Cambridgeshire and Peterborough NHS Foundation Trust

We gave an overall rating for long stay/rehabilitation mental health wards for working age adults of good because:

• Patients we spoke with were very positive about the wards and the care they received from staff and told us they were involved in their care, were listened to and treated with kindness and respect.

• Staff morale was high with staff positive about the leadership of both the trust and their line managers. There were good systems in place to monitor staff performance and the productivity of the ward.

• There was good management of risk, learning from incidents and complaints. Staff shortfalls were managed safely with an active recruitment programme for staff vacancies. Staff were up to date with mandatory training and were able to undertake further training; for example, four nurses had trained in tissue viability and wound management.

• Patients had a full range of activities.

However:

• There was a general lack of psychology input which meant staff did not always have sufficient input to help them manage more complex and challenging patients.

• Oak 4 did not have a dedicated low stimulus/de-escalation area.

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

• Wards were generally clean and safe. Furnishings and clinic rooms were well maintained. Environmental risks were managed in line with the needs of individual patients.

• The service had a good safety record with 21% of incidents recorded over a 12 month period as resulted in ‘low harm’ and staff had received feedback from investigations across their directorate.

• Wards made use of dementia friendly, reminiscence material and activities to meet the needs of the patients.

• Care records showed there was a good response to physical healthcare needs and assessment. Staff showed a good awareness of individual patient needs and how to meet them. There was access to specialists where required. Patients were complimentary about the support they received.

• Staff were observed to interact with patients in a responsive and respectful manner and showed a good understanding of patient’s needs. Staff reported positive job satisfaction and high morale and had been able to undertake development and leadership opportunities. Staff were well supported by their managers/matrons and were empowered to raise concerns

However

• There were clear arrangements for ensuring that there was single sex accommodation on the majority of wards. However, improvement was needed to ensure that arrangements for managing mixed sex accommodation at Maple 1 ward were followed to ensure the privacy of patients.
• Some staff were unclear about what constituted restraint and how this should be recorded.
• Formal assessment and recording of capacity to consent for care and treatment on both informal patients and those subject to Deprivation of Liberty safeguards (DoLs) were not clearly recorded or evidenced by decision specific rationale.

We did not give an overall rating of the eating disorder specialist services as we only inspected part of the service:

• Parts of the wards on S3 and the Phoenix Centre could not easily be seen. However, staff tried to mitigate and manage this by ensuring they were well positioned, enabling them to monitor and observe patients.
• The wards could accommodate males and females without compromising the patients’ privacy or dignity.
• We saw no ligature points in patient areas.

• Medicines were stored appropriately in the clinic room on both wards. Both clinic rooms were well stocked, clean and well equipped with resuscitation equipment and emergency drugs.

• Most staff confirmed that they had received mandatory training. Clinical supervision was offered. Staff appraisals were all completed and in date.

• Physical health checks were completed at the point of admission and were comprehensive. Risk assessment and care plans were very detailed. They had been updated and reviewed. Care assessments had been completed and uploaded onto the electronic system.

• NICE guidelines for eating disorders were followed for inpatient and community services.

• All eating disorder services had good links with Addenbrooke’s Hospital for physical healthcare, including access to paediatrics for young people at the Phoenix Centre.

• Detained patients had appropriate documentation in place, as required, and in line with the Mental Health Act and Code of Practice, including consent to treatment forms, section 132 rights and section 17 leave.

• Patients told us that staff were kind, caring and supportive when they were experiencing difficulties. Patients were involved in their care and treatment and attended meetings to discuss decisions about their treatment and dietary plans. Patients told us that their families were involved too. On admission to the wards patients and families were given an admission pack which had information on treatments, patient rights and how to complain.

• We saw a wide range of rooms on both wards; all rooms were fit for purpose and fully furnished. There were quiet areas on the wards and rooms where patients could meet visitors.

