Norfolk and Suffolk NHS Foundation Trust

We rated Crisis services and Health Based Place of Safety as ‘requires improvement ‘because:

• The last CQC inspection highlighted a number of concerns the trust was required to address. During this inspection we found improvements were still needed to ensure compliance with regulations in a number of areas, for example, compliance with mandatory training for some key subjects, staff receipt of supervision and appraisals, staff availability to support patients in the HBPoS at Fermoy, and compliance with key performance indicators and trust policy for assessment of emergency referrals within four hours.

• Some services had staffing shortages particularly at night. In some services all shifts were not covered at night and lone working practices could not always be followed. At the HBPoS Fermoy Unit, staff were not available to take responsibility for patients detained under section 136 by police and patients did not receive physical or physiological observations.

• Many staff were not in receipt of regular supervision and the trust has no effective oversight to monitor compliance at a local level. There were low levels of compliance with some key mandatory training. Not all staff had received an annual appraisal in line with the trust target and there were gaps in staff supervision across most teams.

• The trust continued to have no overarching operating procedure for crisis services that clearly defined key performance indicators (KPI) and targets for the services. Across most teams, team managers were not able to provide detailed KPI data, which affected their ability to monitor service performance effectively. Data provided by the trust for KPIs was unclear and inconsistent.

• Crisis services were not consistently meeting the trust target for response to emergency assessments. The response to crisis calls out of hours was inconsistent in one service. The crisis line for people not open to mental health services was not easily located on the internet, meaning people might not easily locate the contact number when needed.

• The length of time from admission to a health based place of safety to commencement of a mental health assessment was not always within the three hours target set by the trust and its partners and as recommended in the MHA Code of Practice.

• Environments in some interview rooms were not fit for purpose for assessing patients experiencing a mental health crisis. At the Fermoy Unit, staff managed the risk by remaining with patients while they were on site and for high risk patients, two staff were present.

• There was no alarm system in one crisis service and staff used personal attack alarms when seeing patients, which did not show their location if the alarm was activated.

• The storage of medication in one service did not meet best practice.

However:

• Improvements had been made to the environment of the health based places of safety. Ligature risk assessments had been completed and regularly reviewed.

• Risk assessments were completed for all patients and in most cases updated as the level of risk changed.

• Physical healthcare monitoring was taking place where needed. Overall, improvements had been made in the physical healthcare monitoring of patients in the health based places of safety.

• People told us staff treated them with respect, listened to them and were very professional and caring. They were involved in their care and treatment and were aware of their care plans. Most patients had care plans that considered all their circumstances and were centred on them as an individual.

• Staff communicated effectively with patients and were compassionate. Staff were very positive about team working and the mutual support they gave one another. They felt well supported by their immediate managers.

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We rated acute wards for adults of working age and the psychiatric intensive care unit overall as ‘inadequate’ because

• We had concerns that significant quality and safety risks still remained for patients and others. The trust board were slow to take adequate action to ensure that breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified from our 2014 and 2016 inspections were completed. For example, actions were still needed to reduce environmental risks such as ligature points and line of sights on wards.
• Staff records and checks of patients in seclusion were not always completed, which we had identified at our last inspection. The trust's provision of seclusion rooms on some wards was not adequate.
• Staff were still being trained to use prone restraint (face down) to give rapid tranquilisation injections. This is not in line with best practice guidance.
• The trust had not taken adequate steps to ensure staffing vacancies did not impact on the service and patient care. Staff had reported 406 incidents where this had impacted on the service or patient care. Staff did not receive regular supervision.
• We found examples of patients’ risk assessments and care plan records not being updated and gaps in the monitoring of patients physical health care needs. The trust Mental Health Act 1983/2007 administration oversight was not effective as two patients detention under the Act had expired.
• The trust’s oversight and management of patient admissions and discharges was not effective. A high number of patients were placed out of trust and area; this had increased since the last inspection. Staff moved patients regularly between wards during their treatment and this was not always for clinical reasons. A notable amount of patients faced delays for their discharge or were readmitted soon after.

