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Provider: Essex Partnership University NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 9 October 2019

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

  • We rated effective, responsive and well led as good. We rated caring as outstanding and safe as requires improvement. In rating the trust, we took into account the previous ratings of the nine services not inspected this time. We rated the trust overall for well led as good. At this inspection, we rated two core services as outstanding, one as good and three as requires improvement. Therefore, three of the trust’s 15 services are rated requires improvement, ten out of 15 rated as good and two out of 15 rated as outstanding.
  • The trust addressed many of the issues identified at the last inspection in May 2018. This included increasing the oversight, monitoring and recruiting leaders in service such as end of life care and substance misuse. Staff confidently described knowledge of risk areas in services such as acute mental health wards, they described areas of risk and how they mitigated it to increase patient safety. The trust made improvements to medicines management processes and resolved issues with stock rotation. Staff ensured that they applied for deprivation of liberty safeguard applications in good time and assessed patient’s mental capacity where appropriate.
  • Leadership in the trust was strong and had a clear sense of direction. The board prioritised visibility. In 12 months, members of the board undertook a total of 349 service visits, including unannounced night visits. Staff felt engaged with their leaders and described the introduction of distributed leadership, increasing autonomy and accountability. The board were unitary. Non-executive directors challenged the board positively to improve the performance of the trust. The trust ensured engagement with the wider mental health and social care system to offer support and specialist knowledge. Leaders and staff knew the values of the organisation and this wasutilise incorporated into recruitment processes and appraisals.
  • The trust took opportunities to improve services and provide better care and outcomes for people using services. This included identifying capital to eliminate dormitory accommodation and making significant reductions to the number of local people receiving treatment outside of Essex. During the well led inspection, the number of local people receiving treatment out of area was four. We heard about and saw many examples of innovative practice throughout the trust, this included the trial of a rapid paramedic intervention service for end of life care and the variety of therapy offered to young people on child and adolescent mental health wards. The trust provided space for learning and innovation through a ‘hub’ on the trust intranet.
  • The trust had a clear and robust governance structure to oversee performance, quality and risk. The governance structures of the organisation were in place from the point of merger and the trust reviewed their efficacy on an annual basis, the last review being in quarter three of 2018. Eight governance committees reported directly to the board, with several sub-committees reporting below. Governance spanned the entire organisation, with local managers discussing issues at service level in team meetings. We saw a variety of minutes and papers from meetings during the inspection which demonstrated staff reviewed risk, quality and performance. Local managers knew the reporting structure for sharing information and escalating concerns and could describe the ward to board governance structure.
  • Leaders prioritised culture following the merger in 2017 and continued to see this as a priority. Senior leaders described the ‘command and control’ approach taken immediately post merger to ensure the trust met its immediate objectives bringing two organisations together. Leaders described a shift in approach and a focus on distributed leadership to increase the autonomy of local leaders and increase accountability for their services. The trust freedom to speak up guardian (elected by staff in 2017) worked to encourage staff to raise concerns. Twenty local guardians supported their work. Senior leaders described work relating to embedding a ‘just culture’. A just culture ensures staff involved in incidents relating to patient safety are treated fairly. Just culture promotes a culture of openness to maximise the opportunities to learn from mistakes. Duty of Candour continued to be upheld appropriately
  • The trust used a variety of tools to monitor and assess risk. The trust had a corporate risk register and a directorate risk register. The corporate risk register identified 22 risks and the board reviewed every three months. Directorate risk registers captured service specific risks. The trust had a programme of internal audits to review and monitor aspects of their services, linked to the risks identified on the board assurance framework. Frameworks and action plans set out the ways the trust intended to reduce risks identified.

However

  • The trust did not ensure staff learned lessons from previous incidents and worked in a different way to reduce re-occurrence. Despite a variety of ways in which lessons could be shared, there continued to be repetitive themes identified as recommendations and learning. Examples included: communication with external agencies, record keeping and the administration of emergency treatment. There had been recent difficulties within specific teams tasked with monitoring the implementation of action plans following incidents, which the trust was in the process of addressing.
  • We were not assured the trust was working with pace to reduce the use of prone restraint and to address blanket restrictions. There was no monitoring system for blanket restrictions across the organisation, information about restrictions was held at ward level only. Staff continued to use prone restraint to administer intra-muscular (IM) medication to patients, despite being policy supporting staff to inject in other sites. From March 2019 to August 2019 staff recorded 183 incidents involving prone restraint. Eighty five percent (156) of those incidents occurred to administer IM medication.
  • The trust had challenges with the quality of its data. Staff described difficulties with the electronic record keeping system, the training data and data produced in performance reports. Senior leaders described data as incorrect and the need to provide extra narrative to performance reports to accurately reflect the performance of the service.
  • Engagement with equality and diversity networks and equality and diversity issues required improvement. The trust had increased the number of networks that staff had access to, however had missed opportunities to engage. An example of this was a lack of executive attendance at the equality and diversity conference. Many examples of equality and diversity work described during the inspection focused on the protected characteristic of race only.
Inspection areas

Safe

Requires improvement

Updated 9 October 2019

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

  • The trust did not ensure that staff changed their practice following incidents. Despite several methods used to communicate recommendations and learning, incidents with similar themes continued to occur. Examples included: communication with other agencies, record keeping and methods of administering emergency care. There were 12 outstanding action plans following incident investigations that required signing off to agree that changes had been made. Staff had not reviewed 52% of examples where clients died whilst using substance misuse services.
  • Staff applied blanket restrictions without individual justification. This included restricting patients access to outside space, bedrooms and hot drinks. The trust did not monitor the application of blanket restrictions through its reducing restrictive interventions work, this information was held locally at ward level. Staff continued to restrain patients in the prone position to administer intramuscular medication, despite policy supporting staff to administer in other sites. Training for alternative administration methods was not yet arranged.
  • Staff did not complete paperwork in full that related to the management of patient risks. There were gaps in observation records, seclusion records, physical health records and risk assessments. Medicines records demonstrated there were issues with stock and medicine availability. On acute wards, staff had not recorded all ligature risks on the ligature risk assessment document. However, staff knowledge and management of ligature risks had improved since the last inspection.
  • There were issues with environments that posed a risk to patient safety. There were areas of wards with ‘swing beds’ (beds used to accommodate patients that can be either male of female depending on the admission needs) which meant patients had to walk past rooms of the opposite sex to use bathroom facilities. Staff stored broken equipment in rooms, rather than removing them from the ward and there were delays in addressing maintenance issues such as broken toilets.

However:

  • Most wards had enough staff to meet the needs of the patients. Whilst the trust used bank and agency staff, they were often familiar with the ward and booked in advance, where possible. Staff ensured that new staff received an induction to the wards which included an introduction to patient needs and preferences and familiarisation with the ward environment. The trust ensured the quality of agency staff through agreements with agency providers, ensuring all relevant checks were in place prior to working shifts. Managers prevented any agency staff that did not meet the standards required from working on wards. The trust ensured situational report meetings took place twice daily to monitor staffing levels and ensure patient safety. The frequency of the meetings would be increased if required.
  • Staff understood safeguarding legislation and described how to identify different types of abuse. Staff acted to protect vulnerable patients and worked with external agencies to increase support for patients. The trust offered all staff support with safeguarding through a centralised team that visited wards to increase awareness, offer support and to conduct investigations, where appropriate. The safeguarding team represented the trust at national events to ensure they were in touch with national developments and they communicated learning to ward teams via newsletters and visits.
  • Staff improved how they managed medicines from the last inspection. Staff kept accurate medicines administration records in most services and the organisation of clinical room had improved. There were minimal gaps or errors in medicines administration records.
  • Staff had access to essential systems to record and review clinical information. There were some challenges associated with the use of different systems across the geography but staff that required access could utilise the health information exchange which acted as a bridge between different systems. Staff had access to immediate information regarding risk and treatment via this exchange and trust policy required this information to be available when staff transferred patients to wards in other areas.

