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Provider: Nottinghamshire Healthcare NHS Foundation Trust Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 24 May 2019

Inspection areas

Safe

Requires improvement

Updated 24 May 2019

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

  • We rated five out of 16 services as requires improvement and two as inadequate in the safe key question. Our rating took into account the previous ratings of services not inspected this time.
  • For two of the services that we inspected on this occasion, we had concerns about the quality of the environment. In the child and adolescent wards there was a low wall between the communal areas that could be a risk to patients and staff safety if a patient climbed onto it. The wards had problems with the heating system and safety alarm directed staff to the wrong ward. The trust was working with contractors to resolve the issues. Staff did not make sure that all of the forensic wards were kept clean.
  • Medication management was not robust. There was inconstancy in the application of the medicine policy in the correct storage of medication, temperature monitoring and routinely recording fridge temperatures and the safe storage of medication when taken out into the community.
  • Staff did not always follow the trust’s policy around monitoring patients’ physical health after administering rapid tranquilisation medication in the acute and forensic services.
  • The trust did not meet safe staffing levels across three services inspected. These were the health based place of safety, forensic services, and adult acute admission wards. The trust risk register listed staffing as a major risk and the trust had a robust recruitment and retention strategy in place.
  • We found blanket restrictions in place across acute admission wards.

However:

  • In five services inspected, the clinical premises where staff saw patients were safe and clean. Staff followed best practice in infection control.
  • Staff assessed and managed risk well. Staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • In all services inspected staff followed good practice with respect to safeguarding. Staff understood how to protect patients from abuse and exploitation and worked well with other agencies to do so. Staff had training on how to recognise and report abuse and or exploitation and they knew how to apply it. There was an identified named nurse and doctor for child protection.
  • The community teams we inspected had manageable caseloads and patients had crisis plans in place.

Effective

Good

Updated 24 May 2019

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

  • In all services we inspected staff assessed the physical and mental health of all patients on admission. Staff developed individual care plans which they reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected the assessed needs.
  • In all services we inspected, staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. They supported patients to live healthier lives.
  • In all services we inspected staff used recognised rating scales to assess and record severity and outcomes. They also took part in clinical audit, benchmarking, and quality improvement initiatives.
  • All clinical teams included or had access to the full range of specialists needed to meet the needs of patients under their care. Managers made sure they had staff with a range of skills need to provide high quality care. They supported staff with appraisals, supervision, opportunities to update and further develop their skills. Managers provided an induction programme for new staff.
  • Staff from all disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The clinical team had effective working relationships with other relevant teams within the trust and with relevant services outside the organisation. They engaged with them early in the patient’s admission to plan discharge.
  • Staff in all services understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Managers made sure that staff could explain patients’ rights to them.
  • Staff in all services supported patients to make decisions about their care for themselves. They understood the trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.

However:

  • We rated three out of 16 services as requires improvement for the effective domain. Our rating took into account the previous ratings of services not inspected this time.
  • In three services the quality of care plans was mixed. Care plans were not always personalised, holistic and recovery oriented. In some services staff either did not give, or did not record that they had given patients copies of their care plans.
  • In two services staff did not always record or undertake appropriate physical healthcare checks.
  • In two services staff either did not record staff supervision in line with the trust’s policy, or the rates of supervision were low.
  • In two services staff did not monitor adherence to or audit the use of the Mental Capacity Act to identify areas for improvement.
  • In two services there was limited access to psychological therapies, due to a low number of psychologists.

Caring

Good

Updated 24 May 2019

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

  • We rated 13 out of 16 services as good and two as outstanding for the caring domain. Our ratings took into account the previous ratings of services not inspected this time.
  • In all services, staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment, or condition.
  • In all services staff involved patients and carers when planning care and actively sought their feedback on the quality of care provided. Staff ensured that patients had easy access to advocates when needed.
  • Staff informed and involved families and carers fully and appropriately in assessments and in the design of care and treatment interventions.

However:

  • Staff on the acute admission wards did not always ensure the privacy and confidentiality of patients. The privacy blinds of patients’ doors were left open including when patients were asleep and male staff observed female patients through blinds without informing them. On three wards information boards that contained patient details were visible from the ward.
  • At the time of our inspection, the trust did not provide information in an accessible format in the child and adolescent mental health service. Some parents we spoke with had not received general information before their child’s admission including visiting times and how to make a complaint.