However

• Most patients said they felt safe on wards and spoke positively about the care and support staff gave them. Patients and carers told us staff involved them in their care and treatment.
• Staff gave examples of how they supported patients with diverse needs. There were systems for patients to raise concerns or complaints and have staff respond to them.
• Staff reported good morale and efficient managers at local level. There were examples of effective multi -disciplinary team working. Staff gave us examples of how they were supported to progress with their career and take on new roles and responsibilities. Staff said senior staff were more approachable and responsive since our last inspection.
• Staff gave examples of learning from incidents to reduce reoccurrence and of safeguarding patients.
• Staff gave examples of improvements made to the quality of the service through introduction of the ‘safe wards’ model of care.

We rated community-based mental health services for older people as requires improvement because:

• Some of the concerns identified in the last inspection report as requirement notices had not been addressed by the trust.

• The trust had not reviewed the core staffing levels including the availability of consultant psychiatrists within this service despite the concerns of front line staff in Ipswich. Not all caseloads were manageable particularly in the Bury South West Suffolk IDT. Caseloads in this team were an average of 60-70 with an average of 90 referrals per month. Staff were not able to see urgent new patient referrals within 24 hours, as per the trust’s own performance target.

• Risk assessments were inconsistent and were not all completed or updated. Some staff recorded patient risk in continuation notes, rather than in the specific risk assessment section.

• The wider trust had not addressed the identified concerns relating to the condition of treatment environments and ligature risks across at all services where patients attended for treatment.

• The trust’s electronic recording system was unreliable, when visiting the Bury North DCLL we found that the system had crashed, which meant staff could not access patient treatment information and risk assessments.

• Concerns were identified with all clinic rooms including out of date and uncalibrated equipment. Six of the clinic rooms inspected did not hold emergency medication for use on site or in the community, but continued to administer injections.

• Automated external defibrillators (AED) had been removed by the trust for these services but front line staff lacking knowledge of the alternative arrangements in place.

• Alarm pull cords in some accessible toilets were not working and staff did not appear to know how to respond when these were pulled. Personal safety alarms for staff did not work at Great Yarmouth and West Norfolk CMHS sites.

• Thirteen care plans reviewed in detail were generalised and had the same outcome goals. This meant that these care plans were not patient centred.

• In the Norfolk DCLL team at Chatterton House, consultant psychiatrists only saw the most complex patients. Psychiatrists mostly reviewed the GP scan results to form a diagnosis and would then prescribe medication without a face to face consultation.

• The trust did not provide data relating to supervision for this core service prior to the inspection. Service managers were unable to consistently assure us through data recorded that staff received regular clinical or managerial supervision. It was therefore unclear how training and performance issues were identified and robustly managed.

However:

• There was a clear trust lone working protocol in place. Staff used the buddy system based on a risk assessment of the individual patient and their family.

• Staff knew what incidents to report and we saw evidence of trust wide learning from these across the service.

• Managers monitored the patients on the waiting list to identify any increases in patient’s level of need. These patients would then be prioritised by staff.

• Patients had access to psychological therapies, some teams had a psychologist and they delivered a cognitive stimulation therapy group, which was an evidenced based treatment for people with dementia. Trust staff referred some patients for additional psychological therapies to the wellbeing team.

• Patients said that staff were kind, caring and respectful towards them and took time to listen to them. Several patients spoke highly of their own care co-ordinator and could not thank them enough.

• Managers addressed complaints in a timely manner. Examples were seen of staff being open and honest with the patient and their family.

We rated community-based mental health services for adults of working age as inadequate because:

• Concerns were identified with all clinic rooms. These included out of date equipment. Equipment not calibrated or safety checked. Inconsistent clinic room and fridge temperature monitoring, with a lack of robust systems in place for the monitoring of safe medication storage.

• Automated external defibrillators (AED) were removed by the trust for these services, with front line staff lacking knowledge of the alternative arrangements in place.

• We found six of the clinic rooms inspected did not hold emergency medication, but continued to administer injections.

• There was a 59% completion rate for staff appraisals for community adult services; however, we identified one service with a completion rate of 27% (Bury South ECP). It was therefore unclear how training and performance issues were identified and managed.

• Service managers were unable to consistently assure us through data recorded that staff received regular clinical or managerial supervision .Some service managers held spreadsheets to monitor completion. The trust did not provide data relating to supervision prior to the inspection.

• Only four teams achieved the trust’s 90% or above compliance target for mandatory training.

