Updated 12 July 2023
We inspected Essex Partnership University NHS Foundation Trust (EPUT) because we received information and had concerns about the safety and quality of services.
We carried out an unannounced comprehensive inspection of 6 core services:
- Wards for people with a learning disability or autism
- Acute wards for adults of working age and psychiatric intensive care units
- Mental health crisis services and health-based places of safety
- Wards for older people with mental health problems
- Substance misuse services
- Community-based mental health services for adults of working age
We also inspected the well-led key question for the trust overall.
We chose to inspect acute wards for adults of working age and psychiatric intensive care units to see how many improvements had been made following our inspection in October 2022 where we rated the safe domain as inadequate and issued a warning notice. We chose to inspect 3 core services based on their ratings at comprehensive inspections in 2018 and 2019 to see if the trust had made improvements to quality and safety. We chose 2 core services that were rated as good in 2018 to check if the trust had sustained the quality of care delivered.
The trust provides the following mental health services, which we did not inspect this time:
- Child and adolescent mental health wards
- Community mental health services for people with learning disabilities or autism
- Community-based mental health services for older people
- Forensic / secure wards
- Long stay/rehabilitation mental health wards for working age adults
- The trust provides community health services, which we did not inspect this time:
- The trust delivers the following community health services:
- End of life care
- Children and young people’s services
- Inpatient services
- Adult services
Our rating of services went down. We rated them as requires improvement because:
- We rated safe, effective, responsive and well-led as requires improvement. We reduced the overall rating for caring from outstanding to good because this is a more accurate reflection of how the trust are currently performing overall. Our overall rating considered the current ratings of the 5 mental health core services and 4 community health core services we did not inspect at this time.
- The governance and safety culture of the trust did not always support the delivery of high quality, person centred care. Issues with timeliness in responding to lessons and inaccurate data impacted staff's ability to support people appropriately. Three core services had declined in their quality. Wards for people with a learning disability or autism and community based mental health services for adults of working age went from good to requires improvement and acute wards for adults of working age and psychiatric intensive care units went from requires improvement to inadequate. Two core services – wards for older people with mental health problems and mental health crisis services and health based places of safety had remained requires improvement overall. One of the 6 core services we inspected had improved from requires improvement to good overall: substance misuse services. The trust had plans or had recently launched new strategies to address key safety concerns for example around staffing vacancies and patient safety observation, but many were very new and not yet embedded.
- Across the 6 core services we rated 30 domains associated with the key questions. In 9 examples there was an overall reduction from good to requires improvement. In one example there was a reduction from requires improvement to inadequate. In 1 examples ratings remained the same. In 3 examples domains had improved from requires improvement to good and in 1 example the safe domain improved from inadequate to requires improvement.
- The most concerning ratings were for acute wards of adults of working age and psychiatric intensive care units. We rated safe and well led as inadequate, the other domains as requires improvement which means this service is still inadequate overall. The trust failed to ensure that all the concerns highlighted in the warning notice issued in October 2022 had been achieved consistently across all wards. For example, on some wards staff still applied blanket restrictions. Examples included searching all patients returning to wards and preventing patients from accessing fresh air freely.
- There remained ongoing challenges with staffing wards consistently and we identified problems with staff completing patient observations safely and in line with trust policies. The rating for safe had remained inadequate, the same rating applied during the inspection in October 2022. CQC recognised Trust wide plans to address issues such as staffing. However, several aspects of these plans were not fully implemented embedded to impact care on all the wards yet.
- We also saw a reduction in the quality of care staff provided in wards for people with a learning disability or autism and community based mental health services for adults of working age. Both services overall ratings had reduced from good to requires improvement.
- Whilst there were still improvements required across a number of core services and leadership did not always support the delivery of improvement at pace, the trust recognised this and were in the early stages of implementing various programmes and processes which would drive the quality of care up. The leadership team had been increased to support executives in driving quality improvement. The CQC reflected the need to ensure pace and priority for this work and the trust agreed and committed to this.
Our inspection identified the following areas where further improvement was needed:
- The arrangements for governance, assurance and performance management did not operate effectively. The CQC recognised the timing of the inspection meant there were multiple examples of new strategies, systems, roles and approaches that were in the early stages of implementation. Examples included the trust safety strategy, the appointment of directors of quality and safety and the implementation of ‘Time to Care’ and safety dashboards. All of these required further embedding to directly impact the quality of care people received. The pace of change remained a concern along with ongoing and repeated breaches of regulation identified in services that had been highlighted to the trust during previous inspections dating back to 2019.
- The approach to service delivery and improvement was reactive and the trust were in the early stages of implementing more robust assurance arrangements to support a proactive response to improvement. There remained work to be done to ensure quality improvement initiatives were present in services and making an impact on the services people received.
