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Provider: Tavistock and Portman NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 16 November 2018

However:

  • The monitoring of the quality and performance of the service lines was not sufficiently robust. At the time of the inspection, this took place through line management and an annual service line presentation to the board. Other governance systems looked across the service lines which could potentially lead to issues being missed or not given the focused attention they required.
  • The trust was working to implement a range of measures to improve career progression and address discrimination for black and minority ethnic (BME) staff. Some BME staff felt that these measures had not yet positively affected their experience of working for the trust. The trust leadership team recognised that this will take more time to fully embed.
  • The trust had experienced significant delays over the previous six months in responding to complaints relating to the gender identity clinic and had mostly missed the target for sending a response. Plans were in place to address this back-log. However, the complaint responses were of a high quality and showed empathy and a willingness to apologise where needed.
  • The trust was working to improve health and safety, including fire safety, across the trust, but this work needed to be completed and ongoing safety closely monitored to provide assurance.
  • People in GIC had long waits to access the service. They experienced a 13-month wait time for appointments and the service sometimes had to cancel and reschedule people’s appointment. The trust had tried to work with commissioners to increase funding but people still experienced long waits.
Inspection areas

Safe

Good

Updated 16 November 2018

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

  • At this inspection we rated safe as good in both the services we inspected. When these ratings were combined with the other existing ratings from previous inspections, all four of the trust services that we have inspected were rated good.
  • Staff assessed the risks to people using the trust’s services. They made plans with people and worked with other services to make sure the people using its services were safe. In the specialist community mental health services for children and young people (CAMHS), staff worked with the young people, families, schools and the local authority to develop plans to support young people. In the gender identity clinic for adults (GIC), staff shared information with people’s local services when appropriate to ensure they got the support they needed.
  • The trust delivered its services in premises that were mostly safe and clean. The trust maintained its premises and staff completed risk assessments of the environment. However, some actions were needed to ensure fire safety systems were fully embedded. A fire evacuation drill had never been completed at one of the CAMHS locations, and staff in the GIC had not completed a planned fire evacuation drill since January 2017.
  • Staff understood how to recognise and report safeguarding concerns to ensure people using the service were protected from harassment and discrimination and received the support they needed. Staff put protection plans in place to keep patients safe.
  • The trust had enough staff to keep people safe from avoidable harm and abuse and to provide the right care and treatment. It had low vacancy and sickness rates. Staff in the CAMHS had manageable caseloads and responded to young people’s needs promptly. In the GIC there were enough staff to provide safe care and treatment for existing patients but the service was not commissioned to ensure it had sufficient staff to manage the high levels of referrals.
  • Most staff knew how to report incidents and teams discussed the learning from incidents to make the necessary improvements. However, staff in the GIC did not always report incidents when patients contacted the service in distress or when there was a risk of the person self-harming, and some staff in CAMHS did not know which incidents to report.

However:

  • Although most staff completed most mandatory training, not enough staff had completed safeguarding adults and clinical risk assessment training. Plans were in place to ensure this training was completed and recorded accurately so that progress could be monitored.
  • The current procedure for ensuring staff safety when seeing patients alone for therapy on site in CAMHS was not robust. Staff met patients in therapy rooms without access to an alarm or personal alarm. Staff relied on shouting for help in the event of an emergency.