Effective

Good

Updated 9 October 2019

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

  • Staff assessed the needs of patients in a timely way and used information to develop holistic, person centred care plans. Staff updated care plans when risk changed, or a patient deteriorated. Staff included crisis plans in care plans and reviewed care plans via multi disciplinary meetings to ensure involvement from all disciplines.
  • Staff cared for patients in line with national guidance and best practise. Staff described how their interventions met guidance and supported patient need. Staff provided a range of treatments and interventions across the services, ensuring what was on offer met the needs of the patient group. Staff accessed other services when required and ensured patients had access to physical healthcare and any specialised care. The trust provided services with technology to support patients effectively and provided support with needs such as smoking cessation in response to becoming a smoke free trust.
  • Staff had access to regular supervision and specialist training. Staff received regular appraisals of their work which included time to discuss their training and development. All staff had access to meetings and time to discuss complex cases. Teams consisted of a variety of skills and experience which worked together to support patients. Managers ensure new staff received an induction to their role locally and via the corporate trust induction. Managers ensure staff that did not perform to the requirements of their role, or display the values of the trust, were dealt with in a timely way.
  • Staff applied the principles of the Mental Health Act (MHA) and Mental Capacity Act (MCA) to their work. They ensured patients had access to Section 17 leave. Most patients regularly had their rights explained to them. Staff rarely cancelled section 17 leave and they knew where to access support and advice on MHA and MCA if required.

However

  • Patients in rehabilitation services did not have access to psychological therapies, as recommended by the National Institute for Health and Care Excellence (NICE). Whilst staff supported patients to attend external courses this did not fully address the psychological needs of the patient group. Staff did not ensure that informal patients in rehabilitation had their rights explained to them on a regular basis.

Caring

Outstanding

Updated 9 October 2019

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

  • Staff respected and valued patients as individuals and empowered them to be partners in their care. Staff promoted people’s dignity and offered care that was compassionate, supportive and person centred. Staff committed to working in partnership with patients, and their carers to achieve positive outcomes, they made this a reality for each person. Staff went the extra mile to care for patients and feedback from families and carers indicated that the care exceeded their expectations. Staff consistently displayed the trust values in the care they delivered. Staff valued the emotional and social needs of their patients and embedded them in care and treatment. For example in end of life services, staff had gone food shopping for the relative of a person who had lost weight because they would not leave home in case their relative died whilst they were out. Staff made such offers effortlessly and did so with the sole aim of ensuring the people they looked after, and those important to them, were cared for.
  • Staff recognised that patients need to have access to, and links with, their advocacy and support networks in the community, and they supported patients to have easy access to independent advocates. Staff involved patients and carers in risk assessment and care planning to ensure treatment addressed patient need, in a way that was preferable to them. Staff demonstrated a strong person-centred culture and inspired to offer care that was kind and promoted dignity. Leaders valued the strong, caring and supportive relationships formed between staff, patients and relatives.
  • The trust valued feedback on the services they received from patients and carers. Staff monitored responses and took steps to change services based on feedback provided, to overcome obstacles to delivering care. Staff empowered people who used the services to have a voice and to realise their potential. On the children and adolescents’ wards staff identified areas on the ward where patients could express their feelings including via blackboards and white boards. Staff issued patients with a resource box on admission. Patients could personalise the content of their resource box and use the chosen items when upset or anxious. Patients had led the redesign of an area of the ward. Staff and patients now use this area for de-escalation and patients refer to this area as ‘the snug’. Patients had completed ‘patient reported outcome measures’, which led to meaningful involvement and co-production. The areas covered in the patient reported outcome measure were; ‘having hope’, ‘having an equal say in my care’, ‘being a part of improving the service, understanding my mental health and how to manage it and ‘feeling good about myself’.

Responsive

Good

Updated 9 October 2019

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

  • The trust worked hard to ensure people living in the area received care in Essex. At the time of the well led inspection the trust reduced out of area placements to four. Staff worked to only move patients between wards at appropriate times of day, only for clinical reasons and in a planned way. There were many examples of staff planning discharge at the point of admission and involving the patient in plans. Discharge co-ordinators worked across some services to specifically support patients with issues that may affect their discharge. Examples included support with housing, benefits and debt.
  • There was minimal disruption to care and treatment. People could access the right care at the right time and staff considered urgent need. Waiting times, cancellation of appointments and activities was minimal.
  • Most wards provided enough space to deliver groups, one to one sessions and activities. Patients had ways they could make phone calls in private to loved ones or professionals. Most patients felt the food was satisfactory and could be adapted to meet any dietary or spiritual needs.
  • The trust dealt with complaints with openness and transparency. Staff took complaints seriously and responded in a timely way. Staff kept people informed if there were any delays and the reason for them. The trust provided responses to complaints that demonstrated compassion and they apologised when things went wrong.
  • Staff worked with patients to engage them with the wider community, considering their needs and preferences. Young people received access to high quality education on mental health wards. Patients on rehabilitation wards had access to employment activities in the community. Staff encouraged patients to maintain positive relationships with those important to them, such as families and carers.

However

  • Bed occupancy provided challenge, particularly on acute mental health wards, where occupancy was over 100%. Patients remained on wards when they were ready for discharge.
  • Environments on some wards did not promote recovery or meet the needs of the patients. Some acute mental health wards needed redecoration. Two dementia wards did not provide patients with an environment that supported their needs. There were issues with flooring and a lack of dementia friendly signage. There was minimal access to items that provide sensory stimulation and clocks and newspapers were out of date. Older people could not personalise their bedrooms on wards and the rationale given was a breach of infection control policies.
  • Staff did not guarantee the safety of patients’ personal belongings. There were several wards in the acute mental health services that did not have lockable bedrooms and a complaint from the older adults’ wards related to personal belongings going missing. This complaint had not been escalated by staff.

