Cornwall Partnership NHS Foundation Trust

Updated 22 July 2022

We carried out this short notice announced comprehensive inspection of acute wards for adults of working age and psychiatric intensive care unit (PICU), community-based mental health services for adults of working age, specialist community mental health services for children and young people and child and adolescent inpatient wards of this trust as part of our continual checks on the safety and quality of healthcare services. At our last inspection we rated the provider as good.

We also inspected the well-led key question for the trust overall. We inspected four services and rated one as good (child and adolescent inpatient wards) and three as requires improvement (acute wards for adults of working age and psychiatric intensive care unit (PICU), community-based mental health services for adults of working age and specialist community mental health services for children services). Overall, we rated safe, effective, responsive and well led as requires improvement. We rated caring as outstanding.

We also inspected the trust's urgent and emergency care services in February 2022 as part of our urgent and emergency care programme. The service was rated good. This report is published separately on our website.

Cornwall Partnership NHS Foundation Trust delivers community health, mental health and learning disability services to people living in Cornwall and the Isles of Scilly. Cornwall and the Isles of Scilly have a population of 545,000 with a higher than average aging population. This increases by an average of 300,000 during the summer holidays with a total of 41 million visitors per year. The trust runs over 80 services in 130 sites across Cornwall and the Isles of Scilly. The trust has over 4,300 inpatient admissions annually across the 12 community health hospital sites and over 550 inpatient admissions to the mental health wards. The trust operates ten minor injury units with over 93,000 attendances per year. The trust employs over 4,100 staff.

Our rating of services went down. We rated them as requires improvement because:

• We rated safe, effective, responsive and well-led as requires improvement.
• We rated one of the trust’s services as good. This was the child and adolescent mental health ward (which had not previously been inspected). We rated acute wards for adults of working age and psychiatric intensive care unit as requires improvement overall, with an inadequate rating in the safe domain. This had gone down from the rating of good given at our inspection in February 2018. We rated community-based mental health services for adults of working age as requires improvement. This had gone down from the good rating given at our last inspection in April 2019. We rated specialist community mental health services for children and young people as requires improvement, with an inadequate rating in safe. This had improved from the overall inadequate rating given following our inspection in April 2019. In rating the trust overall, we included the existing ratings of the nine previously inspected services.
• We found environments at a number of the locations we visited to be in poor condition and not fit for purpose. This was a safety risk for patients using these services. On the acute wards for adults of working age and psychiatric intensive care unit the ward environments were not well maintained which caused staff difficulties in safely managing patients within the environments. For example, we found a ligature risk assessment on one ward that was not up to date and on two of the wards there were blindspots. On each ward there were areas of the environment that were not safe or were unfit for purpose and posed risks to the safety of the patients. All the wards we visited needed updating and maintenance work completed to make them more safe, therapeutic and comfortable for patients. For example windows on two of the wards were damaged and had been requiring repair for some months. In the specialist community mental health services for children and young people not all of the premises where young people were seen were safe, clean, well equipped, well maintained and furnished and fit for purpose. Only half of the services visited had environmental risk assessments. In one location there were ligature points such as screws protruding from the walls. In the same location furniture was not compliant with fire regulations. In the community-based mental health services for adults of working age not all of the locations we inspected were fit for purpose and required maintenance work to be undertaken. Three of the six teams inspected were located in premises that required maintenance works to be completed for issues such as damp, poor décor and damaged walls.
• The trust’s estates issues were a key risk to the organisation. The trust was experiencing significant challenges arranging maintenance works across the service. The trust only owned 16% of their estate and in some locations were reliant on external contracts. There were ongoing issues in the management of external contacts to ensure appropriate repairs were carried out in a timely fashion. Some locations were operated through PFI providers. The trust had been experiencing significant difficulties in getting the PFI provider to complete maintenance in a timely manner. The trust informed us that they believe PFI’s were performing at a standard that was considerably below the standard expected in all areas. The trust had engaged NHSE/I, DHSC and the Cabinet office to support rectification of this situation. The estates team were working through these issues and in the process of developing a strategy.
• The trust were facing workforce issues and a number of the teams we visited did not have enough staff and high vacancy rates. In the community-based mental health teams for adults of working age teams had only between 40% and 60% of the staff they should have. As a consequence, there were long waiting lists for patients to be seen and long waits for a range of therapies due to a lack of clinical psychologists and occupational therapists. The specialist community mental health services for children and young people had similar issues with staffing and the teams were not always able to provide treatments as the teams did not have access to the full range of specialist staff. Young people on the external waiting lists were not always monitored to detect, and respond to, increases in their level of risk. The acute wards for adults of working age and psychiatric intensive care unit had high vacancy rates for registered nurses and healthcare assistants. The services had to use high numbers of agency staff to ensure shifts were filled. Patients’ escorted leave or activities were often delayed or cancelled as there weren’t enough staff to facilitate these. In addition, the wards could not always provide patients with timely access to the full range of treatment and therapy options due to a lack of clinical psychologist.
• As part of a governance review it had been identified there were issues in the way the trust was managing and investigating complaints. The trust was not classifying complaints and concerns accurately with a risk of complaints not being reviewed and investigated in line with requirements. The trust had 254 complaints open, 176 of these were outside the trust target of 60 days.
• The trust did not have a current strategy which clearly defined objectives and deliverables aligned to trust and partner strategies. The trust also had a number of strategies which were out of date at the time of the inspection, this included the estates strategy and financial strategy.

