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Provider: North Cumbria Integrated Care NHS Foundation Trust Requires improvement

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

Requires improvement

Updated 25 September 2019

  • We rated 9 of the of the 14 core services provided by the trust as requires improvement overall. This takes account of the previous ratings of core services that we did not inspect this time.
  • We rated safe, effective, responsive and well led as requires improvement for the trust overall. Our rating for the trust took into account the previous ratings of services not inspected this time.
  • We rated well led for the trust as requires improvement overall.
  • The trust did not always have effective governance systems at service level in assessing, monitoring and improving care and treatment.
  • The trust board did not have effective systems in place to monitor operation and compliance of the Mental Health Act or its administration.
  • The trust had not ensured all patient care areas were suitable for the purpose they were being used for. In the health-based places of safety we found areas which did not comply with the Mental Health Act code of practice. Dova ward was not maintained to a reasonable standard. Oakwood and Kentmere wards provided dormitory style accommodation.
  • The trust had not fully implemented the role of the freedom to speak up guardian. Staff did not always know who the freedom to speak up guardian was or their role in the core services. Staff said that the guardian was not independent as they reported direct to the chief executive.
  • Medicines management arrangements were not effective in all areas of the trust.
  • Risk assessment and management were not always updated, individualised or updated in line with trust policy.
  • Blanket restrictions were not individually risk assessed or reviewed and there was no trust policy in place.
  • Not all staff were up to date with mandatory training.

However:

  • We rated caring as good overall.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983, the Mental Capacity Act and their codes of practice.
  • Wards and teams had access to the full range of specialists required to meet the needs of patients. The staff worked well together and with partner agencies and stakeholders.
  • The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders and had active involvement in sustainability and transformation plans. The trust worked closely with local authority public health colleagues. There were good links with health and well-being strategy.
Inspection areas

Safe

Requires improvement

Updated 25 September 2019

  • We rated 8 of the of the 14 core services provided by the trust as requires improvement in safe. This takes account of the previous ratings of core services that we did not inspect this time.
  • Medicines management arrangements were not effective in all areas of the trust. In wards for people with a learning disability or autism there were unlabelled medication in storage and no risk assessment for the use of sodium valproate for women of childbearing age. In acute wards for adults of a working age and psychiatric intensive care units, staff did not always monitor the physical health of patients after the administration of rapid tranquilisation in accordance with national guidance and trust policy.
  • Not all care areas were fit to provide safe care and treatment. Dova ward had some areas where there was an ongoing issue with water leaks from the ceiling, this was in several areas including a patient bedroom. The physical environment of the health-based place of safety at Kendal did not meet the requirements of the Mental Health Act code of practice and were not safe. Some patients on Oakwood ward slept in dormitory style accommodation with beds separated only by a curtain. Kentmere ward had dormitory style accommodation separated by solid partitions and the trust had not made any robust interim measures to asses or manage the risk of patients being accommodated in these areas. There were no nurse alarms in wards for people with a learning disability or autism.
  • Risk assessment and management were not always updated or individualised. In mental health crisis and health-based place of safety risk assessments were not always updated in line with trust policy. Patients at risk of violence and aggression did not have an individualised plan about the use of medication.
  • In acute wards for adults of a working age and psychiatric intensive care units blanket restrictions were not individually risk assessed or reviewed and there was no trust policy in place.
  • The health-based places of safety did not have dedicated staffing establishments. Nursing staff from the inpatient wards staffed and coordinated the assessments of two of the health-based places of safety and two were staffed by the access and liaison integration service and home treatment teams. In the inpatient areas staffing the health-based places of safety, there wasn't always a dedicated member of staff to observe patients in the health-based place of safety suites.

However:

  • Staff knew how to report incidents and made safeguarding referrals when required. Lessons learned from investigating incidents and safeguarding issues were used to improve the service.
  • Staff developed holistic, recovery-oriented wellbeing diaries which were informed by a comprehensive assessment. Wards for older people with mental health problems provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Staff understood how to protect patients 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.

Effective

Requires improvement

Updated 25 September 2019

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

  • We rated 7 of the of the 14 core services provided by the trust as requires improvement in effective. This takes account of the previous ratings of core services that we did not inspect this time.
  • Staff were either not receiving regular supervision or this was not recorded accurately. The trust had no clear way to monitor supervision quantity and quality. We identified problems with supervision in three of the four core services that we inspected.
  • Staff did not always maintain comprehensive care records. In wards for people with a learning disability care plans were not always reviewed, did not always match identified risk, positive behaviour support plans were incomplete, and a care record referred to the patient using the wrong gender. In crisis and health-based places of safety physical health needs were assessed but were not recorded in the correct plan in the patient records and there was no record of patients receiving a copy of their care plan.
  • Staff did not always complete physical health care assessments as required in acute wards for adults of a working age and psychiatric intensive care units.
  • Staff did not always complete necessary basic training. Only 12.5% of staff on the wards for people with a learning disability had completed the mandatory training in mental health legislation. In crisis and health-based places of safety not all staff who were required to complete the prevention and management of violence and aggression had done so.
  • Not all services complied with parts of the Mental Health Act code of practice. In two of the cores services we inspected, not all patients were provided with information regarding their legal position and rights in line with the Mental Health Act code of practice. In wards for older people with mental health problems, section 17 leave forms on Ruskin and Oakwood were generic and not patient specific. Patients were not individually risk assessed to take leave. Families were not given copies of forms. This issue had been raised in the Mental Health Act monitoring visit and was still an issue at the inspection.
  • Staff did not always ensure the physical health care needs of patients on Ramsey ward. Families raised concerns that physical healthcare needs were not always identified and responded to in a timely manner.

