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Provider: North Staffordshire Combined Healthcare NHS Trust Outstanding

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

Inspection Summary


Overall summary & rating

Outstanding

Updated 28 March 2019

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

  • We rated safe, effective, and well led as good, caring and responsive as outstanding. Following this inspection, one of the trust’s 11 services are rated as requires improvement, seven are rated good and three as outstanding. In rating the trust, we took into account the previous ratings of the eight services not inspected this time.
  • The trust had met the requirement notices we set out in our previous report. Medicines safety had improved on the wards for older adults and the community teams. Staff in the community teams now inspected emergency equipment as a matter of routine.
  • There was good leadership across the trust from the board to front line managers. Managers had the right skills to undertake their roles. The board had good understanding of performance.
  • The trust ensured that risk assessments were completed and updated regularly. Staff updated risk assessments for each patient to understand how to best support them. Staff had good access to patient records and stored them safely. Staff knew how to keep patients safe and reported incidents, including abuse, when necessary. Staff learnt lessons from incidents.
  • A range of care and treatment interventions was delivered in line with guidance from the National Institute for Health and Care Excellence (NICE).
  • The majority of staff had good knowledge of the Mental Health Act, the Mental Capacity Act and the Deprivation of Liberty Safeguards. Staff were up to date with training in the Mental Health Act and Mental Capacity Act.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs.
  • Staff involved patients and those close to them in decisions about their care, treatment and changes to the service. Throughout their recent management of change project, the trust had listened and acted on the feedback of patients, their families and carers.

However:

  • The trust had not met its responsibility to make all required notifications to the CQC. There had been no notices made of the outcomes of applications to authorise Deprivation of Liberty Safeguards. We had reminded the trust of this obligation in our last report.
  • The stability of the senior leadership of the trust was at risk with changes in the executive team. The new chief executive, chairperson and remaining board members recognised an opportunity to reflect on their structures, processes and external relationships.
  • Enhanced reporting on clinical activity in community teams had recently been introduced, which provided assurance to the Board and service managers, but required development to fully establish its reliability and usability

  • The trust’s pharmacy team was still developing its strategic plan. The team had made some progress in the last year through development of the team’s capacity and skill base.
  • Some community service’s environmental risk management plans lacked detailed mitigation of identified risks.
  • There were some omissions in community and crisis services patient care plans related to crisis plans, physical care plans.

Inspection areas

Safe

Good

Updated 28 March 2019

Our rating of safe improved. We took into account the previous ratings of services not inspected this time. We rated it as good because:

  • The trust had addressed staffing issues in medicine, nursing and the allied health professionals by developing robust strategies that addressed recruitment and career development. Overall there had been positive movement in the recruitment of clinical staff, retention rates and reduced sickness absence.
  • The trust had maintained its focus on reducing restrictive practices. We saw significant reductions in the number of physical restraints used on the wards for older adults with mental health problems. Highly personalised care plans around the management of behaviours that challenge allowed staff to find alternatives to restraint and it was only used as a last resort.
  • In the community mental health teams there was a good system to monitor and manage caseloads; it used information technology to monitor demand and capacity. The caseload management system would alert mangers to any unsafe of unexpected increases in demand and capacity could be flexibly managed to target those patients most at risk.
  • The level and detail of information contained in the initial assessments of need and risk demonstrated a clear holistic approach to care and treatment. This was consistent across the three cores services we visited on this occasion.

However:

  • Some community services environmental risk management plans lacked detailed mitigation of identified risks.
  • There were some omissions in community and crisis services patient care plans related to crisis plans, physical health care plans.

Effective

Good

Updated 28 March 2019

Our rating of effective stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as good because:

  • Staff provided a range of treatment and care for patients based on national guidance and best practice. Staff supported patients with their physical health and encouraged them to live healthier lives. The trust had continued to expand the range of training available to help staff to identify and mange physical health problems. Having consolidated training in recording physical observation and supporting immediate physical health needs, health promotion training was being rolled out across the clinical services. The early focuses were on smoking and alcohol misuse.
  • Managers made sure they had staff with a range of skills need to provide high quality care. They supported staff with appraisals, supervision, opportunities to update and further develop their skills.
  • Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice. Administration of the Mental Health Act was of a high standard across the three services inspected.
  • Staff supported patients to make decisions on their care for themselves. They understood the trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly. The community mental teams needed to improve their recording of capacity assessments. The practice within the crisis team was good and there was close adherence to the Mental Capacity Act Code of Practice on the older adult wards for best interests decisions.

