  • Staff involved children and young people and their carers in their treatment and care. The service placed strong emphasis on children and young people’s feedback about the new wards and made changes to plans throughout the transformation process to meet their requests. Staff encouraged children and young people, and their carers to be partners in their care through co-production work and monthly carer’s meetings. The service trained carers in trauma informed care to deliver training to staff through sharing their experiences as a parent. Staff described this as “powerful, thought-provoking and extremely insightful”.
  • Staff provided a wide range of care and treatment interventions suitable for the children and young people on the wards. The interventions were those recommended by, and delivered in line with, guidance from the National Institute of Health and Care Excellence. Interventions included a full therapy programme and the use of recognised rating scales to assess and record severity and outcomes.
  • Staff and children and young people had access to an extensive range of rooms and equipment to support treatment and care. Children and young people had access to the provider’s school for educational activities. Staff ensured that children and young people had access to appropriate spiritual support. The service had a multifaith area and access to chaplaincy support, which included access to leaders from different religions including Christianity, Islam and Wicca.
  • The teams included, or had access to, the full range of specialists required to meet the needs of children and young people on the ward. Staff had the right experience, qualifications, skills and knowledge to meet the needs of the children and young people. Teams held regular and effective multidisciplinary meetings.
  • The service supported learning, continuous improvement and innovation. The service published research into dialectical behaviour therapy outcomes and adverse childhood experiences in relation to the impact of physical health on mental health. The provider set up a developmental trauma centre with the aim of being a centre of excellence for trauma informed care.

On this inspection we found that the service made enough improvements and we are lifting the hospital from special measures.

Inspection areas

Safe

Requires improvement

Updated 17 December 2020

We rated safe as requires improvement because:

  • There were inconsistencies in safety practices across the wards. Staff on Meadow, Maple, Brook and Bracken wards (four out of eight wards) did not always ensure a safe environment. On Maple and Bracken ward we found plastic rubbish liners in children and young people’s toilets which could be used to self harm. These were removed as soon as we told the ward managers about this. We did not find this issue on the remaining six wards. Five staff across Meadow, Brook and Bracken wards did not wear protective masks correctly and we identified issues relating to infection control risks for two young people on Acorn and Berry wards. However, we raised this with the ward manager who immediately implemented new infection control processes for staff to follow.
  • Not all staff managed risks to children and young people and staff effectively. Staff on Bracken, Brook and Maple wards did not always follow the provider’s policy and procedures on the use of enhanced support when observing children and young people assessed as being at higher risk harm to themselves or others. We found one example of staff observing the same young person for 11 hours of their shift on Brook ward. Staff routinely observed for periods of four hours and above on Brook ward. Staff did not always record children and young people’s presentations and risk factors correctly on Bracken and Maple wards. The provider reported 249 incidents of children and young people self harming whilst on enhanced observations between 1st May 2020 and 31st August 2020. However, this was a reduction since the last inspection and when incidents occurred the provider reviewed the prescribed observation levels for individual young people, updated risk assessments and management plans and increased support where needed.
  • Levels of restraint, prone restraint and rapid tranquillisation increased since the last inspection on Meadow, Maple and Acorn wards. The service reported a spike in April 2020 which they attributed to significant change experienced by children and young people. This included government imposed coronavirus restrictions and the planned move to new wards. However, this had reduced more recently. Staff on Maple ward did not follow National Institute of Clinical Excellence guidance or the providers policy when using rapid tranquillisation in one example, where they did not monitor a young person's physical health after rapid tranquillisation.
  • Not all staff followed systems and processes when prescribing, administering, recording and storing medicines. On Brook ward there were four doses of diazepam missing. Staff had consistently recorded medicine fridge temperatures on Bracken and Maple ward. Staff had not disposed of expired medical equipment on Maple and Bracken wards. Emergency drugs were not available on Brook ward; however, this was mitigated by access to emergency drugs on the other wards.
  • Staff on Meadow did not always complete daily safety nurse checks and security checks. Staff on Marsh ward had not signed all emergency bag checks. We did not find these issues on the remaining six wards.
  • Staff had not always followed the Mental Health Act Code of Practice in relation to seclusion documentation on two wards. We found missing information in three of eleven records reviewed. Examples included two seclusion episodes on Bracken ward with no seclusion care plans and one episode of 70 minutes on Brook ward with no reviews recorded.

