Essex Partnership University NHS Foundation Trust

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.

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

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

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.

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

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

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

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

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.

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.

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.

We rated it as good because:

• The trust had addressed numerous issues highlighted to them from an inspection of inpatient services in November 2017. The trust had increased the pace of their work to improve patients safety and experience.
• We were impressed by the extent that the values of the trust have been embraced by everyone and were shown and modelled by all the staff we met. This was particularly important following the merger of the trust in April 2017. The trust values were embedded in the services we visited. Staff described the trust’s vision and values. Staff showed the values in their day-to-day work, showed kindness, respect and a caring attitude towards patients, carers, visitors and each other.
• Managers discussed the values with staff in supervision and appraisal and based their team objectives on these values. The trust had worked at pace to harmonise policies and procedures to support staff following the merger. Interviews for new staff were values based and there was a culture within the trust to challenge those directly who did not demonstrate the values.
• Senior staff saw leadership as fundamental to their role and we saw the trust embrace leadership values as being important at all levels of the organisation. Senior managers were very visible in core services and many members of staff told us that the board members were approachable, had visited their services and were willing to hear comments. Team leaders were visible and approachable. 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 trust had a robust governance framework and structure. Service managers attended local monthly clinical governance meetings, which fed into the trust wider governance meetings. Local governance meetings discussed ward issues, such as incidents, safeguarding, staffing concerns, and identified and shared learning from incidents. Managers fed this learning back to front line staff and patients through team meetings, supervision and learning lesson bulletins.
• Staff maintained a risk register at ward level. Staff could escalate concerns and submit items to the trust risk register. Senior trust staff reviewed the trust risk register and non-executive directors openly challenged issues, which the board welcomed. The trust has taken significant steps to improve patient experience following previous CQC inspections. The trust ensured that actions had been prioritised based on risk and we saw significant work had been undertaken in the children and adolescent inpatient services and the wards for people with a learning disability. This had dramatically improved the environments for patients.
• Leaders had oversight of safeguarding and incident reporting and shared lessons learnt. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Each service fed into the trusts governance meetings, which then led into board meetings.
• Compliance with mandatory training, supervision and appraisal was good. Managers supported all levels of staff to attend training relevant to their roles and develop their skills and knowledge and progress in their careers. Leaders encouraged staff to share learning and we saw numerous examples of in house teaching where staff shared knowledge and experience.
• Managers proactively engaged patients and carers at various forums and in service developments. The trust encouraged staff to submit ideas for service development and quality improvement.
• Despite some challenging geography, much had been done to ensure that trust leaders were visible and supported staff everywhere. The trust used technology to ensure teams based furthest away from the centre could take part in meetings and to keep up to date with developments. An example of this, was the use of video conferencing.
• Staff and leaders cared for and supported each other. The executive team worked well together and adopted a ‘no blame’ culture when things went wrong or there was a need for investigations to take place. Leaders at a local level ensured staff felt supported at all times. Local leaders provided debriefs and support to staff through supervision. Staff felt listened to and supported.
• Engagement and joint planning between departments was well developed. For example, the information management and technology department, and finance team brought projects to fruition. They ensured this worked directly for patient care by involving clinicians working directly with the patient groups.
• We heard about and saw many examples of innovative practice throughout the trust. This included the use of personalised activity boxes for patients, strong links with community services to support patients back into employment, virtual dementia tours for families and carers and media applications for young people to ask difficult questions. Staff were enabled to take actions to improve services and to make a difference. Leaders promoted an environment where staff felt able to suggest improvements and ways to better care for patients.
• The trust supported staff to work innovatively. Staff participated in working groups to improve services. We saw this within the work of the reducing restrictive interventions group. Staff and patients contributed to this work so people using services could experience the least restrictive environment whilst receiving care.

However:

• We were concerned by the lack of oversight and leadership in some services. This included end of life care and substance misuse services. We identified issues with governance systems and were not assured that the trust monitored services effectively. End of life services did not provide opportunities for patients, families and carers to provide feedback and did not give patients information about the service. Substance misuse services did not monitor unexpected deaths and did not ensure people were seen for medication reviews.
• The trust’s pace for implementing equality and diversity initiatives across the organisation needed improvement. This was particularly relevant to protected characteristics other than race. The trust supported a BAME network (black and minority ethnic) however, there were no other formal networks available.
• The trust’s system for the management of medicines was inconsistent. There were various examples of poor practice in relation to the rotation of stock, across the organisation.
• There remained inconsistencies in the assessment of environmental risks at some locations. This included the identification and mitigation of ligatures. However, it was evident that the trust had taken significant steps to address this issue. This included the removal of ligature anchor points and the introduction of ligature heat maps.
• Training compliance for services based in Luton and Bedford was poor. This was not helped by the recent closure of training facilities local to the service. Staff expressed concern at the distance and time to travel to training facilities in Essex.
• The implementation of positive behavioural support for patients with a learning disability lacked pace in Bedford services.
• Older adult wards deprived people of their liberty without the appropriate safeguards in place. There were delays in deprivation of liberty applications, best interest decision assessments and capacity assessments.