Effective

Outstanding

Updated 16 November 2018

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

  • At this inspection we rated effective as outstanding in both services we inspected. When these ratings were combined with the other existing ratings from previous inspections, two of the trust’s services were rated outstanding and two of the trust services were rated good.
  • Staff provided care and treatment based on national guidance and reviewed its effectiveness. They undertook research and developed new clinical models to improve the experience of care and outcomes for people using its services. Clinical innovation carried out by the trust had influenced the evidence-base and clinical practice around mental health and wellbeing. The trust has an international reputation for its psychotherapy-based approaches.
  • Staff developed specialist community mental health services for children and young people (CAMHS) based around the needs of young people. The service had worked with other providers to develop the THRIVE model for delivering CAMHS. This model aimed to deliver person-centred and integrated care based around the needs and preferences of young people and their families by promoting linked working between services. Staff in the teams worked closely with external agencies, such as primary care, social services, education, paediatrics and other community teams, including adult services and the voluntary sector.
  • Staff completed a range of audits and used the information to improve the service. For example, they had shown that since the Camden adolescent intensive support service was set up, young people in Camden had spent 48% less time in inpatient units.
  • Staff in the gender identity clinic for adults (GIC) contributed to developing guidance on best practice in gender identity services. They were experienced in supporting people to meet their specific needs and supported them to access the speech and language therapy, counselling and psychological therapies they needed. Staff undertook research and participated in international conferences and used findings to improve practice. They provided training and guidance to external health professionals including delivering workshops for GPs.
  • The trust had improved how it supported patients with their physical health needs. Since our last inspection, it had appointed a physical health lead and staff now included physical health needs in their assessments.
  • Staff from across the trust had access to excellent specialist training opportunities and managers ensured that staff received the necessary specialist training for their roles. Outside of its clinical work, the trust provided a wide range of specialist education. Staff told us they found these links useful.
  • Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update. The GIC was in the process of developing an online portal so people could access and update their personal records.
  • The trust made sure staff were competent for their roles. Managers appraised how staff performed and held supervision meetings with clinical staff to provide support and monitor the effectiveness of the service. Teams held regular business meeting and reflective practice sessions. The trust supported staff with career development and progression.

However:

  • Administration staff did not have access to one-to-one supervision, which meant they did not have protected regular time to meet with their manager to discuss well-being or career development.
  • Staff’s knowledge of the Mental Capacity Act, as it relates to young people over the age of 16, varied between teams. Some staff were unfamiliar with how they would apply the legislation in practice.

Caring

Good

Updated 16 November 2018

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

  • At this inspection we rated caring as good in both the services we inspected. When these ratings were combined with the other existing ratings from previous inspections, four of the trust services were rated good.
  • Staff cared for patients with compassion. Feedback from people we spoke with and on comment cards confirmed that people felt that staff treated them well and with kindness. Staff in gender identity clinic for adults (GIC) provided emotional support to people to minimise their distress during their transition journey, for example people with atypical presentations or with complex medical or psychosocial needs.
  • Staff involved patients and those close to them in decisions about their care and treatment. Staff in the GIC worked with people using its service to develop personalised approaches based around the specific needs and preferences of each person, for example for people who identified as non-binary. Staff in specialist community mental health services for children and young people (CAMHS) demonstrated an in-depth knowledge of the individual needs and circumstances of the young people they supported. They worked with young people and families to offer services and support based around their needs.
  • Staff encouraged patients to give feedback about the service to identify areas for improvement. Staff in CAMHS enabled parents and young people to give feedback on the service they received, via questionnaires and acted on feedback.
  • Staff informed and involved families and carers appropriately. The CAMHS held a six-week psychoeducation group for carers to help them better understand the difficulties young people may face.

However:

  • The GIC had not updated their service user engagement strategy since the change in provider and had not organised any service user groups as identified in our last inspection.

Responsive

Good

Updated 16 November 2018

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

  • At this inspection we rated responsive as good in one service and requires improvement in the other service we inspected. When these ratings were combined with the other existing ratings from previous inspections, three of the trust’s services was rated good and one of the trust services was rated requires improvement.
  • The trust’s specialist community mental health services for children and young people (CAMHS) teams were very responsive and saw young people and their families in a timely manner. Service managers screened referrals to ensure urgent referrals were seen quickly. All new referrals were discussed at a weekly meeting, following an initial screening by a clinician. Waiting lists for therapy was low. The average waiting time between referral to assessment and assessment to treatment was low at three weeks.
  • Staff in the gender identity clinic (GIC) worked closely with the trust’s adolescent gender identity development service to ensure a smooth transfer for young people to the adult service.
  • The trust took account of patients’ individual needs, and it worked to try and develop its services to be more inclusive. The refugee team had developed the ‘recipe of life’ project bringing together patients to share experiences of culture. Staff in the CAMHS were working with a charity called ‘Small Green Shoots’ to co-design and facilitate a programme delivered to schools, youth hostels and community centres to share information about the trust’s services.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. The complaints responses we reviewed were of a high quality.