• Ligature risk audits were out of date, or lacked detail to enable staff to manage and mitigate risks to patients accessing services for treatment.

• Personal safety alarms for staff did not work at the Great Yarmouth and West Norfolk CMHS sites inspected placing staff at potential risk. This was not in line with lone working practices.

• There was variable quality of recording of patient records including care plans, risk assessments and crisis plans with inconsistent details regarding drug sensitivities and health care monitoring.

• Community adult services were 28% over capacity in relation to the number of referrals received, and staffing levels to meet those needs. Norfolk service managers had submitted a joint report to the trust board and this concern was on the trust risk register. At the time of the inspection, these concerns had not been addressed.

• There were high patient waiting lists in some teams, with inconsistent practices in place to robustly manage the risk for those patients awaiting allocation of a care coordinator, access to services or treatment.

• Some staff reported allegations of bullying cultures within the management teams, and reluctance to implement whistleblowing procedures for fear of reprisals.

• Community adult services had staffing vacancies of 9% and 4% sickness levels; with 2954 shifts covered by agency qualified nurses between 1 April 2016 and 31 March 2017. Core service sickness rates were below the trust average of 5% and turnover rates were in line with the trust average of 12%.

• Patients received substandard levels of physical health care monitoring, with staff acknowledging this was as a result of workload pressures.

• Services held patient waiting lists varying in size from 3 to 141 patients. There were inconsistent practices for the management of risks associated with waiting for treatment and allocation to a care coordinator. Based on waiting list numbers provided during the inspection, there were approximately 473 patients on waiting lists who did not have an allocated care coordinator.

• Alarm pull cords in some accessible toilets were not working and staff did not appear to know how to respond when these were pulled.

However:

• Staff interacted with patients and their family members with care and compassion. Staff spoke about the patients on their caseloads with knowledge of their needs, social and medical histories. Staff offered practical and emotional support to carers and family members.

• Staff treated patients with respect, and showed professionalism when handling challenging situations.

• The trust scored 93% in the May 2017 friends and family test for patients who would recommend the service. This was an improvement from the previous year when the trust scored 62%.

We rated wards for people with learning disabilities and autism as good because:

• Patients had access to activities seven days a week. A Pets as Therapy dog came to the ward every week and patients told us they looked forward to this. Patients were able to personalise their bedrooms and they had somewhere secure to store their possessions.

• Shifts were covered by a sufficient number of staff of the right grade and skill mix which enabled staff to maximise shift-time on direct care activities. Staffing levels were sufficient for patients to have 1:1 time with their named nurse every day. Staff knew how to make safeguarding referrals and what constituted abuse. The ward manager had sufficient authority and administrative support within the team.

• Staff showed understanding of patients’ needs in an individual and person-centred way. We observed staff interactions with patients to be caring and staff were respectful at all times. Patients were able to get involved in decisions about their service through regular patient meetings and staff fed back to patients when issues were raised.

• Environmental risk assessments were undertaken regularly and updated when required. Ward areas were cleaned twice daily and the environment was comfortable, well-maintained and with good furnishings.

• There were effective handovers within the team and with other teams in the trust as well as local authority social services. The multidisciplinary team, consisting of psychologist, social worker, nurses and doctor, met three times a week. Staff were supervised regularly and had weekly team meetings.

• Patient accessible information was on display about patients’ rights, how to complain and advocacy. There was a choice of food and the daily menu was displayed in the dining room using patient accessible information.

• There was a full range of rooms and equipment to support treatment and care including a low stimulus room. Patients had access to extensive outside space with quiet areas.

• Staff were trained in the Mental Capacity Act and had a good understanding of how to apply this knowledge. Staff accessed the policy on the intranet and sought advice from the team’s social worker and manager.

• Care records were holistic, person centred and risk assessed.

• Staff said morale was high and teams worked well together. Staff knew how to whistle-blow and felt able to raise concerns without fear of victimisation. Staff members were able to submit items to the Trust risk register.

• Mandatory training compliance was 89% and there were opportunities to undertake specialist and leadership development training.

However:

• Access to speech and language therapy assessments was problematic, confusing and patients experienced long delays. One patient was on the waiting list in the community for six months without being seen (Suffolk West). After the patient was admitted to Walker Close, they experienced a choking incident. Staff made an urgent referral but still waited a further two months before the patient was seen by a speech and language therapist from another team.