We rated child and adolescent mental health wards as good because:

• On all wards, staff followed hand hygiene practices. Clinic rooms were clean, tidy and well managed. Staff followed prescribing practises which met national guidance and best practise. Staff completed thorough and detailed physical healthcare risk assessments of patients
• Wards had minimal vacancies and staff retention was good. At the time of inspection supervision rates for non-medical staff were, Larkwood ward 100%, Longview ward 88%, and Poplar ward 100%. Appraisal rates were: Larkwood ward 82%, Longview ward 94%, and Poplar ward 98%.
• There were clear procedures for patient risk assessment and management plans to address behaviour that challenges. Staff completed robust risk assessments and management plans and updated them regularly. Staff anticipated patients heightened emotions and used de-escalation before patients got too distressed. The wards were working towards reducing restrictive practice.
• The multidisciplinary team provided a holistic approach to assessing, planning and delivering care and treatment. Care plans demonstrated how occupational therapy, psychology, medical and physical healthcare assessments were complimentary and supported each other. Staff designed structured and individualised therapeutic programmes, comprising of a mixture of group work activities, exercise, education and individual sessions, to encourage self-management of health conditions, self-awareness and adaptive coping strategies.
• Staff used outcome measures to evaluate programme effectiveness and treatment interventions. Staff actively engaged in activities to monitor and improve the quality of the service and outcomes for patients. This included a range of clinical audits and benchmarking relevant to their area of work. Staff acted on clinical audits and made changes accordingly.
• Feedback from patients was positive about the way staff communicated with them and treated their relatives. We observed staff treating patients with dignity, respect and kindness during all interactions. Staff and patients had a positive relationship.
• Staff supported patients to be partners in their care and decision making. Patients formulated their own needs plans, coping plans and goals. Patients had been involved in designing and redecorating the ‘chill out’ room, and were involved in recruitment interviews. There was a comprehensive parents and carers workbook to help support families and carers while their relatives were in hospital.
• The service was well integrated with the community and local resources. On Poplar ward patients went off the unit for field trips and staff invited speakers to come onto the unit to discuss specialist subjects such healthy eating and nutrition, benefits (where applicable), supported work and training opportunities.
• Leadership was strong across all wards, and staff we spoke with said they respected their managers and what they had achieved since the trusts merger in April 2017. Staff felt managers had guided the merger well, kept them informed along the way and overall the CAMHS wards had benefitted from the merger.

However:

• Two issues on Larkwood ward presented an infection control risk. We found black mould on the ceiling in the ensuite showers, and storage boxes used to store patients’ clothes and belongings showed signs of damp on the inside, meaning that items stored in the boxes could be getting damp, or damaged by mould.
• On Poplar ward there was potential for patients’ privacy and dignity to be affected throughout any period of seclusion or segregation.
• On Poplar ward, we found some of the diagnostic testing consumables, including dip sticks, blood bottles and drug tests, were out of date. We informed the manager who took immediate action to correct this before we left.
• Staff had not protected the privacy of patients using activity rooms on Poplar ward. At the time of the inspection, staff had removed the curtains as a temporary risk management strategy, but had not replaced the curtains with any other screening. This meant that patients using these rooms could be observed by people in overlooking buildings. The manager told us she would address this situation at the earliest opportunity.
• Staff did not give firm timelines for the implementation of positive behavioural support plans for appropriate patients.

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.

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.

We rated wards for older people with mental health problems as good because:

• The multidisciplinary team completed thorough risk assessments on admission which included individualised risk assessments and patient historic risks. Risk assessments were updated regularly and after incidents. All patients had care plans in place suitable for their needs. There was evidence of patient and family involvement in developing individualised care plans.
• Ward managers participated in safe staffing phone calls twice per day. During the calls ward managers would input their current bed occupancy, patient observation level and current staffing levels. All wards had achieved the safer staffing model at the time of inspection.
• Wards were clean and well maintained and furnishings were in good repair. Clinic rooms were well stocked and had physical health monitoring equipment that was checked in line with manufacturer’s guidelines.
• Staff interacted with patients in a positive, kind and respectful manner. Patients told us there was sufficient staff for patients to have escorted leave and for staff to engage with patients during therapeutic and meaningful activities.
• Staff were able to raise concerns about practice. Staff spoken to were aware of the trust’s whistleblowing policy.

