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Provider: Cornwall Partnership NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 2 July 2019

Our rating of the trust improved. We rated it as good because:

  • We rated the trust as outstanding overall for the key question, 'are services caring' and as good for effective, responsive and well-led. We rated safe as requires improvement overall. At this inspection we rated one of the seven core services that we inspected as outstanding, five as good and one as inadequate. In rating the trust overall, we took into account the current good ratings for the six services not inspected this time.
  • Staff in the trust had worked hard to address the concerns we had raised at our last inspection. Five services that had previously been rated requires improvement at the last inspection were now rated as good. Community health services including community hospitals and minor injury units had all improved, as had community mental health teams.
  • We rated wards for older people with mental health problems as outstanding due to the way that the staff worked with patients and their families and how they ensured patients moved on to appropriate placements despite a challenging environment which had seen over 200 nursing home beds closed locally since 2016. Staff implemented creative solutions so they could get patients discharged home or into a care placement when there were limited placement options. The complex care and dementia nurse consultant who was also the responsible clinician, actively focussed on the discharge of patients through visiting and educating staff in nursing homes about settling patients post discharge. Occupational therapists supported patients on home visits to support the discharge process.
  • Effective leadership in the community health services and community mental health teams had led to improvements in those services. In particular the positive impact of a GP working as primary care director and a nurse consultant overseeing the pathway in the minor injury units. The consultant nurse for MIUs had reviewed the operating policy since the last inspection and had introduced the same one across all MIUs. This covered staffing, training, and scope of practice. The primary care director also worked as a GP and had helped improve links with other health providers.
  • Recent growth of staff in the pharmacy team meant that clinical pharmacy support was more widely available across the trust in both community and mental health services.
  • The trust had developed innovative approaches to improve dementia services for people who identify as LGBT. A specialist nurse had been awarded a Winston Churchill Fellowship and had visited Australia to learn from work completed there.
  • Improvements had been made to how the trust learnt from deaths. A new suicide prevention training program and learning from how the trust engaged with families following deaths and during the investigation had been completed with a parent’s involvement as part of the team.
  • The trust had an experienced stable senior leadership team with the skills, abilities, and commitment to provide high-quality services. The executives and non-executives presented as a strong unified board.
  • The board and senior leadership team had set a clear vision and values that were at the heart of all the work within the organisation. They worked hard to make sure staff at all levels understood them in relation to their daily roles. This was demonstrated by the work to change the culture of the enlarged organisation and bring the trust together as one following the transfer of the community health services contract to the trust in 2016.
  • The culture of the trust had improved and staff morale was high in the majority of services. Staff felt respected, supported and valued by their managers and the trust.
  • Senior leadership in the trust had improved relationships with partner organisations and were engaging positively in the wider health systems.

However:

  • We had serious concerns about the safety of child and adolescent mental health services in the two of the six teams. The trust did not have clear oversight of the large number of children and young people waiting for treatment, the length of time they had waited nor the level of risks for each of those on the waiting list in the two teams. Despite improvements in other child and adolescent mental health teams the trust was not aware of the impact staff moves to newly developing teams had on the mid and east teams’ ability to deliver a service in a timely manner. Concerns by staff about the level of risk in the service had not been escalated appropriately to trust senior team due to changes in the way the services were managed. As a result of the significant concerns identified on the inspection we issued a section 29a warning notice to the trust. The warning notice served to inform the trust that it must take immediate action to address the serious concerns. The trust responded positively and took immediate action to address the concerns and put plans in place to ensure children and young people received a timely, safe service.
  • There were issues with staffing, cleanliness and infection control at three out of the 13 community hospitals. Not all wards had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trust took immediate action to address the concerns at the time of inspection.

Inspection areas

Safe

Requires improvement

Updated 2 July 2019

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

  • We had serious concerns about the safety of child and adolescent mental health services in the two of the six teams. The trust did not have clear oversight of the large number of children and young people waiting for treatment, the length of time they had waited nor the level of risks for each of those on the waiting list in the two teams. Despite improvements in other CAMHs teams the trust was not aware of the impact staff moves to newly developing teams had on the mid and east teams’ ability to deliver a service in a timely manner. Concerns by staff about the level of risk in the service had not been escalated appropriately to trust senior team due to changes in the way the services were managed. As a result of the significant concerns identified on the inspection we issued a section 29a warning notice to the trust. The warning notice served to inform the trust that it must take immediate action to address the serious concerns. The trust responded positively and took immediate action to address the concerns and put plans in place to ensure children and young people received a timely, safe service.
  • There were issues with staffing, cleanliness and infection control at three out of the 13 community hospitals. Not all wards had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trust took immediate action to address the concerns at the time of inspection.