Well-led

Good

Updated 9 October 2019

Our rating of well-led stayed the same. We rated it as good because:

  • The leadership and governance of the trust promoted the delivery of high quality, person centred care. There was a clear vision, embraced by staff and evident in the care delivered to patients. The visions, values and strategies had been developed in a structured way, with engagement from internal and external stakeholders.
  • Senior managers had increased visibility in services and had been proactive at understanding services such as end of life care and substance misuse, which was an issue identified at the previous inspection. Most teams recalled recent visits from executives and non-executive directors and felt they could raise concerns without repercussion.
  • Local leaders demonstrated passion and commitment to their service and morale across the trust was good. The trust supported team leaders to develop their leadership skills. Leadership training was available for all staff at all levels, irrespective of their job role. The trust provided staff with opportunities for career progression. The trust recognised staff success through individual staff and team awards. Managers, at all levels, encouraged and supported staff to develop and attend training for their roles.
  • The governance structures in place identified and monitored current and future risk. Managers escalated issues relating to risk and performance to relevant committee’s which then fed into the board through clear structures. Staff undertook various clinical audits across services to identify improvements. Board papers evidenced that senior leaders prioritised the delivery of safe, high quality care. Local leaders had appropriate oversight of issues relating to risk, safeguarding, admission and discharge and other relevant key performance indicators. Local leaders could submit items to the risk register for monitoring and action.
  • Leader’s ensured staff received appropriate support by way of supervision, appraisal and training. Leaders supported innovation and continuous learning, teams utilised the skills of colleagues by delivering in house training sessions, increasing the skills and knowledge of teams.
  • The trust provided ways for people to raise concerns and to blow the whistle on poor care. The trust gave dedicated time to a freedom to speak up guardian to work in this role outside of their clinical role. Support services such as HR, dedicated time to raising awareness about bullying and harassment and encouraged staff to raise issues. The trust recognised there was work to do regarding culture and had recently created an executive role for this reason. The post had been recently recruited to at the time of the inspection.

However

  • There were challenges for the trust regarding data quality. Local leaders reported ongoing issues with staff training data and its accuracy. Senior leaders in the organisation gave examples of the need to exception report in performance reports due to the quality and accuracy of data. Staff in teams described difficulties accessing the health information exchange when patients transferred from north to south. There remained several different systems across the trust for electronic record keeping.
  • There remained some issues from previous inspections in specific core services. In acute mental health services, the trust had not ensured that staff, leaders and governance processes addressed all risks identified at our 2018 and April 2019 inspections. At this inspection, we identified risks for this core service relating to ward maintenance, cleanliness and bed management. Improvements were still needed for governance processes to ensure staff updated ligature risk assessments in a timely way. In substance misuse services there were gaps in identifying learning from serious incidents and a lack of knowledge about the recovery agenda.
  • Whilst there had been some steps taken to implement equality and diversity initiatives across the organisation, there remained improvement for engagement and the articulation of the equality and diversity programme. Many descriptions of equality and diversity focused solely on the protected characteristic of race. Senior leaders had missed an opportunity to engage with the equality and diversity conference, which disappointed the networks in attendance.

End of Life

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

  • The service had enough skilled staff to care for patients and keep them safe. Staff attended both mandatory and specialist training to equip them with the necessary skills to carry out their role. Staff recognised, assessed and managed risks to patients well and all patient records reviewed had robust risk assessments. Staff we spoke with could clearly evidence learning from incidents and all staff demonstrated a change in practice based on lessons learned, to deliver an improved service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • All staff had a clear drive to improve care in their locality by delivering specialised training to colleagues. They had worked with colleagues in adult social care, hospices, hospitals and ambulance providers to achieve more consistent skills and knowledge. This had demonstrably supported better care for patients.
  • Staff treated patients with compassion and kindness. Staff took account of individual patient needs and helped patients to understand their conditions. Staff completed holistic and individualised care plans detailing patient and family views. Staff also provided emotional support to patients, families and carers. Patients informed us they could access the service when they needed to and provide feedback on the service.
  • Staff had implemented substantial, multidiscplinary programmes to avoid hospital admissions. This included establishing pilot schemes with ambulance providers and hospital teams and joint training exercises to help staff establish joint systems of work.
  • Staff routinely exceeded the expectations of patients, their relatives and carers. They went above and beyond their responsibilities to provide people with a comfortable, supported death in their preferred place.
  • We found numerous examples of staff working with patients and relatives to meet holistic needs in addition to medical and palliative needs. Feedback from carers and relatives supported this and every member of staff described how their passion and perseverance worked to meet individual needs.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. Staff were clear about their roles and accountabilities.

However:

  • Although staff had made improvements in audit and benchmarking processes, there remained gaps in measuring patient outcomes.
  • There were gaps in leadership oversight in some areas, including for the community rehabilitation and assessment team and in relation to the duty of candour.

Child and adolescent mental health wards

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

  • There was a truly holistic approach to assessing, planning and delivering care. Staff provided safe use of a range of innovative approaches to care and treatment interventions suitable for the patient group, consistent with national guidance on best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The continuing development of the staff skills, competence and knowledge was recognised as being integral in providing high quality care. Staff were proactively supported and encouraged to acquire new skills. Managers ensured staff received ongoing supervision and appraisal. Staff from different disciplines and services were committed to working collaboratively together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment. Staff supported patients to make decisions on their care for themselves proportionate to their competence. They understood how the Mental Capacity Act 2005 applied to young people aged 16 and 17 and the principles of Gillick competence as they applied to patients under 16.
  • Feedback from patients and carers was positive about how staff treated patients with compassion and kindness. Staff went the extra mile and their care and support exceeded expectations. Staff displayed a strong, visible patient centred culture. Staff involved patients and those close to them in care planning and risk assessment and actively sought their feedback on the quality of care provided. Staff were fully committed to working in partnership with patients and carers and made this a reality for each patient.
  • Patients’ individual needs and preferences were central to the delivery of the service. Staff planned and managed discharge well. They proactively liaised well with services that would provide aftercare and were assertive in managing the discharge care pathway. Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, patient discharge was rarely delayed for other than a clinical reason.
  • Leaders were compassionate, inclusive and effective at all levels. Leaders at all levels demonstrated the high level of skills, knowledge, capacity and capability needed to deliver excellent and sustainable care. Leaders had an inspiring shared purpose to deliver and motivate staff to succeed. Staff described high levels of satisfaction, including those with protected characteristics under the equality act. There was a fully embedded and systematic approach to improvement, which made consistent use of improvement methodology. Improvement methods and skills were available and used across the organisation. Staff were empowered to lead and deliver quality improvement activities.
  • The service provided safe care. The ward environments were generally safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They aimed to minimise the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

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

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

  • The trust had not ensured that staff, leaders and governance processes addressed all risks in the entirety, identified at our 2018 and April 2019 inspections.
  • Bed occupancy was above 100% on most wards and there were examples where patients remained on wards when they were ready for discharge. The trust had 61 of 1057 (6%) delayed discharges from April to July 2019. The highest was Finchingfield with 17 and Ardleigh wards with 13 patients. Trust data for June 2019 showed 41 delayed discharges, the highest was Grangewater ward with nine. This led to delays in being able to admit patients who needed assessment or treatment. Staff described examples of using section 136 suites for admissions and patients having to move to other wards following periods of leave.
  • Staff did not maintain clean ward environments that promoted recovery. Improvements were still needed for governance processes to ensure ligature risk assessments were updated in a timely way.
  • The service had increased staff vacancy rates and increased rates of bank and agency nursing staff usage in the last year. Managers described problems knowing the skills and experience of agency staff booked to work on wards.
  • Staff did not always manage medicines safely and did not complete records in full. There were gaps in seclusion records, patient observation records, physical health records and risk assessments.
  • The trust did not check that the learning from incident investigations and actions were shared across wards to reduce the risk of reoccurrence. Staff told us they had struggled with implementing the ‘no smoking’ policy.
  • Staff restricted patients access to gardens and hot drinks without individual justification. Staff did not provide facilities for patients to store their possessions securely.
  • Staff did not always actively involve patients and families and carers in the development of ward services. Fifteen of 34 patients and carers (44%) we spoke with said some staff could be more caring towards them.