However:

  • 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. The ward teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
  • The wards and teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers made sure they had staff with a range of skills. They supported staff with opportunities to update and further develop their skills. Managers provided an induction programme for new staff.

Caring

Good

Updated 25 September 2019

  • We rated 13 of the of the 14 core services provided by the trust as good and one as outstanding in caring. This takes account of the previous ratings of core services that we did not inspect this time.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Feedback from patients and carers confirmed that staff treated them well. In wards for people with a learning disability or autism staff used tools to communicate with patients such as Makaton, flash cards, signers and translators.
  • Staff involved patients and carers in care planning and risk assessment. Carers told us they felt informed and involved in the care being provided in most core services we inspected. Staff ensured that patients had easy access to independent advocacy services. In wards for older people with mental health problems staff worked with patients and family members to develop ‘wellbeing diaries’ for each patient. Staff had detailed knowledge about patient’s backgrounds, things that were important to them, personal strengths and the support they needed to maintain wellbeing. Staff proactively used this information to inform the delivery of personalised care.
  • Staff actively sought feedback for patients, their families and carers on the service they received through the use of comments cards, a ‘thank you’ boards and the provider’s complaints procedure.

However:

  • Not all carers spoke positively about the care their relatives received. Three carers from Ramsey ward were unhappy with care on the ward.

Responsive

Requires improvement

Updated 25 September 2019

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

  • We rated 6 of the of the 14 core services provided by the trust as requires improvement in responsive. This takes account of the previous ratings of core services that we did not inspect this time.
  • Staff did not always manage beds effectively. In acute wards and psychiatric intensive care units patients could not access the service when they needed it because bed management was poor. Patients were often on wards a distance away from their communities and families and when they were recovering. If they had leave, they risked losing their bed whilst they were away. There were a high number of out of area placements.
  • Not all care areas were suitable for the purpose they were being used for. In the health-based places of safety we found areas which did not comply with the Mental Health Act code of practice relating to access to toilet facilities, access to outside space, sleeping arrangements and privacy and dignity in the suites. Dova ward was not maintained to a reasonable standard in the communal areas and one bedroom. Oakwood and Kentmere wards provided dormitory style accommodation and the trust had not made any robust interim measures to asses or manage the risk of patients being accommodated in these areas. During the last inspection plans for the relocation of the wards had been agreed, the plans had been delayed and it was unclear when the move would take place.
  • Staff did not always provide enough access to activities for patients. In wards for people with a learning disability or autism there was no activities co-ordinator on the ward and occupational therapy input was limited to two days. We saw little evidence of activities on the ward which was having a negative impact on patients’ morale.
  • Staff did not always attend safeguarding strategy meetings on Ruskin ward. There were instances where staff on Ruskin ward had not attended safeguarding strategy meetings.

However:

  • Staff met the needs of all patients who used the service. Staff assisted patients with communication needs and had access to interpreters, translators and other services designed to meet individual needs. All areas were accessible for people with mobility issues.
  • In acute wards for adults of a working age and psychiatric intensive care units patients had a good range of activities available seven days a week, during the daytime and evening.
  • Patients and carers knew how to complain, staff dealt with complaints appropriately and lessons learned from complaints were used to improve the service.
  • The mental health crisis service was available 24-hours a day and was easy to access. The service could be accessed through a dedicated crisis telephone line. The referral criteria for the mental health crisis teams did not exclude patients who would have benefitted from care. Staff assessed and treated patients promptly. Staff followed up patients who missed appointments.