However:

• We rated the caring domain as outstanding.
• Since our last comprehensive inspection of the trust in March 2019 there had been significant changes to the trust board and a number of new appointments, including a new chair, chief executive, chief operating officer, chief medical officer, chief information officer, chief nursing officer, executive director of finance and an executive director of corporate affairs and assurance. Several members of the executive board were undertaking their first executive appointments. These board members had been offered a mentor and undertook leadership training.
• The trust executive board had a range of skills and knowledge to perform its role and deliver community health services and mental health services. The trust leadership demonstrated awareness of the priorities and challenges facing the trust and had acted at pace during the pandemic. The trust had been in a critical incident for a prolonged period of time and had been working to manage this situation.
• The trust had reviewed governance arrangements and developed a Governance Improvement Plan (GIP). The work around governance identified a number of areas that required improvement. This work had been on going and a significant number of areas related to governance had been incorporated into the GIP. Improvements were on going and were in the process of being embedded to support the overall governance structure of the organisation.
• The director of governance had identified areas of improvement required around risk management within the trust. An internal audit had validated these findings. The trust had taken steps to address this and developed a new risk management strategy which incorporated policy requirements. The implementation of the policy trust wide was early in its adoption and the trust were in the process of embedding a new risk management structure. There was a positive change in the risk culture apparent in the trust. Risk management had been a key focus for the trust and it was evident this work was gathering pace.
• The trust had responded positively to previous inspection findings in 2019. For example, we saw improvements in the way the specialist community mental health services for children and young people age monitored patients on the internal waiting lists to keep them safe and respond to changing risks. This service had been rated inadequate in our previous inspection.
• The trust leadership team had actively engaged with staff following negative staff survey results. The chair had commenced a culture review when new in post and recognised the need for this work with staff. The review had given staff the chance to share their views with the leadership team and make suggestions about improvements they would like to see being made. The leadership in the organisation had developed a plan to address the views and concerns of staff following the findings of the review in the form of a ‘You said, We did’ action plan.
• The trust had introduced a Patient Leader programme. The programme had recruited and trained a number of patient volunteer leaders to ensure the patient and public voice was well represented in all aspects of service design and delivery. Patient leaders supported and co-produced quality improvement projects, review of services and participated in staff recruitment.
• The board were committed to quality and inclusion. There was an active focus on equality, diversity and inclusion represented at board level. There were several staff networks who met regularly.

How we carried out the inspection

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic including on site and remote interviews by phone or online.

We visited six of the trust’s community-based mental health teams for adults of working age, we visited the West, Central and North East locality teams for the specialist community mental health services for children and young people, we visited the child and adolescent mental health ward and four acute wards for adults of working age and psychiatric intensive care unit (PICU).

During the community--based mental health teams inspection, the inspection team:

• visited six ICMHTs (integrated community mental health team) over three days visiting the Team bases and speaking with multidisciplinary team members within each of the teams
• spoke to all managers leading each of the teams
• spoke to the overall teams community matron for service
• interviewed six nurses
• reviewed the quality of the environments
• conducted three staff focus groups with 17 staff members including, employment coordinators, clinical lead occupational therapy, occupational therapy student, nurses, administrative staff, social workers, preceptorship mental health nurse and clinical psychologists
• reviewed six clinic rooms
• spoke to six patients
• reviewed 34 care and treatment records including risk assessments.
• reviewed two team meeting minutes
• attended two multidisciplinary team meetings
• looked at a range of policies and procedures.

