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Provider: Worcestershire Health and Care NHS Trust Good

Read our previous full service inspection reports for Worcestershire Health and Care NHS Trust, published on 18 June 2015.

Reports


Inspection carried out on 9 January 2018

During a routine inspection

Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.

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

  • We rated safe, effective, caring, responsive and well-led as good. Our rating for the trust took into account the previous ratings of services not inspected this time.
  • The trust operated collaboratively as a board, that meant executives and non-executive directors shared responsibility and liability for decision-making.
  • There was a holistic understanding of performance, which sufficiently covered and integrated people’s views with information on quality, operations and finances.
  • The trust board were very visible across all services of the trust. We were told of many examples of how the board visited and supported clinical services.
  • The trust understood the challenges to quality and sustainability, and identified the actions required to address them. This was aligned to the wider health and social care economy of Worcestershire. There was good leadership at trust board and sustainability and transformation partnership level.
  • The trust had refreshed their vision and values for the trust. The strategy and priorities of the trust was aligned to the vision and values, and reflected their part in local sustainability and transformation plans. Staff had an understanding of the vision and values in relation to local services.
  • Overall, the trust was a good place to work in. Staff often told us it was the best organisation they had worked in. The trust was recognised as a disability confident employer and had been named in the top 100 employers of apprentices.
  • Governance systems from ward to board provided good performance management information to make decisions.
  • The trust communicated well with patients, carers, staff and stakeholders. The majority of groups felt included in decisions about service re-design and development. The youth board was a good example of patient involvement and demonstrated that the trust listened to their views and acted on their suggestions.
  • There were robust arrangements in place to identify, record and manage risks. Patients mental and physical health was assessed, and care and treatment planned.
  • The trust worked hard to improve quality and innovation, for example, the digital exemplar programme.
  • Recruitment of staff was a challenge to the trust but they were proactive in attempts to employ people across many of their services.
  • The trust recognised its staff in a number of ways, through a simple thank you to formal awards.
  • There was a culture of learning and research across the trust.

However:

  • In a partnership arrangement with another trust outside of Worcestershire, governance arrangements were complex. However, the trust had learnt lessons and had served notice of the partnership.
  • The policy and procedures for learning from deaths should be reviewed and updated to reflect the gaps we identified.
  • Ward managers in one trust core service could not always identify how many staff had received training, supervision or appraisal.
  • We identified good medicines management across most of the trust however, we saw errors in administration of medication on the acute mental health treatment ward.
  • Although we saw good adherence to, and understanding of the Mental Capacity Act across the trust, there was evidence that decision specific mental capacity assessments were not always fulfilled when staff completed DNACPR forms in community health inpatient services.


CQC inspections of services

Service reports published 1 June 2018
Inspection carried out on 9 January 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 482.08 KB (opens in a new tab)Download report PDF | 2.38 MB (opens in a new tab)
Inspection carried out on 9 January 2018 During an inspection of Community health services for adults Download report PDF | 482.08 KB (opens in a new tab)Download report PDF | 2.38 MB (opens in a new tab)
Inspection carried out on 9 January 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 482.08 KB (opens in a new tab)Download report PDF | 2.38 MB (opens in a new tab)
Inspection carried out on 9 January 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 482.08 KB (opens in a new tab)Download report PDF | 2.38 MB (opens in a new tab)
Inspection carried out on 9 January 2018 During an inspection of Community health inpatient services Download report PDF | 482.08 KB (opens in a new tab)Download report PDF | 2.38 MB (opens in a new tab)
Inspection carried out on 9 January 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF | 482.08 KB (opens in a new tab)Download report PDF | 2.38 MB (opens in a new tab)
Inspection carried out on 9 January 2018 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 482.08 KB (opens in a new tab)Download report PDF | 2.38 MB (opens in a new tab)
See more service reports published 1 June 2018
Service reports published 8 August 2017
Inspection carried out on 7th June 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF | 278.82 KB (opens in a new tab)
Service reports published 31 July 2017
Inspection carried out on 15th May 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 326.31 KB (opens in a new tab)
Service reports published 21 March 2017
Inspection carried out on 16th January 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 299.28 KB (opens in a new tab)
Service reports published 28 June 2016
Inspection carried out on 30 November 2015 and 11 and 13 May 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF | 250.02 KB (opens in a new tab)
Inspection carried out on 30 November 2015 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 272.33 KB (opens in a new tab)
Inspection carried out on 30 November 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 253.06 KB (opens in a new tab)
Inspection carried out on 30 November 2015 and 13 May 2016 During an inspection of Specialist community mental health services for children and young people Download report PDF | 272.79 KB (opens in a new tab)
See more service reports published 28 June 2016
Service reports published 18 June 2015
Inspection carried out on 19th to 23rd January 2015 During an inspection of Wards for people with a learning disability or autism Download report PDF | 262.61 KB (opens in a new tab)
Inspection carried out on 19 -23 January 2015 During an inspection of Community-based mental health services for older people Download report PDF | 274.03 KB (opens in a new tab)
Inspection carried out on 19 – 23 January 2015 During an inspection of Community-based mental health services for adults of working age Download report PDF | 326.2 KB (opens in a new tab)
Inspection carried out on 19 to 23 January 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF | 310.26 KB (opens in a new tab)
Inspection carried out on 19 -23 January 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 297.32 KB (opens in a new tab)
Inspection carried out on 19th January to 23rd January 2015 During an inspection of Community health services for children, young people and families Download report PDF | 283.26 KB (opens in a new tab)
Inspection carried out on 19 - 23 January 2015 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 319.69 KB (opens in a new tab)
Inspection carried out on 19th January to 23rd January 2015 During an inspection of End of life care Download report PDF | 255.91 KB (opens in a new tab)
Inspection carried out on 19 - 23 January 2015 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 257.4 KB (opens in a new tab)
Inspection carried out on 19th January to 23rd January 2015 During an inspection of Community health inpatient services Download report PDF | 300.13 KB (opens in a new tab)
Inspection carried out on 20 – 22 January 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 319.43 KB (opens in a new tab)
Inspection carried out on 19th January to 23rd January 2015 During an inspection of Community health services for adults Download report PDF | 302.5 KB (opens in a new tab)
Inspection carried out on 19 - 23 January 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 358.38 KB (opens in a new tab)
See more service reports published 18 June 2015
Inspection carried out on 30 November 2015 and 11-13 May 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.