Responsive

Requires improvement

Updated 24 May 2019

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

  • We rated five out of 16 services as requires improvement in the responsive domain. Our rating took into account the previous ratings of services not inspected this time.
  • The trust did not always protect patients’ privacy and dignity in their delivery of care and treatment. There were dormitories on B2 ward at Bassetlaw Hospital and Orchid ward. In another service patients were not always able to make a phone call in private.
  • In one service staff did not routinely provide patients and carers with information about how to raise a concern or complaint. In another service staff did not always use complaints as an opportunity to learn or make improvements to the quality of care they delivered.
  • In the acute admission wards families and patients could not always access the family room because staff used this as a health based place of safety for patients when the designated suite was in use.
  • In the acute admission wards beds were not always available locally when needed. However, the trust had commissioned 16 male and 16 female acute beds to reduce the number of out of area placements and ensure more people received care and treatment close to their home area. There were 314 out of area placements between October 2017 and September 2018. Bed occupancy was at 104% across the service. Patients’ beds were not available to them when they returned from leave. The wards used the health based places of safety at Highbury Hospital and Millbrook Mental Health Unit when they could not find a bed. Staff called these ‘step up beds.’

However:

  • Staff planned and managed discharges well. They liaised well with services that would provide aftercare and were assertive in managing the discharge care pathway.
  • In the child and adolescent mental health and forensic services the design, layout and furnishings of the wards supported patients’ treatment.
  • Services met the needs of all patients who use the service, including those with a protected characteristic under the Equality Act (2010). Staff helped patients with communication, advocacy, and spiritual support.
  • Three services treated concerns and complaints seriously, investigated them, learned lessons from the results and shared these with the whole team and the wider service.
  • Staff supported patients to engage with activities and work opportunities within the wider community and encouraged patients to maintain relationships with people that mattered to them.

Well-led

Requires improvement

Updated 24 May 2019

Our rating of well-led went down. We rated it as requires improvement because:

  • We rated two services as requires improvement in the well-led domain and one as inadequate. Our rating took into account the previous ratings of services not inspected this time.
  • Overall the safety of services had deteriorated since our last inspection. In acute wards and psychiatric intensive care units our rating went down from requires improvement to inadequate. In forensic inpatient services our rating for safe went down from good to inadequate.
  • The executive team lacked confidence in carrying out actions in between one chief executive retiring and another commencing. The chair was on various boards outside of the trust. The impact of this led to some loss of leadership focus and action within the trust.
  • There was a disconnect between operational staff and the board in the communication of messages and a lack of consultation and engagement. Relationships between Rampton Hospital medical consultants and management had continued to deteriorate since our last two inspections in 2017 and 2018. Staff did not feel equally respected, supported and valued across all sectors within the trust. The 2018 staff survey results showed in all areas the trust sat below its comparator group and towards the lower end of the scoring range. Morale and staff engagement were equivalent to the worst score.
  • The board assurance framework included a number of risks that were considered to be high impact risks. The board had kept these risks under regular monthly review. Staff and clinical engagement and culture was not specifically defined as one of the organisations top risks despite the deterioration in staff survey results and engagement culture of the organisation since the last inspection.

  • The handling of concerns raised by staff did not always met with best practice. Not all staff felt able to raise concerns without fear of retribution.
  • The workforce race equality standard showed a decrease in the number of that staff who believed the trust provided opportunities for career progression and promotion and was worse than the national average.
  • Where cost improvements were taking place, it was not always clear they did not compromise patient safety and care.
  • Staff did not always manage medicines well in five of the services that we inspected on this occasion for example: - medicine fridge temperatures on a ward in the child and adolescent service and an adult community mental health team were higher than recommended for safe storage on several occasions but staff had not reported this to the pharmacy team to resolve. Staff in the crisis service did not always follow trust guidelines in relation to medicines management. Staff in the forensic services did not always follow best practice when storing, dispensing, and recording the use of medicines. One adult community mental health did not follow safe storage of medication guidance when taking medicines out into the community. On three wards staff did not record the date that they had opened patient medications.
  • Sharing the lessons learnt through audits or complaints to change practice did not consistently happen. We found issues raised in previous inspections had not consistently changed mental health observation practice in forensic services. Checks of resuscitation equipment had not consistently occurred in three services. Physical health checks following rapid tranquilisation did not occur in four services.