Well-led

Requires improvement

Updated 25 September 2019

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • We rated 7 of the of the 14 core services provided by the trust as requires improvement and one as inadequate in well led. This takes account of the previous ratings of core services that we did not inspect this time.
  • Not all of the governance systems at service level were effective in assessing, monitoring and improving care and treatment. Systems and audits had failed to identify issues such as patient observation following restrictive physical interventions, medicines management, mandatory training compliance, clear oversight of supervision, bed management, issues with staff experience and skill mix, care records or staff support following incidents.
  • The trust board did not have a robust system to provide clear oversight of both quantity and quality of supervision. At our last inspection in 2016 we told the trust they must ensure that regular supervision was provided to in line with policy and that this was monitored to provide assurance of compliance to the senior management team. The trust only had local monitoring in care groups which recorded and monitored supervision. The trust planned to continue to audit on a quarterly basis and report this to the board until a more robust solution had been implemented.
  • Not all Fit and Proper Person checks were in place. The trust did not have an appropriate system or process in place to ensure that all existing directors continue to be fit and do not meet any of the unfitness criteria set out in Schedule 4 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
  • Senior managers were not always visible in the trust. Although there was a programme of board visits to services, visits were less frequent in the mental health services. Few staff had seen or spoken with the senior managers of the trust.
  • Not all staff felt engaged in the trust’s vision, values and strategy. Not all staff in the core services were aware of the new values of the trust. Not all staff in the mental health services felt able to contribute to service developments or the strategy for their service. They did not know what the changes would mean for them going forward and staff in the east of the service had received little or no information regarding the changes.
  • The trust had not fully implemented the role of the freedom to speak up guardian. There were areas within the core services where staff did not know who the freedom to speak up guardian was or their role. Staff were concerned that the guardian reported direct to the chief executive and was not independent.
  • Not all staff teams had positive relationships or worked well together. The trust did not ensure that all staff working on Rowanwood ward felt supported, valued or respected following serious incidents. They did not assure that there were measures in place to protect them from reoccurrence of incidents.
  • The trust board did not have effective systems in place to monitor operation and compliance of the Mental Health Act or its administration. Appropriate governance arrangements were not in place in relation to Mental Health Act administration and compliance. The trust had identified that the current structure of governance for the Mental Health Act was not effective and there were plans to address this.
  • Not all areas of the trust provided patients with privacy and dignity. Oakwood wards had dormitory style accommodation and only a curtain between beds. Kentmere had dormitory style accommodation separated by a solid partition. The trust had not made any robust interim measures to asses or manage the risk of patients being accommodated in these areas.
  • The trust had not completed work on the link between the risk register and board assurance framework. At our last inspection we told the trust it must ensure that the risk register is effectively reviewed and managed in line with the trust policy and that there is evidence of a clear link between the register and the board assurance framework. At this inspection the trust had only made some progress on this.

However:

  • Senior leaders were new appointments in the last year and were skilled and experienced. The executive team were passionate and motivated to lead the work that needed to be done to move the organisation forward. There was an acknowledgement that progress had been made and there was a lot of work to do especially with the merge of the organisations.
  • The executive team were able to identify most of the challenges the trust faced across their services, the plans in place to meet those challenges and the current strategic direction for the trust within the wider healthcare system in Cumbria.
  • The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders. This included active involvement in sustainability and transformation plans. The trust worked closely with local authority public health colleagues. There were good links with health and well-being strategy. The trust worked with partners to align strategies and plans for the system rather than individual organisations.
  • Staff generally felt positive and proud about working for the trust and their team. Most teams reported good morale, although acknowledged this could fluctuate in changing circumstances. The coming changes to the trust and merger had led to low morale from staff in some services.
  • The trust recognised staff success by staff awards and through feedback. Staff awards and recognition were taking place. The trust was aware of the need to support and encourage staff through the changes. Over the past two years the Trust had increased its focus on staff recognition introducing Glimpse of Brilliance, weekly staff recognition, staff awards and offering leaders training in appreciative leadership.
  • The trust applied duty of candour appropriately. At our last inspection in 2016 we found the trust were not fully applying the duty of candour requirement. At this inspection staff in the core services had a good understanding of duty of candour. Incidents meeting the duty of candour requirement contained an apology to the appropriate person. There was a trust ‘being open and duty of candour’ policy in place and in date.
  • Staff had access to support for their own physical and emotional health needs through occupational health. The trust had a range of programmes to support staff’s physical and emotional health needs. The trust provided access to complimentary therapies, counselling and stress management services occupational health service.
  • Staff networks were in place promoting the diversity of staff. The trust had four staff networks that met quarterly and they had an executive board sponsor.
  • There were organisational systems to support improvement and innovation work. The trust were working in partnership with organisations across North Cumbria through the Cumbria learning and improvement collaborative (CLIC) and had adopted a common approach to continuous improvement. A common toolkit of lean based improvement tools was available on the Cumbria learning and improvement collaborative website and cross organisational training was available through Cumbria learning and improvement collaborative. Staff in the core services felt engaged in quality improvements.
Checks on specific services

End of life care

Requires improvement

Updated 23 March 2016

Overall we rated the end of life care services by Cumbria Partnership NHS Foundation Trust hospital as requires improvement. We rated safety, caring and responsive as good and effectiveness and being well-led as requires improvement. We identified areas where there was potential for improvement and these had been acknowledged by the trust. We saw evidence that work was in progress to address the shortfalls and improve the services. We have rated well-led as requiring improvement. This is due to the lack of monitoring of quality, lack of evidence of patient choice in treatment arrangements and the lack of measurement of the organisational performance against other similar services.

We saw good evidence that incidents were reported, investigated and outcomes were shared with staff and action taken to avoid it happening again.