We rated Worcestershire Health and Care Trust to be performing at a level that led to a judgement of good.

We found that the trust had reviewed and acted on feedback from the CQC comprehensive inspection of January 2015. This meant that four core services that were rated as requires improvement in January 2015 were now providing good care and treatment to patients and young people.

The trust had commenced and embedded a number of initiatives county wide to support direct care delivery.

The trust had reviewed the re-design of acute wards and community buildings, and future provision of mental health services, with patient groups, trust staff and commissioners.

We saw the trust involved patients and stakeholders to improve services; an example was young people had re-designed a community service for children and young people in Worcester. Patients on wards could see the difference they made with a 'you said, we did' board.

The recovery star was embedded in acute wards. It is an outcome tool that measures change and supports patient recovery.

A new electronic patient records system had been introduced meaning information was held  securely. A single point of access across Worcestershire had been developed meaning patients were triaged and assessed more quickly. Staffing levels had increased in acute wards and across community services.

The living experience of patients admitted to wards had improved, for example, trust staff knew how to change the temperature of the wards and there was sufficient seating in the Harvington ward dining room.

We saw a peer support system was introduced to support patients in wards. Peer supporters have lived experience of mental health. We found peer support workers running therapy groups and they formed part of a patients recovery.  

The trust engaged young people through a youth trust board meaning that stigma about mental health would be reduced. A website had been developed  to promote wellbeing and support for young people.

We did find however, that some buildings presented a risk to patients who may wish to harm themselves.

During this focussed inspection, we found that patients, relatives, staff and senior managers engaged openly to the inspection team.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

Inspection carried out on 19-23 January 2015

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.

During the whole of this inspection, we found that patients, their relatives, staff and senior managers where all willing to engage in an open and frank way.

We rated this provider requires improvement and although we found areas of good practice across most care areas there are some patient safety issues that need to be addressed. At times, the trust did not provide effective care that met the standards of recognised good practice and some teams were not always responsive to the needs of patients and their carers.

Across the mental health services some good standards of patient safety were achieved however, we found unmanaged ligature risks on Harvington ward and in the rehabilitation units. While the service had carried out a ligature risk assessment, they had in some cases, taken no action to address the identified risks. On Keith Winter and Cromwell House there was some confusion about the expectation to address this and the inspection team found an inconsistency of approach to managing ligature risk in this area.

Some teams there had taken an innovative approach to tackling the problems of unsuitable ward environment by using mirrors to enable staff to have improved sight on some ward this was not in place. On Harvington ward there was restricted sight throughout the area to ensure effective patient safety.

In most areas medicines were managed safely however, there were some instances where we found unsafe practice. We found minor concerns across a range of settings including non-adherence to the policy for self-administration and inappropriate or inadequate storage and record keeping.

There was an inconsistent approach to training, ensuring staff understood their responsibilities regarding the Mental Capacity Act (MCA), and in some areas the Mental Health Act (MHA) which was relevant to their role. However, there was high adherence to mandatory training. We found that staff carried out treatment and care in line with recognised evidence based practice.