During the specialist community mental health services for children and young people inspection, the inspection team:

• visited the West, Central and North East locality teams. We also interviewed staff from the eating disorder service, the learning disability team, the intensive support team and the access team
• interviewed the manager for each team and the overall service managers
• reviewed 18 care records
• spoke with three young people and seven parents or carers
• spoke with 26 staff from all the teams
• reviewed a number of policies, meeting minutes and assessments related to the running of the services
• observed two therapy sessions
• observed several staff members in two multidisciplinary team meetings

During the child and adolescent mental health ward inspection, the inspection team:

• visited the site and looked at the quality of the ward environments and observed how staff were caring for young people
• spoke with six young people who used the service and six parents and carers
• reviewed five electronic and paper copies of care and treatment records
• spoke with 11 members of staff including a specialist paediatric pharmacist, the operational lead for inpatient CAMHS (child and adolescent mental health services) and urgent care pathway, a speciality doctor, a family therapist and family liaison officer. We also spoke to healthcare assistants and nurses
• reviewed a range of documents relating to the running of the service
• looked at medicines management, including medicines charts and electronic systems.

During the acute wards for adults of working age and psychiatric intensive care unit (PICU) inspection, the inspection team:

• visited four inpatient wards: Carbis and Perran ward at Longreach House and Fletcher and Harvest ward at Bodmin Hospital. We were unable to enter Cove ward due to an outbreak of COVID-19 on the ward
• spoke with 17 members of nursing staff including registered nurses, health care assistants, agency nursing staff and student nurses
• spoke with seven multidisciplinary team members including occupational therapists, social inclusion officers, pharmacists, and a clinical psychologist
• spoke with leaders of services, including modern matrons, clinical and quality leads, ward managers, a nurse consultant and members of the estates team
• completed a focus groups with mental health advocates that visited the ward
• spoke to members of the estates team
• interviewed 16 patients and five relatives of patients
• reviewed 18 patients’ care and treatment records
• carried out a specific check relating to medication management on the wards and reviewed medicines administration records for 19 patients
• looked at a range of policies, procedures and other documents relating to the running of each service.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 2 July 2019

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

• There were systems and processes to protect patients from healthcare-associated infections. Staff completed risk assessments and the service mostly had suitable premises and equipment. However, the completion of patient records varied and learning from incidents were not always shared effectively across teams in different areas.
• The service delivered care based on current national guidance. Many specialist services used outcome measures to evaluate the effectiveness of care and treatment. There was good multidisciplinary working across all localities although it was a challenge to extend specialist services to the Isles of Scilly.
• Staff were compassionate, and patients told us staff were kind and delivered exemplary care. Staff supported patients’ carers.
• Staff took account of each individual’s care needs. Referral to treatment times were mostly met and referrals were triaged using effective processes. The service did not receive many complaints about care from patients and their relatives.
• Leadership and governance structured had strengthened. Managers promoted a positive culture and most staff told us they felt valued.

Updated 2 February 2018

Overall, community health services for children and young people were good. We rated all five domains as good.

Cornwall Partnership NHS Foundation Trust provides community health services for children and young people and families across Cornwall and the Isles of Scilly.

During the inspection, we spoke to 49 staff including managers, nursing staff, allied health professionals and health visitors. We also spoke with people who use the services including eight parents and staff from other organisations who work with the service. We reviewed 15 sets of patient records and observed staff providing care for children, young people and their families in a variety of settings including clinics, schools and homes.

We found

• There was an open reporting culture which supported staff to learn from incidents and improve services they delivered.

• Patient records and medications were kept securely and confidentiality was maintained at all times.

• Staff were busy but had strategies to manage their case loads safely and were supported by their managers to do so.

• Vulnerable families and safeguarding issues were given priority with safety for patients embedded in practice.

• Staff followed national guidelines to deliver effective care and worked well with other agencies to provide a seamless service for children and their families.

• Staff kept the patient at the heart of what they did and understood how they could deliver services to meet children’s needs.

• Emotional support was offered to patients and their families in a way patients would be able to accept. Staff ensured patients understood their options.

• Services were planned using information from a variety of sources, to inform their decision making. Where staff identified gaps in services they worked together to provide further access for patients.

• Managers made difficult decisions to provide these services in times of financial constraint but maintained their vision of retaining staff numbers and working in collaboration with other agencies.

• Leadership teams provided good informationto staff about challenges and developments about the service although some staff felt this took a long time to filter through to them.

• Good governance procedures gave senior managers oversight of the service and how well it was performing. Systems were in place which fed this information to the local authority commissioners but was not routinely fed back to staff.

However

• We witnessed some occasions when handwashing practices were inconsistently carried out be staff.

• Some of the premises not owned but used by the service were in need of repair or decoration.