• Minutes from team meetings showed actions but no outcomes so it was not possible to determine whether these were followed up. Some notes were vague and did not include discussion details or attendees so were not useful for team members who were unable to attend.

• Six patient discharges over a period of twelve months were delayed due to a lack of suitable placements.

• There were ligature risks in the bathroom of Bungalow 3 as basin taps were not anti-ligature.

We rated Norfolk and Suffolk community mental health services for people with a learning disability or autism as good because:

• The trust had invested in anti-ligature fittings in all the team bases (ligature points are where something can be tied in order to self- harm). The trust had ensured that ligature points across the sites were recorded on the environmental risk registers.

• The community services were situated in accessible areas. Standards of décor and furnishings varied across locations from good in Mariner House to basic in Waveney and Bury south integrated delivery team. There was a range of rooms at all sites that were used for interviews, activities and staff meetings. There were no alarms at the Waveney locations and staff did not carry personal alarms.

• Links with the local GP surgeries and other agencies were robust. Staff worked well as part of the wider integrated delivery teams at each community site as well as within their own multi- disciplinary teams.

• All patients had a care co-ordinator when under the care programme approach.

• Staff caseloads were manageable.

• Staff knew and applied lone working and safeguarding policies as part of their day to day work.

• The trust had clear referral and assessment processes. Assessments were comprehensive and included both current and historical information.

• Staff talked knowledgeably about issues of capacity and could give examples of when they applied this knowledge.

• Patients attended individual care reviews to discuss their care wherever possible. When a patient was assessed as lacking capacity, this was documented. Decisions regarding patient care were made following consideration of the patients’ best interests.

• Staff morale was consistently high across the range of staff roles.

• Staff received managerial 1:1 and group clinical supervision monthly.

• Ongoing professional development was embedded within the learning disability teams.

However:

• The trust had not ensured that patients did not have an excessive wait to access specialist services such as speech and language therapy. Access to speech and language therapy, including for dysphagia assessments, remained inconsistent. This was a requirement of the last inspection in 2016. Patients and families continued to experience excessive waiting time to access speech and language therapy.

• A disparity existed in terms of access to specialist healthcare input dependent on where a patient lived.

• The variety of healthcare professionals available to support patients within teams differed.

• The trust had not advertised for a replacement to the consultant psychiatrist post in Ipswich. Some staff expressed grave concerns regarding the potential lack of consultant psychiatrist availability for this team.

• The child and adolescent community mental health team for people with learning disabilities or autism carried a low staff to patient ratio.

• Staff had not always recorded whether or not a copy of the care plan had been offered to the patient.

• Physical healthcare records were not easy to find or were missing in the notes.

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

• Ligature audits were either not present or incomplete in some teams.

• We had concerns in relation to patients safety at Thurlow House. Treatment rooms were not fitted with alarms and staff were not using personal alarms to summon help if required.

• The waiting rooms were used by young people and adults which was a potential safeguarding risk for children and young people. The trust partially addressed this issue at the inspection.

• At Thurlow House the administration area, interview rooms and rooms used for group session were not sound proofed. During the inspection we overheard confidential conversations relating to patients who use the service. We were concerned that patients were in these areas and could have heard these discussions too which is a breach of confidentiality.

• Staff had not completed 15 of the 44 risk assessments in full on the electronic recording system.

• The quality of care records we reviewed was variable, and dependent upon how confident and knowledgeable the staff member felt about using the electronic system.

• Recording of supervision was not centralised or standardised; supervisors were using different recording systems and tools across the service.

• In Suffolk there was one family therapist compared to seven in Norfolk, and no play therapist in Suffolk while there were five in Norfolk. This meant that Suffolk could not provide play therapy and had longer waiting lists for family therapy than in Norfolk.

• Teams were working in isolation of each other. This meant the service was not cohesive, and that lessons learned and good practice in the service was not being shared across the trust.

• Staff and doctors were only carrying out basic physical health checks, such as blood pressure, height, and weight on those patients receiving medication.

• There were waiting lists for allocation to care co-ordinators ranging from three weeks to eight months, and a seven-month wait for psychology.

• The staff we spoke with did not have a full understanding of the access criteria for children and young people.

