Archived: North Essex Partnership University NHS Foundation Trust

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We rated North Essex Partnership University NHS Foundation Trust as requires improvement overall because:

• On the acute admission wards there were 25 incidents relating to the use of a ligature attached to a fixed object. One patient attempted to strangle themselves with a ligature during our inspection. This was in spite of serious concerns identified to the trust by the Care Quality Commission as part of our ongoing regulatory inspections. Two deaths due to self-ligature had happened over the past 12 months .There were a number of similar deaths in the previous years. The trust had made ligature risk assessments and had plans to address these but there were still an unacceptable number of ligature risks identified during the inspection.

• Finchingfield, Gosfield and Peter Bruff wards, Christopher unit and Shannon House failed to provide segregated accommodation for men and women when the Department of Health said this should no longer happen.

• Some care records and risk assessments did not contain enough detail.They were not personalised or kept up to date. This meant that staff did not know the full or current risks of the patients that they were caring for.

• Restrictive practices were seen on the wards. Patients could not always go to the toilet freely, get into the garden area, or have food and drink when they wanted while they were being nursed by the trust.

• The trust had very high bed occupancy rates. Patients were regularly admitted to beds reserved for patients on leave or patients were sent to hospitals out of the area. This meant that patients could be nursed a long way from home. Patients returning from a period of leave may not have a bed to return to if they needed one.

• The trust’s leadership style did not promote sufficient grip or pace to bring about changes where necessary in a manner that showed stakeholders or internal staff that there was any urgency about improvements. Changes took a long time to implement and consultations on improvements were not given the urgency necessary to give confidence that matters would be resolved. Ligature free doors had not been installed or even commissioned despite these having been agreed some time ago.

• The trust did not have robust governance processes, particularly in the assessment and management of clinical risks, assessment of the quality of care plans, and the management of environmental risks. For example, although the trust had a comprehensive risk management framework that informed management decisions in the identification, assessment, treatment and monitoring of risk, we found little record of the trust acting on these findings. While throughout 2014/15 regular reports were provided to the risk and governance executive, the quality and governance committee and the board of directors, there was little record of action taken to reduce risks to patients.

• The Care Quality Commission and Mental Health Act reviewers have inspected the trust several times over the last five years. Each time they identified areas where the trust must act. For example, around safety on both the Linden centre and the Lakes locations. Each time the trust made assurances that they would make changes. Senior managers and board directors could not explain why the trust had not addressed the problems.

However:

• The trust spent two years planning and consulting for the community transformation programme. They started running this fully in April 2015. Patients confirmed that these changes had led to improved community mental health care and treatment delivery by the trust.

• We found some good examples of positive multidisciplinary work and individual staff support for patients.

• Front line staff consistently demonstrated good morale.

• There was highly visible, approachable and supportive local leadership within some of the services we visited. For example, in the child and adolescent mental health service and community mental health services for adults.

Following this inspection, we identified that the trust was not meeting Regulations 9,10,12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We carried out enforcement action with the trust and told them to ensure compliance by 30 November 2015. The trust sent us their action plan to meet the regulation and we will check further on this.

We rated forensic inpatient and secure wards as requires improvement because:

• The security of the building was compromised as the magnetic doors which opened to the outside could be breached by kicking them open. Some of the internal doors could be opened by using a credit/bank card or similar.

• There were significant staff shortages. Therefore the ward relied heavily on agency and bank staff. Section 17 leave was cancelled due to staff shortages on some occasions.

• There was limited availability of psychological therapies and no specific offence related work took place.

• Historical Current Risk -20 assessments were not reviewed and updated regularly. The trust did not use the health of the nation outcome scores for secure services.

• Front line staff had a limited understanding of the trust’s values and vision.

• Most staff had not received regular monthly supervision and annual appraisals. For example, staff supervision rates for July were only 55%.

• Actions arising from local audits had not been clearly addressed by senior managers.

• The trust did not provide a reporting structure for learning from trust wide incidents including complaints and service user feedback.

• Staff could not confirm any of their key performance indicators.

However:

• The ward had a full multi-disciplinary team which included medical, nursing, psychological, and occupational therapy. Weekly review meetings took place to assess individual progress. Daily handovers took place to ensure that staff were kept updated of changes to individual needs and risk.

• Care and treatment records showed physical healthcare checks took place.

• Staff demonstrated an understanding of individual patient need. This was demonstrated by our interviews with staff, review of care and treatment records and our observations of the care and treatment being provided.

• Patients were aware of how to complain and the ward fedback to patients on changes that had been made to the service via ‘You said we did’ posters.

• Staff morale was positive. Front line staff spoke highly of the new managers. We noted that staff were comfortable in approaching senior managers and were able to raise individual concerns with them. Bank staff stated they felt part of the nursing team.