However:

  • Staff on Marsh, Acorn, Berry and Seacole wards ensured they cared for children and young people in safe environments. These wards assessed and maintained the ward environment to minimise risk to children and young people. All staff knew about any potential ligature anchor points and mitigated the risks to keep children and young people safe. Managers displayed a ligature heat map on every ward which identified high risk areas. The service had enough nursing and support staff on all wards to keep children and young people safe. On Marsh, Acorn, Berry and Meadow wards staff completed observations in line with the providers policies and procedures. Staff on Marsh, Acorn, Berry and Meadow wards managed medication safely and all wards, except for Maple, followed the correct procedures for the administration of rapid tranquilisation, including checking children and young people’s physical health after the event.
  • The service made improvements in how staff managed times when children and young people required seclusion. Staff ensured children and young people had immediate access to mattresses, chairs and blankets unless it was assessed as unsafe for the individual. Staff worked with children and young people to end seclusion at the earliest opportunity and managers reviewed records of seclusion to assure themselves this was happening. Seclusion rooms and extra care suites on all wards met the Mental Health Act Code of Practice.
  • Staff across all wards completed risk assessments for each child and young person on admission, using a recognised tool, and reviewed these regularly.
  • The service had enough nursing and support staff on all wards to keep children and young people safe.
  • The service effectively managed safeguarding through support and training for staff and had made improvements in completing timely investigations, which identified any lessons to be shared with staff. Staff had positive relationships with the local authority.
  • The service proactively reduced the number of restrictive practices. All wards had restrictive practice logs, which evidenced staff and children and young people discussed any restrictions in place. The provider held monthly ‘proactive and positive care’ meetings, which reviewed the use of restrictive practices.

Effective

Good

Updated 17 December 2020

We rated effective as good because:

  • Staff completed comprehensive mental health assessments for children and young people and developed care plans to meet identified needs. These included ‘Positive Behaviour Support’ (PBS) plans for all children and young people and Structure, Positive approach, Empathy, Low arousal, Links (SPELL) plans. Staff created holistic, personalised and recovery orientated plans. Staff updated care plans when necessary.
  • Staff provided a range of care and treatment interventions suitable for the children and young people on the ward. The interventions were those recommended by, and delivered in line with, guidance from the National Institute of Health and Care Excellence. Interventions included a full therapy programme and the use of recognised rating scales to assess and record severity and outcomes.
  • The teams included, or had access to, the full range of specialists required to meet the needs of the children and young people on the ward. As well as doctors and nurses, teams included or could access occupational therapists, technical instructors, physiotherapists, clinical psychologists, social workers, pharmacists, speech and language therapists and dieticians. Staff had the right experience, qualifications, skills and knowledge to meet the needs of the children and young people. Teams held regular and effective multidisciplinary meetings as evidenced in the meetings we observed.
  • Staff supported children and young people to access physical healthcare support from the provider’s physical healthcare team. The provider allocated one nurse practitioner to the service who provided wound care, diabetic reviews, naso-gastric feeds, asthma support, vaccinations and all physical health checks.

However:

  • Staff did not always complete children and young people’s physical health assessments on admission. Staff on Meadow ward had not completed physical health assessments for two young people on admission, with no explanation recorded.
  • Staff did not always attend shift handovers on time, we reviewed 34 handover audit records completed between June and September 2020. Auditors recorded 26 staff as being late to handover and five staff as not attending, with no explanation recorded. Staff raised concerns that the 15 minutes allocated to handovers would not be sufficient once the wards were full.

Caring

Good

Updated 17 December 2020

We rated caring as good because:

  • Children and young people described staff ‘going the extra mile’ for example, carers told us staff hired a soft play centre out of hours for a young person's birthday and staff supported a young person to cook with his mum via video call.
  • Staff generally treated children and young people with kindness, dignity and respect on seven of the eight wards inspected. We observed positive and relaxed interactions between staff and children and young people. We observed care delivered by staff that demonstrated staff knew the needs of the children and young people on the ward.
  • Carers spoke positively about staff, describing them as “lovely”, “supportive”, “encouraging”, “professional”, “fabulous” and “fantastic”. Carers told us staff supported them to keep in contact with their relative throughout the coronavirus lockdown.
  • Staff involved children and young people and their carers. Children and young people were involved through co-production work and implemented changes at the new service, for example choosing furniture that was homely and safe. A young person spoke to the board of trustees about co-production at the service. Carers attended monthly carer’s meetings and felt empowered to raise issues and reported they felt listened to.
  • Carers told us about their involvement in trauma informed care training through sharing their experiences as a parent. Staff described this as “powerful, thought-provoking and extremely insightful”.

However:

  • Staff on Meadow ward did not always treat children and young people with kindness, dignity and respect. We reviewed a seclusion record when staff failed to respond to a young person's request to use the toilet for at least 45 minutes. We found an example of staff using inappropriate language in a young person's record.
  • Carers reported inconsistencies in communication with staff on Bracken, Meadow and Maple wards.