However:

  • Although care planning was improving, we found errors and omissions within care plans in each of the core services we visited.

Caring

Outstanding

Updated 28 March 2019

Our rating of caring improved. We took into account the previous ratings of services not inspected this time. We rated it as outstanding because:

  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs.
  • Staff involved patients and those close to them in decisions about their care, treatment and changes to the service. Throughout their recent management of change project the trust had kept briefed and listened to the feedback of patients, their families and carers.
  • Staff on Ward 4 had developed very positive initiatives around the involvement of families in the care of their relatives. Some family members now volunteers on the wards to support others. In crisis and community services

Responsive

Outstanding

Updated 28 March 2019

Our rating of responsive improved. We took into account the previous ratings of services not inspected this time. We rated it as outstanding because:

  • The trust had taken the lead in developing a system wide response to the CQC’s local systems review of the care pathways for older adults between health and social care. This had led to a system wide improvement in reducing delays to transfers of care.
  • In the community mental health teams for adults, access and crisis teams there were systems in place to offer urgent appointments and access to treatment.
  • The high-volume service user service team (part of the crisis service) was judged as being highly responsive and had been successful in reducing the number of visits of mental health patients to emergency departments.
  • Staff in all services proactively engaged with partnership agencies to ensure holistic treatment responses to patients with substance misuse problems. This meant that patients received a holistic service that recognised the impact their mental health had on their substance use.
  • The crisis services had worked closely with the local police to provide responsive support to those patients without a home that were the most vulnerable and difficult to engage.
  • Dedicated staff on the mental health wards for older adults were responsible for ensuring that timely discharges were effectively planned. They did this in collaboration with the patients and their families.
  • All service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. Any complaint and concerns across the trust were reviewed alongside clinical incidents in the safety improvement group. New learning from complaints could therefore share across directorates.

However:

  • One ward for older adults had shared sleeping arrangements whereby patients had to share bedrooms. The arrangement did not promote the privacy and dignity of patients using them.

Well-led

Good

Updated 28 March 2019

Our rating of well-led stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as good because:

  • The trust had an experienced leadership team with the skills, abilities, and commitment to provide high-quality services. The trust executive leadership team had a comprehensive knowledge of current priorities and challenges.
  • The board and senior leadership team had a clear vision and set of values that were at the heart of the work within the organisation. They wanted to continue their journey from an assurance led organisation to a more improvement led organisation. They aimed to achieve this through the empowerment of staff at all levels within the organisation. Collaboration with stakeholders, partners and regulators within the system at all levels was another key objective.
  • The trust was actively engaged in leading, influencing and shaping local sustainability and transformation plans. The board recognised that partnership was essential to the achievement of the trust’s vision for future services within the local system. Great strides forward had been made with the majority of stakeholders.
  • Senior leaders visited all parts of the trust and fed back to the board to discuss challenges staff and the services faced. The trust included and communicated effectively with patients, staff, the public, and local stakeholders.
  • Overall the trust had been able to successfully recruit staff in a challenging recruitment environment, improve the retention of existing staff and reduce sickness rates.
  • The trust had developed a lot of initiatives around the Workforce Race Equality Standards since our last inspection. The trust acknowledged, this work was in development and the impact not yet demonstrable within the lived experience of staff.
  • Since the last inspection the trust had completed implementation of a new electronic patient record system. This has improved the quality of clinical data available to support managers in the form of dashboards and reports in most core services.
  • There had been a large organisational change project which affected the majority of staff in the trust within the last year. Managers had listened to the concerns of some staff and changes had been made to the original plans and timetable for change. Staff’s positive view of manager’s approach to the project was not universal, but was supported by the vast majority of staff we met.
  • There were positive examples of individuals and teams developing new ways of working in the core services we visited. The trust was at an early stage of developing and embedding a continuous improvement approach through raising the awareness and training of all staff. The recent establishment and appointment of quality leads in each of the new directorates were seen as pivotal to the delivery of the quality strategy of the trust.

However:

  • The trust had failed to notify the CQC that they had made a standard authorisation for the Deprivation of Liberty Safeguards (DoLS) when they knew the outcome.