• Ten staff and managers told us they were unclear about the overarching strategy and development plan for the children, family, and young people’s service in Norfolk and Suffolk NHS.

• Not all managers were working to the same key performance indicators and governance systems such as monitoring supervision, training, and monitoring of waiting lists were not centralised.

• Managers did not ensure that staff completed a compliance level for all mandatory training of above 75%.

• Managers had not ensured that they had addressed the issues that were raised in the inspection carried out 2016.

However:

• Managers had been creative in addressing their staffing issues.

• Managers had introduced new systems for managing referrals and monitoring people on waiting lists.

• Patients waiting for care coordination had face-to-face initial assessments and eight weekly follow up reviews by the MDT team.

• Staff were following robust safeguarding processes, including joint working with other agencies.

• We saw evidence of effective handover between services within the organisation, such as community to crisis team or inpatient services.

• Patients and carers spoke positively about the flexibility of the services, the knowledge and skills of staff to explain difficult concepts, and the trustworthiness of the information staff gave them.

• Services we visited were meeting their referral to assessment targets.

• Patients and carers waiting for care co-ordinators were offered regular support including brief intervention therapies based on skills training, manging stress and coping strategies.

• Staff reported that local level management was good. There were opportunities for professional development, and a stronger focus on regular staff support through clinical and managerial supervision, including opportunities for upskilling.

• Reporting and learning from incidents, and sharing this learning within individual teams was effective.

We rated child and adolescent mental health wards as outstanding because:

• Managers had addressed issues that were highlighted during the inspection carried out in 2016 in relation to prone restraints, ligature assessments and levels of staffing.

• The unit was exceptionally clean and well maintained throughout. The unit had an up to date ligature risk audit, staff mitigated the risk on the unit by observing patients.

• There were separate sleeping arrangements for male and female patients that complied with the Department of Health and Mental Health Act 1983 (MHA) Code of Practice guidelines on eliminating mixed sex accommodation.

• Doors were labelled with whose office it was on unit room doors, for example - occupational therapist. This meant patients could easily contact clinicians on the unit.

• The trust had a named safeguarding lead for patients. Staff were trained in safeguarding and knew how to make a safeguarding alert.

• In line with trust policy, staff only used physical restraint in exceptional circumstances. Managers were in the process of identifying specialist staff training for restraint, appropriate for children and young people.

• Care records were comprehensive, person centred, recovery focused and up to date. Care records showed that a physical examination had been undertaken and that there was ongoing monitoring of physical health problems.

• Staff were knowledgeable about how both Mental Health Act and Mental Capacity Act applied or not, to the young people they worked with. Staff sought appropriate consent from patients, for example, Gillick competency for examinations and treatment. Staff had explained rights to patients detained under the Mental Health Act and repeated these atregular intervals. Consent practices and records were actively monitored and reviewed to improve how patients were involved in making decisions about their care and treatment.

• We observed excellent staff handover within the team shift to shift. The service used a structured handover system, which ensured staff communicated all aspects of patient’s care and treatment between shifts. We observed a formulation meeting, and effective multidisciplinary team planning for one patient.

• The service provided a wide range of age appropriate health promotion information in the welcome pack and in the reception area. Staff assessed patient’s nutrition and hydration needs when they came to the Dragonfly unit. A dietician provided specialist advice.

• Staff were appraised and supervised and had access to regular team meetings. Staff were experienced and qualified and received specialist training in children and young people. The continuing development of staff skills, competence and knowledge was integral to ensuring high quality care.

• Each patient had a named nurse and associated worker who offered regular and ad hoc sessions.

• Staff provided patients with an information pack and verbal information about the unit in a way they could understand.

• Patients gave feedback about the service. Some patients had contributed to a design mood board with ideas for decorating a communal room and had made soft furnishings.

• Patients were involved in staff recruitment.

• We saw sensitive handling of difficult issues. Staff understood the individual needs of patients. We saw staff show exceptional care and respect for a patient who was distressed.

• Staff recognised and respected the need to empower families to look after their children. Staff reflected individual needs in the delivery of patient care. There was a strong visible person centred culture from all staff.

• All staff showed encouraging, sensitive and supportive attitude to patients and those close to them.