However:

  • Risk was managed well in the majority of the services that we inspected. For example, there were improvements in the way minor injury units triaged patients since our last inspection. There were clinical protocols for the recognition of a sick adult, sick child, and life-threatening conditions such as sepsis. The trust now had an agreement in place with the local NHS ambulance provider to prioritise these calls from the MIU’s.
  • Staff understood safeguarding and it was managed well across the trust.
  • Recent growth in staff in the pharmacy team meant that clinical pharmacy support was more widely available across the trust in both community and mental health services. Where medicines safety risks were identified, they were actioned and shared appropriately within the trust and with external partners. Learning actions from medicines incidents and audits were shared across the trust.
  • Improvements had been made to how the trust learnt from deaths. A new suicide prevention training program and learning from how the trust engaged with families following deaths and during the investigation had been completed with a parent’s involvement.

Effective

Good

Updated 2 July 2019

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

  • Staff assessed the health needs of all patients. They worked with patients and families and carers to develop individual care plans and updated them as needed. Care plans reflected the assessed needs, were personalised, holistic and recovery-oriented.
  • Staff provided a range of treatment and care for patients based on national guidance and best practice.
  • Services included or had access to the full range of specialists required to meet the needs of patients under their care.
  • The trust made sure staff were competent to undertake their roles. Staff demonstrated competence in their roles. Most staff received timely annual appraisals and regular supervision.
  • The trust had robust arrangements to monitor use of the Mental Health Act from ward to board.

Caring

Outstanding

Updated 2 July 2019

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

  • At this inspection we rated Garner Ward, a ward for older people with mental health problems outstanding. This is the fourth service in the trust that we have rated outstanding for caring. Three other services we did not visit at this inspection were rated outstanding for caring at our last inspection.
  • Staff treated patients with compassion and kindness. Staff were highly motivated and inspired to offer care that was kind and promoted patient’s dignity and privacy.
  • All staff demonstrated a strong visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted patients’ dignity. Relationships between patients who use the services in the trust, those close to them and staff are strong, caring and supportive. These relationships are highly valued by staff and promoted by leaders.
  • Patient’s emotional and social needs were seen as being as important as their physical and mental health needs.
  • Feedback from patients who use the services in the trust, those who are close to them and stakeholders is continually positive about the way staff treat people. People said staff go the extra mile and the care they receive exceeded their expectations.
  • Patients and carers were involved in decisions about their care. On Garner ward staff involved carers through newsletters and tea parties. Ward staff made regular telephone contact with carers to update them about patients’ care.

Responsive

Good

Updated 2 July 2019

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

  • We rated Garner ward, a ward for older people with mental health problems as outstanding in responsive due to the way the nurse consultant and occupational therapist worked with the staff team and families to ensure appropriate placements to move on to despite a challenging environment which had seen 200 care home beds close locally. Staff implemented creative solutions they could get patients discharged home or into a care placement when there were limited placement options. The complex care and dementia nurse consultant who was also the responsible clinician, actively focussed on the discharge of patients through visiting and educating staff in nursing homes about settling patients post discharge. Occupational therapists supported patients on home visits to support the discharge process.
  • The trust had developed innovative approaches to improve dementia services for people who identify as LGBT. A specialist nurse had been awarded a Winston Churchill Fellowship and had visited Australia to learn from work completed there.
  • The trust planned and provided services in a way that met the needs of local people.
  • Services were accessible to all who needed it and took account of patients’ individual needs. Staff helped patients with communication, advocacy and cultural support as and when needed.
  • The trust treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

However:

  • The trust did not have a clear understanding of how many children and young people were waiting for treatment following assessment in two out of the six child and adolescent mental health teams. The trust took immediate action to address the issue when we raised this.