• The ward had low sickness and absence rates. For example, between March and August 2015 this was at 1 %.

Overall we rated acute wards for adults of working age and psychiatric intensive care units as ‘inadequate’ because:

• Some ward environments were unacceptable. Improvements were needed to make them safer, including reducing ligatures and improving lines of sight and ensuring the safety and dignity of patients. This was despite previous concerns being raised through CQC inspections and Mental Health Act review visits.

• Some wards did not meet the Department of Health guidance and Mental Health Act 1983 Code of Practice in relation to the arrangements for mixed sex accommodation. We found that Finchingfield, Gosfield and Peter Bruff wards, and the Hub, did not meet the Department of Health’s guidance on eliminating mixed sex accommodation.

• The seclusion room on Ardleigh ward and Peter Bruff ward was not fit for purpose, due to the design and layout.

• Restrictive practices were evident during our inspection. These included, for example, the use of the Hub, access to toilets, access to the gardens, and access to snacks and beverages.

• Patients did not have personalised or holistic care plans. Seven patients told us they did not have a copy of their care plan and ten patients told us that staff gave them a copy just before the inspection. We saw limited evidence of patients’ involvement in the care planning process in the care records we reviewed.

• Mental capacity was not always assessed on admission or on an ongoing basis.

• Bed occupancy rates were consistently very high, with out of area beds and beds of patients on leave used frequently to admit new patients to.

• The Trust had not complied with the three requirements in place, from April 2015, at the Lakes Mental Health Wards (Ardleigh and Gosfield wards) which related to good governance, safety and suitability of premises, and dignity and respect.

However:

• We found positive multidisciplinary work and saw staff supported patients.

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

• The service identified ligature points across the wards and environmental risk assessments were in place to reduce the risk to young people in the service. Staff observed patients in areas of the ward where there was risk, to ensure they were not able to harm themselves.

• The service complied with mixed sex accommodation guidance which meant that privacy and dignity was maintained.

• The managers ensured staffing levels were appropriate to maintain the observation levels of young people and to ensure safety on the wards. Escorted leave took place regularly. Managers used agency and bank staff appropriately to cover staff absence.

• Staff were 85% compliant with mandatory training. Staff were 100% compliant with safeguarding training.

• Staff completed comprehensive risk assessments on admission and staff updated them regularly to ensure they reflected accurate information.

• Staff reported incidents regularly and appropriately. Managers reviewed incidents and learning was shared across the staffing team.

• Psychologists provide a wide variety of psychological therapies. Young people were able to have taster sessions of different therapies to see if they were helpful prior to committing to a full programme.

• The Multi-disciplinary team (MDT) met regularly to review and update patient care and treatment plans.

• Compliance with the Mental Health Act and Mental Capacity Act was good. Legal paperwork was scrutinised appropriately and young people were aware of their rights.

• Staff interacted positively with patients and demonstrated in depth knowledge of the individual needs of young people and their preferences.

• Patients talked about their positive relationships with staff and said they felt supported, cared for and involved in their treatment.

• Staff invited patients to attend MDT reviews and ward rounds to participate in their care planning.

• The service involved families and carers in young people’s treatment where this was appropriate. They were consulted about changes to the ward for example; the introduction of mobile phones.

• Managers of the service managed the beds appropriately and young people were able to return to their bed following periods of leave.

• Staff used interpreters in appointments where required.

• Staff reported good working relationships with peers and spoke with passion regarding their roles in the teams.

• Managers provided staff with regular supervision and access to mandatory training.

• Staff delivered education flash sessions in team meetings so staff with specialist knowledge or interests could share information and knowledge across the disciplines.

• Managers monitored levels of sickness within the team and the rates were low. There were no cases of bullying and harassment.

• Managers provided appropriate levels of support to staff following incidents.

• Staff worked innovatively within the service. For example, work was being undertaken to increase family and carers ability to visit their children on the wards.

• The service participated in QNIC (Quality Network for Inpatient CAMHS) and was peer reviewed and would be submitting an application for QNIC accreditation.

However:

• Staff did not manage medication appropriately. There were errors in medication administration records and discrepancies in stock audits. This was bought to the trust’s attention and they addressed this immediately.

• Young people did not like the quality of the food provided to them.

• The trust managed formal complaints centrally which meant there was no complaint information available for ward based staff to review and learn from.

We gave an overall rating for community based services for older people as requires improvement because:

• Some patients did not have risk assessments in place, or these had not been updated. At some sites, staff had difficulties in accessing all of the information relating to patient care on the trust’s computerised record system.
• Some key targets to measure referral to triage and triage to assessment times were not in place. Where target times were identified, for example at some memory clinics, these were not always being met and no plans were in place to improve performance.
• Formal systems to review learning from incidents and complaints were not in place across the sites we visited.
• Systems were not in place to ensure that good practice was followed when patients were subject to community treatment orders under the Mental Health Act.
• There were concerns about the quality of key performance indicator data.