- Staffing remained a challenge. Bank and agency use was higher than the trust targets. Managers described ways they attempted to book staff familiar with the wards and patients, but staff and patients told us unfamiliar staff were an issue, especially during evenings and weekends. Sickness was rated as ‘amber’ on the trust risk register at 6%. There were challenges in recruiting to roles, vacancy rates for qualified staff were 21%. We continued to find issues with how staff observed patients, with examples of staff sleeping and not interacting in a therapeutic way. However, it was recognised there were some early programmes of work which may have a positive impact in the future, such as the recruitment programme for internationally trained nurses.
- Data quality affected the trust’s ability to monitor and mitigate against poor performance, risk and poor quality. Data provided about key elements of service performance from executive level did not match with information we found at ward level. An example that supports this can be found in the report for acute wards for adults of working age and psychiatric intensive care units relating to supervision and appraisal data. There was a lack of pace relating to over 10 items reflected on the board assurance framework. From October 2022 – January 2023 there were 7 strategic and 8 corporate risk items that had shown no movement is their score. We identified issues with quality audits not highlighting gaps in the quality of care being provided, an example of this related to governance systems providing false assurance to the board about the quality of patient observations being delivered on wards. There were issues with inpatient services having low bed occupancy despite community teams having increased caseloads and waiting lists. An example of this was seen in acute wards for adults of working age and psychiatric intensive care units and community home treatment teams, this had not been robustly addressed by the trust.
- The trust were due to launch their new data strategy following the inspection to build on their digital strategy. This would provide focus on how best to utilise data to provide robust intelligence and information to improve patient outcomes. Electronic systems and data quality required attention and pace. The trust have been using 7 different electronic patient record systems since the merger in 2017 and 6 years later are in a position of having funding approved to develop and implement a single system for the trust. In August 2019 we highlighted to the trust issues with training data, performance data and staff difficulties with multiple electronic recording systems. However, the health information exchange (HIE) remained in place to support record sharing between teams.
- Medicines optimisation and management across the trust required improvement. Pharmacy workforce challenges affected the quality and sustainability of medicines services. Pharmacy teams operated with a 45% vacancy rate overall. Organisational restructures and reporting lines meant Pharmacy teams felt removed from operational decision making. There were issues with medicines management on wards and the capacity of Pharmacy teams to audit and offer support was compromised by staffing challenges. The trust continued to advertise Pharmacy roles but had trouble in recruiting.
- Leaders did not always support staff effectively. Supervision and appraisal rates did not consistently achieve the trusts target meaning not all staff had regular access to this support. Meetings and opportunities to share learning did not take place consistently and regularly. This applied at all levels in the trust and minimised lessons and learning influencing strategy and practice. Feedback from staff about their engagement with the trust varied greatly, some staffing groups felt disconnected and that leaders did not listen to or recognise their concerns, whilst other groups were mainly positive. Forty two percent of the focus groups expressed some level of concern regarding their ability to express concerns and engagement with the organisation.
- Long standing complaints required attention to ensure complainants received responses in good time and knew what was happening with their case. One example showed a complaint being made in August 2021, not resolved and the most recent contact recorded as April 2022. Whilst recognising the very recent implementation of a new complaints process, we were not assured that there was enough focus on resolving long standing complaints.
Our inspection identified a number of areas where improvements had taken place:
- There was a full recognition by the trust of the need to continually improve the culture of the organisation. The freedom to speak up guardian, although in an interim post, had worked hard to increase their visibility and share the importance of speaking up. Many of the staff we met during the inspection talked about the improvements in the workforce culture, although there were still pockets of poor morale, mainly due to staffing challenges and some issues identified via an internal inquiry following a television broadcast. The trust board displayed positive role modelling behaviours which they demonstrated throughout the well led review. The trust made sure learning featured at different levels in the organisation from the executive level learning sub- committee group through to learning newsletters displayed on wards and in services. Executives made themselves available to staff via ‘grills’ where staff could directly challenge leaders about their concerns or any issues. The trust appointed 500 engagement champions who could access the CEO directly, however there remained challenges with capturing the voice of staff working on inpatient wards. The trust set expectations about staff behaviour and developed a behaviour framework to outline clear boundaries about unacceptable behaviour and consequences for those behaviours. This was initially driven by the need to support staff who experienced racial abuse (identified at the CQC inspection in November 2022) but was not limited to this issue.
