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Provider: North Cumbria Integrated Care NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 21 MAY 2019 to 25 June 2019

During a routine inspection

  • 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.


CQC inspections of services

Service reports published 25 September 2019
Inspection carried out on 21 MAY 2019 to 25 June 2019 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 21 MAY 2019 to 25 June 2019 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 21 MAY 2019 to 25 June 2019 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 21 MAY 2019 to 25 June 2019 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 25 September 2019
Service reports published 26 January 2018
Inspection carried out on 5 Sep to 11 Oct 2017 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 5 Sep to 11 Oct 2017 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 5 Sep to 11 Oct 2017 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 5 Sep to 11 Oct 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 5 Sep to 11 Oct 2017 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 5 Sep to 11 Oct 2017 During an inspection of Community dental services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 26 January 2018
Service reports published 20 July 2017
Inspection carried out on 13 14 15 February 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Service reports published 21 April 2017
Inspection carried out on 10-12 January 2017 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Service reports published 16 February 2017
Inspection carried out on 11 and 20 October 2016 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)
Service reports published 23 March 2016
Inspection carried out on 10-11 November 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 9 -13 November 2015 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
Inspection carried out on 10, 11, 12 November 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 9-13 November 2015, 23-24 November 2015 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 9-13 November 2015 During an inspection of End of life care Download report PDF (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
Inspection carried out on 10 November 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Inspection carried out on 10th -17th November 2015 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 10 November 2015 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)
Inspection carried out on 9-13 November 2015 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 9 - 13 November 2015 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 10 November 2015 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)
See more service reports published 23 March 2016
Inspection carried out on 5 Sep to 11 Oct 2017

During a routine inspection

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

  • We rated 8 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 at the trust level as requires improvement. The trust was going through a period of significant change including the recent appointment of a new chair and chief executive. The roles and responsibilities of the executive team were under review to reflect the joint working arrangements with North Cumbria University Hospitals NHS Trust.
  • Managers did not review risk registers to ensure they were completed in line with trust policy. There was no direct link between the risk register and the board assurance framework.
  • Staff did not apply the Mental Capacity Act and Deprivation of Liberty standards were not consistently applied in services across the trust. The trust had not put in place a robust arrangement for monitoring compliance with the Mental Capacity Act and Deprivation of Liberty standards.
  • Risk assessments and care plans were limited within specialist mental health services for children and young people.
  • The service did not have sufficient numbers of appropriately skilled and qualified staff to deliver evidence based care in line with national guidance.
  • In some services waiting times for patients to receive assessment and then treatment were above local and national targets.

However:

  • The majority of patients and carers were positive about how staff provided their care and treatment.
  • The values of the trust were embedded throughout the organisation a positive and open culture. The majority of the staff we spoke to described a positive and open culture.
  • Staff across all services demonstrated a commitment to good patient care.
  • We rated caring as good and found it to be outstanding in community dental services and Wards for older people with mental health problems.
  • The senior management team were visible and engaged with staff in leading a significant change within the organisation.

Inspection carried out on 10, 11 and 12 November 2015

During a routine inspection

We found that the trust was performing at a level which resulted in a rating of Requires Improvement because:

  • In some services, the assessment of patients’ needs was not always holistic and there was limited evidence of the patients’ participation in developing their plan of care.

  • The trust has both electronic and paper care records in use across services. Not all staff had access to current, complete and contemporaneous care records to support the care and treatment of patients. The trust had a project in place to move to a single electronic care record across services. However, its implementation was delayed with the implementation taking place through 2016.

  • The trust did not have a named nurse for children’s safeguarding at the time of the inspection, although we were told that this post had been filled. A duty rota was in place to give advice and support to staff. The systems and frameworks for safeguarding procedures and safeguarding supervision were in early development. Safeguarding supervision had been incorporated into managerial supervison and training for managers was taking place.

  • The requirements of the Mental Capacity Act (2005), including deprivation of liberty standards, were not being met in some services. Patients’ capacity and ability to consent to their care and treatment was not routinely documented in care records.

  • Managers and staff did not have a clear understanding of Mental Capacity Act (2005) including deprivation of liberty standards. The trust did not have a system to monitor how they meet the requirements of the Act.

  • The trust did not have a restrictive interventions reduction programme in place to meet Department of Health guidance.

  • The environment of the health based places of safety in Carlisle and Kendal did not meet the expected standard to meet national guidance. This placed people who used these services at risk and did not provide an environment which supported good care and treatment.

  • On Kentmere ward, and Victoria Cottage hospital the environment did not meet all the requirements of the Department of Health guidance on same sex accommodation.

  • Mandatory training compliance in the trust was variable across services and 63% overall. This was below the trust target of 80%. The trust’s appraisal rate was 49% for non-medical staff. This was below the appraisal rate we would expect in an NHS trust.

  • The trust did not have a robust system in place to record staff training and appraisal. Individual and team records did not match centrally held trust records on training attendance. Therefore the trust could not be assured staff had received training to maintain their skills and knowledge to carry out their roles safely and effectively and were up to date with changes to best practice.

  • In some services, national best practice and guidance was not being followed in relation to the availability of suitably trained or skilled staff. In other areas, we found vacant posts within multidisciplinary teams such as consultant psychiatry and occupational therapy.

  • The trust did not have a robust process in place to ensure that trust policies and procedures were reviewed within agreed timescales. The meant that policies and procedures may not always reflect current good practice or changes in legislation.

  • Participation in clinical audit and the learning and improvement from these audits was variable across services.
  • Within community health services for children and young people, there was no paediatric resuscitation equipment in areas where children attended for treatment for minor injury and illnesses. In addition, there were no paediatric trained staff at these centres.

However:

  • The trust had a clear strategy, which established its long term vision and strategic goals, underpinned by the values of the organisation.

  • Staff treated patients and their relatives with kindness, dignity, respect and compassion.

  • Most patients shared positive experiences of care and treatment from the services they used.

  • There was evidence of good communication between professionals involved in providing care and treatment to patients through structured handovers and multi-disciplinary meetings in most services.

  • In community health services for adults, the referral to treatment times in relation to physiotherapy, diabetes and neuroscience were similar or better than the national target.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.