Well-led

Good

Updated 2 July 2019

Our rating of well-led improved. We rated it as good because:

  • There was a culture of improvement across the trust. Staff at all levels in the trust had worked hard to address the concerns we had raised at our last inspection. Five services that had previously been rated requires improvement at the last inspection we have now rated as good and a service previously rated as good was rated as outstanding. Community health services including community hospitals and minor injury units had all improved as had community mental health teams.
  • Effective leadership in the community health services and community mental health teams had led to improvements in those services. In particular, the positive impact of a GP working as primary care director and a nurse consultant overseeing the pathway in the minor injury units.
  • The culture of the trust had improved with high morale in the majority of services. Staff felt respected, supported and valued by their managers and the trust.
  • The trust had an experienced stable senior leadership team with the skills, abilities, and commitment to provide high-quality services. The executives and non-executives presented as a strong unified board. They recognised the training needs of managers at all levels, including themselves, and worked to provide development opportunities for the future of the organisation.
  • The board and senior leadership team had set a clear vision and values that were at the heart of all the work within the organisation. They worked hard to make sure staff at all levels understood them in relation to their daily roles. This was demonstrated by the work to change the culture in community health services and bring the trust together as one organisation following the merger in 2016.
  • The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. The positive culture of learning in the trust was embodied by the response to our warning notice. The trust accepted our findings in full and all levels of staff from the board to members of the CAMHs teams took responsibility, contributing to a comprehensive response detailing what went wrong and how the issues could be addressed.
  • Despite the challenge of the geography, senior leaders made sure they visited all parts of the trust and fed back to the board to discuss challenges staff and the services faced.
  • The trust had a clear structure for overseeing performance, quality and risk, with board members represented across the divisions. This gave them greater oversight of issues facing the services and they responded when services needed more support. There was excellent challenge from non-executive directors.
  • The leadership team worked well with the clinical leads and encouraged divisions to share learning across the trust.
  • The board reviewed performance reports that included data about the services, which divisional leads could challenge. There was strong rigour at board. Non-executive directors were able to act as critical challengers but be supportive at the same time.
  • The trust recognised the risks created by the introduction of new IT and business systems in the services. Staff managed these risks well at ward level.

However:

  • Although the trust had appropriate systems in place to gather data, it was not always presented in a way that would help senior leaders identify areas of concern. The trust board was aware of this and was in the process of looking at new systems and assurance framework to address the gap. Currently data was broken down to ward level for inpatient services which helped identify concerns, but community teams were presented at service level. This meant that the positive performance of four community CAMHs services had masked the issues in the east and mid teams.
  • We were concerned that, in contrast with other services, the local governance systems were not robust enough in the mid and east CAMHS teams to identify issues with waiting times and staffing levels. Local leaders were not able to interrogate systems so could not identify and act on issues; issues raised by staff were not escalated. Senior leaders did not have oversight of the issues in these two teams. The trust took immediate action following the warning notice to manage the risks and engage with staff.
  • Not all of the board had a clear understanding of the level of financial challenge the trust faced despite good challenge from nonexecutive directors and positive action from the director of finance.
  • No strategic overview of patient involvement in the trust was in place.

Checks on specific services

Community-based mental health services for adults of working age

Good

Updated 2 July 2019

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

  • Staff completed and updated risk assessments for each patient and used these to understand and manage risks appropriately. The service responded well to safeguarding concerns and managed patient safety incidents well.
  • Staff developed individual care plans and updated them when needed. Staff provided a range of treatment and care for patients based on national guidance and best practice.
  • Managers ensured they had staff with a range of skills needed to provide high quality care. They supported staff with opportunities to update and develop their skills.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005, seeking support within the team as needed.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs.
  • Teams had worked to reduce their waiting lists, and developed systems and processes to ensure oversight of all people waiting for allocation or support.
  • Managers had the skills and abilities to run the service, and promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

  • Staff did not follow best practice when dispensing and recording medicines. We found a number of errors and omissions in recording information on patient medication charts. Staff did not always recognise medication errors as patient safety incidents and did not report these appropriately.
  • Physical healthcare checks were not carried out for all patients in line with National Institute for Health and Care Excellence guidelines. Staff only carried out routine physical healthcare checks for high risk patients. The service acknowledged that there were improvements to be made in physical healthcare monitoring and support. There were plans in place and actions being progressed to address this at the time of the inspection.

