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Provider: Leeds and York Partnership NHS Foundation Trust Requires improvement

Read reports from our previous inspection of Leeds and York Partnership NHS Foundation Trust, published on 16 January 2015.

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 8 Jan to 2 Feb 2018

During a routine inspection

  • We rated three of the 11 core services as requires improvement overall. Our ratings took into account the previous ratings of services not inspected this time. Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.
  • The rating for the acute mental health wards for adults of working age and psychiatric intensive care unit had gone down, and the rating had gone down in one additional key question in the wards for people with a learning disability or autism. This suggested that these services had got worse since the last inspection. The requires improvement rating remained the same for the forensic and low secure services overall, and in the same key questions.
  • Issues that contributed to the breach of regulation at the last inspection in July 2016 had not been fully resolved at this inspection; in some services clinical supervision rates remained low and patient records were not always maintained in a consistent manner. Training compliance remained an area of concern in the forensic and low secure services.
  • The wards for people with a learning disability or autism was rated as requires improvement for caring as patients’ communication needs were not always assessed, nor were adaptive communication strategies used to enable patients to participate fully in their treatment and care. Also on these wards, blanket restrictions were in place, patients had limited access to psychological therapies and therapeutic activities, and there was an inconsistent approach to assessing risk and care planning for patients with epilepsy.
  • The National Inpatient Centre for Psychological Medicine was rated as requires improvement for responsive at this inspection because the premises were not suitable for the purpose they were being used. The trust still had no timescale or confirmed plans for the proposed new location for the service..
  • We had concerns relating to staff monitoring patients’ physical health following rapid tranquilisation in accordance with national guidance, best practice, trust policy and medicine administration on the acute wards for adults of working age with a mental health problem and the psychiatric intensive care unit.

However:

  • We rated the trust as ‘good’ in caring, responsive and well-led. Our rating for the trust took into account the previous ratings of services not inspected this time.
  • The trust rating in the well led key question at the trust level improved since the last inspection in July 2016.
  • The crisis and the health based place of safety core service had improved from requires improvement to good overall, and good in all five key questions at this inspection.
  • The supported living service had improved from requires improvement to good overall; outstanding in caring and good in safe, effective, responsive and well led.
  • The National Inpatient Centre for Psychological Medicine was rated as outstanding in effective and caring at this inspection.
  • All services now complied with the eliminating mixed sex guidance.
  • Mandatory training compliance across all the services had improved since the last inspection and remained on an upward trajectory. As at 30 September 2017, the overall training compliance for trust wide services was 90% against the trust target of 85%.
  • Non-medical staff appraisal rates had increased since the last inspection to 80% though they remained below the trust compliance rate. Appraisal rates were on an upward trajectory from September 2017 to January 2018.
  • Systems were effective to ensure that documentation was in place and readily available demonstrating that directors met the fit and proper person requirement, regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
  • There was good practice in relation to the application of the Mental Health Act and the Mental Capacity Act. Audits were completed to monitor the compliance with these Acts.
  • Governance systems were established to assess, monitor, and improve the quality and safety of the service, and manage risk, and operated effectively across the trust and were embedded in locally in most services.
  • The trust responded to requests for information from the Care Quality Commission and reported all incidents to the national reporting and monitoring systems, in a timely way.
  • Medication administration and storage, and physical health monitoring had improved.