Updated 2 July 2019

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

• Staff recorded patient risks and completed comprehensive risk assessments. Staff understood safeguarding processes and knew how to report abuse. Staff reported incidents and learned from them.
• Staff across all wards followed national guidance when providing care to patients. The ward teams worked well together when planning, assessing and managing patient care.
• Staff were highly motivated and delivered compassionate care to patients. Staff treated patients with dignity and respect. There were good interactions between staff and patients. Feedback from patients and carers was positive. The trust sought feedback from patients and carers to improve service delivery. Staff were considerate of patients spiritual, cultural and religious beliefs.
• Each ward had clear admission criteria which staff understood. Patients were able to make choices about their care. Care and treatment were delivered in collaboration with health and social care providers to meet the needs of patients. Patients were able to raise concerns and staff reviewed and acted upon these appropriately
• Staff felt supported by the leadership within the trust. The trust had a vision and strategy which staff within the services understood and signed up to. The service had a system of governance in place to improve the quality of care provided to patients. The trust engaged well with staff, patients and carers.

However:

• Cleanliness on four wards at three hospitals was not good enough. There were gaps in cleaning rotas, poor compliance with infection control and unhygienic food standards. Equipment was not always maintained well.
• Staffing levels on two wards at two hospitals was not always met and shifts were unfilled. This created additional pressure on staff.
• There were some gaps in the recording of patients’ capacity to consent.
• Staff found the electronic rostering system frustrating and time consuming to use.

Updated 2 July 2019

• Staff completed and updated risk assessments for each patient and responded when the patient’s condition deteriorated. Community staff kept detailed records of patients’ care and treatment. The services followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medicines at the right dose at the right time. In the wards and community there was timely access to equipment to support patients at the end of life. Nutrition and pain needs were met. The service adjusted for patients’ religious, cultural and other preferences.
• The community service had enough nursing and medical staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. Doctors, nurses and other healthcare professionals supported each other to provide good care. Staff worked collaboratively with other health professionals and across healthcare disciplines to ensure continuity of specialist and individualised care for patients.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers monitored the effectiveness of care and treatment and used the findings to improve them. Audits were completed on the wards through the guidance of the end of life care facilitator, and in the community by the specialist palliative care teams.
• The trust set a target of 85% for completion of mandatory training. The compliance for mandatory training courses at 30 November 2018 was 78%. Of the training courses listed, 15 failed to achieve the trust target. End of life staff confirmed they had completed the mandatory training and found it relevant and helpful. Further specific training was provided to staff to support end of life care. Staff all confirmed they felt supported in their development and had supervision in the last year.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent. Since our last inspection in 2017 a review had taken place of the treatment escalation plan, this is a form for clinical guidance which includes mental capacity and agreed ceilings of care. Audit results showed an improvement in completion.
• Staff cared for patients with compassion. Patients gave feedback that staff treated them well and with kindness. Throughout our inspection we observed patients being treated with the highest levels of compassion, dignity and respect. Staff provided emotional support to patients to minimise their distress and involved patients and those close to them in decisions about their care and treatment.
• The trust planned and provided services in a way that met the needs of local people. The service took account of patients’ individual needs. The trust worked with stakeholders, including commissioners and other providers, to promote end of life care across the county.
• The service treated concerns and complaints seriously, investigated them, learned lessons from the results, and shared these with all staff. Complaints were managed in an effective way.
• Leaders at ward level and in the community had the right skills and abilities to run a service providing high-quality sustainable care. The trust had a vision for what it wanted to achieve and was working on plans to turn it into action. In Cornwall the work on an end of life strategy was being implemented as part of a whole system approach.
• End of life leads across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. We found there was a positive culture across the services we visited.
• The trust used a systematic approach to monitoring and improving the quality of its end of life services.
• There were systems to ensure end of life services were monitored and appropriate action taken to improve services. The service had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust had recently implemented an end of life risk register.
• The end of life service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
• The end of life service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

• At Camborne Redruth, Newquay, Helston, Bodmin, St. Mary’s and Falmouth hospitals, end of life care plans were not consistently used and the care plans were not as personalised as they could have been.
• Care and treatment was not always provided in accordance with national guidance. The Gold Standards Framework system was in place across the service but was not used consistently used. At Camborne, Redruth, Newquay, Helston, Bodmin, St. Mary’s and Falmouth hospitals, staff did not fully complete the Gold Standard Framework care plans.
• The Continuing Health Care Team provided by the trust was only available in part of the county. The trust was only commissioned to provide this service for part of the county. This meant that the team, that covered the middle of the county, could provide a more responsive and accessible service although good care was provided in all areas of the county Training was not consistently provided across all areas of the county. Nurses on the Isles of Scilly required update training for both syringe drivers and verification of death.
• The trust leadership was not visible to all the end of life care service. Changes were planned following staff feedback, which would see the process being updated.