Specialist community mental health services for children and young people

Inadequate

Updated 27 November 2019

This inspection was a focussed inspection so therefore did not provide a rating. The purpose of the inspection was to see if the provider had made significant improvements to the service following the issuing of a section 29 warning notice in April 2019.

  • The trust had recruited to all but two of their vacancies. The trust had employed more than 30 additional clinical associate psychologists to support assessments and an additional quality lead to provide oversight and assurance for team leaders to make the required improvements following the section 29a warning notice. The trust had developed and implemented an escalation plan for managers to use should staffing incidents pose a threat to the safe running of the service. This was being implemented effectively at the time of our inspection. Staff morale was much improved with increased engagement and development opportunities being provided by the trust.
  • Since our inspection in March 2019, every young person on the waiting list had been contacted and their risk reviewed. Urgent and emergency cases were being followed up by the CAMHS crisis team or early intervention in psychosis team as required. The crisis team undertook a thorough assessment including an assessment of risk after the first appointment. Urgent cases were seen within 48 hours. Young people on the waiting list were being contacted regularly to ensure staff were aware of any change in presentation or risk.
  • The trust had developed and implemented new electronic caseloads, with reporting functions, to ensure appropriate management of waiting lists within teams. Waiting times in the mid teams had reduced significantly and were improving in the east teams. The trust had developed an operational plan to address the long waits for a first assessment.
  • Individual staff caseloads were now much lower due to the increase in staffing and transparency in viewing caseloads on the new electronic system. New managers no longer held a clinical role and therefore did not hold the large caseloads we saw during our last inspection.
  • The trust had developed processes which meant they had complete oversight of the key issues raised in the warning notice. Operational managers and other senior members of staff monitored and audited a live waiting list to ensure wait times were reducing and high risk young people were being seen. Staffing issues were now known to the senior management team via a new escalation process and incident reporting and complaints were being monitored through operational governance meetings.
  • All staff had received training and ongoing support in incident reporting, processing complaints and learning from adverse events. Incidents and complaints were now a standing agenda item during team meetings.

However:

  • At the time of our inspection, 73% of young people in the east teams had breached the trust’s target of being seen within 28 days for an initial assessment. Current wait times for a first assessment was 117 days (17 weeks) in the east teams. There were 47 young people waiting for treatment in the east teams who had been waiting for an average of 37 weeks. 54% of young people had breached the trust’s target of 84 days of being seen for treatment following their assessment.
  • The manager for the east teams had several overdue incident reports to review.
  • Some staff in the east teams were not keeping the wait list up to date.

Community health inpatient services

Good

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.

Community urgent care services

Good

Updated 2 July 2019

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

  • Staff in the minor injury units had received training to ensure they could keep patients safe. The staff team followed the correct procedures to keep the MIUs clean and reduce the spread of infection. Staff made sure all equipment was correctly maintained so it was ready for use. Staff recorded patient care and incidents following trust processes. Staff shared learning and apologised for mistakes.
  • All the MIUs worked to the same policies and procedures. Staff assessed pain and gave effective pain relief promptly. The trust collected information from across the MIUs and used it to improve services. The teams worked well together and with other services. Staff considered patients’ capacity before giving care.
  • Staff treated all patients with dignity. Staff were professional when giving care. Staff had made reasonable adjustments to ensure all patients were involved in their care.
  • The staff worked across the MIUs to ensure services were available where needed. Staff worked to meet the needs of all patients. Staff followed procedures so that if patients’ needs changed they recognised this and met them. The trust had addressed the delays in acutely ill patients being transferred by ambulance from the MIUs to the local general hospitals. Patients were advised how to raise complaints with the trust and learning was shared.
  • Staff felt supported by leaders at all levels in the trust. There was a vision for the MIUs and the trust was reviewing the services to ensure it met the community’s needs.