Staff had a good understanding of the procedures for making safeguarding referrals. Patients and family members told us that they were satisfied that staff members respected their wishes and that they did not feel threatened or worried by them.

We observed staff adhering to the infection prevention and control policies when attending to patients. When visiting patients, staff carried with them hand gel and personal protective equipment and used them appropriately.

District nurses said that their jobs were challenging as they had high caseloads and also hadg to travel long distances when visiting patients in their homes. They said they prioritised and ensured patients with end of life care and palliative care needs were attended to. Community nurse specialists also got involved and worked alongside by delivering advice and treatment in the community.

Patients and families told us that staff continuously assessed the level of pain and administered appropriate pain relief. Although pain killers were in use, staff also introduced patients to other ways of relaxing and easing pain, such as aromatherapy and massage. Anticipatory medication prescriptions for pain relief were in use for people requiring end of life care and it was managed by district nurses or the community nurse specialists.

We attended two multidisciplinary meetings and found them patient focused, discussions were open, transparent and all attendees’ views were considered when decisions were made about the management of patients. At each meeting in-patients and community patients were discussed.

We observed examples where staff sought valid consent from patients and gave patients time to understand what was discussed. Staff did not hesitate to revisit discussions when they found the patient was having difficulty concentrating.

Patients and their family members told us that staff were sensitive to their feelings and able to support when they were distressed. They said nothing was too small for staff and ‘went that extra mile’ to help them resolve problems.

Part of planning and offering care for palliative and end of life care patients meant that patients after treatment had to travel long distances between treatment centres and their homes/ community hospitals. Although this could not be helped, patients and carers said this was distressing for them. They said a lack of choice and the lack of treatment centres near them made it difficult for everybody.

People who used the services told us that they knew how to make a formal complaint and said that they were confident to speak up if they were unsatisfied.

We received positive comments from patients and relatives which confirmed that end of life and palliative care patients received a seamless service between the hospital and the community. We saw that the trust governance arrangements included the local GPs; where agreement had been reached to work to Gold standard frame work.

Medical, nursing staff and managers were fully aware of the required improvements in the service and also the need for up-skilling staff to sustain good quality care. Further work identified were: end of life care Pathway was not established and this remained on their risk register, Care of the Dying Patient programme had not been implemented and a meeting with the acute trust was held to take this forward and there were plans to fund Care of the Dying facilitators and provide education for staff.       

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

Requires improvement

Updated 25 September 2019

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

  • The governance systems and processes in place were not always adequate. Bed management did not ensure beds were always available locally. Staff on Rowanwood were not assured of the effectiveness of the serious incidents reviewed. Staffing and recruitment was an increasing issue, despite measures already in place to eradicate this.
  • Staff did not do all that was reasonably practicable to mitigate risks to the health and safety of patients. Blanket restrictions were in place without being individually assessed. Staff did not always monitor patients’ physical health needs following use of rapid tranquilisation and repairs to Dova Unit were ineffective to ensure a patient room was suitable for use.

However:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

Wards for older people with mental health problems

Requires improvement

Updated 25 September 2019

Our rating of this service stayed the same. We rated it as requires improvement because

  • There were notable variations between the ward environments. Oakwood ward had not improved since the last inspection and dormitory accommodation was still in place. The ward was not fit for purpose and it was unclear when the relocation of the ward would take place.
  • There were vacant nursing posts on Ramsey ward which could not be filled. This meant that the ward relied on bank and agency. Feedback from carers was mixed about the care and treatment on the ward.
  • There had been a number of serious incidents on Ramsey unit. The trust had carried out investigations, but these continued to be areas of concern.
  • Section 17 leave forms on Ruskin and Oakwood were generic and not patient specific.

However:

  • There had been improvements since the last inspection in relation to the mental capacity act, the introduction of psychology onto Ramsey ward and staff supervision.
  • Ruskin ward provided a dementia friendly environment with a good balance between patient safety and ensuring patients were comfortable.
  • Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented wellbeing diaries which were informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • The service was well led, and governance processes were in place to monitor the service.