Updated 27 May 2022

Cornwall Partnership NHS Foundation Trust provides urgent care at 10 minor injury units located across the county. Minor injury units (MIUs) provide treatment and advice on a range of minor injuries and illnesses not serious enough to require accident and emergency department treatment.

Our inspection was a short notice announced inspection so we could check if all sites were accessible on the day of inspection. We had a focus on the urgent and emergency care pathway for patients across the integrated care system in Cornwall. We carried out a comprehensive inspection of this service so we could provide a rating of the service.

A summary of CQC findings on urgent and emergency care services in Cornwall

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Cornwall below:

Cornwall

The health and care system in this area is under extreme pressure and struggling to meet people’s needs in a safe and timely way. We have identified a high level of risk to people’s health when trying to access urgent and emergency care in Cornwall. Provision of urgent and emergency care in Cornwall is supported by services, stakeholders, commissioners and the local authority and stakeholders were aware of the challenges across Cornwall; however, performance has remained poor, and people are unable to access the right urgent and emergency care, in the right place, at the right time.

We found significant delays to people’s treatment across primary care, urgent care, 999 and acute services which put people at risk of harm. Staff reported feeling very tired due to the on-going pressures which were exacerbated by high levels of staff sickness and staff leaving health and social care. All sectors were struggling to recruit to vacant posts. We found a particularly high level of staff absence across social care resulting in long delays for people waiting to leave hospital to receive social care either in their own home or in a care setting.

GP practices reported concerns about the availability of urgent and emergency responses, often resulting in significant delays in 999 responses for patients who were seriously unwell and GPs needing to provide emergency treatment or extended care whilst waiting for an ambulance. GPs also reported a lack of capacity in mental health services which resulted in people’s needs not being appropriately met, as well as a shortage of District Nurses in Cornwall.

A lack of dental and mental health support also presented significant challenges to the NHS111 service who were actively managing their own performance but needed additional resources available in the community to avoid signposting people to acute services. The NHS111 service in Cornwall worked to deliver timely access to people in this area, whilst performance was below national targets it was better than other areas in England.

Urgent care services were available in the community, including urgent treatment centres and minor illness and injury units and these services were promoted across Cornwall. These services adapted where possible to the change in pressures across Cornwall. When services experienced staffing issues, some units would be closed. When a decision was made to close a minor injury unit (MIU) the trust diverted patients to the nearest alternative MIU and updated the systems directory of services to reflect this. However, this carried a potential risk of increased waiting times in other minor injury units and of more people attending emergency departments to access treatment. This had been highlighted on the trust’s risk register.

Due to the increased pressures in health and social care across Cornwall, we found some patients presented or were taken to urgent care services who were acutely unwell or who required dental or mental health care which wasn’t available elsewhere. Staff working in these services treated those patients to the best of their ability; however, patients were not always receiving the right care in the right place.

Delays in ambulance response times in Cornwall are extremely concerning and pose a high level of risk to patient safety. Ambulance handover delays at hospitals in the region were some of the highest recorded in England. This resulted in people being treated in the ambulances outside of the hospital, it also meant a significant reduction in the number of ambulances available to respond to 999 calls. These delays impacted on the safe care and treatment people received and posed a high risk to people awaiting a 999 response. At the time of our inspection, the ambulance service in Cornwall escalated safety concerns to NHS England and NHS Improvement.

Staff working in the ambulance service reported significant difficulties in accessing alternative pathways to Emergency Departments (ED). When trying to access acute assessment units, staff reported being bounced back and forth between services and resorting to ED as they were unable to get their patient accepted. Many other alternative pathways were only available in specific geographical areas and within specific times, making it challenging for front line ambulance crews to know what services they could access and when. In addition, ambulance staff were not always empowered to make referrals to alternative services. The complexity of these pathways often resulted in patients being conveyed to the ED.

Hospital wards were frequently being adapted to meet changes in demand and due to the impact of COVID-19. There was a significant number of people who were medically fit for discharge but remaining in the hospital impacting on the care delivered to other patients. The hospital had created additional space to accommodate patients who were fit for discharge but were awaiting care packages in the community; however, staff were stretched to care for these patients.

Delays in discharge from acute medical care impacted on patient flow across urgent and emergency care pathways. This also resulted in delays in handovers from ambulance crews, prolonged waits and overcrowding in the Emergency Department due to the lack of bed capacity. We found that care and treatment was not always provided in the ED in a timely way due to overcrowding, staffing issues and additional pressure on those working in the department. These delays in care and treatment put people at risk of harm.

In response to COVID-19, community assessment and treatment units (CATUs) had been established in Cornwall. These wards were designed to support patient flow, avoid admission into acute hospitals and provide timely diagnostic tests and assessments. However, these wards were full and unable to admit patients and experienced delayed discharges due to a lack of onward care provision in the community.