However:

  • Staff at the Helston MIU could not observe all patients as they waited in the waiting rooms due to the layout. Not all the units had separate staff teams and staff occasionally had to stop the treatment of one patient to triage another patient who had just come into the MIU to ensure they didn’t need urgent attention. Not all staff had signed the patient medicines group directions to show they had read and understood them.
  • Not all staff in each of the MIUs had received supervision.
  • It was not clear on the trust’s website when GPs were available at the Camborne and Redruth.

Community health services for adults

Good

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.

Wards for older people with mental health problems

Outstanding

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.

Community end of life care

Good

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.

Community mental health services with learning disabilities or autism

Good

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.

Mental health crisis services and health-based places of safety

Good

Updated 2 February 2018

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

Good

Updated 2 February 2018

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

  • Patients told us that they had been treated with respect and dignity and staff were polite, friendly, and willing to help. Patients told us that staff were nice towards them and were interested in their wellbeing. Staff showed patience and gave encouragement when supporting patients. We observed this consistently throughout the inspection. Patients told us that they were the priority for staff and that their safety was always considered. Patients were involved in their care and all patients had either signed a copy of their care plans or said they did not want to sign the plans. The approach of the staff towards patients was person centred, individualised and recovery orientated. The trust encouraged feedback from patients and satisfaction surveys were available for patients to complete on every ward. On each ward a ‘you said we did’ initiative was advertised on patient information boards and gave examples of staff making changes on the wards in response to patient requests.
  • The wards provided safe care. 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. Staff on each of the acute wards had created areas of the ward for particularly vulnerable patients to use, for example, older adults who may be quite frail. There were sufficient staff to deliver care to a good standard and the staffing rotas indicated that there were always sufficient staff on duty. There were low staff vacancies on the wards. Staff practiced relational security to a high standard and staff actively promoted de-escalation techniques to avoid restraints and seclusion where possible. As a result of this approach, the number of seclusion episodes had decreased by 64% compared to the previous year. The number of restraint incidents had decreased by 6% compared to the previous year.
  • Staff shared risks in the daily handover meetings in a written handover to all staff. The handover was recorded on the electronic system. In addition each ward carried out a daily ‘safety huddle’ which is a nationally recognised good practice initiative to reduce patient harm and improve the safety culture on the wards. The meetings involve all available staff to discuss specific patients’ risks and any potential harm that may affect patients.
  • Staff worked together to provide effective care. In all of the 27 care records we reviewed across the four wards, there were detailed and timely assessments for patients. Staff had assessed all patients for their current mental state, previous history and physical healthcare needs. The care plans were recovery focused. Patients told us that they were included in the planning of their care. Staff used National Institute for Health and Care Excellence guidance when prescribing medicines, in relation to options available for patients’ care, their treatment and wellbeing, and in assuring good standards of physical health care delivery. Patients had discharge plans and told us staff helped them to achieve these plans. Well-staffed multidisciplinary teams worked across the wards. Regular and inclusive team meetings took place.
  • The wards were well led. The senior management and clinical teams were visible and staff said that they regularly visited the services. All staff and patients knew who the senior management team were and felt confident in approaching them if they had any concerns. Governance systems were in place with comprehensive clinical quality audits, human resource management data and data on incidents and complaints. The information was summarised and presented monthly, for managers to measure their progress and achievements.

However:

  • There was one blind spot, impairing staff observation, in the garden area of Harvest ward. There was a risk of patients gaining access onto the low roofs, accessible to patients, in all of the four ward gardens, across both hospital sites. There had been one incident, on Perran ward when a patient climbed onto the roof. The patient came down from the roof voluntarily and was transferred to Harvest ward.

  • The trust should consider, highlighting high dose antipsychotic medicine on medication administration charts, to ensure there is a method to easily alert any nurse administering medicines.

  • The privacy windows in the bedroom doors on Harvest ward did not afford patients privacy and dignity. Patients were not able to close the blinds, when they were in their bedrooms. The doors and blinds had been scheduled for replacement in November 2017, soon after our inspection.

  • There was one incident, involving one patient when staff did not carry out physical observations and record these accurately, post rapid tranquilisation, to reduce the risk of adverse effects.
  • Staff did not always complete care records to reflect discussions on decision specific ‘best interests’ assessments when they have taken place.
  • The locality model on the acute wards was difficult to organise because at any one time there could be between six and 16 different doctors looking after their patients on the wards. This put nursing staff under pressure, to organise and hold several clinical meetings at the same time.
  • Occupancy figures and length of stay figures were high on Carbis and Fletcher wards because a number of patients were on extended leave from the ward under Section 17 of the Mental Health Act.