Responsive

Good

Updated 17 December 2020

We rated responsive as good because:

  • Staff and children and young people had access to an extensive range of rooms and equipment to support treatment and care. This included activity rooms, games rooms and courtyards on each ward. Within the secure perimeter of the building there were family visiting rooms, numerous sports facilities, an animal courtyard, a tranquillity garden, a horticultural garden, sensory rooms, music, art and craft rooms, a hairdresser, a café, social areas, therapy kitchens and a multifaith area. Smyth House replicated the provision of rooms and equipment available at Fitzroy House on a smaller scale. The lead occupational therapist presented a paper to the provider’s board to ensure the sensory facilities and animal courtyard provided at Fitzroy House were included in the new service.
  • Children and young people had access to the provider’s school for educational activities. Each child or young person had an individualised timetable to meet their needs. Education staff ensured all children and young people had an education, health and care plan in place and liaised with the young person's home area local authority to monitor and review. Children and young people were also able to access the provider’s on site light industry workshop.
  • Staff ensured that children and young people had access to appropriate spiritual support. The service had a multifaith area and access to chaplaincy support, which included access to leaders from different religions including Christianity, Islam and Wicca.

However:

  • Children and young people reported, in the most recent satisfaction survey (2019), that they were not confident that complaining made a difference. Only 24% of children and young people who complained thought it made a difference.

Well-led

Requires improvement

Updated 17 December 2020

We rated well-led as requires improvement because:

  • Managers had not ensured the practice across all wards was of a consistent standard, demonstrated by discrepancies in medication management, observations of children and young people, completion and quality of seclusion records and ward safety checks. Whilst the issues identified did not relate to all wards, they did relate to issues identified at the inspection in December 2019.
  • Whilst the service had made improvements, particularly relating to previous issues that affected children and young people's experience, treatment and upholding dignity and human rights, senior leaders had not yet achieved consistency of standards across all wards.
  • Findings in the safe key question demonstrated that managers did not have clear oversight and assurance across all wards and this was yet to be embedded in practice.

However:

  • The provider made improvements in other areas that we raised as areas of concern at the previous inspection. The provider had made management changes, new leaders implemented actions to change the culture of the service and staff reported a shift to people taking responsibility and raising issues in an open and honest way. Leaders displayed the values of the service and ensured staff worked with children and young people in ways which were supportive and not punitive. We saw an overall improvement in seclusion and restraint practice, safeguarding investigations and staff stopped using punitive language in children and young people's records. Leaders implemented new governance systems, improved their processes and acted to address poor staff conduct quickly.
  • Local and provider level leaders were visible on wards and approachable. The service leadership team attended ward team meetings and executives visited the wards: including the chief executive and deputy chief executive working shifts as healthcare assistants.
  • The service provided a clear framework of what must be discussed at a ward, team or directorate level in team meetings to support essential information, such as learning from incidents and complaints, being shared and discussed.
  • The service supported learning, continuous improvement and innovation. The service published research into dialectical behaviour therapy outcomes and adverse childhood experiences in relation to the impact of physical health on mental health. The provider set up a developmental trauma centre with the aim of being a centre of excellence for trauma informed care.
Checks on specific services

Child and adolescent mental health wards

Requires improvement

Updated 17 December 2020

Safe- Requires improvement

Effective- Good

Caring- Good

Responsive- Good

Well-led- Requires improvement

Services for people with acquired brain injury

Good

Updated 16 September 2016

  • Rose ward is a medium secure male ward.

  • Tallis, Tavener, Althorp, Berkeley Close (1st floor) are male locked wards.

  • Berkeley Close (ground floor) is a female locked ward.

  • Berkeley Lodge, 37 and 38 Berkeley Close and 19 The Avenue are locked units

  • Walton is for male patients with Huntingdon’s disease.

  • Harper – specialist ward for male and female patients with Huntingdon’s disease.

Wards for people with a learning disability or autism

Good

Updated 16 September 2016

  • Hawkins is medium secure ward for men with learning disabilities (LD).

  • Sitwell is a medium secure ward for women with LD.

  • Naseby is a low secure ward for men with LD.

  • Spencer North is a low secure ward for women with LD.

  • Mackaness is a male medium secure ward for people with ASD.

  • Harlestone is a male low secure ward for people with

    ASD.

Forensic inpatient or secure wards

Requires improvement

Updated 16 September 2016

  • Seacole Ward is a medium secure ward for women.

  • Stowe Ward is a medium secure ward for women.

  • Sunley ward is a medium secure ward for women.

  • Elgar ward is a low secure ward for women.

  • Spencer South is a low secure ward for women.

  • Sinclair ward is a low secure ward for women.

  • Robinson ward is a medium secure ward for men.

  • Fairbairn is a medium secure ward for men with hearing difficulties.

  • Prichard ward is a medium secure ward for men.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 16 September 2016

  • Thornton ward is a locked rehabilitation unit for women.

  • Ferguson ward is a locked rehabilitation unit for men.

  • Spring Hill House is a locked facility rehabilitation unit for Women offering 23 beds.

Wards for older people with mental health problems

Good

Updated 16 September 2016

  • O’Connell ward is a locked ward for male older adults.

  • Compton is a locked ward for male and female older adult patients.

  • Foster is a locked ward for male older adults.

  • Cranford is a medium secure ward for male older adult patients.

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

Requires improvement

Updated 16 September 2016

  • Sherwood ward is the psychiatric intensive care unit.