• Patient’s emotional and social needs were highly valued by staff at all levels and were embedded in their car and treatment.

• Feedback from patients and those close to them was continually positive. One patient said this was the best child and adolescent unit they had been to. A parent described the service as resilient, safe and secure for their relative.

• The service provided structured and individualised therapeutic programmes, comprising of a mixture of group work, activities, exercise, individual sessions and education.

• Patients were provided with education services and educational materials required for continuing their education.

• Patients had opportunities for regular exercise for example Friday exercise class, cycling, dance classes, walks on the beach, yoga, and gardening.

• The trust employed staff to prepare freshly cooked meals on site. There was a choice of food to meet dietary requirements. The service bought fresh fruit and vegetables from local farms, meat from local butchers and some patients grew their own lettuce and tomatoes.

• Patients had access to a multi-faith room and regular spiritual support. Patients on the ward had created the designs on the walls and decorated the space themselves.

• Staff told us there was strong leadership, and staff were well supported.

• The team leader had visited other child and adolescent units and brought ideas back as well as sharing their successes.

• There was sufficient staff to provide care and treatment to patients.

• The unit provided for patients and staff a, “What stuck with you this week” board. This was a way for patients and staff to communicate things that had, had an impression on them that week. This could be anything from one of the patient’s doing a Zumba class for the first time, down to a fun meal.

• Staff participated in regular clinical audits. This included audits such as care programme approach, Mental Health Act and anti-psychotic medicines.

• There were good opportunities for leadership development.

• The service was working towards the Quality Network for Inpatient CAMHS (QNIC).

We rated the forensic inpatient/secure wards as good because:

• Staff completed a risk assessment of every patient on admission and updated this regularly and after every incident. Managers had a clear oversight of incidents that had taken place on their wards and ensured that staff learnt from incidents and complaints by discussing them in monthly team meetings and governance meetings with senior managers

• Staff completed comprehensive and timely assessments when patients were admitted to the wards. Staff involved patients in the writing of their care plans and the staff fully documented patient’s views.

• Weekly multi-disciplinary meetings took place to discuss patient care and treatment; staff and patients attended this.

• Care records showed physical examinations were undertaken and ongoing monitoring of physical health took place.

• The seclusion rooms on Earlham ward and Foxhall house met the required standard as set out in the Code of Practise. Staff fully documentation all episodes of seclusion in the case records.

• Staff interacted with patients in a caring and respectful manner. We observed staff throughout the inspection engaging patients in meaningful activities and responding to patients needs in a discreet and respectful manner. Staff took time to listen to patients so they fully understood what support the patient required.

• The majority of the patients we spoke reported they felt safe on the wards. They said staff were kind and caring and took time to support them when needed by either talking or doing activities.

• Staff demonstrated the values of the trust when they talked about their work and caring for patients. Clinical team leaders ensured that their team objectives reflected the trust organisation’s values and objectives.

• The provider used key performance indicators to gauge the performance of the team. These were presented in an accessible format and discussed with staff in order to improve on them.

• Staff we spoke with reported that morale was high with their teams and felt that levels of job satisfaction were high. Staff reported that they felt listened to by their teams and were never afraid to raise issues, as the team or managers addressed them.

However:

• Ligature audits recorded what actions were required to reduce the risk for patients. However, there were no set timeframes for the work to be carried out to protect patients from the risk of ligatures. This issue had been identified at the last inspection in July 2016 and had not been addressed.

• The seclusion room on Yare Ward was not in use due to damage. In the interim, the ward had a temporary seclusion room, a converted bedroom. This temporary room did not meet the required standard set out in the Code of Practice. Whitlingham ward seclusion room was not in use at the time of the inspection due to a flood.

• Staff did not address issues with temperatures in the clinic room on Thorpe ward. Hot temperatures in clinic rooms can affect the efficacy of medication. This issue was highlighted in the 2016 inspection.

• The shower room in Yare ward had a broken extractor fan and mould on the walls and ceilings. Staff had reported this to maintenance but no action had been taken.

• Whilst ward managers were able to adjust the staffing levels daily to take into account patient need by requesting additional staff they were not always achieved for unplanned activities, for example admission to the general hospital or seclusion. This resulted in levels of staff on the ward being reduced and cancelled sessions and cancelled section 17 leave.

