Cornwall Partnership NHS Foundation Trust

Following the inspection in September 2017, we have rated Cornwall Partnership NHS Foundation Trust as requires improvement because:

• At the time of our inspection, three of the trust’s 13 hospitals were subject to an organisation review under Section 42 of the Health and Social Care Act 2014. This related to a number of safeguarding concerns initially raised under organisation abuse by CFT in April 2016 following the transfer of services from PCH on 1 April 2016. The trust had implemented an action plan to address these concerns; this was ongoing.

• 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. The physical environments at Bolitho House, Truro Health Park and St Austell required improvements; including some basic maintenance and ensuring safe and age appropriate environment for children and young people. Truro integrated community mental health team had not carried out a health and safety audit since 2013. Staff based at Caradon did not know how to activate the emergency alarms. Within some community health services, lone working systems and processes did not ensure the safety of staff. This left staff working on call vulnerable and posed a risk to their safety.
• Some community-based services did not have a sufficient number of staff. Five out of the six integrated community mental health teams that we inspected had vacancies. At the time of the inspection there were approximately 114 patients unallocated for treatment and the trust did not have a clear process in place to monitor these patients. In the minor injuries unit’s reception staff did not work out of core hours or at weekends and there was no observation of patients in the waiting room at these times; there was a risk that patients with serious or life-threatening conditions may not be identified promptly. In the specialist community mental health services for children and young people there was not enough provision of service to provide a safe service for the numbers of children and young people need care.
• Medicines management systems were not robust in all trust clinical settings; not all clinic rooms contained the expected equipment and in some cases where there was medical equipment it was not calibrated or tested in line with the trust policy. None of the six integrated community mental health teams had a robust system in place for the management of medicines. We found out of date medicines and medicines not being stored at the correct temperatures. A fridge in the Bodmin clinic had not had the temperature recorded since November 2016.The cards used to record patient’s depot medicine had essential information missing from a number of cards. In Kerrier, a paliperidone injection box (an anti-psychotic individually prescribed medication), had its patient label removed. Cover provided by pharmacists and pharmacy technicians across the community inpatient service was inconsistent.
• Compliance with mandatory training was low; data provided by the trust up to May 2017 showed that the training compliance for trust-wide services was 54% against the trust targets of either 85%, or 95%.

However, we found the following areas of good practice:

• Staff were positive about working for the trust as an employer and said it encouraged individual services to improve and had a ‘no-blame’ culture. Staff knew who senior managers were and generally felt they were visible. Senior managers and executive board members had visited all locations, though staff on the Isles of Scilly felt distant and at times forgotten by the organisation following several cancelled visits. Non-executive directors had a good understanding of the trust’s strategy and presented appropriate challenge to the executive team.

• There was good assessment and management of risk throughout most services. For example, ligature risk assessments were in place and well managed either by rectifying the issues identified or by actively managing the areas where risk was identified to reduce the risk to patients.

• Generally, the wards and community environments were clean, bright and well furnished. The trust was committed to refurbishing environments that required it. However, at the Bodmin hospital site there were difficulties with refurbishment and maintenance programmes. The site was managed as part of a private finance initiative and the provider struggled to get the landlord to make changes and improvements as required in a timely manner. The trust had taken legal action against the landlord to get improvements made.

• The trust had robust infection control policies and procedures and staff adhered to these across almost all environments.

• Staff delivered care and treatment to patients in a kind, caring manner that respected their dignity. Where concerns had been expressed by patients and carers this had been addressed appropriately and in line with the expectations of duty of candour. Staff described an awareness of the need to be open and apologise to patients when necessary.

• There was a strong commitment to patient safety, the community team for learning disabilities and autism would routinely follow up service users discharged from their service to identify any changes to their epilepsy. This aimed to reduce cases of sudden death in epilepsy.

• The majority of the patients that we spoke with on the wards were positive and complimentary about the support they received from staff. Staff interacted with patients positively and respectfully. They demonstrated that they knew the patients well in their interactions with patients and in their responses to them. This was particularly apparent on Fettle ward where there were many opportunities for patients to have their voice heard and staff helped them realise their potential. Staff truly valued patients emotional and social needs and were committed to helping them recover in a meaningful way.