Wards for people with a learning disability or autism

Updated 25 September 2019

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

  • Medicines management arrangements on the ward were ineffective. We found two unlabelled medicines in storage. There was no risk assessment in place in relation to the use of sodium valproate to treat a female patient of child bearing age despite there being known risks of birth defects and abnormalities associated with the drug.
  • Staff did not carry out physical observations following the use of restraint and ‘as required’ medication was given after each of the nine restraint instances we reviewed without the rationale being recorded. Staff had not completed body maps for five of the nine incidents of restraint.
  • Patients did not have access to sufficient therapeutic activities. There was no activities co-ordinator on the ward. We saw little evidence of activities on the ward which was having a negative impact on patients’ morale.
  • Staff on the ward had not completed their local induction or mental health legislation training. The provider reported that only 57% of staff had completed their local induction and 12.5% had completed their mental health legislation training. Ten other modules were below the provider’s 85% compliance target.
  • Staff did not receive regular supervision. Since August 2018, out of the 24 staff members on the ward, nine had not received any supervision and 14 others had only received supervision between one and three times.
  • Governance systems for the ward were ineffective. Audits had failed to identify issues in relation to physical interventions, rapid tranquilisation, medicines management, confidentiality agreements, care records and a positive behaviour plan. The service had failed to address issues around mandatory training compliance that had been found during our previous inspection in October 2016.
  • Staff had not reviewed the care plan relating to a patient’s ‘as required’ medication since January 2018. A care record contained an incomplete positive behaviour support plan, lacked information about the patient’s strengths, goals, needs and problems and their epilepsy plan did not contain steps to support a safe bathing process. The care record also referred to the patient using the wrong gender.
  • We were told by staff that for physical healthcare emergencies during the night, staff used the NHS 111 system. However, we understood within the organisation that the agreed arrangements were to contact Cumbria Health On Call Limited when medical emergencies arose.
  • There were no confidentiality agreements in place for two patients who had been deemed as having mental capacity. There was no nurse call system on the ward which made it more difficult for patients to call for assistance.
  • Four members of staff lacked knowledge about the duty of candour and the role of the provider’s freedom to speak up guardian.
  • Two members of staff were unable to access suitable specialist autism training for their role and development needs.

However:

  • Staff treated patients and carers with kindness, dignity and respect and involved them in decisions about care and treatment. Staff used tools to communicate with patients with communication issues such as Makaton, flash cards, signers and translators. Staff undertook regular risk assessments of patients and put plans in place to mitigate risks. Staff ensured patients’ physical health needs were met and monitored.
  • Staff ensured patients had access to spiritual support and food choices to meet their dietary needs. The ward was accessible for wheelchair users.
  • Staff adhered to the Mental Capacity Act and Mental Health Act and there were systems in place to monitor how the Acts were used on the ward. Staff carried out capacity assessments and we saw evidence that best interests’ decisions were made appropriately if patients lacked capacity.

Mental health crisis services and health-based places of safety

Requires improvement

Updated 25 September 2019

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

  • The systems and processes established were not operating effectively to assess, monitor and improve the safety and quality of the service or assess monitor and mitigate the risks relating to the health safety and welfare of patients.
  • The physical environment of the health-based place of safety at Kendal did not meet the requirements of the Mental Health Act Code of Practice.
  • There was not always a dedicated member of staff to observe patients in the health-based places of safety.
  • Some facilities in the health-based places of safety did not promote the privacy and dignity of patients.
  • Not all staff supporting patients in the health-based places of safety were trained in the prevention and management of violence and aggression.
  • There was not always a record on the electronic patient record system that patients had their section 136 rights explained when accessing the health-based places of safety.
  • Care plans were not always completed on the right documentation and a record of whether all patients received a copy of their care plan was not evident.
  • Staff managing patient care were not receiving supervision and appraisal in line with trust policy.
  • Staff did not feel supported by senior management.
  • Most staff did not feel respected, supported and valued. They did not feel able to raise concerns without fear of retribution. Not all staff were aware of the Freedom to Speak Up Guardian.

However:

  • The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • 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 mental health crisis service and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately.

Community-based mental health services for adults of working age

Good

Updated 26 January 2018

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

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

  • Services were well managed with good governance structures in place to ensure a good flow of information up and down the structure through the relevant forums.
  • The trust had acted upon our feedback from our last comprehensive inspection and made some improvements.
  • The trust’s vision and values were well embedded into teams. Staff knew and applied the trust’s values in their daily work.
  • Staff morale was good and team cultures were described as supportive, open and honest so staff were confident about raising concerns.
  • Feedback from patients and carers was universally positive. Patients said that staff had a good understanding of their individual needs and treated them with dignity and respect.
  • Patients were assessed quickly and comprehensively and prioritised according to needs and risks. If patients were placed on a waiting list they were regularly monitored by clinical leads.
  • Care records were up to date, personalised, recovery orientated and included evidence of ongoing physical care, informed consent and appropriate consideration of mental capacity.

However:

  • Not all premises had disabled facilities and so were not accessible for all patients.
  • There were inconsistencies in the storage and management of medicines at the three locations inspected.
  • Although mandatory training for the core service was just below the trusts target rate, some classroom based training courses were significantly below this target.
  • Supervision was taking place but not always 4-6 weekly and the templates used varied. There was also no central monitoring of supervision for senior management oversight.
  • The trust measures referral to assessment times but does not record or monitor referral to treatment for patients.

Community health inpatient services

Requires improvement

Updated 26 January 2018

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

  • We rated safe, effective and well led as requires improvement. We rated caring and responsive as good.
  • Although staff had Mental Capacity Act and Deprivation of Liberty Safeguards training, not all staff had an understanding.
  • Patient care documentation was a mixture of electronic and paper. Records were not all up to date or contained completed risk assessment and reviews. The records were not individualised and updated to reflect patient’s needs.
  • Managers used a dependency and acuity tool to determine safe staffing levels and had a staffing escalation plan in place. However, on some wards they used additional health care support workers to maintain safe staffing levels. This meant that on some occasions registered nurses were not able to take a break away from the ward in line with the national working time directive.