However:

  • We rated 13 out of 16 services as good in the well-led domain. Our rating took into account the previous ratings of services not inspected this time.
  • The trust had a clear vision and set of values with quality and sustainability as the top priorities. The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders.
  • In all the core services we inspected leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed. In five of the services leaders were visible in the service and approachable for patients and staff.
  • All teams had access to the information they needed to provide safe, effective care and used that information to good effect.
  • Our findings from the other key questions demonstrated that governance processes operated effectively at team level and that performance and risk were managed well in five of the services we inspected.
  • Staff in all services engaged actively in local and national quality improvement activities.
  • Fit and proper person checks were in place. Public governors were actively involved in the operation of the trust and took part in the programme of board visits to services.
  • Leadership development opportunities were available, including opportunities for staff below team manager level.
  • There were organisational systems to support improvement and innovation work. There was a strong programme of staff training.
  • The trust demonstrated a commitment to research and partnership with universities. There was involvement in national projects such as reducing restrictive interventions including a black and minority ethnic restraint project. The National Institute for Health and Care Excellence had recognised the trust’s restrictive practice training manual and the trust will be a pilot site for the new NHS Equality Delivery System 3.
Checks on specific services

High secure hospitals

Updated 24 January 2020

We undertook this inspection to see if the trust had made improvements since our comprehensive inspection in July 2019. This was a focused inspection, we did not inspect all key lines of enquiry and did not rerate. The ratings from the comprehensive inspection in July remain.

  • The service continued to not have enough nursing and medical staff. To maintain safety, staff were moved between wards, sent as escorts off the ward, worked additional hours and went without breaks. This impacted on relational security, the quality of patient and staff experience, access to patient activities and access to fresh air. Relational security is the knowledge and understanding staff have of patients and the environment, and the translation of that information into appropriate responses and care. Caseloads of social workers, psychologists and occupational therapists were high in comparison to other high secure hospitals. This prevented them carrying out all aspects of their role.
  • Instances of lone working at night continued, which posed a risk should an emergency occur in a bedroom as three staff were required to go in.
  • Not all staff were aware of what and where ligature assessments for the ward they were working on were kept or whether accurate records were kept of the maintenance of ligature cutters.
  • Staff did not always respond to alarm calls promptly when incidents occurred. Staff continued to say they did not always report incidents or have time to write them up in detail.
  • Staff continued to be inconsistent in following the observational policy when recording observations. Staff continued to report they did not always receive breaks from continuous observations.
  • We found issues with the storage of medication such as a lack of stock rotation for supplementary medications. Staff did not consistently sign to record patients had received medication or follow National Institute for Health and Care Excellence guidance in reviewing the effects of medication when using intramuscular injection medication.
  • Staff did not receive effective handovers that included information about patient risks when they moved wards.
  • Staff did not consistently accurately record long term segregation on the electronic patient record.
  • Ward staff did not have adequate physical health care training and reported that the quality of clinical supervision was poor.
  • Patients continued to raise issues of inappropriate language, racist attitudes by staff and that their privacy and dignity was not respected and confidentially was not maintained by staff.
  • The hospital culture required improvement. Staff continued to report that they did not feel able to speak up about concerns without fear of retribution and morale was poor in some areas.
  • Governance systems did not operate effectively enough to manage or monitor the impact of staff shortages. In addition to this, there was a lack of consistent, effective recording of shortages or loans to other wards.

However:

  • The Rampton hospital implementation board had developed an action plan and we saw evidence that actions were being implemented.
  • Management changes across the trust and at Rampton hospital had started to occur and were welcomed by staff and medical consultants, although it was too soon to evaluate the impact.
  • All wards were safe, clean, and fit for purpose. Staff followed the infection control policy including hand hygiene.
  • Staff assessed the physical and mental health of all patients on admission. Staff completed risk assessments on admission and updated these regularly. They developed personalised individual care plans. They included specific safety and security arrangements and a positive behavioural support plan. Staff used recognised rating scales to assess and record severity and outcomes.
  • The ward staff participated in the provider’s restrictive interventions reduction programme. Mechanical restraint was used with a clear rationale and with individualised care plans.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service had access to a full range of specialists to meet the needs of the patients on the wards.