However:

  • People in the GIC had long waits to access the service. They experienced a 13-month waiting time for appointments and the service sometimes had to cancel and reschedule people’s appointment. The trust had tried to work with commissioners to increase funding but people still experienced long waits.
  • Staff in the GIC did not communicate with people and other providers promptly. The service took eight weeks after appointments to send letters to people and health professionals. The trust had made some improvements since we identified in our last inspection, but it still needed to make further improvements.
  • Although the trust had undertaken work to ensure the information it provided was in a range of formats and in line with the accessible information standards, it did not always provide information in the necessary range of formats. The GIC did not provide information in an accessible format for people with learning disabilities. The CAMHS teams did not provide information in accessible formats for younger children.
  • The trust did not respond to all complaints promptly. The trust had experienced significant delays over the previous six months in responding to complaints relating to the gender identity service and had mostly missed the target for sending a response. At the time of our inspection, it had plans in place to address this back-log.

Well-led

Good

Updated 16 November 2018

However:

  • The monitoring of the quality and performance of the service lines was not sufficiently robust. At the time of the inspection, this took place through line management and an annual service line presentation to the board. Other governance systems looked across the service lines which could potentially lead to issues being missed or not given the focused attention they required.
  • The accountability framework did not use standard agendas, which meant that there were variations between directorates in the areas covered in the governance meetings. Information was not always shared consistently at team meetings, which meant there were teams who might not have access to adequate learning from incidents, complaints or other methods of assurance such as clinical audits.
  • Whilst the use of data was improving across the trust, team leaders did not yet have access to a dashboard of information in an accessible format to support them to undertake their management roles.
  • The trust was working to implement a range of measures to improve career progression and address discrimination for BME staff. Some BME staff felt that these measures had not yet positively affected their experience of working for the trust. The trust leadership team recognised that this will take more time to fully embed.
  • The trust had experienced significant delays over the previous six months in responding to complaints relating to the gender identity service and had mostly missed the target for sending a response. Plans were in place to address this back-log. However, the complaint responses were of a high quality and showed empathy and a willingness to apologise where needed.
  • The trust was working to improve health and safety, including fire safety, across the trust, but this work needed to be completed and ongoing safety closely monitored to provide assurance.
Checks on specific services

Specialist community mental health services for children and young people

Good

Updated 16 November 2018

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

  • 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. Staff had manageable caseloads and responded to young people’s needs. Staff turnover and sickness for the team was low.
  • Staff had developed services based around the needs of young people. The service had worked with other providers to develop the THRIVE model for delivering CAMHS. This model aimed to deliver person-centred and integrated care based around the needs and preferences of young people and their families by promoting linked working between services.
  • Teams worked well with other services both within the trust and externally to provide a consistent and seamless service to children, young people and their families. For example, CAISS staff worked closely with emergency department staff to support young people presenting at the local general hospital with mental health deterioration, and CAMHS practitioners provided sessions to young people in schools. Staff were flexible and offered appointments outside of traditional office hours if required and in a range of venues.
  • Young people and families said that the services had been helpful to them and this was reflected in feedback surveys that services collected each month. Staff involved families and carers, for example the service conducted a six-week psychoeducation group for them to help them better understand the difficulties young people may face.
  • Teams were very responsive and saw young people and their families in a timely manner. The average waiting time between referral to assessment and assessment to treatment was low at three weeks. Service managers screened referrals to ensure urgent referrals were seen quickly. The waiting rooms at Camden CAMHS south and north were bright, colourful and spacious.
  • Staff were very positive about their teams, said that they felt supported by colleagues and managers and that everyone was dedicated to supporting young people who accessed their services. Leadership development opportunities were available for managers and staff below team manager level. The trust was committed to improving services by promoting training, research and innovation.
  • The trust had set up the Camden adolescent intensive support service to work with 11-18 year olds and their families who experienced a significant deterioration in their mental health to prevent tier 4 admission. Managers analysed performance data that demonstrated young people of Camden were spending 48% less time in tier 4 psychiatric hospitals since CAISS was set up.
  • Since the last inspection in January 2016, the trust had successfully addressed most of the areas needed for improvement. This included ensuring staff shared crisis plans with young people, providing information leaflets on how to complain, ensuring staff recorded information about young people on the electronic patient record systems, and ensuring all young people had a clear plan of care and treatment in care records.