Community nursing teams had been recently established to support admissions avoidance and improved discharge. This work spanned across health and social care; however, at the time of our inspections it was in its infancy so we could not assess the impact.

The reasons for delayed discharge are complex and we found that discharge processes should be improved to prevent delays where possible. However, we recognise that patient flow across the Urgent and Emergency Care pathway in Cornwall is significantly impacted on by a shortage of staffed capacity in social care services. Staff shortages in social care across Cornwall, especially for nursing staff, are some of the highest seen in England. This staffing crisis is resulting in a shortage of domiciliary care packages and care home capacity meaning many people cannot be safely discharged from hospital. A care hotel has been established in Cornwall providing very short-term care for people with very low levels of care needs; this is working well for those who meet the criteria for staying in the hotel, however this is a relatively small number of people.

Without significant improvement in patient flow and better collaborative working between health and social care, it is unlikely that patient safety and performance across urgent and emergency care will improve. Whilst we have seen some pilots and community services adapted to meet changes in demand, additional focus on health promotion and preventative healthcare is needed to support people to manage their own health needs. People trying to access urgent and emergency care in Cornwall experience significant challenges and delays and do not always receive timely, appropriate care to meet their needs and people are at increased risk of harm.

Summary of Cornwall Partnership NHS Foundation Trust urgent care service

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

• Staff had training in key skills and had completed the required mandatory training, they understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records.
• Staff triaged patients within national target times and the prioritisation system was clear. The clinical need of the patient dictated the priority in which they were seen. The service had access to mental health liaison and specialist mental health support.
• Staff within the service managed medicines well. They managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment and gave patients pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• The service had enough nursing and support staff to keep patients safe.
• The trust had robust arrangements in place if a minor injury unit had to close due to staffing issues. Patients would be redirected to another minor injury unit to be seen quickly. The trust had highlighted this on the risk register and monitored the impact on patients and on whether it impacted on increased pressure on Emergency Department attendances.
• The minor injury units occasionally stayed open past their commissioned hours in order to support an increase of patients within the system.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Outcomes for patients were positive, consistent and met expectations, such as national standards.
• Staff met daily with ambulance crews, doctors, GPs, clinical specialists and emergency nurse practitioners to discuss patient care and ensure any issues facing any party could be addressed speedily.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. Managers made sure staff received regular wellbeing checks during the Covid 19 pandemic. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Blood pressure machines at Camborne Redruth minor injury unit required safety checks – we found these had not been recalibrated when required in September 2021.
• Staff did not always label medicines supplied to take home with the hospital address.
• We saw that’s some healthcare assistants (HCAs) were not supervised when carrying out certain assessments that required direct supervision by a senior practitioner, for example, when carrying out assessment of head injuries
• Staff working in minor injury units did not have access to the trust’s main shared electronic patient record which caused frustration for staff when trying to access information about a patient who had used other services within the trust.
• Staff working at St Austell minor injury unit were following an out of date printed standard operating procedure for minor injury units.
• Not all staff were receiving regular supervision and appraisals, completion of these had been affected by Covid 19 although managers made sure that staff received regular well being checks
• Community assessment and treatment units had been set up specifically to care for older people which MIU teams could request admission to for local, rapid assessments and treatment. However, these units were full and patients experienced delays to their discharge due to a lack of onward care provision in the community.
• Some staff were not always using approved translators to communicate with patients who required this service.
• The trusts patient advice and liaison service (PALS) did not always respond to patients and families who made complaints about the service in a timely manner.

How we carried out this inspection

We visited six out of the 10 minor injury units at Camborne and Redruth, Helston, Liskeard, St Austell, Bodmin and Newquay. The minor injury units were nurse-led and provided advice and treatment for minor injuries. The full range of services on offer varied greatly, including the treatment of minor illness depending on the staff available and the setting the service was provided in. Primary care medical support was available from a General Practitioner at one minor injury unit, Camborne and Redruth. Patients who needed to access the service were advised to contact NHS 111 by phone or online to find out where they should go and when. These patients were then offered appointments at the most suitable unit. However, patients who turned up without an appointment were still seen and prioritised according to clinical need.

Services were provided in most units seven days a week from 8am to 10pm (Helston 8am to 8pm). Each unit was staffed by registered nurses and/or paramedic practitioners, healthcare assistants and a receptionist. The MIUs employed band six and seven nurses, with band five nurse development posts. Not all units had access to a health care assistant and a receptionist outside of normal working hours and at weekends. Of the 10 minor injury units, nine locations provided X-ray departments. Attendances at the minor injury and illness units fluctuated, with an increased demand during holiday seasons.