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

Inadequate

Updated 24 May 2019

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

  • We found that there was inconsistency and lapses in governance across wards. Risk and safety were not always well managed including staffing and clinical activity that kept patients safe. There were issues with bed management and availability of beds. Supervision did not always take place and neither did team meetings, therefore there was inconsistent evidence of learning from complaints and incidents.
  • Staff did not always monitor patients’ physical health adequately and had sometimes not completed National Early Warning Scores when indicated. Staff did not always undertake physical observations after giving patients rapid tranquilisation
  • Staff did not always carry out checks to see if emergency resuscitation equipment worked properly.
  • Staff did not always manage risks well. We reviewed 36 care records. Five of these contained no record of a risk assessment and, in a further seven, the risk assessments were not fully developed or did not contain all the risk information required.
  • On Lucy Wade Unit, some staff did not know how to open all the anti-barricade doors. There were three doors that had a different opening system. However, the trust was replacing these doors.
  • Wards had restrictions in place. All patients had restricted access to outside space and there were various restrictions in relation to the use of crockery and cutlery that were not always individually risk assessed. On B2 ward, staff restricted female patients’ access to bathrooms, toilets and bed space and male patients’ access to bathrooms.
  • There were not always sufficient staff numbers on the wards and the wards relied on bank staff. There were 23% of shifts where staff fill rates fell below 90% between July and September 2018. Staff told us they felt under pressure and that there were not always two nurses on the ward. This meant it was not always possible for a nurse to be available in communal ward areas and made it difficult for staff to offer patients one to one sessions. At the time of inspection staff vacancies had reduced but staffing continued to be reported as an ongoing issue.
  • There were some omissions in medication management. We observed that patients did not have care plans for medication that doctors had prescribed patients to take as required. Also, staff did not always record the date that they opened patients’ medication that became short dated when opened.
  • Care plans were personalised but did not always demonstrate a holistic approach. In 15 of the 33 care plans we saw this was not the case.
  • Patients had limited access to psychological therapies and activities. However, the trust had already taken steps to improve this and new staff started work following our inspection to provide this.
  • Staff did not always ensure the privacy of patients. On some occasions, staff left the privacy blind on patients’ bedroom doors open. We observed a male member of staff carrying out observations without telling female patients he was looking through the blinds. Also, on one ward we could clearly see patient information displayed on the patient information board, staff had not covered this when it was not in use.
  • Patient community meetings did not always take place as planned on a weekly basis. Staff did not always record what patients had discussed at meetings or actions from them. There were areas for family visits, but these were not always available as these rooms were used as a place of safety when the 136 suites were unavailable.
  • There were dormitories on B2 ward at Bassetlaw Hospital and Orchid ward. The trust was considering how they could eradicate dormitories however there were no firm plans in place at the time of inspection.
  • Beds were not always available locally when needed. However, the trust had commissioned 16 male and 16 female acute beds to reduce the number of out of area placements and ensure more people received care and treatment close to their home area. There had been 314 occasions when a patient had been admitted to an out of area bed between October 2017 and September 2018. This had increased since our last inspection. The wards used the health based places of safety at Highbury Hospital and Millbrook Mental Health Unit when they could not find a bed as a short-term measure. Patients’ beds were not always available to them when they returned from leave. The trust did not have current data about how often this happened.
  • Staff were not familiar with the trust’s vision and values.

However:

  • Staff undertook regular environmental risk assessments. Wards were clean, and staff followed good practice in infection control, and checked equipment regularly.
  • Staff were kind and responsive when interacting with patients. Patients engaged well with staff and spoke positively about how staff treated them. Staff supported patients to access education and work opportunities. Staff were trained to work with families and carers and did this well.
  • Staff ensured that patients understood their rights under the Mental Health Act and followed trust policy in relation to patients’ leave. Staff ensured patients had access to an independent mental health advocate who visited the wards and worked with patients. Staff supported patients to make decisions about their care for themselves, they assessed and recorded capacity where patients had impaired capacity.
  • Staff understood how to protect patients from abuse and exploitation and worked well with other agencies to do so. Staff were comfortable to raise concerns about patient safety without fear of the consequences.
  • Staff monitored side effects of medication and audits. They completed blood tests for patients who were being prescribed medication that required additional monitoring. Staff used recognised rating scales to assess and record severity and outcomes. Staff participated in clinical audits and took part in quality improvement activities.

Forensic inpatient or secure wards

Requires improvement

Updated 24 May 2019

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

  • The service did not consistently provide safe care across the three hospital sites. Not all of the ward environments were safe or clean and staff did not always know how to use emergency equipment. The wards did not have enough qualified nursing staff to support patient care and treatment. The service did not effectively minimise the use of restrictive practice or follow good practice with regards to medicines management.
  • Staff did not use clinical audit and complaints effectively to evaluate and improve on the quality of care they provided.
  • Staff did not follow the trust’s policy around the use of observation and did not follow national guidance to monitor deterioration in patients’ physical health.
  • The governance processes did not ensure that wards were safe or that staff used every opportunity to improve on their practice.
  • The service did not consistently protect and promote patients’ privacy and dignity.
  • Vacancies in the psychology department at The Wells Road Centre had resulted in some patients having poor access to psychological therapies.