Community-based mental health services for older people

Good

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.

Long stay or rehabilitation mental health wards for working age adults

Outstanding

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.

Forensic inpatient or secure wards

Good

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.

Community health services for children, young people and families

Good

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.

Reference: not found

Updated 2 July 2019

Reference: Urgent care services not found

Requires improvement

Updated 9 September 2015

We rated this service as requires improvement overall because:

  • Out of hours and at weekends patients were not always kept safe because reception staff were not scheduled to work. This meant that patients with serious or life-threatening conditions may not have been identified promptly. There was also no observation of patients in the waiting room.

  • Risks associated with out of hours staffing and emergency ambulance transfers had not been highlighted at department level and there was no evidence that safeguards were put in place to mitigate these risks.

  • The trust did not record and monitor how quickly patients were assessed by triage or were seen by a nurse practioner. The recording of the time triage started did not include the time patients waited to be booked in and so did not recognise the risk that a serious or life threatening condition may not have been identified promptly.

  • The practice of when the time triage started was not clear and so did not inform the trust accurately. It was unclear in some MIUs when the ‘clock started’ in order to meet the 15 minute triage target. In some MIUs patient records showed that the triage time started and stopped with the receptionist taking the initial booking information. This would indicate that the receptionist triaged the patient when we saw that the nurse or trained health care assistant did the full triage.

  • There was no auditing of the reasons patients attended the units to identify any themes or trends. There were no risk assessments and reviews of the units which presented specific geographical challenges and how they should be managed.

  • Mandatory training compliance did not meet the trust’s target and not all staff received mandatory training in line with trust policy. Due to the amalgamation of two providers, training records were unclear and the trust was still in the process of reviewing them, despite having had 18 months to have completed this. Training attendance was difficult for the staff at St Mary’s MIU on the Isles of Scilly. No systems had been considered to enable staff to remain updated.

  • Staff did not have consistent knowledge of policies and procedures in place to support them to run the service to within the planned opening hours and so staff were delayed in closing the units. There was no planning consideration for planned public events during the holiday season, other than at St Mary’s Hospital. These events meant a substantial influx of visitors to a small town, without consideration of how this impacted on demand for MIU services.

  • The trust website did not reflect when primary service GPs were not available at Camborne Redruth MIU. This meant that patients were not correctly informed about the medical services available and who would be available to see and treat them.

  • Staffing planning systems did not meet the needs or geographical challenges of the region. The rostering of staff at St Mary’s MIU on the Isles of Scilly did not address the locations specific challenges with regard to access to the islands because of the weather.

  • There was a corporate vision and strategy in place for staff but there was no specific minor injury unit vision or strategy in place.

  • Not all premises were suitable for patient assessment, treatment and maintaining confidentiality. Falmouth, Newquay, Bodmin and Liskeard hospitals stored hazardous substances in unlocked sluices, including bleach tablets, cleaning solutions and nail varnish remover. These substances if ingested would be hazardous to health and should be secured.

However:

  • There were systems in place to report, investigate and learn from incidents.

  • Cleanliness, infection control and hygiene were well managed in most of the minor injury Units.

  • Medicines were managed in a way that kept patients safe. Medicines were stored securely.

  • The management of patients’ pain was established as part of triage and treatment.

  • Systems were in place to ensure patients’ information was kept .safe. Records were stored securely.

  • Policies and procedures were in place to support the safeguarding of vulnerable adults and children. Patients’ consent to care and treatment was sought in line with legislation and guidance. Staff had a clear understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.

  • The trust’s policies and services were developed to reflect best practice and evidence-based guidelines. The trust had in place systems to monitor aspects of the service, which included the minor injury and illness units.

  • Staff treated patients with kindness, dignity, and respect. Staff interacted with patients in a positive, professional, and informative manner. The hospital took account of patients’ specific needs and had access to support services.

  • There was a strong ethos of teamwork and staff felt well supported. There was flexibility and willingness among all the teams and staff. Staff worked well together, and positive working relationships existed to support each other.