• Care plans mostly documented patients’ wishes and feelings about their treatment with the exception of the community mental health teams where there was a lack of recording to show that the patient had been involved in developing their care plan. Where it was appropriate carers and family members were involved in the care planning process. Staff referred carers for assessments and advocacy support when needed.

• The trust had processes in place to identify and report serious incidents. Risks were generally well managed across most services with locally held risk registers that fed into the trust wide risk register. There were robust processes in place to review risks at both local and trust level and plans were agreed at board level to reduce significant risk across the organisation.

Overall we rated community inpatient service as requires improvement because:

• Staffing levels across the service were inconsistent. There were high levels of vacancies, which, despite a high agency and bank staff use, resulted in unfilled shifts.
• Feedback from incidents was not provided promptly.
• Storage of medicines was not always safe.
• Cover provided by pharmacists and pharmacy technicians across the service was inconsistent.
• The recording of equipment across the service was not always effective which presented safety issues.
• There were delays in repairing and replacing equipment.
• Processes for checking resuscitation trollies were not always followed across the service.
• Safety issues occurred in relation to infection, prevention and control measures as process were not always adhered to.
• Staff did not always follow policy, guidance and legislation regarding the Mental Capacity Act as documentation was not always completed.
• Clinical supervision was not formalised or embedded across the service.
• Managerial supervision was inconsistent.
• Patients using the community hospital alcohol detoxification service were receiving treatment from staff who had not received the appropriate training.
• The training offered by the service was not easily accessible to all staff.
• Confidential patient matters were not always kept private as telephone conversations could be heard when taking place at nurses’ stations.
• Some patients were left without assistance during mealtimes.
• The senior management team did not always communicate important information, regarding changes to services at community hospitals, to ward staff.
• There was limited engagement with ward staff regarding significant decisions regarding the hospitals they worked in.
• The processes for identifying, managing and mitigating risk were not effective.
• The vision, strategy and specific values of the community inpatient service were not known by all staff.

However,

• Incident reporting was encouraged and staff were supported to do so by their supervisors and service leads.
• The duty of candour was understood by all and applied in all appropriate circumstances.
• An organisational safeguarding action plan had been implemented and was being followed in response to an increase in alerts regarding staff conduct.
• Record keeping within the service was of a high standard.
• Thorough risk assessments were carried out and mitigated at all appropriate times.
• Assessments were carried out to assess patient’s pain and regularly reviewed to ensure treatment was given to increase comfort.
• Patient nutritional and hydration needs were regularly assessed and reviewed. Appropriate referrals were made to specialists when required.
• Communication and cooperation of staff was good which enhanced the multidisciplinary team working within the service.
• Discharge planning was commenced upon admission and all staff were dedicated to ensuring patients achieved good outcomes.
• Staff were compassionate, kind and sensitive to patient, relative and visitor’s needs.
• Staff communicated with patients clearly and kept them updated on their condition, progress and treatment.
• The service planned and delivered services which met patient needs.
• Staff showed commitment to ensuring patients accessed the right care and treatment at the right time.
• There were low levels of complaints within the service but they were investigated thoroughly.
• There was good local leadership within the community hospitals as leaders were approachable, supportive and visible.
• Safe care and treatment was central to the culture within the service.
• Most staff were happy in their roles which contributed to positive morale on most wards.
• Managers and supervisors addressed any concerns raised by staff.