However:

  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
  • Managers ensured that staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

Child and adolescent mental health wards

Good

Updated 24 May 2019

We have not rated this service before. We rated it as good because:

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the wards who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

  • Staff did not always use the systems in place to keep information about patients confidential.
  • Staff did not all have access to specialised training in eating disorders, taking blood tests and how to care for patients on the psychiatric intensive care unit.
  • There were some issues relating to a new build including heating, security and parental controls for the new Wi-Fi system and inconsistent alarms, that required action to fully resolve for which the trust had actions in place to remedy. Staff were not always aware of who to contact to resolve these issues.
  • Staff did not update the personal emergency evacuation plans of patients who needed them when the patient moved between wards or was cared for in the seclusion room.
  • Staff did not ensure that medicine fridge temperatures were always within the range for safe storage of medicines.
  • Staff did not have access to all of patients’ paper records in the electronic patient records system, so they could use it effectively.
  • Patients and their carers did not have all the appropriate information available to them in an accessible format at the time of admission and throughout admission. However, the trust confirmed it was in the process of printing leaflets in different languages and formats to be made available for patients and carers using the service. 

Mental health crisis services and health-based places of safety

Good

Updated 24 May 2019

Our rating of this service

stayed the same

. We rated it as

good

because:

  • Clinical premises where staff saw patients were safe and clean. The number of patients on the caseload of the mental health crisis teams and of individual members of staff, was not too high. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff had provided a range of treatments suitable to the needs of the patients and staff engaged in clinical audit to evaluate the quality of care they provided.
  • The mental health crisis teams included or had access to the full range of specialists required to meet the needs of patients. Managers ensured staff received training. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.
  • The mental health crisis service and the health-based places of safety were easy to access. Staff assessed people promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude people who would have benefitted from care.

However:

  • Staff working for the mental health crisis team at Millbrook Mental Health Unit had not always developed holistic, recovery-oriented care plans and staff at Millbrook Mental Health Unit and Bassetlaw Hospital had not offered all patients a copy of their care plan.
  • Managers had not ensured that staff received supervision and appraisal in line with their policy.
  • Staff did not always follow trust guidelines in relation to medicines management. Highbury Hospital staff did not safely deliver medication to patients as they did not secure the medicine in a safe way to transport it to a patient’s home or get patients to sign they had received it.
  • In the section 136 Cassidy suite the locks and bolts on the suite doors were not suitable and therefore did not provide a safe environment for patients or staff.
  • Although the environment at the Cassidy suite met the requirements of the Mental Health Act Code of Practice the Jasmine suite did not because there was no clock visible to patients when they were detained in the suite.
  • Staffing levels in the section 136 suites did not meet safe staffing levels when there were emergencies.

Community mental health services with learning disabilities or autism

Good

Updated 24 May 2019

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

  • The service provided safe care. The number of patients on the caseload of the teams, and of individual members of staff, was not too high. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Teams included, or had access to, the full range of specialists required to meet the needs of patients in the community. Managers ensured that staff received training and supervision. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
  • Staff understood and performed their roles and responsibilities under the Mental Health Act and the Mental Capacity Act.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. Staff involved patients and families and carers in care decisions.
  • The service was easy to access and staff and managers managed access and caseloads well. The service did not exclude people who would have benefitted from care. Staff assessed and initiated care for people who required urgent care promptly and those who did not require urgent care did not wait too long to receive help and start treatment.

However:

  • The trust reported that it had received no complaints from patients under the care of the intellectual and developmental disabilities services. However, staff working in this service did not routinely provide patients and carers with information about how to raise a concern or complaint. Staff were aware of the availability of complaints leaflets, but they were not clear about how patients and carers would access them without asking.
  • Some teams within the service had appraisal rates for non-medical staff that were significantly below the trust’s target.
  • Omissions were present in care planning practices. Records did not always demonstrate that staff always developed care plans to address the identified needs of patients. Additionally, records did not clearly demonstrate when staff had offered or shared care plans with patients.
  • Clinical audit practices were not always robust. Outcomes of audits were not always consistent with practices seen during the inspection and staff were not clear how the trust audited the application of the Mental Capacity Act.