However

• S3 and the Phoenix Centre had difficulty when using bank or agency staff because of the special needs of the patients and the support required at meal times.

• When a patient required blood tests on S3 there was no direct link to the computer system at Addenbrooke’s for staff to make a request on-line. There had been incidents when names were entered incorrectly on the computer system at Addenbrooke’s.

• At the Phoenix Centre we saw that capacity and consent had not been assessed and recorded on admission in line with the code of practice.
• In order to maintain patients’ safety the Phoenix Centre, as a temporary measure, only admitted one patient per week. This was because of the staffing levels and the acuity of patients.

• At times, on S3, meal choices were limited, popular food ran out and there was a lack of choice for vegetarians.

The service was rated as requires improvement overall because.

• There was evidence that the service was unable to meet the needs of an expanding population with some services experiencing increasing referrals for which they did not have the capacity to meet. Services had been commissioned based on 2010 population figures which were not representative of the population today. The population had increased by 11% and there had been an increase in the transient population who came for seasonal rural employment. As a result the service was struggling to meet the demand for children and young people’s services in a safe manner.
• This was particularly evident in speech and language therapy (SALT) where low staffing levels and increased referrals had resulted in an inability for the service to meet demand.
• Community nurses were unable to update electronic care plans in a timely manner due to workload.
• There was a lack of robust data collection to facilitate national comparators for service improvement.

However:

• There had been a change in trust management over the preceding eighteen months which had had a positive effect on the staff working within the directorate who expressed positivity about the future of the service.
• There was a positive incident reporting culture with evidence of sharing and learning from incidents being shared with staff. There were established systems for safeguarding within the children and young people’s service which was reflected across the trust.
• Multi-disciplinary teams worked well together to deliver holistic care for children and actively involved parents and carers.
• Staff were passionate about the service they provided to community children and young people. The service planned and provided safe individualised care using a family friendly inclusive approach.
• New young parents were particularly well supported by the family nurse partnership initiative and by health visitors who tailored home visits to meet individual needs when needed.

We rated the forensic inpatient/secure ward as good because

• Staffing levels were safe and recruitment was in progress for vacancies. The ward was also awaiting 3 staff nurses to start. Staff were up to date with mandatory training. Staff were trained in and aware of safeguarding requirements.

• There was an effective incident reporting system in place and there was learning from serious incidents. All staff knew how to report an incident.

• Comprehensive assessments were completed in a timely manner. Care records showed personalised care which was recovery oriented. Physical healthcare needs were considered during admission and patients’ had access to the same. Risk assessments were recorded and updated regularly. The ward used HCR-20 and the trust risk assessment processes. All patients were assessed prior to going on leave.

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

• Staff were respectful and caring when they spoke with people.

• Managers monitored performance and addressed any issues. Staff had received appraisals. All staff said they could raise issues with their manager if required and action would be taken. Clinical and managerial supervision was taking place for qualified staff. Staff knew who the senior managers and executive directors were.

• Staff were aware of the trust’s vision and values and could describe them. They had met the chief executive who had worked on the ward. They said they felt supported by the board members and senior management. Staff said they had raised issues with the chief executive and felt they had been heard and action had been taken. Staff said morale was high.

• All staff had access to appropriate alarm system and support from other wards when required. All staff inducted into the unit in order to access keys.

• The ward was awarded the recovery award for 2015.

However:

• The seclusion room was placed away from main area of the ward on the male side of the ward and did not have en-suite facilities. Access to a toilet meant taking the patient out of the seclusion area.
• There was no record of supervision for unqualified staff.
• There were some blanket restrictive practices on the ward.
• The food was rated as poor by patients.

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

• Interview rooms were fitted with panic buttons. Staff and visitors to inpatient wards were provided with personal safety alarms. All areas were clean and well maintained. Cleaning records were up to date and demonstrated that the ward environments were regularly cleaned.