• Managers did not ensure that staff completed a compliance level for all mandatory training of above 75%. Managers did not complete staffs annual appraisals.

We rated long stay/rehabilitation mental health wards for working age as requires improvement because:

• There was a ligature risk audit in place but no date recorded for the completion of outstanding actions to mitigate risk.

• There was access to personal alarms but no nurse call systems. We observed that staff at St Catherine’s did not use the alarms and there was no system in place for signing alarms in and out.

• Staff vacancies and turnover were high and between 1 April 2016 and 31 March 2017 the service had used bank or agency staff to cover 40% of shifts. Four per cent of nursing assistant shifts had not been filled. There was not always a qualified nurse on duty at St Catherine’s.

• Not all care plans reviewed reflected the patient involvement.

• We reviewed five out of seven medication charts at Suffolk Rehabilitation and Recovery Service. There were discrepancies in three of the consent to treatment forms that we looked at. One included physical health medication in additional to mental health, one was not correctly updated and the frequency of the dosage was incorrect in another.

• The trust were unable to provide the clinical supervision data for non-medical staff for the period 1 April 2016 to 31 March 2017. Ward managers found it difficult to access supervision data electronically.

• As of March 2017, the overall appraisal rate for non-medical staff was 46%. The trust target was 89%, all wards within this core service failed to meet this target. The highest appraisal rate was Suffolk rehabilitation and recovery service with 52% of staff having had an appraisal. St Catherine’s appraisal rate was 33%. As of March 2017, the trust had provided data that suggested that no permanent medical staff required or have had an appraisal in this core service.

• There were 19 readmissions within 28 days of discharge out of a total of 149 patients discharged, as reported by the service from 1 April 2016 to 31 March 2017. On average patients were being readmitted to long stay/rehabilitation wards within 11.8 days of being discharged. Follow up care and treatment was provided by the crisis home treatment team. Staff also highlighted that some patients discharged themselves.

• Ward systems were not always effective in ensuring that patient and staff safety was maintained.

• The electronic system did not support managers in ensuring that supervisions and appraisals were up to date.

• Shifts were not always covered by a sufficient number of staff of the right grades and experience. Bank and agency staff were often used to provide cover for sickness and absence.

However:

• Staff undertook a detailed risk assessment of every patient on admission and updated this regularly and after every incident. This was evidenced at both wards and in all 13 of the patient care records that we reviewed.

• Care records showed that a physical examination had been undertaken and that there was ongoing monitoring of physical health problems.

• Patients at both wards told us that staff were cheerful, caring and supportive. They said that staff were always available and helpful with their needs.

• There was a carer’s protocol, carers’ information pack and a carers’ champion on each of the long stay/rehabilitation mental health wards for working aged adults. When a patient is admitted, carers were offered a 1:1 carers forum meeting as part of the overall planning process for the patient

• There was access to a range of activities during the week and at weekends. There was a detailed timetable of activities on the noticeboard and patients told us that they engaged in activities both on the ward and in the community, including trips home to promote independent living.

• Mandatory training was above trust compliance rates.

This report describes our judgement of the quality of care provided by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each core service, location or area of service visited.

We rated Norfolk and Suffolk NHS Foundation Trust as inadequate overall because:

• The board had failed to address all the serious concerns that had been reported to them since 2014. The breaches of regulation identified at our previous inspections had not been resolved. The board did not ensure that the services provided by the trust were safe. They had not taken action to ensure that unsafe environments were made safe and promoted the dignity of patients. They had not ensured that there were sufficient staff to meet patients’ needs safely. They had not ensured that unsafe seclusion and restrictive practices were minimised or eradicated. The trust was not safe, effective or responsive at all services. The board needed to take further and more timely action to address areas of improvement.
• We had a lack of confidence that the trust was collecting and using data about performance to assure itself that quality and safety were satisfactory. The direction of travel could not be determined due to the contradictory nature of the data. Information was not always robust. The board needed to ensure that their decisions were implemented and brought about positive improvement.
• Performance improvement tools and governance structures had not facilitated effective learning or brought about improvement to practices in all areas.
• Key mandatory training was below acceptable levels. Many staff had not received regular supervision and appraisal.
• A lack of availability of beds meant that people did not always receive the right care at the right time and sometimes people had been moved, discharged early or managed within an inappropriate service.
• Community and crisis teams’ targets for urgent and routine assessments following referral were not always being met in all areas.
• The poor performance of the single electronic records system had a negative impact had on staff and patient care.
• There were errors in the application of the Deprivation of Liberty Safeguards and the Mental Health Act.