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

During the inspection visit, the inspection team:

• visited six of the 10 minor injury units and looked at the quality of the environment and observed how staff were caring for patients;
• spoke with 42 members of staff across the units including: registered nurses, health care support workers, paramedics, administrators and a consultant nurse;
• spoke with 25 patients and one carer;
• looked at 45 patient records;
• looked at the medicines storage and medicines administration records at all sites;
• reviewed local policies, procedures and audits at all sites.
• held a staff focus group for those staff unable to contribute during the inspection.

Updated 22 July 2022

Updated 22 July 2022

Updated 2 February 2018

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

• There were safety procedures and protocols in place that staff followed in relation to personal safety, infection control and medication storage. Each team had access to a full range of experienced health professionals. Caseloads were of a manageable size. There were some staff vacancies and speech and language provision had been placed on the team risk register.

• Staff completed comprehensive assessments of service users which included physical health needs. Staff reviewed the assessments regularly. Staff and service users could easily access a psychiatrist during office hours. Out of office hours psychiatric help was only available as part of the general psychiatry on call rota. In April 2015, we said that the trust should discuss with commissioners out of hours provision. Team managers we spoke to told us that following the April 2015 inspection they had reviewed learning disability contacts to the out of hours service and found that the impact of not having a learning disability specific psychiatrist on call had a limited impact. There had been two contacts over three months.

• There were evidence based care pathways in place that led to the development of personalised care plans.

• In April 2015, we said the trust should continue to improve working relationships with the adult social care service to further develop the model of care in line with current and projected population changes. During this inspection, we found that the teams had effective working relationships with other services. However, staff felt that moving away from the co-location model had not helped maintain these relationships.

• The team had addressed the risk of over-use of psychotropic medication in learning disabilities, by introducing innovative practice such as the purple book. The purple book was a record that the service user could carry that showed what medication they had been prescribed and why.

• Service users and carers reported that staff always treated them with respect and that they were involved in their care. The teams showed learning from complaints. Staff had recorded service user involvement in the electronic record. Service users had helped develop the service by being on interview panels and the learning disability advisory group. Staff recorded communication needs on the electronic record as an alert and the teams had trained communication champions across Cornwall.

• There were no waiting lists and the teams met their targets for referral to treatment times. Staff had made reasonable adjustments to appointments to meet the needs of the service users.

• During the April 2015 inspection, we told the trust that it should ensure that all staff and team managers have access to well-structured and effective support and supervision through the re-design process, with a clear plan to monitor and undertake impact assessments on staff health and wellbeing. During this inspection, we found that managers gave staff regular structured supervision.

• Staff reported team morale as good and staff felt they could approach their managers if they needed to raise an issue. Staff felt they had the opportunities to input into service development.

• Team managers had put plans in place to monitor and review risks to service provision, particularly around staffing.

Updated 2 February 2018

We rated community-based services for older people as good because:

• Staff were risk aware, and despite a low number of serious incidents, staff demonstrated an understanding of how to report, deal with and learn from incidents.
• Staffing levels were sufficient to meet the needs of the patients.
• Staff demonstrated a good understanding of safeguarding.
• Care plans were completed well and involved the patients and carers in the process, and were made in accordance with National Institute for Health and Care Excellence guidance. Risk assessments and crisis plans were completed comprehensively to ensure safety.
• Patients were monitored effectively and supported. If their needs changed, staff took appropriate action, utilising the necessary assessment tools to ensure appropriate care was provided.
• Staff were skilled in their jobs and there were tools in place to ensure professional development.
• Staff demonstrated that they went over and above the call of duty, for example staying beyond their working hours. They exhibited a passion and enthusiasm for their job in delivering care of the highest standard, and this was supported by testimonials from patients and carers.
• There was no waiting list at the service due to the efficiency with which referrals were handled.
• Support was offered to patients in various forms, from providing information, intermittent assessment and treatment, increasing accessibility to premises and a complaints process.
• The service was well-led with visible management. Performance was monitored and training, supervision and appraisals were all offered to staff.
• Good governance was displayed through reviewing and learning from incidents, complaints and practice within the service.

However:

• Some actions from the previous inspection had not been addressed. There was still limited psychology input and there was no formal out of hours support.
• The environments did not always appear to be well maintained, for example the environment at Penzance appeared tired and in need of updating.