However:

  • Patients told us most staff treated them with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They had holistic, recovery-oriented care plans informed by a comprehensive assessment.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. Staff felt respected, supported and valued. They were proud of their work with patients and proud of their teams. Staff were keen to improve. Leaders encouraged innovation and participation in research.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The trust treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and the wider service.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff participated in clinical audit, benchmarking and quality improvement initiatives.

Long stay/rehabilitation mental health wards for working age adults

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

  • Wards were clean, fit for purpose and well-staffed. The multidisciplinary team had a range of specialists and worked together to ensure there were no gaps in patient care. Managers of the service provided an induction, appraisals, supervision and mandatory training in key skills. Staff felt respected and valued, had access to professional development and understood how the visions and values of the service applied to their work. Managers at a local level had the right skills and abilities to run a service providing high-quality sustainable care. They understood the service they managed, collected and analysed data, and followed a recognised model for rehabilitation care.
  • Staff achieved the right balance between maintaining safety, managing challenging behaviour, and positive risk taking. They did not use restraint or seclusion. Staff thoroughly risk assessed patients on admission and developed care plans around these assessments. They planned for discharge and co-ordinated their efforts with aftercare services. Staff had easy access to clinical information and it was easy for them to maintain high quality clinical records. They used recognised rating scales and audits to monitor severity and outcomes.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. They recognised incidents, reported them appropriately and apologised when things went wrong. The service had not received any concerns or complaints. Staff and managers understood how to handle complaints and felt comfortable raising concerns.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s mental and physical health. Staff assessed the physical and mental health of all patients on admission and encouraged them to live healthier lives.
  • Staff understood the trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity. Staff treated patients with compassion, kindness, dignity and respect and involved them and those close to them in planning their care. They supported patients to access regular leave, external work opportunities and courses. Staff helped them keep in touch with the people that mattered to them.

However:

  • The ward did not offer psychological therapies as recommended by the National Institute of Health and Care Excellence.
  • Staff did not record when they explained to informal patients their rights under the Mental Health Act. Staff did not know how the trust monitored compliance to the Mental Capacity Act or how to get advice.
  • Some staff felt that the trust executive team were not visible enough and others felt excluded from the communication chain.
  • Staff did not have access to a suitable clinic room, which met infection control standards, to examine patients.
  • During the inspection we found blind spots and ligature anchor points which staff had not identified or mitigated. Whilst staff could improve their awareness of these issues, patients were low risk and capable of having independent access to the community where they would have access to many similar risks.
  • Learning from incidents was not fully embedded. Some staff did not attend meetings and others were unaware of recent safety alerts and incidents which had occurred elsewhere in the trust.

Wards for older people with mental health problems

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

  • Staff were aware of safety risks but the approach to safety was not consistent across the wards. The trust used beds which were used for male or female patients, dependant on the needs, known as ‘swing beds’, on one of the wards which potentially impacted on patient safety, privacy and dignity. Staff applied blanket restrictions on eight out of ten wards where patients could not access their bedrooms themselves. There were discrepancies between the types of falls risk assessments completed across the wards and whether these were updated following a fall. Staff needed scissors to cut the tag on a defibrillator bag which could potentially delay patient access to emergency intervention. Not all areas of the wards were well-maintained.
  • Environments did not support the patient group. Two of the five dementia wards did not provide patients with a dementia friendly environment. Most of the wards for patients with organic diagnoses had aspects that were not dementia friendly. Staff did not ensure that clocks and newspapers showed the correct date, there was a lack of pictorial signage or colour zoning on the wards. Staff did not encourage patients to personalise their bedrooms on two of the five dementia wards.
  • Staff illegally detained a patient on a ward for over 12 hours under Section 2 of the Mental Health Act 1983 while waiting for a Mental Health Act assessment for a Section 3. Not all wards held regular team meetings. On two wards there was a gap of four months between team meetings just prior to our inspection.

However:

  • Staff kept ward areas and clinic rooms clean and managed medicines safely and in line with trust policy. Staff had knowledge of patient risks, they completed comprehensive risk assessments and managers shared learning from incidents and implemented changes as a result. Staff knew how to protect patients from abuse and completed mandatory training.
  • Staff provided evidence-based care and followed guidelines and legislation. There was evidence of assessment and ongoing physical health care monitoring of patients. Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. The team included and had access to the full range of specialists required to meet the needs of patients on the ward. Staff used technology to support patients effectively. There was a multidisciplinary collaborative approach to care and treatment. Staff collaboratively offered a range of activities for patients and identified patient interests. Care plans, particularly on the wards for patients with a functional diagnosis, were comprehensive, holistic and recovery-oriented. Discharge, transfer and transitions to other services were planned in advance and involved holistic assessment of people’s ongoing needs. Staff had a good understanding of the Mental Capacity Act and the five statutory principles and had applied for Deprivation of Liberty Safeguards in a timely way. Staff were appropriately qualified, competent and received regular supervision.
  • Staff treated patients and carers with dignity and respect. Patients felt supported, safe and well-cared for as a result. Carers were kept informed of changes to treatment and were happy with the care their relatives received. Patients spoke highly of the choice, quality and portion size of food on the ward. Staff sought patient feedback in a variety of ways and put changes in place as a result. We observed that staff knew the individual patients and their needs, and that staff took steps to meet their needs.
  • Staff knew who the senior managers were and told us that their service managers and modern matrons were visible. Staff felt supported and valued, they told us they enjoyed their work. We saw that there was a culture on the wards that was patient focussed, multidisciplinary staff had a good understanding of the service they provided. There was a clear framework to ensure staff had access to essential information, such as learning from incidents and complaints. There was evidence of continuous learning and improvement.

Specialist mental health services – substance misuse

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

  • Staff recorded an incident when a client died, but there was delays in reviewing deaths and identifying lessons learnt. Between May 2018 – May 2019 staff recorded 33 deaths system for patients that died whilst accessing the service or that accessed the service in the past. Of these, 12 were accessing the service at the time of their death. Staff had not reviewed 52% of client deaths to identify any immediate learning.
  • The emergency equipment available at South Essex STaRS was limited and did not match the equipment found at other sites.
  • Staff from partner agencies used different IT systems and paper systems alongside the trust IT system, meaning it was hard to see chronologically which appointments the client had attended and the outcomes of them. It was not made clear within the recording system used by the trust if clients were seen as joint appointments with partner agencies.
  • All services opened until 7pm on a Tuesday, meaning that clients did not have the opportunity to attend later evening appointments or later appointments on any other day during the week.
  • Staff told us that above local leader level they had not been visited by the senior management team. Staff felt disconnected from the trusts senior leaders.
  • Staff did not describe how they supported clients in line with the national recovery agenda. One staff member described recovery capital and staff did not refer to how they discussed reduction of medication with clients.