Overall, we found the community adult service required improvement because:

• Risk assessments, risk management plans and reviews were not being consistently completed by the community nursing teams. Therefore, assessments were not used to respond positively to patient risk or to minimise harm to patients. We saw examples of serious incidents investigations where risk assessments had not been completed for patients.
• Monthly audits for the Titration of Diabetes Medicines by Diabetes Specialist Nurses were not being carried out according to trust policy.
• Learning from incidents was not always shared between the teams. Investigations into serious incidents were insufficient and did not always demonstrate learning had been fully understood. Actions did not demonstrate how learning was to be implemented and embedded into practice. There was little evidence to demonstrate how learning or action was taken to improve safety.
• Compliance with mandatory training was poor and not meeting the trusts target. Compliance with mandatory training was just 36% for the community adult service.
• The sepsis screening tool was not fit for purpose, as the nursing staff did not have the tools identified on the chart to monitor patients for sepsis. The community nursing service was not using a national early warning score to identify deteriorating patients and the trusts sepsis policy was not based on the most recent National Institute for Health and Care Excellence guidelines for sepsis (NG51).
• Staff at the leg clinic were not working in line with the Nursing and Midwifery Council Code Of Conduct: Professional standards of practice and behaviour for nurses and midwives standard 10.4 (2015).
• Risks were not always accounted for or managed appropriately when planning and delivering services. There was a lack of challenge from senior staff with regards to anticipated patient risk during handovers.
• The management of pain was inconsistent and did not always include an appropriate assessment and management plan for patients who were, or could be, experiencing pain.
• There was poor compliance countywide with completion of initial nutrition and hydration assessment for patients.
• Not all community nurses received any formal supervision sessions.
• The process of receiving referrals into the service was not clearly defined.
• Staff were not always compliant with the trust’s consent policy and completion of the consent to sharing information documentation.
• Not all staff provided us with assurance they understood their role and responsibility around the Mental Capacity Act and best interest decisions.
• There were mixed feelings about the senior management team and their understanding about caring for patients with physical problems. However, teams spoke highly of the support from their local managers.
• The governance system needed to be reviewed to ensure processes were standardised and aspects of quality and safety were fully understood.
• Meeting minutes did not demonstrate any depth or quality as to the content of the meeting. Minutes did not demonstrate how incidents were scrutinised for trends to ensure learning was identified, to improve performance and safety for future patients.
• Not all risks to the community adult service had been identified and recorded on the risk register.
• Lone working systems and processes did not ensure the safety of staff. This left staff working on call vulnerable and posed a risk to their safety.
• There was confusion between the community adult service teams with regards to the introduction of a new electronic records system being introduced in November 2017. At the time of our inspection, staff still had not received any training on the new system being implemented.
• Specialist nursing teams were concerned about the future sustainability for their services and the need for financial investment.

However

• Staff understood their role and responsibility to report safeguarding concerns and knew the process to carry this out.
• Patient group directions used by the community nursing teams and the musculoskeletal service were complete, signed and in date.
• Infection, prevention and control practice was adhered to by the majority of the staff.
• Staffing levels, skill mix and caseloads accounted for patient risk and acuity when they were planned and reviewed
• Care and treatment was based on relevant evidence based practice, national guidance and legislation. Staff were able to demonstrate how they were underpinning national guidance to support their practice.
• Audit programmes captured positive information about patient outcomes.
• Teams provided comprehensive training for staff to upskill them in their roles. Staff were competent to carry out their roles effectively.
• Staff received yearly appraisals to determine their development for the following year.
• We saw good examples of multidisciplinary working both internally and also with external partners.
• Patients were consistently positive and complimentary about the care they received. Staff worked hard to empower patients to manage their own health and wellbeing.
• Staff treated patients with kindness, dignity, compassion and respect, and interacted with patients in a respectful and considerate manner.
• Staff ensured patients understood the care and treatment they were receiving and understood the importance of involving family members or carers as partners in their care.
• Patients were given timely support and information to cope emotionally with their condition.
• Where possible, services were planned to meet the needs of the local population. Staff used information about the local population to support the planning for future service delivery.
• Team leads in specialist nursing teams demonstrated knowledge about what their services were commissioned to deliver.
• Services were planned to take into account the needs of individual patients, and staff were non-judgemental in the way they cared for patients.
• Teams delivered services which took into account the needs of patients with complex needs such as learning difficulties and dementia.
• Access to the majority of community adult teams on the whole was timely, and where possible, services prioritised care and treatment for patients with urgent needs.
• Leaders at local level understood the challenges faced by the community adult services and staff felt supported by their leaders at local level.
• A clear vision and strategy had been set out for the service which staff were on board with and able to discuss.
• There was a programme of internal and external audit to monitor quality and performance.
• There was a strong culture of patient centred care.