However

• We reviewed care records on all 11 wards and found nine Mental Capacity Assessments and Best Interest Assessments were not complete in full, on five wards; these were on Bernard, Roding, Kitwood, Topaz and Tower wards. We found gaps ranging from two to 13 days between the dates where patients who were detained under the Mental Health Act became informal and when clinical staff had applied for Deprivation of Liberty Safeguards as the patients lacked the capacity to consent to their care and treatment. This meant that patients were being treated on these wards without a lawful basis to do so.

We rated Substance Misuse Services as requires improvement because:

• Not all patients receiving detoxification or maintenance substitute prescribing had regular medication reviews. The Department of Health guidelines on clinical management of drug misuse and dependence recommend 12 week reviews with a prescriber. Non-medical prescribers did not review medication levels for over six months in most cases and in some cases over a year.
• Mandatory training levels were low and below the trust target. Of the 26 mandatory training courses, only 7 courses had met the trust target and 14 had below 75% completion. 27% of relevant staff had up to date medicines management training in place and 50% had dual diagnosis training within date.
• Managers had not addressed the low levels of mandatory training and supervision across the service and there was no plan or process in place to improve these. Appraisal rates had also been low prior to the inspection and managers did not have a clear oversight of staff performance.
• The trust did not have a clear overview of staff competencies and risk. The trust had implemented an in-house competency framework for non-medical prescribers with no experience or qualification in substance misuse. However, managers and clinicians had different understandings of how the non-medical prescribers would work whilst undertaking the portfolio. This meant that the trust could not be assured that non-medical prescribers were working within their scope of competency.
• The trust had not conducted any service wide audits. Local managers had completed some audits for their site but these were individual to their locations and not shared across the service. As a result, managers were not aware that medication reviews were not happening within recommended timelines.

However:

• Staff assessment and monitoring of physical healthcare was thorough and included physical health clinics for patients with additional needs.
• The service did not have waiting lists for assessment following referral and 97% of patients commenced treatment within three weeks of assessment.
• Patients spoke highly of the staff and service they had received. Staff were respectful, kind and supportive.

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.

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.

We rated community end of life care as requires improvement because:

• There was a lack of effective monitoring of patient outcome data. There was no end of life clinical audit plan in place and no qualitative auditing had taken place over the past year. Data that was captured was not used to develop or improve services.
• We could not be assured that the service was meeting objectives set out in national guidance. This was because the framework in place was new and the implementation of action plans were in the early stages.
• Staff did not have access to competency training or regular clinical supervision.
• Governance systems were not well established. There had been no board assurance sought on the quality of end of life services in the past year. Reporting through the governance structure was weak. There were no formalised methods for the service to take account of risks, complaints, incidents, patient feedback or other monitoring data. This meant the service could not adequately assess where improvements were needed.
• Staff were not supported with polices and guidance. There was no end of life care policy in place nor a policy to describe to staff how they should care for person following their death in the community.
• The service did not gain patient or family feedback specifically relating to end of life services. Not all patients received written information about the support services that were available for them.

However:

• The service was safe. There were clear safeguarding, infection control and medicines management practices in place and being adhered to. Equipment and records were well maintained and people were given holistic care assessments to ensure their needs were met.
• Staff were passionate about the care they provided to patients. There were many examples of how staff had gone above and beyond to support patients at the end of their lives. Patients and their families were involved in developing care plans and given information to help them understand choices available to them.
• The service was responsive to people’s needs. There were a variety of referral methods and staff were able to see patients at short notice. Vulnerable people had their needs met and there was good access to specialist staff and support services.

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%.

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.

We rated long stay or rehabilitation mental health wards for working age adults as requires improvement because:

• Resuscitation equipment was available in the clinic but items were missing. Digital scales and the blood pressure machine were broken but still in use. Safe checking systems and processes were not in place. The ward manager took immediate action on the day of inspection.
• Two patients risk assessments were not up to date or sufficiently detailed.
• Patients gave mixed feedback about the heating in bedrooms. Staff were unable to control the heating in the unit.
• There was no staff room within the unit. The ward manager had raised this with managers.
• Relationships some members of the multidisciplinary team were mixed. Not all staff felt respected, supported and valued. Some staff did not feel able to raise concerns without fear of retribution.There had been a turnover of four managers over four years. Staff found this concerning and affected staff morale and stability of the team.
• The ward manager did not maintain a complete risk register at ward level.