CQC inspections of services

Service reports published 27 April 2018
Inspection carried out on 8 Jan to 2 Feb 2018 During an inspection of Wards for people with a learning disability or autism Download report PDF | 459.41 KB (opens in a new tab)Download report PDF | 2.26 MB (opens in a new tab)
Inspection carried out on 8 Jan to 2 Feb 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 459.41 KB (opens in a new tab)Download report PDF | 2.26 MB (opens in a new tab)
Inspection carried out on 8 Jan to 2 Feb 2018 During an inspection of Child and adolescent mental health wards Download report PDF | 459.41 KB (opens in a new tab)Download report PDF | 2.26 MB (opens in a new tab)
Inspection carried out on 8 Jan to 2 Feb 2018 During an inspection of Other specialist services Download report PDF | 459.41 KB (opens in a new tab)Download report PDF | 2.26 MB (opens in a new tab)
Inspection carried out on 8 Jan to 2 Feb 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 459.41 KB (opens in a new tab)Download report PDF | 2.26 MB (opens in a new tab)
Inspection carried out on 8 Jan to 2 Feb 2018 During an inspection of Forensic inpatient/secure wards Download report PDF | 459.41 KB (opens in a new tab)Download report PDF | 2.26 MB (opens in a new tab)
See more service reports published 27 April 2018
Service reports published 18 November 2016
Inspection carried out on 11 - 15 July 2016 During an inspection of Wards for older people with mental health problems Download report PDF | 396.61 KB (opens in a new tab)
Inspection carried out on 11-15 July 2016 During an inspection of Child and adolescent mental health wards Download report PDF | 299.75 KB (opens in a new tab)
Inspection carried out on 11/07/2016 During an inspection of Community-based mental health services for adults of working age Download report PDF | 334.83 KB (opens in a new tab)
Inspection carried out on 11-15 July 2016 During an inspection of Community-based mental health services for older people Download report PDF | 339.96 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 330.86 KB (opens in a new tab)
Inspection carried out on 12 to 15 and 20 July 2016 During an inspection of Wards for people with a learning disability or autism Download report PDF | 427.4 KB (opens in a new tab)
Inspection carried out on 11-15 July 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 441.95 KB (opens in a new tab)
Inspection carried out on 11 July-15 July 2016 During an inspection of Forensic inpatient/secure wards Download report PDF | 361.46 KB (opens in a new tab)
Inspection carried out on 15 to 20 July 2016 During an inspection of Other specialist services Download report PDF | 385.51 KB (opens in a new tab)
Inspection carried out on 11-15 July 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 326.76 KB (opens in a new tab)
Inspection carried out on 11 July – 16 July 2016 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 365 KB (opens in a new tab)
Inspection carried out on 14 July 2016 During an inspection of Other specialist services Download report PDF | 304.09 KB (opens in a new tab)
See more service reports published 18 November 2016
Service reports published 8 January 2016
Inspection carried out on 9 and 10 September 2015 During an inspection of Reference: not found Download report PDF | 215.2 KB (opens in a new tab)
Inspection carried out on 9 and 10 September 2015 During an inspection of Reference: not found Download report PDF | 232.97 KB (opens in a new tab)
Inspection carried out on 11 July – 15 July 2016

During a routine inspection

We rated Leeds and York Partnership NHS Foundation Trust overall as Requires Improvement because:

  • The trust did not have robust governance arrangements in place in relation to staff training, supervision and appraisal, medication management and audit, application of the Mental Capacity Act, systems and guidance to support the application of the Mental Health Act, the delivery of seclusion, restraint and rapid tranquilisation in line with the trust policy, accurate and contemporaneous records, the timely reporting of incidents, the crisis assessment unit’s service provision, policies and procedures being sufficiently embedded. The trust did not have a systematic approach in place with regard to the documentation required to assure themselves, or the Care Quality Commission, that the directors met the fit and proper person requirement, regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

  • Systems and guidance were either not in place, not sufficiently embedded, or not operated effectively to ensure the delivery of safe and quality care. Incidents were not reported to the National Reporting and Learning System in a timely way and systems were not robust enough to ensure that incidents were reported to the trust from some services, including the supported living service and the forensic and secure inpatient services. The trust did not always meet its own targets or those agreed with the commissioners, for example the clustering targets. The trust did not return the data requested by the Care Quality Commission during the inspection in a timely way. Records were not always accurate and contemporaneous and did not always include all decisions about patient’s care and treatment within their care record.

  • The provider failed to ensure that all people receiving a service were protected from potential harm because the emergency equipment and medication checks were not sufficiently robust on some wards, including the inpatient wards for older adults and the long stay and rehabilitation wards, where items were out of date or missing and equipment like blood glucose testing meters were not being recalibrated. The trust compliance was low for training courses including essential life support, intermediate life support, and safeguarding children level two and three. The low compliance with essential and immediate life support meant that the service could not guarantee that all staff could respond to patients in a medical emergency.