Community-based mental health services for adults of working age

Good

Updated 24 May 2019

  • The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high and staff managed waiting lists well to ensure that people who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. Staff ensured all carers felt listened to and empowered patients to be actively involved in their recovery.
  • The service was easy to access. Staff assessed and treated people who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The service did not exclude people who would have benefitted from care.
  • The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

  • The team at City North had medication that had not been stored properly prior to be disposed of and a problem with the temperature gauges for recording fridge temperatures. They did not transport medication safely when completing visits in the community.
  • There was a lack of evidence of the involvement of patients and carers in decision making about the service.

Wards for people with a learning disability or autism

Good

Updated 14 August 2018

We only looked at parts of the four key lines of enquiry at this inspection that related to the concerns raised. These were in safe, effective, caring and well led.

We did not rate the service at this inspection as we only inspected one ward and looked at specific issues relating to the concerns we had received.

We found:

  • Care records contained up to date and detailed information about patients. Risk assessments and management plans were thorough. Care plans and activity timetables were personalised and indicated that staff understood patients’ needs.

  • There were regular and effective multi-disciplinary meetings. The team had effective working relationships with other professionals. These relationships enabled access to care for patients who required hospital treatment or other physical health care off the ward

  • We observed staff to be kind in their interactions with patients and responded to patients appropriately. Staff protected patients’ privacy and dignity and demonstrated that they understood each patient’s individual needs, preferences and preferred communication methods.

  • Staff on the ward had made changes to improve communication with carers. Carers now had opportunities to talk to staff and discuss the care of their family member or discuss concerns.

  • Managers had identified risks that related to the ward and these risks matched staff concerns The ward had had a robust action plan to reduce risks and updated these plans regularly.

  • Staff reported and learnt from incidents, complaints and feedback. Nurses had been trained in offering debriefs so that they could support staff when incidents occurred on the ward.

However:

  • Staff did not monitor when patients were due for an annual physical health screen which meant that patients could miss annual health screening opportunities.

  • When staff carried out physical health observations and there was increased physical health risks identified, they did not always complete and record increased observations; neither did they record a rationale for not completing these.

  • Certificates to authorise treatment were not attached to medicine cards. This meant that staff could not be sure that they had the legal authority to administer medication.

  • Staff indicated that morale was low and had been affected by both a high level of assaults upon staff and increased scrutiny following a serious untoward incident. Not all staff felt consistently supported and some staff had not received supervision or found it hard to find the time to complete training.

Specialist community mental health services for children and young people

Updated 23 December 2015

Specialist community mental health services for children and young people:

  • young people and their families felt listened to, respected and treated with dignity

  • young people and their carers told us staff involved them in planning, reviewing and updating their care

  • the service provided access to advocacy and plenty of age appropriate leaflets and posters in the waiting area

  • the service involved young people in the recruitment process for new staff

  • there were enough rooms for young people to meet with professionals

  • rooms were clean, bright and created a relaxed, therapeutic environment

  • staff told young people if things went wrong

  • people with disabilities, including wheelchair users, could access the unit

  • the multi-disciplinary team consisted of a good range of disciplines, who were happy working in the team.

  • the service had systems to ensure staff received mandatory training, appraisal and supervision

  • staff received specialist training in recognised and recommended psychological interventions

  • staff had a working knowledge of the Mental Health Act and Mental Capacity Act

  • staff received safeguarding training and had a clear understanding of their responsibilities in relation to this

  • risk assessments were comprehensive and up to date

  • staff used clinical outcome measures to monitor young people’s progress

  • the service had a process for dealing with complaints and made sure staff learned lessons from them

  • staff could describe the duty of candour and the importance of it

  • staff informed us they felt confident raising concerns without fear of victimisation

  • staffing levels were adequate, and at the levels commissioned. Vacancies were actively being recruited to

  • staff knew who the senior managers were within the organisation

  • managers were supportive and visible

  • staff understood and followed the procedures on lone working.

However:

  • Four out of seven care records we reviewed did not contain a current plan of care.

  • Six out of seven records were incomplete and inconsistent with limited up to date information and, in some cases, gaps of up to two years in the notes

  • care plans were not recorded electronically, which made it difficult to access all information

  • staff recorded notes on an electronic system so each young person had two sets of notes making it difficult to access all the information. The different types of notes put young people and staff at risk because vital information could be missed

  • there were no records of face to face contacts, assessments or therapy sessions.

Reference: not found

Updated 30 October 2015