• Innovative work was being carried out by the specialist nursing teams.       

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.           

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.

Overall, we found that end of life care required improvement because :

• Not all staff were up to date with the required mandatory training. The recording and monitoring of this training meant accurate up to date figures were not available.

• There were inconsistencies in the completion of the patient TEP forms (Treatment Escalation Plan) which could mean

• There was inconsistent understanding on the wards of the GSF (Gold Standards Framework) system being used to monitor and deliver end of life care. We found patients who were coded incorrectly and also staff who did not understand what the various codes related to, in terms of the stages of end of life.

• There was a lack of personalised information being recorded in the care plans for patients. There was little detail completed about any personal preferences or wishes, which may have been identified through discussion with a patient or their family.

• There were inconsistencies in the completion of specific end of life training, and also the levels of training undertaken. There was no record of the training provided by the specialist palliative care teams to other staff, nor any formal plan for what was provided. There was a lack of clarity around how this was organised, and what was available to ward and community staff.

• Staff working for the continuing care at home team were not provided with sufficient training in end of life care.

• There was a lack of clarity for some staff regarding the role of the specialist palliative care teams.

• There was inconsistency in the recording of capacity assessments on the TEP forms (Treatment Escalation Plan).

• There was variable provision for supporting patients in their own homes. The trust ran a continuing care at home team, that was very responsive and could be organised quickly, but this was only commissioned for one locality.

• There was no trust wide strategy group that focused on the implementing of trust policies and initiatives in relation to end of life care. There were no regular formal meetings which involved representatives from all staff involved in delivering end of life care.

• There was a fragmented approach to end of life care, due to a variation in service provision and the lack of visibility of the leadership for end of life care. There was lack of clarity about the future use of the GSF (Gold Standards Framework).

• There was only one end of life care facilitator and they were required to cover a wide geographical area, covering a range of staff teams and different hospitals.

• The trust did not have had an overarching vision for what it wished to achieve in relation to end of life care.

• There was not a bespoke risk register for end of life care. There was no assurance that any potential risks to the effective delivery of end of life care were being identified and recorded.

However:

• The service managed patient safety incidents well. Staff understood how to report incidents and felt confident about reporting them.

• Staff had training on how to recognise and report abuse, and knew how to apply it. Within the services we inspected in relation to end of life care, including the specialist palliative care team and the continuing care at home team, all were up to date with their mandatory safeguarding training.

• Patients receiving end of life care were prescribed anticipatory medicines, and these were well managed by staff. Appropriate and up to date guidance was in place.

• Staff kept appropriate records of patients’ care and treatment. Records were securely stored and patient confidentiality was protected.

• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse, and to provide the right care and treatment.

• Audits were completed to monitor the effectiveness of care and treatment, and the findings used to develop improvements.

• Staff spoke positively about the supervision and support they received from managers. All staff had an annual appraisal, and those requiring clinical supervision were having this completed.

• We observed compassionate care in the approach from all the staff working in the wards and in the community. Feedback from patients was very positive about the caring and professional approach of staff.

• Staff ensured that patients and families were involved in their care and understood their treatment and prognosis.

• Emotional support and information was provided to those close to people who use services, including carers and dependants.

• The trust worked with other stakeholders, commissioners and providers to promote end of life care across the county. There was a county wide strategy group for end of life care which was chaired by the Director of Primary Care.

• Relatives were supported to visit and stay in the community hospitals and most wards could provide side rooms for end of life care patients.

• Ward staff and community teams worked proactively to support patients to achieve their preferred place of care. Audits showed that improvements had been made over the previous 12 months.

• When care packages were available, the ward staff could organise a rapid discharge and could co-ordinate well with the community teams and local GPs.

• There was evidence of good local leadership, with staff speaking positively about their managers and the support and direction of the service.

• Staff were clear about the governance structure within their services, both in the hospitals and in the community teams. There were regular team meetings and opportunities for staff to talk to their managers.