Updated 2 February 2018

Updated 2 February 2018

We rated forensic inpatient/secure wards as good because:

• The ward provided safe care. Despite a number of ligature point being evident on the ward staff had received training on managing ligature risks and staff were able to tell us where the high-risk ligature anchor points and ligatures were and how these risks were mitigated and managed. There was a good sense of relational security. A low level of restrictive interventions and serious incidents had occurred in the last 12 months. Patients and carers told us the ward felt safe.
• There was a stable team. There were sufficient skilled and experienced staff to deliver care to a good standard and the staffing rotas indicated that there was always sufficient staff on duty. There were low staff vacancies on the wards.
• The staff team worked collaboratively with patients. Morale was good; staff appeared motivated and told us they felt well supported.
• There was a good understanding of and adherence to legal requirements such as the Mental Health Act, Mental Capacity Act and safeguarding.
• There was an embedded multi-disciplinary approach to patient care. Assessments and care plans were comprehensive and patients were involved in discussions about risk. There was a recovery-focussed approach to care and staff considered and responded to carer’s needs and concerns.
• There were good incident reporting and monitoring processes. There was learning and changes in practice following incidents.
• There were good links with other agencies and providers in the southwest.

However:

• There were challenges in providing free access to fresh air for patients because the garden had not been maintained and the anti-climb rollers on the roof were rusty. As a result, patients could not use the garden unless there were two members of staff with them. The private finance initiative landlord was responsible for this maintenance and despite every effort by the trust the landlord had not made the required improvements in a timely manner. The trust was actively continuing to address this issue.
• Staff had difficulties accessing some key training.

Updated 2 February 2018

We rated Long stay/rehabilitation mental health wards for working age adult as outstanding because:

• Staff focused on ensuring the safety of patients through assessing the patients, and the environment. These risk assessments were comprehensive and updated regularly to help staff provide safe care. If things did go wrong, staff would give patients a sincere and prompt apology and keep them informed on steps taken to prevent it from happening again.
• Systems were in place to ensure that the ward had adequate staffing. Staff were skilled and experienced at delivering care in that environment. Although there was some difficulty in obtaining places on training courses, staff demonstrated knowledge that meant patients could receive high quality care.
• Patients and staff co-created care plans that were holistic and recovery centred. Staff supported patients to set goals to help them reach their objectives, and provided a range of activities and nationally recommended therapies to help them to do this. Staff had continued to use the protocols for patients to self-administer their medicines safely that we had seen on the last inspection. This was still working well in helping patients to become more independent and prepare them for living in the community. They worked to ensure that patients’ wishes about their care were taken into account and were valued.
• Staff had strong links with local services, and had social inclusion workers that helped patients to access training and activities in the community. We saw examples of patients volunteering, gaining employment and entering higher education.
• Patients were only transferred from the ward when they needed care that could be better provided in another setting. The ward was full at the time of inspection and there was one person waiting for a bed. Staff would only discharge patients when there was a suitable placement for them and worked hard to find somewhere where patients could move to without their health deteriorating. The average length of stay was 538 days.
• Throughout our inspection, patients told us that staff were caring and kind and we saw that staff were truly dedicated to giving high quality, person centred care in a respectful way. They had made changes to the ward environment to help protect patients’ privacy, as well as ensuring that the communal areas were well decorated and there were plenty of things for patients to do while they were on the ward.
• Staff benefitted from stable leadership from the ward manager; staff of all levels said that they felt the team was supportive and cohesive. They had a team vision of recovery and the way the they should deliver care that echoed the values of the trust.

Updated 2 July 2019

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

• All staff demonstrated a strong, visible, person-centred culture. Staff were highly motivated and inspired to offer care that was kind, compassionate and promoted patients’ dignity. This was reflected in the way staff interacted with patients, patients care records and during multidisciplinary meetings.
• Patients were active partners in their care. Staff were fully committed to working in partnership with patients and 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 appropriately and clearly. Feedback from all carers was positive and all felt staff went the extra mile.
• Patients had comprehensive assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. Staff developed holistic care plans informed by a comprehensive assessment.
• Patients’ individual preferences and needs were always reflected in how care was delivered. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. The expected outcomes were identified and care and treatment were regularly reviewed and updated. Staff engaged in clinical audit to evaluate the quality of care they provided.
• Staff actively and holistically focussed on the safe and supportive discharge of patients. Despite considerable difficulty in finding placements for patients following discharge staff worked together as a team and with other agencies to support the patients’ safe and timely discharge wherever possible.
• Staff supported patients with family relationships. Families were encouraged to visit their relatives on the ward, there were no restrictions around visiting times. Patients were supported to visit their families at home as appropriate.
• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk thoroughly. Staff managed medicines safely and followed good practice with respect to safeguarding adults at risk.
• 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 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.
• The service was well led and the governance processes ensured that ward procedures ran smoothly. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Updated 22 July 2022

Updated 22 July 2022