NAViGO Health and Social Care CIC

We rated NAViGO Community Interest Company as good because:

• The service structure included patient and staff members who were involved in making decisions regarding the organisation through member votes, this included setting the organisations vision and values at an annual meeting. As a result, all the staff we spoke to knew the organisations vision and values.

• Patients records were all held on a central electronic recording system enabling all staff to access the relevant information for the patients they were supporting.

• Staff were seen to be kind and respectful when supporting patients and carers. We saw evidence that staff performed regular physical health checks with patients, staff referred patients to a GP if they had any concerns.

• Risk assessments were up to date and staff regularly reviewed and updated them. Assessments contained crisis plans, including what actions to take and where to get support. We saw evidence that the service had a process in place to respond in times of crisis.

• The care plans were holistic and included a pen picture summarising the individual needs of the patient. They also covered a range of needs including mental health, physical health and wellbeing, medication, housing, spiritual needs, and patient strengths. Patients and carers were involved in decisions around the care provided and staff recorded their views in the care plan.

• The service provided a range of therapeutic interventions in line with The National Institute for Health and Care Excellence (NICE) guidance including Cognitive behavioural therapy and Dialectical behaviour therapy. One member of staff in the memory service received training in Cognitive Stimulation Therapy.

• We saw evidence of capacity assessments within patient records including evidence of best interest decisions being made and communicated where patients did not have the capacity to make a decision.

• Where staff completed capacity assessments, we saw evidence that staff had assessed patient’s ability to understand, retain, use and weigh up the information necessary to make a decision.

• The service offered access to complimentary therapy including reiki and sleep therapy for patients and carers

• The service assessed new referrals within 10 days of a referral; or four hours for emergency referrals. Where this was not possible, there was a process in place to enable the home treatment team to complete the initial assessment. at the time of the inspection there were no waiting lists for assessment or treatment. staff provided care under a multidisciplinary framework, staff held regular multidisciplinary meeting and we saw evidence that the teams worked well together.

• The memory service has achieved a rating of excellent under The Memory Services National Accreditation Programme (MSNAP).

• The service had processes in place to listen to staff patients and carers including staff representation at board meetings and managers attendance at team meetings. The service had an effective complaints process and all the patients and carers we spoke to knew how to make a complaint.

We rated the integrated services for older people with mental health problems as good because:

• Staff did a comprehensive risk assessment for each patient, highlighting risks and setting out the individualised care and treatment required. They reviewed and updated risk assessments regularly. Each patient’s records could be seen by staff in the community and on the ward, which helped provide continuity of care.

• Staff did a physical healthcare assessment of each patient admitted to the ward and patients had good access to physical healthcare. Care plans were person-centred and holistic; they were updated for patients as they moved in and out of hospital.

• The integrated team included a wide range of mental health trained professionals. Staff applied recommended best practice and guidance to ensure patients received a high quality of care. They received professional development and ongoing managerial supervision to ensure they could meet the needs of patients in their care effectively.

• We found staff well informed about issues of capacity and the application of the Mental Capacity Act, including Deprivation of Liberty Safeguards. The Mental Health Act code of practice was understood by staff and had become part of practice both on the ward and in the community.

• Patients and relatives told us the staff treated them with dignity and were respectful at all times. Where patients were unable to tell us, we saw staff treat patients with kindness and compassion. Staff supported carers and kept them involved in the care of their loved ones. Staff across the service promoted support groups for patients and carers.

• Patients were admitted to Konar ward if a full assessment showed it was where their needs would best be met. Staff planned patients’ discharge with care given to prepare patients and their relatives. Ongoing support from the older people's home treatment team gave continuity of care before and after discharge.

• The ward environment and associated outside areas, optimised patients’ recovery by meeting their needs and offering stimulation. The ward had achieved accreditation for inpatient mental health service wards for older people (AIMS-OP) with excellence.

• Staff spoke about being part of an excellent team. Work across the multidisciplinary team was respectful in the way it shared practice and morale was high.

• The whole team had a strong commitment to positive practice that would improve the quality of care for older people with mental health needs. Staff felt involved in service development and believed that if they had an idea it would be listened to.