The care provided by this trust, with the exception of one ward, was of a good standard and we found that the services were well led in most core services with strong senior leadership driving through change and developments. The teams worked to uphold the values and vision of the trust and provide good care for patients.

Across the community health services, we found overall, the services were delivered to a good standard, with the exception of two patient safety concerns at each of the two injuries units where we found an unsuitable mattress, equipment not maintained and inappropriate storage of hazardous products.

We found in the community inpatients wards that arrangements to minimise risks to patients were in place with measures to prevent falls and pressure ulcers. We saw evidence of good practice including the use of safety dashboards; clean clinical areas and good infection prevention and control practice.

In the end of life services, we found a new audit process, delivered by peers, was producing a new energy and motivation about fundamental aspects of nursing care such as infection control, record keeping, risk assessment and medicines management.

We had positive feedback from patient, carers and we saw that interventions were delivered in a sensitive and dignified way. There were some exceptions to this and in Harvington ward, we found that staff were not able to respond to all patients in a timely manner.

Complaints were handled effectively the feedback and learning was shared at local level and via the executive team if necessary. Trust premises were, in the main, accessible for patients. Interpreters were available and staff knew how to access the service if needed. The inspection team noted that information was available to patients and carers in a range of languages.

Across all core services, staff knew how to support people who wanted to make a complaint.

However, access to treatment in some core services was not responsive to patient need. In the CAMHS and community mental health service, we found long wait times to access some treatments.

The trust displayed the vision, values and strategy across the wards and patients areas. The staff told us the senior leadership had high visability and welcomed the patient safety walkbouts carried out by the chair and the chief executive.

Staff morale, in the main, was good and staff told us that they felt it was a good place to work. Mostly, we saw services being well led at local level and staff teams felt supported in their role.

The trust were keen to learn from incidents and feedback and showed a commitment to improving practice by participating in a range of external peer review and service accreditation schemes. The trust were keen to improve their record on staff appraisal and discussed this with the inspection team as a priority action for the coming year.

Overall, the inspection team found the trust had some issues that needed to be addressed but that the leadership and senior team were best placed to make the changes required.

Mental Health Act responsibilities

The governance structure for the monitoring of the Mental Health Act (MHA) was undertaken by the MHA Monitoring Group which was chaired by a non-executive director and attended by further non-executive directors and associate managers. MHA governance is separate from the wider governance arrangements, resulting in a lack of a consistent approach to auditing and monitoring of the MHA. The MHA monitoring group does not have any representation from the quality team but does report into this group. However, this does not allow the rich data available from the independent group of managers to be fed into the quality governance or patient experience. There is an annual MHA report to Trust Board

The MHA administration team clearly demonstrated their roles, systems and processes. The team members could provide a clear outline of their arrangements for assuring the powers and duties of the MHA are completed. The MHA administration team were very clearly focused on documentation for admission, renewal and hearings. Other statutory papers were seen to be outside their scope, including checks on consent to treatment forms and section 17 (leave of absence) forms. These documents therefore did not receive any review or scrutiny beyond the clinical team.

Issues identified on the wards are detailed later in the report.

Mental Capacity Act and Deprivation of Liberty Safeguards

Knowledge and practice of the Mental Capacity Act (MCA) was variable. Some staff where well informed about their legal responsibilities under the MCA which was reflected in practice.

In older people’s services, staff were aware that capacity could fluctuate and that lack of capacity in one area did not mean capacity was restricted in other areas. Patients were involved in their care and we observed on a number of occasions that staff obtained verbal consent before carrying out any interventions.

People were supported to make decisions where appropriate and when they lacked capacity, decisions were made in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. There were records of best interests meetings in some patient files. In some teams, MCA assessments were discussed in multi-disciplinary meetings.

However, some consent to treatment forms were signed by carers when it had been assessed that a patient lacked capacity to consent. This would only be lawful if the carer had lasting power or attorney for personal welfare which was not evident in the notes.

Staff’s knowledge and understanding of the Mental Capacity Act was less evident in some of the inpatient services and rehabilitation team. In some teams staff felt they did not have any responsibility under the MCA and did not know how the legislation applied to their work with patients. It appeared that some staff had a limited understanding that capacity was linked to specific decisions and some records showed that where it was assessed that the patient lacked mental capacity this was for all decisions the patient would make.

The trust informed us that MCA training was covered in safeguarding training and not a mandatory requirement for staff. Records seen demonstrated that in some services training in the MCA and DoLS formed part of the locally agreed training programmes, but in other services it was not monitored. Some staff were not able to tell us who they would contact as the lead person on MCA within the trust

Issues identified on the wards are detailed in the core services report.

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.