• Staff were trained in safeguarding and demonstrated a good understanding of how to identify and report any abuse. Staff were supervised appraised and had access to regular team meetings. Staff received the necessary specialist training for their role. On both inpatient wards bank staff were regularly deployed to ensure the required higher staffing levels were maintained for the patient group.

• Patients and their relatives told us that staff were very positive and respectful. Staff demonstrated that they understood the needs of the patients well. Patients and their relative were involved in their care planning where appropriate. Patients had access to advocacy services.

• There were a full range of rooms and equipment to support the assessment, treatment and care of children and adolescents. Patients and carers language needs were met with the assistance of interpreting services. Patients’ individual communication systems were used and understood by staff. Patients knew how to make a complaint and staff processed complaints appropriately.

• Staff knew how to use the whistle blowing process to raise any concerns. Staff had opportunities for leadership development. Staff were offered the opportunity to give feedback on services and input into service development through the annual staff surveys. The trust used key performance indicators to gauge the performance of the team and developed action plans where there were issues.

• The trust took immediate action to respond to our concerns identified on IASS ward around the single sex accommodation. Improvements were made at the time of our inspection.

We rated the Darwin Centre and The Croft Child & Family Unit Mental Health Wards as good because:

• Both wards were clean and there were dedicated cleaners employed. The furnishings were clean and in good repair. The clinic rooms were well equipped with resuscitation equipment, emergency drugs, fridge and tools to monitor physical health.
• Staff reported that there were good systems in place to share learning from incidents across the Trust. Staff told us that they knew how to report incidents and were supported after incidents had occurred on the wards.
• All care plans were comprehensive, up to date and reviewed weekly at the ward round or after an incident. They included patient views, with a full range of problems and needs. Patients had copies of their care plans. We saw evidence of physical health care checks being carried out on admission and there was evidence on all care plans that this was being reviewed.
• Staff confirmed that they had received mandatory training. Clinical supervision was offered and staff attended regularly. Staff appraisals were all completed and in date. Staff reported good morale and were supported by their colleagues. Governances systems were in place and managers had access to trust data and used this to gauge the performance of the team.
• Staff were trained in and had a good understanding of the MHA, the Code of Practice and the guiding principles. Consent to treatment and capacity requirements were adhered to and copies of consent to treatment forms were attached to medication charts where applicable. Section 132 rights were being given two weekly and recorded in line with the trust policy.
• Patients told us staff treated them with dignity and respect and felt staff were approachable. We observed interactions with staff, patients and families. We found that staff communicated in a calm and professional way. Staff showed an understanding of individual needs of the patient. We found that patients were actively involved and participated in their care planning. Patients gave feedback on the service they received on monthly patient/parent feedback forms.
• There was a full range of rooms and equipment to support treatment and care on the ward. There were quiet areas on the wards. The outside space was used. Patients were involved in choosing colours of the walls and art work.
• The Trust had used QNIC Guidance and professional judgement to set core staffing levels.

However:

• We saw a number of potential ligature areas at the Darwin Centre.
• The bedroom and bathrooms on Croft Unit were not gender specific. However, all bedrooms were family rooms so it was not possible for bedrooms to be single sex. The bathrooms were unisex so children can change the gender prior to using the room, but this does not fully meet the expectations in the code of practice.
• The seclusion room on the Croft Unit did not meet the required standards for seclusion defined within the Mental Health Act 1983: Code of Practice. The Darwin Centre did not have a seclusion room however the staff were using an intensive nursing area (INA). We were told by staff they did not seclude patients but the description staff gave of how the INA was used constituted seclusion as defined in the Mental Health Act 1983: Code of Practice. The INA environment did not meet the safety specifications for a seclusion room as outlined in the Code of Practice.

We rated Cambridge and Peterborough NHS Foundation Trust specialist community mental health services for children and young people as requires improvement because:

• Interview rooms used by therapy staff were not fitted with alarms or viewing panels on the doors.