However:

  • Mental Capacity Act and Deprivation of Liberty Safeguard training was now compulsory for all staff. Compliance for the inpatient services in May 2017 was 100%, which exceeded the trust target of 80%.
  • All staff received mandatory training and had an appraisal.
  • Staff checked and ensured resuscitation and emergency equipment was ready for use.
  • Medicines management had improved since the last inspection.
  • Staff assessed patients who were at risk of falls are assessed and the occupational therapy staff used TOMS outcome measures.
  • Managers had introduced quality safety checks in inpatient services to assure themselves that quality was being monitored.
  • Managers shared learning from incidents and investigation was shared with staff.
  • The end of life document reflected national best practice guidance and contained a pathway for patients with mental health conditions.
  • There were strong multi-disciplinary team working relationships between therapists and nursing staff.

Some staff were concerned about the outcome of the service reviews and how that would affect the community wards and the forward strategy. However most staff we spoke with said that staff engagement and communication about proposals was positive.

Community dental services

Requires improvement

Updated 26 January 2018

This was the first time we had inspected this service. We rated it as requires improvement because:

  • At the time of our inspection, there were 743 patients on the treatment waiting list for more than the 18 weeks notional target. Of this total figure, 278 patients were waiting for treatment under General Anaesthesia (GA), including 172 children, some of whom were likely to be in pain. Some of the patients had been on the GA waiting list for nine to twelve months.
  • The service completed risk assessments and audits and some of the results were stored centrally. The service did not have oversight of some of these documents and we observed action plans were not always completed.
  • The service did not have an effective system to ensure that all dentists in the emergency dental service and University of Central Lancashire, with honorary contracts, were up to date with continuing professional development and registration requirements issued by the General Dental Council.
  • The service and commissioners had developed a set of acceptance and discharge criteria so that only the most appropriate patients were seen by the service. The service had not taken steps in the last 12 months to work with referring dentists to identify inappropriate referrals and to review processes surrounding this to effectively manage the waiting list.

However:

  • Staff reported incidents appropriately. Incidents were investigated, the results of the investigation shared, and there was evidence of lessons learned.
  • Staff understood their safeguarding responsibilities and could describe the safeguarding policies and procedures. Staff had up to date safeguarding training at the appropriate level.
  • Staff stored, handled and administered medicines safely.
  • Staff maintained equipment well and it was fit for purpose.
  • Staffing levels were appropriate and met patients’ needs at the time of inspection.
  • Patients’ care records were comprehensive and included the information required to keep people safe. Relevant information was recorded appropriately and staff had access to the information they needed before providing care.
  • Standards of cleanliness and hygiene were generally well maintained. Systems were effective in preventing and protecting people from healthcare associated infection.
  • Mandatory training was provided for staff and compliance met or exceeded the trust targets in most topics.
  • Staff had the necessary qualifications and skills they needed to carry out their roles effectively. Further training and development opportunities were available for staff.
  • Appropriate systems were used to respond to medical emergencies.
  • Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
  • The service followed effective evidence based care and treatment policies which were based on national guidance.
  • There was evidence of good multidisciplinary working with staff. Teams and services worked together to deliver effective care and treatment.
  • During the inspection, we saw and were told by patients, that all staff working in the service were kind, caring and compassionate at every stage of their treatment.
  • People were treated respectfully and their privacy was maintained in person and through the actions of staff to maintain confidentiality and dignity.
  • Staffs were sensitive to the needs of all patients and were skilled in supporting patients and young people with disabilities and complex needs. We saw there were systems to ensure that services were able to meet individual needs, for example, for people living with dementia and learning disabilities.
  • Staff involved patients and those close to them in aspects of their care and treatment. Information about treatment plans was provided to meet the needs of patients.
  • There was an effective system to record concerns and complaints about the service. Complaints were reviewed and actioned appropriately with a view to improving patient care.
  • Staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.
  • There was a very positive and forward looking attitude and culture apparent among the staff we spoke with.

Specialist community mental health services for children and young people

Requires improvement

Updated 26 January 2018

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

  • Risk assessments were not present or incomplete in nine of the 19 records reviewed.
  • Care plans were not present in the records we reviewed, young people were copied into letters to GP’s which were described not being in an accessible format by patients and their carers.
  • Consultant psychiatrist posts had been filled by locums which had impacted on the continuity of care for people who use the service. The service was not meeting its target times from referral to initial assessment and then to appointing care coordination and intervention for routine referrals. Under the NHS constitution, no patient should wait more than 18 weeks for any treatment. The service did not monitor waiting times for specific conditions such as first episode psychosis or eating disorder waiting times in line with the national guidance.
  • The service did not have a methodology or tool to assess the services staffing requirements and it was unclear how staffing levels and skills mix were calculated.
  • The service did not have the staff with the necessary skills to provide the full range of evidence based interventions recommended by the National Institute for Health and Care Excellence and were unable to offer evidence based interventions to all.
  • Mandatory training and appraisal figures were not compliant with trust targets.
  • At the time of the inspection there was no comprehensive out of hours service provision for young people as the trust had not been commissioned to provide this service.
  • The waiting area for patients at Workington CAMHS service was shared with a GP surgery and did not promote the privacy and dignity of the young people who attended the service.
  • Staff morale was low with staff telling us they did not feel supported by senior members of the trust.