However:

  • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each client’s physical health. The service offered additional physical health clinics for patients with complex needs and offered take-home naloxone and blood borne virus testing to all clients.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team.
  • Managers supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff.
  • Managers conducted local audits of their services and acted on the findings of these audits.
  • Staff treated clients with compassion and kindness. They supported clients to understand and manage their treatment and sought client’s feedback on the quality of care provided. Clients were involved in setting their prescribing goals at their clinical assessment and during clinical reviews. Staff made clients aware of harm minimisation and the risks of continued substance misuse.
  • Teams held daily clinics for clients who had missed their appointment and the service offered satellite clinics so that patients did not have to travel long distances to attend reviews.
  • The design, layout, and furnishings of treatment rooms supported clients’ treatment, privacy and dignity. Clients could access hot and cold drinks and snacks whilst waiting for appointments.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team.
  • Hub managers had the skills and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for staff. Staff felt respected, supported and valued by hub managers. They reported that the trust promoted and provided opportunities for career progression.
Checks on specific services

Wards for people with a learning disability or autism

Good

Updated 26 July 2018

We rated wards for people with a learning disability or autism it as good because:

  • The trust had refurbished the physical environment of the ward to a high standard. Furniture was sturdy and suitable for patients who had behaviours that challenged. The trust had reduced ligature risks and staff mitigated these by observations. The clinic room was clean and tidy; medicines were well organised and staff prescribing practices were good.
  • The service had reviewed and increased staffing levels to ensure there were enough staff to support patients safely. Staffing in the month prior to the inspection matched these identified levels. Staff had regular one to one time with their nurse and for identified therapies, participated in regular group activities and had regular time away from the ward.
  • Staff received regular training, appraisal and supervision; staff said that managers supported them well and made them feel valued. Managers debriefed staff after incidents, ensured regular team meetings took place to discuss issues, learn lessons from incidents and discuss patients’ treatment. Morale was high and staff were proud of the team and were passionate about providing high quality care.
  • Staff undertook assessments and care plans in a timely manner. Staff completed detailed physical healthcare assessments and staff supported patient’s physical health issues throughout their stay. Staff gave positive behaviour support plans to patients, which were detailed and person centred and identified positive strategies to reduce patients’ challenging behaviours and helped them gain insight and positive coping strategies. Handovers reinforced these plans by repeating positive strategies to ensure staff were familiar with them and knew how best to support patients. Staff used positive behavioural support plans to help reduce physical interventions.
  • Staff involved patients in care planning and asked patients how they wanted staff to support them. Staff encouraged patients to participate in daily ward meetings and monthly patients’ forum meetings. They enabled patients to lead meetings and to take the minutes. Patients used these meetings to request changes and received feedback from previous meetings.
  • Patients undertook a wide variety of activities, including individual and group sessions away from the ward. Patients chose items and activities for their activity box which they accessed at any time to occupy their time and to calm them when they felt distressed.
  • The service worked closely with other agencies. Staff worked with the community learning disability team adjacent to the ward to ensure high quality transition plans were in place for patients moving from children’s to adult services. Staff reviewed positive behaviour support plans on discharge and worked closely with their community colleagues to enable patients to move back into community placements positively.
  • Patients and carers told us that staff were caring, kind and polite. We observed staff speaking to patients in a positive and caring manner.
  • Staff used accessible communication methods with patients. This included one to one discussions, signs, symbols and pictorial resources. Staff had produced documents covering a range of issues in easy read format and made great efforts to aid patient understanding.
  • The ward manager and multidisciplinary team had driven significant changes to the service. Managers ensured systems were in place to monitor the performance of the team and take action when needed. Managers encouraged staff to participate in service development and were well informed about changes. Leadership was strong and the ward manager worked closely with staff to enable them to make changes effectively.

However:

  • There were a number of out-of-date dressings, glucose test strips and sterile tubes and strips in the clinic room. There was also one out-of-date medication in the fridge. Managers had not put a system in place to check these items to ensure that they staff replaced them when they reached their expiry date.
  • The service used the female-only lounge on some occasions to support a male patient who needed a quiet environment.
  • Clinical supervision, where staff could reflect on their practice, took place during supervision with managers. Registered staff did not meet separately with a clinical supervisor of their choosing. This was not required by Trust policy.
  • Patients did not understand the role of the independent advocate.
  • Bed occupancy rates were often in excess of 100%, above the 85% recommended for acute wards by the Royal College of Psychiatrists.

Child and adolescent mental health wards

Inadequate

Updated 15 September 2021

We carried out this unannounced focused inspection following the notification of a serious incident on one of the wards and we received information of concern about the safety and quality of the services.

We inspected all three wards of the children and adolescent mental health service; Larkwood ward, Longview ward and Poplar unit.

Due to the serious nature of the concerns we found during this inspection, we used our powers under section 31 of the Health and Social Care Act 2008 to take urgent enforcement action and imposed conditions on the provider’s registration. This included a condition to restrict the provider from admitting any new patients without the prior written agreement of the Care Quality Commission and a condition to staff all three wards with the required numbers of suitably skilled staff to meet the patient’s needs and to undertake patient observations as prescribed.

We did not rate all key questions of this core service, however, our ratings of safe, caring and well-led went down because:

  • The service did not have enough nursing and support staff to keep patients safe. Staffing establishments were not regularly reviewed in response to current patient need. Managers did not accurately calculate and review the number and grade of nurses and healthcare assistants for each shift. The service did not have enough staff on each shift to carry out any physical interventions (for example, restraint) safely and complete patient observations.
  • Bank and agency staff use was high, and managers were not assured as to the skills and experience of agency staff. The lack of regular and familiar staff impacted on the quality of patient care. Staff did not always understand the needs of the patients. We saw evidence where unfamiliar staff did not always understand the needs of the patients they were caring for.
  • Staff missed opportunities to prevent or minimise harm and did not always act to prevent or reduce risks. Staff did not always follow the trust policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk of harm to themselves or others.
  • Staff did not always have the correct items of clothing to respond to risks posed by patients on Larkwood ward and Longview ward.
  • Staff were not always responsive to patient needs. There was a lack of suitable tear proof clothing on both Larkwood ward and Longview ward.
  • Staff did not always report incidents clearly and in line with trust policy. Lessons learned were not always completed in incident forms or shared effectively across wards.
  • Not all leaders had the skills, knowledge and experience to perform their roles. Not all ward leaders had a good understanding of the services they managed. Governance processes did not operate effectively at team level and that risks were not always managed well. Managers were reactive in responding to risk.

However:

  • Ward areas were clean, well maintained and well furnished. Staff knew about any potential ligature anchor points and mitigated the risks. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff reviewed risk assessments and positive behaviour support plans; where patients had them, regularly. Staff involved patients and gave them access to their care planning and risk assessments. Staff made sure patients understood their care and treatment. Staff involved patients in decisions about the service, when appropriate
  • Patients had access to areas such as de-escalation and chill out rooms.

We undertook a focused inspection of this service. For this inspection, we reviewed all of the safe, caring and well led key questions and parts of the effective and responsive key questions.

Essex Partnership University NHS Foundation Trust provide community health, mental health and learning disability services for a population of approximately 1.3 million people across Bedfordshire, Essex, Suffolk and Luton.