However:

• Morale was found to be good across the trust. This was supported by the staff survey and the staff element of the Friends and Family Test.
• We observed some positive examples of staff providing emotional support to people.

On the basis of this report we are recommending that the trust is placed into special measures.

We rated wards for older people with mental health problems as requires improvement because :

• Staff had made Deprivation of Liberty Safeguards applications for a number of patients across all wards. On patient records checked, all but two had not been authorised by the local authority. On six wards, the urgent authorisation had expired and there was no evidence that staff had applied for an extension. One patient on Abbeygate had been secluded twice without a Deprivation of Liberty Safeguards authorisation in place.
• There were staff shortages across most wards. We saw evidence that wards often ran below established qualified staffing levels. One ward had run at less than half the required qualified staff at night, on average, from January 2017 to March 2017. The service had high vacancy rates and used a high number of bank and agency staff to cover shifts. There had been six reported incidents where there were not enough trained staff to provide patients with the physical interventions required to keep them and others safe. The service medical input was below the established level. This meant that consultants did not review patients as often as needed.
• On Willows, there were a number of medicines management issues. These included medicines being out of date, for example eye drops and skin treatments. There were a number of creams opened that staff had not labelled with individual patient details. Staff had not labelled liquid medicines with the date opened on Willows and Abbeygate.
• The seclusion room on Abbeygate did not comply with the Mental Health Act code of practice. The bathroom was located in the low stimulus area outside the seclusion room, there was no staff observation area and the room was located on the main corridor of the ward. Staff had not completed seclusion records for one patient in line with the trust policy. Observations had not been recorded, there was no seclusion care plan for one episode and the name of the practitioner who authorised the second seclusion had not been recorded.

However:

• The environment on wards was clean and safe. Managers had completed up to date ligature audits and risk management plans with mitigation in place and known by staff. Staff ensured equipment was maintained and checks were up to date.
• Risk assessments for patients were detailed and up to date for all patient records reviewed.
• The team used a range of assessments and outcome measurements to support patients.
• There were full and well organised multidisciplinary teams on six of the eight wards.
• The atmosphere on the wards was calm and we observed positive interactions between staff and patients.
• There was a full range of rooms and spaces to provide therapy and care to patients. The service provided a range of activities.
• Staff felt supported by their managers and were able to raise concerns if necessary.

As this was a focussed inspection to one ward, in response to the concerns identified by a member of the public, we did not rate this core service.

However, the trust needs to address the following areas of concern:

• There was no dedicated ward manager for this ward. This post was shared with an adjacent ward. We found a lack of direction on the ward.

• There was no formal system to ensure that each individual patient’s welfare was checked and reviewed at regular intervals throughout the day. Individual care plans were in place but these had not been updated in some cases to reflect increased risks to patients and staff.

• Some care records reviewed included incorrect or contradictory information. For example relating to the physical healthcare needs of patients.

• There was no current dependency tool used to establish staffing levels. We found that adequate numbers of staff were not deployed to meet the needs of the patients on this ward.

• The ward layout did not protect patient’s privacy, dignity and safety to meet the Department of Health guidance in relation to the arrangements for eliminating mixed sex. We found that one female patient had to use the communal bathroom as her en-suite facility was out of order. This had been reported by front line staff but was awaiting repair.

• Staff reported problems with en-suite showers. Some were not working properly. Frontline staff confirmed that these issues had been reported to the trust’s maintenance department. However, these maintenance concerns had not been addressed.

• Concerns identified by us during this inspection had not been identified or addressed by the trust’s own governance processes. There was no coherent and consistent ward based response when local concerns and complaints were raised.

• Staff morale was low and some staff said that middle managers ignored their concerns.

However:

• Frontline staff were working hard to deliver care and support to patients, who often presented with behaviours that could be challenging, without effective direction from senior staff.

• Medication records were well kept and we noted the low level of use of antipsychotic medication. Documentation for the administration of covert medicines was up to date.