However:

• Safeguarding procedures and practice were good across services. There was rapid access to a consultant psychiatrist when needed.
• Good relationships had been developed with GP practices and there were systems in place to carry out physical health checks and monitoring.
• Patients and carers spoke highly of the service they received. We observed positive, caring interactions between staff, carers and patients. Reviewed care plans were in place for patients.
• There was a good understanding and appropriate use of the Mental Capacity Act.
• Staff teams worked well together and felt supported by local and senior managers. A range of research projects and national accreditation processes were in place across the sites that we visited.
• Systems to monitor staff supervision, appraisal and mandatory training were in place at each site, managers monitored these and appropriate action was taken as needed.

We rated  community based services for adults as good overall because:

• The teams worked to a comprehensive lone working practice protocol. Staffing levels were safe and recruitment was in progress to fill vacancies. Staff were trained in and aware of safeguarding requirements and used the appropriate referral process. Clinical areas were clean and well maintained and infection control information was on display. Caseloads were managed proactively, re-assessed regularly and discussed in individual supervision.

• There was an effective incident reporting system in place and staff knew how to report an incident.

• Medicines were managed safely and there was learning from medication incidents.

• Comprehensive assessments were completed in a timely manner. Most care records showed personalised care which was recovery oriented.

• Staff followed National Institute for Health and Care Excellence (NICE) guidance. The community transformation changes had ensured that this guidance was followed regarding access to psychological therapy, family interventions and appropriate medication management. Physical healthcare needs were considered during assessment and during treatment.

• The teams were multi-disciplinary and consisted of psychiatrists, psychologists, nurses, social workers, occupational therapists and support workers. There was effective working with other agencies and services.

• Staff were consistently respectful and caring when they spoke with people. People who used the services and their carers gave positive feedback about staff. Several individual staff members were highly praised by people who used the services and their family members.

• People said they felt involved in their care planning and treatment and this was documented in the care records. Information on advocacy was available in waiting rooms.

• Staff were flexible about timing of appointments to meet patient need. The specific needs of people were considered, for example cultural and disability needs. There was access to interpretation services when required. Teams responded to and learned from complaints. Local resolution was tried wherever possible.

• There was access to a psychiatrist when required. There was joint working with crisis services. Carers’ assessments were completed within the team by identified staff.Waiting lists for the teams and psychological therapies were kept to an absolute minimum. The community teams had no waiting list and psychological therapy had a wait of between one and eight weeks.

• Managers monitored performance and addressed any issues. Most staff were aware of the trust’s vision and values and could describe them. Most staff knew who the senior managers and executive directors were. They had met the chief executive and executive and non-executive directors. Staff said they had raised issues with the chief executive and felt they had been heard and action had been taken. All staff said they could raise issues with their manager if required and action would be taken. Clinical and managerial supervision was taking place.

• Sickness rates were low, poor attendance was addressed using the relevant policies. Managers said they had received advice and support from human resources.

• Teams could add items to local risk registers when necessary. Literature on the community transformation was comprehensive and well consulted on. The clinical model and care pathways were well laid out.

• Despite concerns arising from the changes, and the size and significance of the community transformation, the teams were organised and delivering an effective service.

However:

• Risk assessments were not always detailed and updated.

• Evidence that medical equipment, such as weighing scales, had been checked and re-calibrated according to the manufacturer’s instructions was incomplete.

• 80% of staff were up to date with their mandatory training. This is short of the trust target of 90% for mandatory training.

• Teams did not always hold de-brief sessions post incidents.

• The electronic record system was at times slow to use and as records were placed into different places on the system this made it difficult to track information easily.

• The level of detail in care plans, including information about personalisation and the recovery approach, was inconsistent. This increased the risk of key information being missed by professionals who may not be familiar with the person receiving care.

• In two teams the legal documentation relating to the Mental Health Act was disorganised and not readily available.

• There was some tension around the community transformation implementation. Some senior doctors felt isolated and not included and they said there was a lack of medical leadership and support.

• The teams had little confidence in the accuracy of data quality reports taken from the electronic care record system. Managers had no access to the electronic staff records system. This led to different processes and ways of monitoring team performance. The three areas, North East, Mid and West Essex, had developed different structures which led to staff confusion about the different models of care used across the trust. Teams and services had adopted different titles which further compounded this issue. This could be confusing for people using the services.

We gave an overall rating for mental health crisis services and health-based places of safety of requires improvement because:

• Environmental risks were identified in the three HBPoS used for adults. This included potential ligature points and limited ability to observe people who were detained under S136 of the MHA. Two people had absconded from the HBPoS in Colchester between 1 September 2013 and 31 August 2015 by jumping over the fence.