  • The Board Assurance Framework (strategic risk register) was comprehensive however some items were over inclusive in the detail of assurance offered which blunted the effectiveness of reporting the current priorities for action.
  • The Freedom to Speak Up Guardian was a senior manager working closely with the executive team, this had caused some staff to be concerned whether confidentiality would be maintained. This is a challenge within a smaller organisation and opportunities to work in collaboration with Guardians within the wider system would give greater independence to the role.
  • Further work was needed to improve both the validity and reliability of the community safety matrix. This was a dashboard for mangers to monitor the clinical performance of community services. Managers were still refining the number of care records sampled and the frequency of review to make this an effective tool.
  • Senior manager’s engagement with psychology professionals within the organisation had deteriorated since our last inspection. The trust had plans to address and develop the engagement and contribution of this professional group.
  • The board needed to review both the capacity and skills of the executive team to balance the internal priorities and those external objectives within the wider healthcare system and integrated care system.
  • There was an opportunity to review the involvement of the non-executive directors in the performance review process for executives.
  • Managers had failed to inform some community teams of changes to emergency equipment and related procedure
Checks on specific services

Mental health crisis services and health-based places of safety

Outstanding

Updated 28 March 2019

Community-based mental health services for adults of working age

Good

Updated 28 March 2019

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

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

However:

  • The management plan on how to reduce the risk of identified potential ligature risks was not detailed enough to identify how all the risks were to be mitigated.

Wards for older people with mental health problems

Requires improvement

Updated 28 March 2019

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

  • Care plans were not all individualised. On Ward 6, we found three records where partial identical information had been duplicated across three different patient’s care plans, including the wrong patient’s name. Two records on Ward 4, two did not contain a care plan relating to specifically to factor identified in the risk assessment, for example, fall risk and diabetes.
  • Ward 7 had two multiple occupancy dormitories which restricted the privacy of patients accommodated in those rooms .

However:

  • The service provided safe care. Wards were safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Wards had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

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

Good

Updated 15 February 2018

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

A summary of our findings about this service appears in the Overall summary.

Wards for people with a learning disability or autism

Good

Updated 15 February 2018

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

A summary of our findings about this service appears in the Overall summary.

Specialist community mental health services for children and young people

Good

Updated 15 February 2018

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

A summary of our findings about this service appears in the Overall summary.

Long stay or rehabilitation mental health wards for working age adults

Outstanding

Updated 15 February 2018

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

A summary of our findings about this service appears in the Overall summary.

Community-based mental health services for older people

Outstanding

Updated 21 February 2017

We have changed the rating for community mental health services for older people with mental health problems from good to outstanding and effective from requires improvement to good because:

  • During our inspection in September 2015, we asked the trust to ensure that patients have crisis and contingency plans that reflected patients individual circumstances and that these were easily accessible to staff. At this inspection we found that skilled staff worked within a multidisciplinary approach to ensure they were responsive to urgent referrals or patient crises.
  • The teams had developed excellent external links to GPs, care homes, social services and other local agencies, to ensure that patient’s holistic needs were thoroughly care planned.
  • During our September 2015 inspection, we asked the trust to ensure that accurate and up to date risk assessments were completed for patients. At our inspection in September 2016 we found that staff had the information they needed to consistently assess and review risks to patients.
  • The service used audit and outcome measures to great effect in order to improve patient care whilst evaluating the effectiveness of the service.
  • In our inspection in September 2015, we asked the trust to ensure that care plans reflected patient views and were person centred. At this inspection patients received individualised treatment and their care plans were personalised and holistic.
  • Innovative ways to improve patients’ health and wellbeing were used that were based on evidence from research and from working with a local university and clinical commissioning group.
  • In September 2015, we asked the trust to ensure that staff had the skills and knowledge to routinely undertake and record mental capacity assessments in accordance with the Mental Capacity Act 2005. At this inspection we found that staff had a good working knowledge of the Mental Capacity Act and recorded this fully in patients’ care records.
  • Patients told us staff were caring, compassionate and responsive to their needs, providing emotional and practical support. Staff involved patients and their carers in their care and looked after their best interests. Staff showed excellent levels of care for both patients and carers. Carers told us that staff “went the extra mile”.
  • There were adequate numbers of staff available to provide information to patients, carers and referrers ensuring they knew what to do if the patient’s condition deteriorated.
  • The service used opportunities to learn from incidents, complaints and audits which resulted in improvements being made.
  • Staff received regular supervision and support from their team managers, and attended to their training needs. Staff told us morale was good and they worked well as a team.