  • We had concerns about the management of medicines in some settings. Medicines across the trust were not being stored at the correct temperatures to remain effective. Staff in many of the clinical areas throughout the trust were not monitoring ambient room temperatures and where they were, temperatures were exceeding the room temperature recommended by the World Health Organisation guidelines. Staff in clinical areas were either not recording the fridge temperatures or not always taking action when temperature readings were outside of the required range. The internal audit systems were not always sufficiently robust to identify missed doses or other medication issues and errors in some services.

  • The trust did not ensure that staff received appropriate training, supervision and appraisal. The trust had not met its target of 90% compliance for appraisals and some services had low compliance. The trust compliance for clinical supervision was low across the trust except for the mental health services for children and young people.

  • Compliance in the mandatory level two Mental Health Act community and inpatient level two training was low and five teams or services had below 75% compliance in the Mental Capacity Act training, including Deprivation of Liberty Safeguards. The application of the Mental Capacity Act in some services was not in line with the trust policy or the Act and the trust did not always ensure that patients who did not have the capacity to consent to their care and treatment were detained using the appropriate legal authority such as by Deprivation of Liberty Safeguards. The systems and guidance in place did not fully support, or ensure, the application of the Mental Health Act across the trust and the code of practice was not sufficiently embedded across all the services or detailed in the trust policies.

  • Not all ward environments were safe or clean. There were concerns in relation to the trusts management of mixed sex environments and maintaining the patients’ dignity and privacy at three of the inpatient services we visited including the Yorkshire Centre for Psychological Medicine, Two Woodland Square and the crisis assessment unit. We did not accept that the Yorkshire Centre for Psychological Medicine met the requirements of the Department of Health guidance on same sex accommodation (2010), or the Mental Health Act code of practice at the time of the inspection. The provider had outstanding actions on the trust’s reducing restrictive interventions action plan and the use of seclusion; restraint and rapid tranquilisation were not always completed in line with the trust policy. In the community services systems were not in place in all services to manage risk effectively. This was in relation to supporting patients whilst they were on the waiting lists to access the service, managing the premises, and employing sufficient lone working systems to protect staff and patients. Also, there were delays above 20 weeks for patients to access some psychological therapies identified in the integrated community services for working age adults and older adults with mental health problems.

However:

  • The community services that supported deaf and hearing impaired children and young people, as well as children and young people with mental health problems whose family had hearing impairments, was rated as an outstanding service.

  • The trust was committed to improving and developing its services, using information from the local population and through working in partnership with the commissioners, other statutory, third-sector and voluntary organisations. Patient involvement appeared to be embedded in the trust’s approach to shaping its services and informing care and treatment. It had a well-established service user network and involved patients in research projects, delivering training and recruitment.

  • The trust had implemented a new recruitment strategy in 2016 and had implemented a number of measures to attract new staff to work in the trust. It had successfully recruited newly qualified and experienced staff through its recruitment events and its work with the universities, using values based recruitment. Whilst there continued to be regular use of bank and agency staff across the trust, the staff used were either substantive staff who worked extra shifts, or staff who worked regularly in particular areas but who chose not to take substantive posts to ensure the continuity of care for patients. Staff were respectful, caring and compassionate towards patients, relatives and carers and mindful of the best way to communicate with patients in order to support them.

    The trust did not own all the premises it delivered care or treatment from. It had identified this as one of its strategic risks and was committed to improving working arrangements with its private finance initiative partners and NHS Property Services Ltd, to improve response times for maintenance and repairs and the overall management of its estate. The trust had completed a significant amount of work in relation to the identification and removal or mitigation of ligature risks across all its wards and services. They had robust systems in place to assess, report and communicate any ligature risks, supported by the trust’s ligature risk procedure.