Essex Partnership University NHS Foundation Trust provides child and adolescent mental health in patient services to young people and their families living across the country where a community setting would not be a safe or appropriate place for the young person’s treatment. The child and adolescent mental health inpatient service consists of three wards located across two sites at the St Aubyn Centre, Colchester and Rochford Hospital.

The St Aubyn Centre accommodates Larkwood ward and Longview ward. Larkwood ward is a ten bedded, mixed sex, locked psychiatric intensive care unit. It provides acute and intensive psychiatric care and treatment for young people between the ages of 13 and 18, who are experiencing acute, complex and / or severe mental health problems.

At the time of inspection there were seven patients on the ward, all the patients were detained under the Mental Health Act.

Longview ward is a 15 bedded, general psychiatric mixed sex ward, providing inpatient assessment and treatment for young people aged 13 to 18 years. At the time of our inspection there were 13 patients on the ward, seven of whom were detained under the Mental Health Act.

Rochford Hospital accommodates Poplar ward, a 13 bedded general psychiatric, mixed sex ward providing inpatient assessment and treatment for young people aged 11 to 18 years. At the time of our inspection there were 12 patients. All three wards had education facilities on site, providing education and vocational opportunities in line with the national curriculum.

CQC have registered this service for the following regulated activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983.
  • Treatment of disease, disorder or injury.

The inspection team visited all three wards between 11 May and 19 May 2021 and completed further off-site inspection activity until 07 June 2021. During the inspection we:

  • Visited the service and observed how staff cared for patients
  • Toured the clinical environment
  • Spoke with four patients that were using the service
  • Interviewed 21 staff and managers
  • Spoke with five carers
  • Observed two multidisciplinary meetings, one care programme approach meeting and two community meetings
  • Reviewed 14 patient care records relating to physical health
  • Reviewed 21 prescription charts
  • Reviewed policies and procedures relevant to the running of the service.

What people who use the service say

All patients we spoke with told us they felt uncomfortable with unfamiliar staff and it made it hard to build therapeutic relationships.

A patient told us they felt exposed as they were not wearing appropriately sized tear proof clothing.

Patients told us there was not enough activities after school. Patients told us they would ask staff for items such as the television or computer remote control, but staff would tell them to wait and then staff forget.

Carers told us that incidents often happen due to the bank and agency staff not having sufficient knowledge of the patient’s and their risks and whilst the patient was being observed on enhanced observations. Carers told us staff do not always understand the patients complex needs.

Carers told us that their relative had had their activities and escorted leave cancelled due to staffing issues.

Not all carers felt staff kept them informed of their relatives care. However, carers stated that their relative was involved in their review meetings and that they got to share their views on their care and treatment.

However, all carers stated that their relative was involved in their review meetings and that they got to share their views on their care and treatment.

Carers told us their relative had a positive behaviour support plan that staff should follow when their relative was in crisis.

Patients, relatives and carers knew how to complain or raise concerns. All carers we spoke with said that they had not had to make a formal complaint. Two carers said that they had made informal complaints to nursing staff and that these were dealt with appropriately.

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

Requires improvement

Updated 14 January 2021

Community end of life care

Outstanding

Updated 9 October 2019

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

The summary for this service appears in the overall summary of this report.

Substance misuse services

Requires improvement

Updated 9 October 2019

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

The summary for this service appears in the Overall Summary of this report.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 9 October 2019

Our rating of this service improved. We rated it as good.

The summary for this service appears in the overall summary of this report.

Wards for older people with mental health problems

Requires improvement

Updated 9 October 2019

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

The summary for this service appears in the Overall Summary of this report.

Community health inpatient services

Good

Updated 26 July 2018

We rated community health inpatient as good because:

  • Patient safety was prioritised, which was reflected in the running of the service.
  • Care and treatment was delivered effectively by competent staff.
  • Patients were involved in their care, and were shown compassion by the staff working with them.
  • The service was planned based on the needs of local people, and new initiatives were set up to improve the service.
  • There was an open and transparent culture with engaged and experienced leadership.

Mental health crisis services and health-based places of safety

Good

Updated 26 July 2018

We rated mental health crisis services and health based places of safety as good because:

  • Staffing was sufficient to meet need and managers could bring in additional staff when needed. New staff received a trust induction and a team induction which involved shadowing experienced staff. Staff received mandatory training and compliance was 81%, with some staff on long term leave so not available. Managers monitored training through monthly reports and discussed at team meetings. Staff knew about safeguarding and considered this as part of their multidisciplinary meetings. Staff received supervision and annual appraisals. Staff accessed specific training when needed.
  • The environment for the health based places of safety was safe, clean and ensured clear sight for observation. Staff managed medicines well and kept accurate records of medicines used. Ligature assessments were up to date and accurate, apart from the Lakes.
  • Staff identified and managed risk well using a red amber green rating and zoning for caseload management. Staff were patient focused and respectful whilst managing risk. There was a robust incident reporting system and staff knew how and what to report. Apart from the Linden crisis team, managers shared lessons from incidents in team meetings.
  • Staff kept records up to date and overall the records were detailed and person centred. Staff discussed mental capacity at the multidisciplinary meetings and handover and documented patients’ capacity. There was the expected range of professionals in the team and managers were recruiting to the vacancies in psychology, social work and occupational therapy.
  • Patients and carers said they felt involved in their treatment.
  • The section 136 (health based place of safety) policy had been updated to comply with the Policing and Crime Act 2017.
  • Targets for seeing patients within four hours of referral were met consistently. Staff in the health based place of safety at Rochford demonstrated responsiveness to patients and their family. For example, they provided some clothes to enable a patient to have a shower and they washed the patient’s own clothes to give them as soon as they were dried, they charged the patient’s mobile phone so they could keep in touch with family and facilitated a relative to visit a patient in the health based place of safety.
  • Leadership was strong and staff said they felt supported and could raise any concerns if needed. Managers received monthly reports which they used to monitor the service and staff performance. They acted when required to deal with any issues.

However:

  • At the health based place of safety in the Lakes and Linden Centre there was closed circuit television in place with no signs telling people this was the case. The ligature assessment for the Lakes health based place of safety was incorrect. The hot spot map was of another area. The author of the ligature assessment had described the furniture incorrectly as too heavy to throw when the furniture could be lifted and thrown. There were also electric sockets in the room which had not been identified as a risk. These posed a potential risk to patients and staff.
  • The handover at Linden and the Lakes was not documented.
  • Crisis plans lacked detail about what a patient should do in a crisis. There were gaps in some records at the Linden team. At the Lakes, the records were not scanned onto the system from the health based place of safety.
  • There was an identified need for more approved mental health professionals (AMHPs). The approved mental health professional lead was monitoring access to AMHPs for Mental Health Act assessments and was encouraging more staff to train to fill the gap. Despite the shortage any delay in accessing an AMHP was never more than one or two days, according to staff and the AMHP lead.
  • Caseloads for the teams could reach more than 32 in which case the situation was escalated. The caseload at the Lakes was 47 at the time of our inspection and had been escalated.
  • Teams were unsure of the plans for teams across the area since the merger of the two trusts. They were unsure what the plans were for changing the assessment process, home treatment and whether it would be standardised across the trust. There was little evidence of working across the north and south of the area. There was a crisis response and home treatment steering group which staff from the north had only recently started attending.