However:

  • We observed good interactions between staff and young people who used the service.
  • Staff had a clear understanding of safeguarding policy and procedures
  • Risk for young people on the waiting list was discussed and priority given to young people in crisis, the service met their target times for young people highlighted as a priority.

Community-based mental health services for older people

Requires improvement

Updated 26 January 2018

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

  • The environment in Whitehaven was poor and did not meet service users’ needs. There was a lack of space and no disabled access facilities. Furniture was old and worn.
  • Care plans and risk assessments were missing or not completed well. Risk assessments and care plans were often out of date and did not correspond to current information.
  • Staff supervision was not recorded or poorly recorded. Information about staff supervision was not shared with senior managers. It was not possible for senior managers to be assured that supervision was taking place.
  • Staff training and appraisal rates for non-medical staff were below the trust target.
  • There was a delayed response to items placed on the trusts risk register. There had been limited action regarding the poor environment in Whitehaven. This was affecting staff morale.

However:

  • Positive initiatives were encouraged and shared within the service. These included the virtual memory clinic and the delirium outreach support service. There were effective strategies to save time and costs.
  • Assessments were comprehensive and completed in a timely way. Service users were seen quickly from being referred.
  • Staff were kind and caring towards service users and carers. Staff were highly praised by service users and they were observed to be empathic and sensitive.
  • There were strong links with external services such as care homes and GP’s. Staff met regularly to discuss service users with complex needs.

Community health services for children, young people and families

Good

Updated 21 April 2017

Overall rating for this core service

Overall, we rated community health services for children, young people and families as good because:

  • The leadership, governance, and culture promoted the delivery of high quality person-centred care. Senior managers and staff had made significant improvements since CQC’s previous inspection, in November 2015. A strong, cohesive senior leadership team, supported by a proactive team of managers, had good oversight of risks and incidents, which they monitored and reviewed regularly.
  • Staff protected children and young people from avoidable harm and abuse, and they followed appropriate processes and procedures to keep them safe. The named nurse for safeguarding children had been instrumental in the establishment of a robust safeguarding supervision model, to ensure staff shared best practice and lessons learnt from serious incidents and serious case reviews involving children and young people.
  • Managers and staff managed caseloads well and there were effective handovers between health visitors and school nurses to keep children safe at all times. On a day-to-day basis, staff assessed, monitored, and managed risks to children and young people. This included risks to children who were subject to a child protection plan or who had complex health needs.
  • Children, young people, and families felt staff communicated with them effectively, kept them involved and informed about care and treatment, promoted the values of dignity and respect, and were kind and compassionate.
  • Services for children and young people were organised to meet the needs of children and young people. Managers and healthcare professionals from the team worked collaboratively with partner organisations and other agencies to ensure services provided choice, flexibility, and continuity of care.
  • Since the previous CQC inspection, in 2015, managers and staff had improved waiting times to ensure children and young people received the right care at the right time in community paediatrics, audiology, learning disability nursing, and physiotherapy. Although occupational therapy and speech and language therapy services waiting times were still outside of the required target, managers had taken appropriate action to reduce the time families had to wait.
  • Senior managers had developed a strategy that planned to introduce a new service delivery model, which included changes to the structure of the Care Group. Senior managers and staff had worked collaboratively with the local authority and commissioners and had proactively engaged with staff. The planned changes included the introduction of a dedicated team caring for the most vulnerable children and families across the county.

However:

  • Staff did not consistently complete care records within the required timescales recommended by the Nursing and Midwifery Council. Although staff had their own laptops, most did not use them to update patient records whilst away from their office base.
  • The trust did not provide a qualified specialist community public health nurse (SCPHN) for each secondary school in the county, which was in breach of Royal College of Nursing guidelines. Also, the school nursing service did not provide health promotion initiatives in local schools.
  • Morale was low amongst some staff due to the planned service changes. Although staff acknowledged senior leaders had shared information and provided regular updates, staff were unclear if their views had been included.

Community mental health services with learning disabilities or autism

Good

Updated 23 March 2016

We rated Cumbria Community Learning Disability Team as good because

:

  • staff were caring and treated patients with dignity and respect

  • people had mostly been involved in the development of their care plans

  • staff responded quickly to changes in people’s health or level of risk and there were no waiting lists for initial assessment

  • complaints were listened and responded to appropriately

  • all staff had received safeguarding training and had a good understanding of how to raise and report safeguarding concerns or alerts

  • there were effective processes for managing staff caseloads

  • staff worked effectively to lone working practices and adhered to the trust policies and procedures

However:

  • Care records had inconsistencies and gaps that meant some people had incomplete risk assessment plans, reviews and recording of risks.