However:

• The separation of patients with organic illness (caused by disease affecting the brain) and functional illness (a diagnosed mental health problem) was not always possible. This could mean that at times patients, particularly those with functional illness found the ward noisy and distressing. The inpatient unit was originally two five bedded units; one that cared for functional patients and the other for organic patients. Due to a reduction in funding from the clinical commissioning group, this was amalgamated into one unit.

• Half the ward’s patients prescribed ‘as required’ medication had their prescription recorded across two medication cards. This could lead to dispensing errors. The prescribing doctor assured us that this would be changed.

• On Konar ward 82% of staff had completed all mandatory training and 60% of the older people's home treatment team, making a joint figure of 71%. Each team’s figures fell below the provider target of 85%. The senior operational leader and team leaders had a specific action plan to address this, with actions identified for both the service areas and the training team. Managers expected all staff to have met the provider target by April 2016.

• On Konar ward, 67% of staff had completed intermediate life support training. Staff that had not yet accessed this training were expected to receive it within the next three months.

• Staff used Restraint Elimination System Practical Effective Control Technique (RESPECT) training to de-escalate difficult situations. Staff were required to update their RESPECT training every six months. All staff had completed their initial training however, the proportion of staff who had completed refresher training was low at 42% compared with the provider’s target of 85%. Managers had an action plan to address this, which included a RESPECT instructor on site helping staff if required.

• Following the decommissioning of fifteen care beds, which had provided step-up, step-down support, the range of care options had reduced.

We rated NAViGO Community Interest Company as good because:’

• The premises were clean and tidy with separate spacious waiting areas. The teams worked to a lone working practice protocol. Interview rooms were alarmed or systems were in place to keep staff safe. Staffing levels were safe to meet the needs of patients.

• Staff were aware of safeguarding requirements and showed they understood the referral process into the local authority. Caseloads were managed and re-assessed regularly and were discussed in supervision.

• There was an effective incident reporting system in place and there was learning from serious incidents. All staff knew how to report an incident.

• Risk assessments were recorded and updated regularly. Comprehensive assessments were completed in a timely manner. Care records showed personalised care, which was recovery oriented. Physical healthcare needs were considered during assessment and throughout treatment. There was consideration of mental capacity assessment throughout treatment and this was documented. Outcome measures were used to evaluate the effectiveness of care and treatment. Medicines were managed safely and there was learning from medication incidents.

• Staff were respectful and caring when they spoke with people. People said they felt involved in their care planning and treatment and this was documented in the care record.

• There were no waiting times from referral to triage due to the single point of access. Referral to assessment waiting times were 11.5 days against a10 day target and referral to treatment or second offered contact date was 22 days. The east team did not have a waiting list and the west team were monitoring those on the waiting list.

• Managers monitored performance and addressed any issues. Staff received appraisals and regular supervision. All staff said they could raise issues with their manager if required and action would be taken. Staff knew the senior managers and were aware of the trust’s vision and values. The chief executive attended regular staff meetings and some staff were members of the board. They said they felt supported by the board members and senior management. Team morale was good and staff worked well together.

However:

• There were continuing staffing issues at the east team and the team were under pressure to manage the workload. The staffing issues had continued for a considerable amount of time. This meant that caseload sizes were increasing and the west team had started to give assistance.

• Mandatory training compliance was below target for safeguarding adults, safeguarding children, and information governance.

We rated NAViGO Community Interest Company as good because:’

• The design and layout of the environment allowed for effective observation of patients, all areas were clean and well maintained, and furniture and fittings were anti-ligature, designed to reduce the potential risks for patients with risks of self-harm. The service also maintained a comprehensive ligature audit.

• There was an alarm system that operated in times of emergencies and where patients required additional assistance in vulnerable situations.

• The service had a clearly established staffing establishment and had employed a range of effective methods to address shortages and vacancies.

• The service operated an effective handover process that involved doctors, managers, clinical leads and staff.

• Incidents were managed efficiently and the service worked at being open and transparent with patients and staff. They operated a confidential 24 hour advice and support service for staff.

• The service had achieved recognition for Accreditation for Inpatient mental health Services (AIMS) and star wards as the overall winner.

• Patients received comprehensive and timely risk assessments on admission.

• The service worked closely with other teams and organisations to ensure patients received the best mental health support.