Community-based mental health services for older people

Good

Updated 26 July 2018

We rated Community-based mental health services for older people as good because:

  • Overall, staffing levels were good. The trust determined staffing levels across the service and the number and grade of members of the multidisciplinary team required at each service. Overall, staffing levels were sufficient to meet the needs of the patients. Repeat appointments were held at appropriate intervals and were rarely cancelled.
  • Staff could get access to psychiatrists for patients if urgently required. Staff responded promptly if they identified deterioration in a patient’s health and staff could refer to dementia review support teams, or to dementia intensive/crisis support teams.
  • Staff monitored patients on waiting lists to detect and respond to increases in levels of risk. Staff used a red, amber and green traffic light system to highlight patient’s risk levels.
  • Staff provided a range of care and treatments to patients. Staff held wellbeing groups for carers and patients. Kingswood Centre held a weekly dementia café in the community for patients, carers and members of the public interested to learn more about dementia. Patients were provided with information and support with employment, housing, benefits and interventions that enable patients to acquire living skills.
  • We observed effective working relationships with other teams in the organisations. A newly funded role for care liaison looked to diagnose patients in care homes with dementia, and to support hospitals to prevent unnecessary admission to inpatient wards.
  • Staff involved patients in care planning and risk assessment. At Brentwood and Basildon teams staff used ‘my care and my support’ plans with patients to gain the patient’s view of their needs. Examples of patient and carer involvement across the services included inviting patients and carers to care plan approach reviews. Staff knew patients’ needs and responded in a timely way.
  • The buildings that accommodated the teams were clean, except one for one area that was dusty. They had good furnishings and were generally well maintained throughout. The trust had systems for cleaning, and adhered to control of substances hazardous to health guidelines. Staff followed infection control principles, including hand washing.
  • Managers completed environmental risk assessments, including ligature risk assessments, except one. Patients were not left unattended in any of the rooms at all services. Staff had access to alarms when using interview rooms and staff were on site to respond to alarms.

However:

  • There was a lack of oversight by managers and the wider trust in the managing of medicines and equipment on the older people’s mental health community services. Staff at the Basildon team had not checked and disposed of out of date medication. We found that four types of medication had expired, including four depot injections. This posed a risk that medication would not be effective for patients.
  • We found some equipment had passed its use-by date in teams posing a risk that it would not be effective if staff used it with patients. For example, at the Harland team there were electrocardiogram pads which had expired in 2008. At Thurrock the blood pressure cuff and blood glucose strips had expired. The blood glucometer had no calibration date.
  • Staff had not assessed ligature risks at Brentwood, which meant risks to patients had not been identified or mitigated.
  • Across teams, patient care records were limited in information and detail. Three patient records reviewed had no care plan.
  • Staff across teams did not have a consistent approach for completing physical health annual reviews and checks and records were difficult to find.

Community mental health services with learning disabilities or autism

Good

Updated 26 July 2018

We rated community mental health services for people with a learning disability or autism as good because:

  • Staff completed comprehensive assessments of risk that they updated when risk to patients changed. Staff ensured that if a patient suffered a crisis, there was a plan in place for the patient and carers to follow to reduce risk. Staff monitored patients on waiting lists and allocated patients according to priority of risk.
  • Staff completed mandatory training and teams met the trust target for this. Managers provided regular supervision and yearly appraisals of staff’s performance. Staff had access to a trust wide leadership and development programme to increase their skills and support career development.
  • Staff knew how to report incidents and what to report. Staff were trained in safeguarding and knew how to make a safeguarding referral.
  • Care records were personalised. There was evidence that patients were given pictorial and easy read care plans. Staff made records of physical health assessments in the patient notes and kept GPs informed of care plans.
  • We saw evidence of mental capacity assessments and best interest meetings had been held where necessary.
  • Staff were caring and passionate about the care they provided. Patients we spoke with told us they were pleased with the service that they received. Carers told us the team went above and beyond to support their relative. Staff were inclusive of patients’ needs and those in the children’s service involved parents and children in the care planning and risk assessment process.
  • Staff provided a rapid response to support patients who experienced sudden to deterioration in physical or mental health. Carers told us that if they called the adult’s community learning disability team, they would get a response back the same day.
  • There was evidence of parents evaluating the children’s learning disability service provision at the exit interview when children were discharged.
  • Staff received feedback from complaints at team meetings and supervision.
  • Manager’s had an open-door policy and aside from this there was a two hour protected time slot twice per month where staff could meet with the associate director and raise any issues.
  • Service users were involved in recruitment.

However:

  • There was no medical cover outside the hours of 9am to 5pm for this core service. Patients care plans instructed them to telephone the police or attend local accident and emergency departments if their safety was in danger.
  • There continued to be long waits for psychology and Asperger’s assessment and treatment.

Community health services for adults

Good

Updated 26 July 2018

We rated community health services for adults as good because:

  • The service managed patient safety incidents well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service planned for emergencies and staff understood their roles if one should happen.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • The service provided care and treatment based on national guidance and evidence of effectiveness. The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff of different kinds worked together as a team to benefit patients.
  • Staff understood their roles and responsibilities under the Mental Capacity Act 2005.
  • Staff cared for patients with compassion, involving patients and those close to them in decisions about their care and treatment. Staff provided emotional support to patients to minimise their distress.
  • The trust planned and provided services in a way that met the needs of local people. The service took account of patients’ individual needs. People could access the service when they needed it. Response times and waiting times were monitored and senior staff took action to improve access to the service.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action, developed with involvement from staff, patients, and key groups representing the local community.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers across the trust promoted a positive culture that supported and valued staff.
  • The trust had a systematic approach to continually improve quality and safeguard high standards of care and treatment by creating an environment in which excellence in clinical care would flourish.
  • The service had effective systems for identifying risks and planning to eliminate or reduce them. The trust collected, analysed, managed and used information well to support all of its activities, using secure electronic systems with security safeguards.
  • The trust engaged well with patients, staff and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.

However:

  • Staff had not always completed mandatory training provided, to the trust’s target.
  • Equipment was kept on the floors of large storage cupboards, which reduced effective cleaning of these areas to prevent healthcare associated infections.
  • Patient records did not demonstrate that all patients received timely risk assessments such as malnutrition universal screening tool and Waterlow risk assessment.
  • Records provided by the trust showed compliance with staff appraisal did not meet the trust’s target of 90%.

Community health services for children, young people and families

Good

Updated 26 July 2018

We rated community health services for children and young people as good because:

  • Staff kept children and young people safe from harm and abuse. Staff understood and followed procedures to protect all children and young people including those that were vulnerable. Staff assessed and monitored individual patient risk.
  • Staff had appropriate skills, knowledge and experience to deliver effective care and treatment. There was effective multidisciplinary working across the service and care was delivered in line with national and best practice guidelines. Staff planned and delivered services to meet individual needs.
  • Staff cared for children, young people and families with compassion, dignity and respect. Staff involved patients and carers in decisions and their care and treatment.
  • There was a strong, visible person-centred culture and staff are highly motivated and inspired to deliver care that is kind and promotes children and young people’s dignity. Parents and children we spoke with valued their relationships with the team and felt that staff often went the ‘extra mile’.
  • Staff supported the children and young people to minimise their distress.
  • Complaints were effectively managed and the outcomes used to improve the quality of the service.
  • The service had governance frameworks, risk management plans and quality monitoring systems in place to improve patient care, safety and outcomes.
  • There was a systematic programme of clinical audits across the service to reassure senior staff of the safety of the service.
  • There was a child friendly patient satisfaction survey to provide feedback.
  • Staff were given opportunities for further learning and development. Several staff members described how they had developed and progressed within the organisation. Managers spoke of succession planning.