However:

  • Since the last inspection in January 2016, the trust had not successfully addressed three areas needed for improvement. This included failing to demonstrate regular cleaning of toys used by children, staff not ensuring that all young people having risk assessments in place, and teams not providing information in accessible formats for younger children.
  • The service did not have a system in place to ensure front-line staff had opportunities to learn from incidents, audits and complaints. They did not have access at a team level to the risk register to directly report risks or see what action was being taken.
  • The staff needed the improve the safety of the environment. The current procedure for ensuring staff safety when seeing patients alone for therapy on site in the event of an emergency was not robust. Fire safety systems at both sites were not robust.
  • Not all staff were clear about which incidents needed to be formally reported.
  • Administration staff did not have access to one-to-one supervision, which meant they did not have protected regular time to meet with their manager to discuss well-being or career development.
  • Staff’s knowledge of the Mental Capacity Act varied between teams. Some staff were unfamiliar with how they would apply the legislation in practice.
  • IT systems could not always be accessed by clinicians when they were offsite. This meant staff had to travel back to the team office to update patient records, which was a time-consuming task.

Gender identity services

Good

Updated 16 November 2018

This was the first comprehensive inspection of this service. We rated it as good because:

  • The trust had improved the service since becoming the provider. At the last inspection in January 2016, governance processes at the service needed to improve. During this inspection, we found the trust had improved the governance and administrative processes.
  • Motivated and skilled staff with the right qualifications, skills, training and experience provided care and treatment based on national and international best practice and benchmarked against other similar services. People using the service could access specialist speech and language therapy, counselling and psychological therapies.
  • Staff cared for people who used the service with compassion. Feedback from people we spoke with and on comment cards confirmed that people felt staff treated them well and with kindness. Staff planned care together with people on an individual basis to ensure they accessed the treatments and support they needed.
  • The service worked with people’s GPs, and with endocrinology and surgery services, to support people to access the support they needed. The service worked closely with the trust’s adolescent gender identity development service to ensure young people transferred smoothly to the adult service.
  • The service made sure staff were competent for their roles. Staff completed mandatory training, and managers supervised and supported staff. The service had regular team meetings, a monthly multidisciplinary meeting and annual away days. The service supported staff with career development and progression.

  • Staff said the morale and culture of the service had greatly improved since the change in provider. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The service had a low staff sickness and vacancy rate.

  • Staff kept appropriate records of people’s care and treatment. Records were clear, up-to-date and available to all staff providing care. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff completed a range of audits and used the information to improve the service, for example the information included in first assessment reports and non-binary voice and communication.

However:

  • People waited a long time to access the service. At the time of the inspection, people waited 13 months from referral to initial assessment. The service had experienced a large increase in the number of referrals in the previous years, and the trust worked with commissioners to try and increase the funding for the service. However, the current funding combined with restricted working environment made it hard for the service to meet demand. The service still cancelled some appointments, but it had put in place a new system to rearrange cancelled appointments quickly.
  • The service did not ensure that important information was shared promptly following appointments. At the time of the inspection, the service took eight weeks to send letters to people using the service and health professional following appointments. We identified this at our previous inspection. The trust had shortened the time it took to send these letters, but it still needed to reduce the time further.
  • The service did not investigate and respond to people’s complaints within the 40-day extended timescale. Twenty-eight out of 53 complaints in the last six months did not meet the target. The trust informed people when their complaint response would be delayed.
  • The service did not have robust systems in place to ensure fire safety. It had not completed a planned fire evacuation drill since January 2017.
  • Five people we spoke with said they would like better communication before their appointments and a reminder about their appointments. Eight comment cards also included feedback about the service improving communication regarding their appointments.
  • The service did not provide information in an accessible format for all people who may use the service.
  • The service had not updated their service user engagement strategy since the change in provider and had not organised any service user groups as identified in our last inspection.