• Staff had a good understanding of the Mental Health Act (MHA), the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards. The service adhered to the MHA and MHA Code of Practice, and MHA documentation was in place and up-to-date.

• Patients gave positive feedback about the service, staff and management and all patients. All patients were given an opportunity to voting members of Navigo CIC and opportunities to be engaged with such functions as the Tukes Employment Scheme

• The service had a clear governance structure, with effective systems and processes for overseeing all aspects of care including regular management meetings, a programme of audits and access to a service improvement team.

• There was good morale among staff. They experienced job satisfaction, they felt valued and supported by colleagues and managers.They shared the provider’s vision and values for their service.

However:

• At the time of inspection the service did not have a full multidisciplinary team but had access to psychology and occupational therapy which underpinned the model of care for assessment, treatment and recovery.

• The provider had only one pharmacist who was responsible for the whole service.  Navigo did have a contract with Lloyds Pharmacy which ensureed regular pharmacy cover to take account of sickness and leave”.

• Not all staff received regular supervision.

• Not all care plans demonstrated evidence of person centred care.

We found that Navigo Health and Social Care CIC was performing at a level which resulted in a rating of good because:

• We found that Navigo as a social enterprise had embraced the concept of patient involvement to its utmost with patients having an active voice in decision making as members of the community interest company. They also through their Tukes employment scheme work actively to engage patients to maximise their working potential to re-integrate patients with mental health problems back into the local community.

• Laing Buisson present annual awards to organisations dedicated to innovation, effective practice and high quality delivery of healthcare in the United Kingdom. In March 2015, Laing Buisson awarded the specialist care award for Excellence in Dementia Care to the Konar team.

• Restraint was only used once de-escalation techniques had failed. The service operated restraint elimination system practical effective control technique (RESPECT) training to de-escalate difficult situations training in response to managing the risks of patients.

• The ward layout on all inpatient areas allowed staff to observe all parts of the ward, with clear lines of sight from the main lounge area.

• None of the incidents of restraint were of prone restraint or resulted in rapid tranquilisation.

• In the adults of working age community teams each patient had a care programme approach (CPA) assessment carried out at least annually and the east team had 95% completion with the west team having 93%.

• We saw examples of staff following National Institute for Health and Care Excellence (NICE) guidance in the older adults inpatient service.

• The Memory Services National Accreditation Programme (MSNAP) accredited the Navigo memory service. The memory service had achieved a rating of excellent for their previous reviews under the scheme

• Navigo had amended their policies in order to adhere to the revised Mental Health Act (MHA) Code of Practice which was issued in April 2015

• We received 173 comment cards from service users, carers and staff, an exceptional amount based on the size of the provider. Of these comment cards 152 were positive and 21 were negative.73 of the positive cards commented about the caring attitude of staff.

• Konar Suite family and friends test had remained at 100% for over a year.

• Navigo had been involved in the development and delivery of a joint training programme to support police officers understanding of personality disorder and Section 136 of MHA

• Navigo had a membership of over 750 people made up of staff, people using the services and carers. All members had equal voting rights.

• Low sickness and absence rates and reports from staff showed Navigo had a healthy culture. Staff throughout the organisation referred to Navigo as a family. Staff felt supported and were able to contribute and challenge decisions in their areas.

• It was clear from senior management that the organisations greatest risk was financial sustainability.

However

• The community memory service had some issues with control and storage of medication

• The process in place at the Eleanor Centre for the disposal of the sharps box stored on the premises did not meet the requirements of the hazardous waste regulations

• At the time of inspection the service did not have a full multidisciplinary team but had access to psychology and occupational therapy which underpinned the model of care for assessment, treatment and recovery.

• On the acute services all staff had received their annual appraisal however the service had identified that’s some staff had not received their supervision as frequently as was expected. The service had implemented changes to address this

• Navigo had provided training for staff on awareness of mental health and this included Mental Health Act awareness, however the provider has recognised that this training needs to be separate and has been addressed on their training action plan

• There were some discrepancies in training figures that were provided to us. Navigo told us that this was due to the electronic system that collated training data.

• We looked at seven complaint files. We found that all complaints were thoroughly investigated with balanced responses. Navigo’s policy on complaints stated that responses to complaints should be within 35 days. However, only one of the seven complaints met this target