• We found there was a positive culture across the services we visited. Staff were proud of their work and committed to providing high quality end of life care. Managers promoted a culture that supported and valued staff.

• The trust engaged effectively with staff to ensure they were kept informed of changes and developments, and also to provide opportunities to give feedback.

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.

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.

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.

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.

We rated community based mental health services for adults as requires improvement because;

• Staffing levels were not safe. Five out of the six integrated community mental health teams that we inspected had vacancies. The vacancies had affected all five integrated community mental health teams as at the time of inspection, there were approximately 114 patients unallocated for treatment and the trust did not have a clear process in place to monitor these patients.
• The trust had not taken all of the actions to keep staff safe. Truro integrated community mental health team had not carried out a health and safety audit since 2013. Staff based at Caradon did not know how to activate the emergency alarms. The trust did not have an effective process in place to manage risk when staff met with patients that staff had assessed as high risk.
• The provider did not ensure patients receive physical health checks in line with national guidance. The emergency equipment available in each clinic room varied and some of it was out of date. We found four integrated community mental health teams did not have resuscitation masks. Eight of the masks found were out of date. In three integrated community mental health teams the dates recorded on physical health, monitoring equipment had expired. For example, two tympanic electronic thermometers dates expired in March 2015 and December 2015. However, there was no risk to patients, as staff did not carry out physical health checks.
• Staff did not work together with GPs to ensure patients had robust health monitoring in place. None of the six integrated community mental health teams had a robust system in place for the management of medicines. We found out of date medicine. Medicines were not being stored at the correct temperatures. One fridge in the Bodmin clinic had not recorded the temperature since November 2016. The cards used to record patient’s depot medicine had essential information missing from a number of cards. In Kerrier, a paliperidone injection box (an anti-psychotic individually prescribed medication), had its patient label remove.
• Staff recognised that they did not always report incidents. This was because staff had high workloads and did not get the chance to complete the paperwork. In two of the three sites visited, the managers told us they were behind and had outstanding incidents awaiting manager sign off. The September 2017 team brief highlighted there were 203 outstanding incidents.

• The quality and detail of patient risk assessments was inconsistent. We found risk assessments that were out of date. Staff had not updated risk assessments following significant change/incidents involving patients and in particular, five of the 12 records reviewed had no risk assessment.

• Care plans varied in quality, style, and content. There was little evidence that patients had been involved in their care planning. At Carrick, integrated community mental health team seven of the 12 care records reviewed did not contain a care plan, and a further three were out of date.
• Mandatory training attendance was low. Rates across the six locations ranged from 58%-87%, core essential training 66%-77% and other 52%-73%. This included safeguarding training where 52% of staff had attended level two safeguarding training

However;

• The trust responded to the time it took to carry out an assessment by creating a dedicated assessment team. There were six core members of the team with a further six members of staff rotating from their roles within the integrated community mental health team.

• Patients found staff to be kind, polite, respectful, supportive, caring, and encouraging.

• Patients described staff as excellent despite so many organisational changes.

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.

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

• The provider had addressed the issues found in the April 2015 inspection.
• The ward staff team was well led and morale was good.
• Despite the challenges, the team were happy, resilient and supportive of one another.
• Staffing levels were safe but senior nurses had at times stepped down to ward based roles to provide enough staffing to keep the ward safe when bank or agency staff could not be found.
• The service had closed two beds in response to the needs of the current patient group and to ensure that the staffing levels were safe to respond to individual patient need.
• The provider had ensured that mental capacity assessments for cardiopulmonary resuscitation had improved with input from family where the patient had lacked capacity. This was a requirement of the previous inspection. However, one of the cardiopulmonary resuscitation records that we looked at had not been reviewed with the family in a timely way.
• The provider had ensured that there were lasting arrangements for independent mental health advocate input to Garner ward. This included weekly visits to the ward to support detained patients. This was a requirement of the previous inspection and had been fully addressed. An IMHA service had been in place since April 2015. This was embedded and staff and carers were aware of the advocacy support.
• Staff were very caring and carers commented very positively about this. Staff told us how well the multidisciplinary team worked together and we observed this during a discharge planning meeting.
• Carers had been supported to develop a carers group and had also developed a ward information leaflet with hints and tips of what to expect when their relative was admitted to hospital
• Psychology was embedded on the ward and the psychologist had introduced systems that had reduced incidents and the use of physical restraint. Individual behaviour plans were in place that had demonstrated a positive impact on both patients and ward staff, this had let to a reduction in incidents of restraint.