• Staff were relocated from the local acute ward when a person was brought into the HBPoS rather than having dedicated staff. The number of staff on the acute wards was only uplifted to reflect the needs of the HBPoS in Colchester.

• There were some delays in people being discharged from S136 due to a lack of awareness of the the doctor’s ability to discharge the S136 following their assessment if no AMHP was available.

• Some staff we spoke with were mistaken about the point of time that a person was detained under S136. This could result in an incorrect calculation of the period of detention and time the S136 would expire

• The AMHP and doctor did not always attend within three hours as recommended in the MHA Code of Practice.

• People detained under S136 were usually transported to the HBPoS by police rather than by ambulance.

• Some information was missing in many of the S136 records we reviewed. This included physical health, whether the person had a learning disability, the person’s language and the times the doctors or AMHPs were called or assessed the person. This meant it was difficult to audit that the MHA was being applied correctly.

• The trust’s new policy on S136 did not reflect the requirements of the MHA Code of Practice in monitoring that the MHA was being applied correctly in relation to S136.

• There was no clear lead for the HBPoS in the St Aubyn Centre and the Christopher Unit in the Linden Centre.

• There was no clock visible from the assessment room to help avoid disorientation in time in any of the four HBPoS. There was no shower in the HBPoS in the St. Aubyn Centre.

• There was limited space to store medicines for the access, assessment and brief intervention teams in Colchester and Chelmsford.

• Learning from some serious incidents had not been shared across the three access, assessment and brief intervention teams.

• Target times for assessment were set for the access and brief intervention teams in Colchester and Chelmsford but not in Harlow.

However:

• The trust had set safe staffing levels and these were followed in practice in the access, assessment and brief intervention teams.

• Risk assessments were undertaken at initial assessment and updated regularly.

• Comprehensive holistic assessments and care plans were completed and reviewed in a timely manner. Interventions included support for housing, employment and benefits. People who used the service had access to a range of psychological therapies. People’s physical health needs were considered and discussed at the point of assessment.

• Staff treated people who used the service with respect, listened to them and were compassionate.

• Proactive steps were taken to engage with people who find it difficult or are reluctant to engage with mental health services.

• The trust’s innovative partnership with the Samaritans and the introduction of street triage had improved access to services for people with a mental health crisis.

•   Staff generally had good morale.

We rated inpatient rehabilitation wards as good overall because:

• The unit was clean and each patient had their own bedroom. Two bedrooms were en-suite. The furnishings were of good quality. There was evidence of recent re-decoration having taken place. The service had identified a number of ligature risks within their environmental risk assessment. Admission guidelines to this unit were designed to minimise risks to patients within this environment.

• Sufficient staff were on duty and duty rotas confirmed that the trust’s staffing levels were consistently met. The ward manager had the autonomy to adjust the staffing levels and mix according to the assessed needs of patients. Patients and staff told us that they felt safe on the unit. Individual risk assessments were updated in ward rounds and care programme approach meetings.

• There was an effective incident reporting system in place and staff knew how to report an incident. Each patient had care plans which were reviewed with their key nurse. Each care plan was individualised. Care and treatment records demonstrated personalised care which was recovery oriented.

• Patients told us that staff treated them well and with respect.Staff were observed to be supporting patients appropriately.

• The service was well led at a local level. There was a new ward manager and modern matron. There was new leadership in place at senior operational level to give support. These changes had improved morale on the ward. Staff told us that they enjoyed working on this unit.

However:

• There was no use of outcome tools such as the health of the nation outcome scores or the recovery star.

• There were no psychological therapies for patients. There were no audits to evaluate the outcomes of any of the interventions used on the ward.

• There were no staff supervision records available to us or present on the ward. The annual staff appraisal rate was 60%. The unit’s mandatory staff training rate was 87% which was below the trust’s own target of 90%.

We rated community mental health services for children and young people as good overall because:

• Staff were knowledgeable about safeguarding and they were trained to level four. They appropriately identified risks and recorded referrals.

• Each care and treatment record contained detailed risk assessments and risk management plans. These were reviewed at every contact.

• There was a good range of disciplines within the multi-disciplinary teams.

• Patients had access to a wide range of treatment options.

• There was a good level of understanding about the Mental Capacity Act and staff understood how to assess capacity and make best interest decisions, if necessary, with patients over 16 years old.

• Patients had access to advocacy services and staff knew how to support patients to make sure they got this.

• Patient information leaflets explaining how to complain were available in all locations and many locations also had suggestions boxes. Staff knew how to respond to complaints.

• Staff felt their managers were approachable and supportive.