  • In the majority of services and teams, comprehensive assessments were completed using recognised assessment tools, care plans were holistic and person centred, risk was assessed and addressed. Staff produced different versions of care plans in accessible formats, for example in the community services for deaf children and adolescents and the community services for learning disabilities or autism. Care and treatment was delivered by a multidisciplinary team and was reviewed regularly. Patients told us that they were involved in their care and most of the patients spoken to during the inspection told us they could have a copy of the care plan if they wanted one.

  • A range of information was available to patients in accessible and appropriate formats for the patients in the wards or services. The trust had a robust and effective complaints process and almost all the wards and services we visited during our inspection demonstrated a positive culture of reporting complaints and learning from complaints. Patients knew how to complain if they wanted to and were supported to do so.

Inspection carried out on 30 September, 1 and 2 October 2014

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence. This statement should be in all provider level reports.

Bootham Park Hospital, despite significant work having been taken around ligature points and further work planned is not fit for purpose as a modern inpatient setting. The building no longer meets the needs of psychiatric patients in acute distress. Staff could not observe all parts of the wards due to the layout and design of the building. Bedrooms were large and airy, but doors opened out into corridors. There were sash windows in bedrooms and bathrooms. There were other features of a building that was built in the 18th century meaning that ligature points could not be fully eliminated.

In York specifically, the facilities and premises at Bootham Park Hospital were not appropriate for the services being provided. The trust during and subsequent to the inspection provided documents that outlined their engagement and documented concerns about the premises with the relevant parties from July 2013 to find a solution, including Vale of York commissioning group, the NHS area team and NHS property services. Solutions were put in place and included English Heritage, but have not as yet been implemented.

We saw that this had been the case with Lime Trees child and adolescent unit but that the trust had worked collaboratively with the specialised commissioning team and NHS England to make immediate changes and move the service to another location.

Staff did not always identify safety concerns about ligature points quickly enough. We identified ligature points across the Leeds’ inpatient areas that were not all recorded on the trust risk register.

We found the use of patient group directions was unlawful in the crisis assessment service in Leeds. The trust suspended their use before the end of the inspection.

Staffing levels were usually maintained at the level set by the trust. The expected qualified nurse staffing levels at Field View were not maintained on the week of our inspection. There was limited medical cover in some locations in the trust and this meant that it could be difficult to get medical assistance in an emergency.

Safeguarding vulnerable adults, children and young people had a raised profile in the trust as they had just appointed a non – executive director lead. Training for all staff was in place. Policies and procedures were easily accessed and staff understood them.

The trust did not meet the Department of Health guidance on same sex accommodation and did not comply with the Mental Health Act Code of Practice. Four wards including one rehabilitation ward, Acomb Gables and three older people’s wards Meadowfields, Worsley Court and ward 6 did not comply. These were all wards in York. We concluded that the trust was not promoting sexual safety and not ensuring patient privacy and dignity was being maintained at all times.

Prior to our inspection, we heard that patients, carers and relatives did not find it easy or worried about raising concerns and complaints. We found during our inspection that when issues were raised locally, they were dealt with at ward/team level. However, corporately there was a backlog of complaints. Patients’, carers’ and relatives’ were in receipt of unsatisfactory responses after waiting for a response for a long time. The trust was not meeting its own targets for response times. Information on how to make a complaint was not displayed in all ward areas or areas of public access. We concluded that patients’ concerns and complaints do not always lead to improvements in quality of care.

Staff had access to learning and development opportunities. The learning opportunities offered to staff did not fully meet their needs. Mental Capacity Act training was not in place. The trust did not monitor the number of people who had undertaken Mental Health Act training. We concluded that the trust cannot be assured that the relevant staff had up to date knowledge regarding Mental Capacity Act, Deprivation of Liberty Safeguards and Mental Health Act legislation. Specialist training was limited in York. Training programmes were held both in Leeds and York although staff in York told us they found it difficult to attend.

Representatives from the York commissioning groups told us that the trust did not engage positively with them and did not involve the local communities or other organisations in how services were planned or designed. The trust also told us that the relationship between them and the commissioning groups in York was a difficult one. We were concerned that this might adversely affect the provision of high quality patient care.