However:

• A shortage of band 5 nurses and difficulties with recruitment and retention was a particular issue for this ward and a trust wide risk. The ward was successful in recruiting to band 3 health care assistant posts which were fully staffed.
• The clinic room was very hot for staff to work in and this was logged as a risk on the health and safety risk register. The ward and pharmacy staff managed this by monitoring the temperature and following guidance to dispose of medicines kept above the recommended temperature within a shortened time period.
• Psychology support was reducing on the ward to provide community provision as part of a wider planned programme. This left some temporary gaps, such as facilitated reflective practice sessions for staff.
• Supervision, appraisal and training systems were in place, but staff reported difficulty with the new statutory and mandatory training system and staff did not routinely record one to one supervision.
• Despite the delays in some discharges due to the limitations of suitable community placements, discharge planning was good and a discharge liaison role supported this.
• The environment was not dementia friendly in places and many rooms were not personalised.

We rated specialist community mental health services for children and young people as requires improvement because:

• The service was not able to respond to the needs of all children and young people who might benefit, because the criteria for access were so high that children and young people had to be seriously ill before they were accepted. There had been a significant increase in the number of referrals over the previous two years but no increase in funding. As such, in discussions with Kernow Clinical Commissioning Group the trust had to raise the criteria for when to accept children and young people into the service.

• All referrals were triaged through a single hub by members of the CAMHS team. If the child or young person did not meet the criteria for CAMHS, they would then be signposted to a range of other services. Staff, children, young people, and their families all said that the other services, despite being of good quality, could not always meet the needs of children and young people and as such, their mental health would deteriorate. Once their mental health had deteriorated to a level where they met the criteria, they would then be accepted into CAMHS. If a child or young person went into crisis, they would be seen quickly.
• Waiting times varied across the teams. The longest waiting times were in the east team where one young person had been waiting five months for an initial assessment. The trust did not meet the 28-day referral to assessment set by commissioners. The waiting time across the service was between two and three months.
• The physical environments at Bolitho House, Truro Health Park and St Austell needed improvements. None of the waiting rooms were child and young person friendly and they offered no age-appropriate books, toys, games or information leaflets. At St Austell 26 staff had to use one toilet in a facility that smelt damp and needed redecoration.

• Staff members had not ensured that the scales used to weigh children and young people and blood pressure monitors were calibrated in the east or west sites.

• Children and young people had unsupervised access to knives and other dangerous objects in the staff kitchen in the Truro site.

• The service did not always provide families with copies of letters or care plans.

• The trust did not ensure cleaning fluids were always stored safely.

However:

• Children and young people and their families were extremely positive about the care they received once they had accessed the service. Children and young people in crisis received a prompt service.

• Teams ensured there were detailed assessments of children and young people’s needs. Care plans reflected the assessed needs and, in the main, were recovery focused.

• Staff provided an out-of-hours advice service to colleagues in other organisations should they be worried about the mental health of a child or young person. They were commissioned to provide an on-call clinician to provide advice to professionals working with young people out of hours.

• The staff we met were conscientious, professional and committed to doing the best they could for the children and young people in their care.

• Senior managers in the service were well aware of the impact that increasing the threshold for access to services was having and had a detailed knowledge of all of the risks in the services. These risks had been escalated to the trust senior leadership team and were high on the trust agenda. The senior leaders and service managers were addressing staffing shortfalls by having an active recruitment programme to fill vacancies. The trust senior leaders were actively working with Kernow Clinical Commissioning group to find a resolution to all of these issues.

• At the time of the inspection staff felt under pressure due to vacancies of some key disciplines such as clinical psychologists. However, the trust recruited a psychologist in the east team who started work shortly after the inspection. Staff felt this would alleviate some of the pressure they were under.