However:

• The environment was safe and clean with ligature risks assessed and mitigated. Facilities included rooms for therapies and activities.
• The unit had an adequate number of staff to provide safe care. Where there were vacancies, managers were actively recruiting new staff. They used suitably skilled bank and agency staff to cover gaps. Staff were up to date with all mandatory training at 90%. There were regular team meetings and supervisions and appraisal.
• Staff knew how to report incidents and managers monitored these reports to identify and implement any lessons learnt. The ward manager undertook a daily call to senior managers around the management of patient care and risks. Staff managed and administered medication correctly.
• Staff created a holistic and robust overview of patient care and treatment. Staff used care plans, recovery star and my care, my recovery documents to achieve this with the patients.
• Staff reviewed paperwork for any detained patients weekly and information about the Mental Health Act was available to patients. Patients had access to an advocacy service, and knew how to make a complaint if they needed to.
• Patients received regular physical health checks and staff supported patients to live healthier lives. For example, patients were encouraged to participate in smoking cessation schemes. Staff provided breakfast and patients were supported to prepare and cook their own lunch and dinner. Patients had access to a Recovery College where they could develop a wide range of skills to support them in the future.
• Staff offered carers the opportunity to discuss their needs and create their own care plan (where appropriate).
• Staff were respectful and caring. We observed positive interactions between patients and staff. Staff understood the individual needs of patients. Patients said staff treated them well. Each patient had an allocated key worker named nurse and healthcare assistant (co-worker).
• Staff planned for patient’s discharge, including good liaison with care managers/co-ordinators.
• Patients attended spiritual support in the community. Patients had opportunities to feedback to the service.

We rated acute wards for adults of working age and psychiatric intensive care units it as requires improvement because:

• Managers had not ensured safe environments on six out of 13 wards. We found unidentified ligature points on Grangewaters, Chelmer, Ardleigh and Peter Bruff wards. We found unidentified ligature risks in gardens, kitchens, laundry rooms, bathrooms and bedrooms. Managers had identified ligature risks but not mitigated against them on Hadleigh psychiatric intensive care unit and Gosfield ward. We found unidentified blind spots on Ardleigh and Chelmer wards.
• The service did not always have beds available when needed. Patients often did not have a bed to return to following leave. Managers and staff spoken with told us that there was pressure to admit new patients to leave beds. Managers told us that patients would also be discharged following leave if no bed was available. We were given examples of patients having to wait to access a bed. There had been a serious incident and complaints relating to beds not being available.
• Staff had not completed detailed risk assessments for all patients. We reviewed six patients’ records that did not include a detailed risk assessment. On the Mental Health Assessment Unit, we reviewed three patient records. Staff had not completed detailed risk assessments or risk management plans. There was no evidence of ongoing assessment of patients’ mental state. These patients had presented with serious risk issues on admission to the ward. On Ardleigh, Peter Bruff and Cedar wards, we found one patient record on each ward that did not contain an up to date and detailed risk assessment.
• Staff did not always follow procedures for safe management of medicines. Staff had not labelled all liquid medicines with the date of opening and the medicine fridges were not clean on Peter Bruff unit and Ardleigh ward. There was no adrenaline available on Peter Bruff unit. Staff had not signed in medication on Ardleigh ward. Staff were not checking patients’ vital signs following the administration of oral lorazepam on Chelmer ward.
• The trust had not ensured learning from incidents was shared. Staff spoken with were not always aware of relevant incidents that had occurred on other wards within the service. We reviewed 25 incidents, of these, 16 did not include any lessons learned and in three, lessons learnt had not been shared.
• Staff did not always complete care plans to meet patients’ specific physical healthcare needs. On Peter Bruff ward, we found a patient with a physical health condition who did not have a care plan to meet their physical health needs. On Ardleigh ward, a patient with diabetes did not have a clear plan as to how staff should manage their condition and another patient did not have a care plan to address their specific physical healthcare need.

However:

• The trust had made significant improvements to managing environmental risks across the service. The trust had funded work to remove and reduce ligature risks. On Gosfield ward, high risk areas had been reduced from 20 to eight. Window handles had been removed from wards. Wards had ligature packs with information on environmental risks easily accessible for staff.
• Wards were clean and well maintained with good quality furnishings. Staff adhered to infection control procedures, for example, handwashing and the application of hand sanitiser. Staff prompted us to apply hand sanitiser before entering the wards.
• Clinic rooms were fully equipped with accessible resuscitation equipment. We inspected nine clinic rooms at Hadleigh, Chelmer, Stort, Ardleigh, Peter Bruff, Christopher psychiatric intensive care unit, Galleywood, Cedar and the Mental Health Assessment Unit. The CQC medicines team inspected Grangewaters clinic room.
• Staff had completed up to date, personalised, holistic and recovery focused care plans in 98% of patient records and full physical health assessments in 95% of records reviewed.
• We observed staff behaving in a kind, respectful and compassionate manner when interacting with patients. Patients told us that staff were respectful, kind, polite, compassionate and fair. Patients told us that staff kept them safe, listened to them and were responsive to their needs.
• The trust had introduced regular bed management meetings and discharge coordinators supported the service to ensure smooth transfers of care.
• Staff felt able to raise concerns without fear of retribution and were aware of the trust’s whistleblowing policy. Staff advised that they were able to raise concerns anonymously on the trust’s intranet and told us about the trust’s freedom to speak up guardian.

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.

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.