After the inspection, the York commissioning groups informed us that there had been improvements in the three months post inspection. They identified that the context of their discussions with CQC had all previously been shared with the trust. This included their view that the trust had been the provider of services for over two years but had not progressed key estates issues including actions relating to ligature points despite the resource being identified prior to the trust taking over the contract.

The trust submitted documents after the inspection that showed a timeline of partnership and engagement within the York localities of which the first dated evidence is January 2013. There were a number of pieces of evidence that supported the trusts view that they had actively engaged with the clinical commissioning group through a variety of different groups and meetings. They also included several pieces of evidence demonstrating how they had engaged and involved local communities in how services were designed and planned. The trust included a document that detailed the different partnership groups that members of the trust attend. Minutes were provided that demonstrated that the trust had engaged in a board to board meeting with the Vale of York commissioning group in February 2014 followed by an executive to executive meeting in April 2014. These meetings included discussions on the way forward with Bootham Park Hospital and the respective roles and responsibilities going forward.

The arrangements for governance and performance management did not always operate effectively below senior management level. As a result it was not clear that the trust had the full range of information from the care teams to manage current and future performance. However the structures had been seen to be working well and embedded at senior management and board level. We saw that performance issues were escalated to the board through the relevant committees. Financial pressures were not compromising the quality of care.

Staff planned and delivered care and treatment in line with evidence based practice. They undertook comprehensive assessments of needs. However they did not always collect or monitor measures or outcomes of patient care and treatment regularly or robustly. The eating disorder service was an exception to this. Participation in external benchmarking was limited, although we could see that plans were in place to develop this approach. The trust had undertaken national benchmarking for the first time in 2013.

Overall the application of the Mental Health Act was good. However we found some practices did not always meet the Mental Health Act Code of Practice. We raised these at the time with the ward staff. Staff appeared to be knowledgeable about the application of the Mental Health Act. We found mail being withheld for one patient contrary to the rules in the Mental Health Act. There was inconsistent practice in giving people copies of section 17 leave forms and some evidence of scrutiny of documents not always taking place, in as short a period of time as possible, following the application for detention.

Staff understood and fulfilled their responsibilities to report incidents. When things went wrong, there was a thorough investigation that involved all the relevant staff, patients’ and their carers’. Lessons were learnt, however it was not clear from the investigation reports how widely they were communicated.

Despite the lack of available training, we saw that the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards were met where its use was required. However we found inconsistencies in staff understanding of the application of the Mental Capacity Act.

Patients were supported, treated with respect and were involved in their care and treatment. Prior to the inspection, we were told that patients were not always involved with or have their care plans reviewed, however during the inspection the majority of patients told us they had been actively engaged in reviews of care. There was variation between services in Leeds and York, with Leeds services engaging patients, carers and or relatives more proactively. Staff had a good understanding of the different needs that patient’s had on the basis of gender, race, religion, sexuality, ability or disability within services.

Patients could access the right care at the right time. Bed occupancy was marginally higher than that of the national average. The introduction of single point of access had improved response times to referrals. Patients did not have problems contacting services when they needed to.

In Leeds, we saw and heard that other organisations and the local community were involved in planning and delivering services to meet patients’ needs.

A clear statement of vision and values had been developed through engagement with internal and external stakeholders including patients and governors. A strategy had been developed with clear objectives that were reviewed regularly. The board and the non-executive directors had the experience and capability to ensure that the strategy was delivered. Staff understood the vision and values but did not always understand how that related to them at a more local level.

We heard that not all of the managers and clinical leads in York had the necessary experience, knowledge, capacity or capability to lead effectively. As a result, the trust had recently moved a number of senior managers across from the services in Leeds to address some of the challenges that this had created.

Staff felt supported and valued. We saw that there was good collaboration between teams.

There had been the introduction of the Mental Health Act committee in the preceding 12 months. This meant that CQC Mental Health Act reports were reviewed by non executive board members and the board was made aware of any outstanding actions. Statistical information on the MHA was being monitored.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.