However:

  • Clinical supervision was not offered to all staff and formal supervision was not recorded in all teams.
  • Appropriate signage was not provided to help patients find their way around the memory service at maple house.
  • Patients had access to psychological therapies but not always to psychologist.

Substance misuse services

Good

Updated 21 February 2017

We have changed the overall rating for substance misuse services from requires improvement to good because:

  • Services had made important improvements since their last inspection in 2015. These improvements included consistent approaches to risk formulation and management across all services. There was a strong focus on ensuring the safety of staff and those who used services and the introduction of new systems and processes maintained a robust focus on managing the risk of harm.

  • There was a commitment from leadership to standardise a consistent supervision system across all of substance misuse services. There were career development opportunities, role specific training and organised reflection and learning and development sessions for staff at all levels.

  • There was good partnership working between the trust community teams and their partner agency Addiction Dependency Solutions. They were fully integrated clinical and medical services with recovery at the forefront.

  • Services were patient, family, carer and community focused and led. Recovery and building recovery capital were the objectives of stakeholders. There was a strong focus on providing support to families and carers, involving them and supporting them in managing some of the difficulties that they might experience.

Child and adolescent mental health wards

Good

Updated 21 February 2017

We rated the child and adolescent mental health service (CAMHS) wards as good because:

  • During this most recent inspection, we found that the services had addressed the issues that had caused us to rate wards for children & adolescents with mental health problems as requires improvement following the September 2015 inspection.

  • Staffing levels on both wards were sufficient and ensured safe clinical practice and risk assessments were completed and up to date for all patients. Staff also provided therapeutic time for patients who used the service.

  • Darwin ward staff had a good understanding of the Mental Capacity Act (MCA) and how it was applied to patients over 16 years of age. All staff on Darwin ward received guidance on the Mental Capacity Act MCA and the trust’s quality assurance manager monitored this.

  • Staff on both wards staff knew how to use the trust safeguard system to report incidents and complete incident forms. Staff on Darwin ward received feedback from investigation of incidents from the monthly senior leadership meeting through minutes that went to weekly nurses meeting.

  • Risk assessments were positive, collaborative and inclusive of patient’s thoughts and feelings, completed on time and reviewed regularly.

  • Physical health was a high priority and delivered by skilled and well-trained staff. This helped to reduce the risk of patient’s mental health problems worsening their physical health problems


Community mental health services with learning disabilities or autism

Good

Updated 21 February 2017

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

  • We found that services were clean and well maintained. Staff received mandatory training and were able to demonstrate how they met the changing needs of patients. Incidents were reported and, following review, staff met to discuss and learn from outcomes.

  • Teams were multidisciplinary and supported patients to meet a wide range of needs. Staff used national institute of health and care excellence guidance to plan and deliver patient care. Treatment records we looked at contained a comprehensive assessment from which care plans were developed and progress reviewed. Staff we spoke with demonstrated an understanding of the Mental Health Act and Mental Capacity Act.

  • We saw that staff spoke with patients in a caring, polite and respectful way. Staff communicated and gave patients information in ways that they could understand. Carers we spoke with described staff as helpful, friendly and easy to contact. Service user involvement activities were well established and staff encouraged patients to participate.

  • The services had facilities that promoted recovery, comfort, dignity and confidentiality. There was a clear criteria for people referred to the services. Staff contacted referrals in a timely manner and within agreed indicator times. Staff we spoke with demonstrated how they tried to engage people reluctant to use services and made contact with those that had missed appointments. While the service had received no recorded complaints, there were processes in place for staff to discuss and learn from the organisation as a whole.
  • The trust had a range of established governance systems to met the needs of community mental health services for people with learning disabilities or autism. This included training, supervisory and whistle-blowing processes. Staff told us that they enjoyed their jobs and felt they were part of a good team. They reported good local management and were familiar with their directorate senior managers. However, some staff felt that above directorate level there was little understanding or value given to the services

Reference: not found

Updated 28 March 2019