  • Care plans did not always demonstrate holistic, person-centred or treatment focused care in line with best practice guidance, such as positive behavioural support plans. Care records did not contain any evidence of advance decisions.

  • People did not receive care in accordance with their assessed needs. The service did not follow best practice and guidance in relation to supporting patients with communication difficulties and complex behaviours.

  • care records were difficult to navigate, this meant that important patient documents and information was not always easily found within the care records

  • the service had experienced continuing difficulties with staffing, including recruitment, retention and sickness, which meant that staffing, was not adequate to meet the needs of the people who use the service

  • some of the community teams did not have a full complement of professionals within their multi-disciplinary team which meant that people could not always access these professionals in a timely and effective way

  • staff appraisal figures were low with an average percentage of staff in the service that had received an appraisal in the last 12 months at 39% and non-medical staff appraisals averaging 30%

  • there was a lack of consistency across the service for people accessing treatment following assessment

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 23 March 2016

We rated long stay/rehabilitation mental health wards for working age adults as good because

:

  • There were enough staff for people to receive the care and treatment they required

  • staff identified ligature points (places where someone intent on self-harm might tie something to strangle themselves) and took action to remove or minimise risks

  • the ward was clean and tidy and was maintained to a high standard

  • the staff were caring and treated patients in a respectful and dignified manner

  • there was good multidisciplinary team working and staff engaged well with community teams as well as outside organisations

  • there were no complaints about this service in the last twelve months

  • the clinical leadership on the ward was clear and all staff said that they felt supported and listened to

  • staff were aware of the trust vision and values and were committed to providing good care in line with this.

However:  

Patients’ bedrooms were on the first floor of the building except two bedrooms on the ground floor. There was no nurse call system or alarm system in patients’ bedrooms. There were blind spots on the first floor, these were mitigated by the use of parabolic mirrors. However, staff did not routinely work on the first floor, the only staff presence was during hourly observations. This meant there patients had no means of summoning staff help or support in an emergency. This is a breach of regulation 12 of the Health and Social Care Act 2008.

Community health services for adults

Good

Updated 23 March 2016

Overall rating for this core service was good:

Staff were encouraged to report incidents and systems were in place following investigation to help rapidly disseminate learning.

The delivery of care and treatment was based on guidance issued by professional and expert bodies such as the National Institute for Health and Care Excellence (NICE) guidelines in the treatment of head injury.

Patients had self-management plans to help them to stay well and manage long-lasting respiratory conditions; therefore they avoided hospital admission. The response times to treatment in relation to restorative dentistry, physiotherapy, diabetes, and neuroscience were good.

Patients and their relatives were treated with kindness, dignity and respect, and we saw compassionate care being delivered.

The service was planned and delivered to meet patient needs. People with urgent care needs were prioritised for treatment and their needs were met in a timely way. Patients waited less than 18 weeks for a first appointment relating to physiotherapy, diabetes, and neuroscience. This was similar or better than the national target of 95% for a first appointment to attend these specialist services within 18 weeks.

Complaints were taken seriously, discussed with staff in their team meetings and included lessons learnt.

The service had a vision, mission and strategy which they clearly published for people and staff to see. Their values were known by staff. The chief executive and their team encouraged people and staff to have a voice and contribute to the way the service developed.

There was good local management and leadership. However, due to the recently restructure of the service some staff did not have confidence in the changes and told us they did not feel supported by middle management. They felt the changes in working practices relating to staffing, had not been fully discussed and they had not felt listened to.

The trust produced a ‘Trust Talk’ newsletter for patients, the public and members of staff. The newsletter kept people up to date with information about the services and included patient stories and challenges the trust needed to address.

We also found:

Work had commenced to review staffing levels in relation to caseloads and service provision. However, not all actions had been fully implemented or embedded in practice. In some areas there were shortfalls in staffing and although due to the goodwill of staff they continued to provide a service, they were not able to fully meet the needs of the patients.

Data showed mandatory training compliance across the teams was 75% with a trust target of 80%.

Training had been added to the risk register for the community teams in the north and south of Cumbria and the physiotherapy team in Furness. The service had an action plan, with a review date to address the concern and for staff to access training.

Information provided by the trust showed not all non-medical staff had an appraisal in the last 12 months. However, records held locally showed staff had received a 12 months appraisal, or they had a date booked when their appraisal would take place.

Record keeping was generally of a good standard. However, not all staff had been consistently recording in both electronic and paper care documentation when the information related to the same patient. Managers were aware of these issues and were implementing through a pilot, the use of mobile laptops in the community. Staff also reported they were in the process and being supported to use the electronic form of record keeping. This meant paper records would not be used which would address the inconsistencies in record keeping.

Several policies were past their review date. This could have meant staff did not always follow up to date guidance.