- The trust was actively involved work across the systems relevant to Essex. Three members of the executive team served 3 integrated care boards (ICB’s) relevant to the trust’s portfolio. The trust was part of four integrated care systems and were involved in 6 place based alliances. The trust also engaged with 3 local authorities which served different areas to those associated with the ICB’s. Trust leaders understood the need to design, plan and develop effective services to meet the needs of the local population. A priority for the board was to ensure that the trust faced outwards and developed a reputation of transparency and openness. The trust opened their committees to governors to increase challenge and accountability and support the work of the non-executive directors. Feedback from people was integral to planning and reviewing services. The patient experience team developed multiple ways for people to provide feedback on their experiences by working with local teams to understand what fitted their demographic. This included the use of text messages, quick response (QR) codes, paper ballot boxes and forms. The work on creating a variety of feedback methods contributed to an 800% increase in feedback from August 2022 – January 2023. Work was ongoing to ensure that patients and people who use service featured as a key stakeholder. The ‘your voice’ community provided challenge and feedback to the board and the trust launched ‘I want great care’ in January 2022. The patient experience annual review from November 2022 demonstrated positive results for involvement including 92% growth in the recruitment of volunteers (from 126 in 2021 to 243 in 2022) and a 720% growth in recruitment to the lived experience team (from 10 in 2021 to 82 in 2022).
- The trust participated in the early adoption of the patient safety incident response framework (PSIRF). This sets out the NHS’s approach to developing and maintain effective systems and processes for responding to patient safety incidents. The purpose is to develop a culture of learning to improve patient safety. The patient safety team engaged regularly with the national team to support the re-design of materials to improve their quality. The trust made a commitment to PSIRF despite the fact it was promoted as a cost neutral programme but has needed investment. Responses to patient safety incidents demonstrated compassion and answered all questions and concerns put forward by families and carers.
- The trust was the lead provider for the COVID-19 vaccination programme and was integral to ensuring people of Essex had access to this. They set up multiple vaccination sites quickly, delivered 1.6 million vaccinations and worked with local systems and partners to offer vaccinations to hard to reach and marginalised groups. The trust used creative ways to increase vaccination uptake such as vaccination busses and home visits.
How we carried out the inspection
Before the inspection visit, we reviewed information that we held about each of the core services.
During the inspection visits, we:
- Visited 29 wards, 17 teams and 4 health based places of safety
- Spoke to 224 staff performing a wide range of roles
- Spoke to 104 patients and 17 relatives or carers
- Looked at 182 individual patient records
- Looked at over 116 medication records
- Attended 29 meetings including staff handovers, multidisciplinary meetings and patient community meetings. We observed 5 examples of patient care by sitting and watching from patient areas.
- Attended 4 home visits
- Held 12 focus groups with staff of all grades on a variety of topics
- Looked at records, policies and procedures involved in the day to day operation of the services.
You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
What people who use the service say
We spoke to 104 patients and 17 relatives and carers across the services we inspected. Patients and carers gave largely positive feedback about the way staff treated them and the support they offered. Patients and carers gave examples of staff treating them as individuals and involving them in their care.
On acute wards for adults of working age and psychiatric intensive care units, most patients told us staff working day shifts treated them with kindness and helped them to be independent. Patients liked the choice of food and the fact they could have snacks and drinks throughout the day. On wards for people with a learning disabilities and/or autism people told us staff treated them with kindness and that staff provided activities that they enjoyed such as cycling and colouring. Staff supported carers to attend the ward for visits and clinical meetings and involved them in planning the care and discharge of their loved one. On the wards for older people with mental health problems patients told us that staff listened and helped them to understand their care. Patients felt safe, valued and respected.
In the community-based mental health services for adults of working age, patients and carers praised the staff for making sure everyone was involved in care decisions and that staff looked at physical and social needs alongside their mental health. They felt the service responded to their needs quickly and involved other services which could help. Patients liked the frequency of their appointments and the fact that there was a team approach so they could be seen by others if their worker was on leave or absent and didn’t have to repeat their care story. In the mental health crisis services and health-based places of safety, patients said staff treated them kindly and offered flexible appointments to meet their needs. Patients felt staff offered them opportunities to be involved in their care and did everything they could to provide care in the community and help people stay out of hospital. In substance misuse services, people felt staff had an excellent knowledge of substance misuse and this helped them feel supported. They described staff as being available when they needed them and making every effort to involve people in their care.
There were however some areas for improvement identified by people who used the services. On the acute wards for adults of working age and psychiatric intensive care units’ patients and carers described issues with staff working nights. This included 5 patients describing staff falling asleep at night, 3 patients told us that staff talked in different languages during night shifts and were ‘uncaring’. Four patients told us that staff observing them did not engage with them. One patient described issues with the food portions and 11 patients told us that the coffee was decaffeinated so staff could support them with good sleep hygiene. On wards for people with a learning disabilities and/or autism there had been an issue with a walk being cancelled due to staffing shortages and not all carers had a copy of their relative’s care plan.
In the community-based mental health services for adults of working age, some people told us they would like more definite goals and to see the Doctor more often for reviews.