Forensic inpatient or secure wards

Good

Updated 26 July 2018

Our inspection was announced (staff knew we were coming) to ensure that everyone we needed to talk to was available. Before the inspection visit we reviewed information that we held about these services and information requested from the trust.

Between 1 and 3 May 2018 the inspection team visited all seven forensic wards in Essex. We inspected the two forensic wards in Bedfordshire on 15 and 16 May. During both visits the inspection team:

  • visited all nine wards and looked at the quality of the ward environment and observed how staff were caring for patients
  • spoke with 51 patients who were using the service
  • spoke with seven carers of people who were using the service
  • interviewed the managers for each of the wards and one senior manager
  • spoke with 62 staff members; including nurses, doctors and an occupational therapist
  • attended and observed two handover meetings and five multidisciplinary clinical meetings
  • looked at 46 care and treatment records of patients
  • carried out a specific check of 110 medication charts
  • Looked at a range of policies, procedures and other documents relating to the running of the service.

We rated Forensic inpatient or secure wards as good because:

  • Staff completed individual patient risk assessments. They only searched patients who they had assessed as posing a high risk. Staff locked some rooms when not in use and maintained a presence in patient areas.
  • Ward areas were visibly clean, had good furnishings and were well maintained. Staff had access to protective personal equipment, such as gloves and aprons in accordance with infection control practice. Posters advising staff of the principles of effective handwashing techniques were on display on all wards. Wards had fully equipped clinic rooms with examination couches and accessible resuscitation equipment, which staff checked regularly. Staff maintained equipment; stickers were in place specifying when it had been cleaned.
  • Managers calculated the number of staff required to cover shifts, the staffing rotas showed there was the appropriate number of staff on each shift. Ward managers reported that they could adjust staffing levels to take account of increased clinical need. The number of nurses and healthcare assistants matched this number on all shifts. The ward manager could adjust staffing levels daily to take account of case mix.
  • Staff identified and managed specific risk issues and gave examples where they provided specialist equipment to meet the needs of a patient who was terminally ill to prevent pressure sores. Staff identified and recorded changing risks on the risk assessment form in the electronic care record. Staff had access to ligature cutters in all areas in the event of an emergency occurring.
  • Staff followed National Institute for Health and Care Excellence guidelines in relation to practice and when prescribing medications. These included regular reviews and physical health monitoring. Staff described applicable NICE guidelines and how they used these with patients. Psychologists used a variety of treatments including offence based therapy and an offending behaviour groups.
  • Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw staff responding to patient's needs in a discreet and respectful manner. Staff treated patients with dignity and supported them to engage in a variety of meaningful activities, including education and employment. Staff interacted with patients in a timely way and at a level that was appropriate to individual needs.
  • Patients had their own bedrooms, they could personalise these, for example with artwork and photographs. Patients stored their possessions in lockers adjacent to their bedroom. Wards had sufficient rooms for patients to access 1-1 time with nursing staff, to receive visitors or to participate in ward based activities.
  • Wards had information boards detailing the staff on duty and staffing levels. These informed patients of the staff available for care and treatment for that day. Managers and staff facilitated weekly community meetings, these allowed patients to raise concerns and provide feedback about the wards. The minutes of the meetings showed that actions taken following the meetings, for example purchasing games and equipment for patients to use. Patients told us they had met with senior leaders when they visited the wards.

However:

  • The kitchen fridge on Dune and Alpine wards and at Edward House contained open items of food. However, labels were not in place indicating when the food had been opened and when it should have been consumed by.
  • Staff told us that one patient on Alpine ward was being cared for under the trust long term segregation policy and at times the patient also required periods of seclusion. We reviewed the records and found staff had not implemented the appropriate trust documentation when seclusion commenced. Staff had not completed the checks required for secluded patients under the Mental Health Act Code of Practice.
  • We reviewed two seclusion records at the Robin Pinto unit. We found gaps in the recording of two hourly nursing and four hourly medical reviews. We also found that one patient had not had a medical review for 11 hours which is not in line with the Mental Health Act Code of Practice.

Community-based mental health services for adults of working age

Good

Updated 26 July 2018

We rated community-based mental health services for adults of working age as good because:

  • Staff followed best practice clinical guidelines. They undertook ongoing physical health check clinics and staff were trained to do so. Managers ensured that nursing staff had undertaken training in physical health. This included training in phlebotomy, which enabled staff to take patient blood for testing when required. Staff provided a range of care and treatment interventions suitable for the patient group in line with guidance from the National Institute for Health and Care Excellence. Several innovations were in place across the service.
  • Staff undertook annual audits of the environment to assess for potential ligature points. They had acted to mitigate the identified risks and communicated these actions to staff. Staff had access to lone worker tracking devices and there were appropriate alarms in case of an incident.
  • Staff managed risks to patients well and ensured that patients did not wait too long for assessment and treatment. Patients had risk assessments in place, which had been regularly updated. Most staff dealt with any specific risk issues as they arose. A robust procedure was in place for responding to patients who did not attend planned appointments. There were no waiting lists for psychological therapies once a patient had commenced treatment. Emergency referrals were responded to within one to two days of receipt of referral.
  • The majority of patient care plans were personalised, holistic and recovery-focused. Staff supported patients to understand and manage their care plan, and manage their care and treatment. Staff ensured that patients had access to education and work opportunities. Staff attitudes and behaviours when interacting with patients showed that they were discreet, respectful and responsive. Patients identified several staff who had gone the extra mile. Staff knew how to handle complaints appropriately and there was oversight of complaints and concerns by each team manager.
  • Staff in all teams held regular and effective multidisciplinary meetings and shared information about patients at team meetings. There were some good examples of joint working arrangements with general practitioners.
  • Leaders had the skills, knowledge and experience to perform their roles. Staff told us that their team leaders supported them and that the service was being well managed. Leaders in Brentwood and Basildon had supported clinical staff by allocating staff with protected days for administration.
  • Staff felt respected, supported and valued by their team leaders and felt that they had authority to undertake their role. Staff felt able to raise concerns without fear of retribution. Staff and leaders did not report any examples of bullying or harassment within teams.

However:

  • Risk management plans for five patients in Canvey Island and Basildon, did not contain crisis and contingency plans. Of the forty care plans inspected, five were not personalised, six were not holistic and nine were not recovery focused.
  • Over a third of staff reported that information systems were poor and time consuming. Managers had developed improvement plans which were in place, however the electronic health record remained difficult to navigate.
  • We found a box of medications which were out of date. There was a week’s gap in the recording of medication fridge temperatures in the Linden centre, Chelmsford and the Taylor centre Southend.
  • The level of patient involvement was limited and could be improved.
  • Managers above team level did not visit the clinical areas often. This meant staff did not know them well. Managers did hold meet and greet events which staff could attend. Staff had not had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.