• Insufficient levels of staffing affected the referral to assessment and treatment times in community mental health teams. This was up to 62 weeks for some young people, with further delays for some treatments.
• Referrals to the ADHD service had been suspended due to lack of staff.

• Risk assessments were not present on all electronic records and risk assessments were not always reviewed when the young person’s situation changed.
• We saw no evidence in the notes that consent and capacity was being discussed with young people or recorded.

• Managers and staff told us that whilst supervision was offered to all staff no records were available to demonstrate this.

However:

• The trust told us that funding has been sourced in order to address the long waiting list and recruit more staff.

• Young people waiting for treatment were prioritised according to their risk.
• Treatment programmes were bespoke and based on the case formulation of the young people and were in accordance NICE guidelines

• We observed staff communicating with young people in a kind and respectful manner. Staff were observed to be sensitive to the needs of the young people and when speaking about them showed good knowledge of their problems and how they could help them.

• Managers had access to trust data to gauge the performance of the team and compare against others. Key performance indicators (KPIs) were used to gauge performance. The KPIs that we saw were in an accessible format.

• Staff were open and transparent with young people and their families.

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

• The trust had set safe staffing levels and these were followed in practice. Cover arrangements for sickness, leave and vacant posts meant people who used the service could be kept safe.

• Risk assessments were undertaken at initial assessment and updated regularly. Lone working protocols were in place. Incidents were reported and learning from such incidents was used to improve the service.

• Comprehensive holistic assessments and care plans were completed and reviewed in a timely manner.

• Multi-disciplinary teams and inter-agency working were effective in supporting people who used the service.

• Staff were experienced, received supervision, appraisals and specialist training for their role. Staff were trained in and had a good understanding of the MHA and MCA.

• Staff treated people who used the service with respect, listened to them and were compassionate. They showed a good understanding of people’s individual needs.

• Target times for assessment were set and met. This meant urgent referrals were seen quickly by skilled professionals. Proactive steps were taken to engage with people who found it difficult or were reluctant to engage with mental health services.

• People who used the service knew how to complain. Concerns and complaints were handled appropriately and findings acted upon.

• Good governance arrangements were in place, which supported the quality, performance and risk management of the services. Key performance indicators were used to gauge performance.

• There was effective team working and staff felt supported by this. Staff knew how to use the whistleblowing process and could submit items to the risk register.

• There was a commitment to quality improvement and innovation.

However:

• Some medication was not signed in or out when delivered by staff to people living in their own home and some medication was not transported using secure bags or cases.

• Some areas in the health-based place of safety could not be observed. Staff were aware of these and had taken mitigating action to ensure people who used the service were observed at all times. Facilities in the health-based place of safety did not promote privacy and dignity.

• People using the services provided by the CRHT teams had limited access to psychological therapies and there were no psychologists working within the teams.

• Interpreters were available but there could be a delay in accessing them in a crisis.

• Staff’s knowledge of the organisation’s values and vision was inconsistent.

We gave an overall rating for community-based mental health services for older people of good because:

• The support provided by older persons CMHTs, CRHTs, day therapy service and memory clinic was thoughtful, respectful and considered patients individual needs. The teams worked closely with carers and relatives and with other agencies. Teams were appropriately staffed, and where there were vacancies appropriate arrangements were in place to manage these.

• Risk assessments were undertaken on every patient during the initial assessment. This information was reviewed regularly. However, in one instance we found that the risk assessment had not been updated. All incidents were reported and staff had opportunities to discuss and learn from these. However, managers at some sites did not have access to detailed information relating to incident reporting within their team and two staff reported that when reporting incidents they were not always clear how to rate the incident.

• Comprehensive assessments were completed in a timely manner, and care records were up to date. However, a small number of care records did not evidence that patients had been given a copy of their care plan. Some care plans were not recovery orientated, did not consider holistic needs or contain the patients’ views. One patient we spoke with told us that they were not aware of the out of hours arrangements for contacting services.

• Staff were using NICE and other best practice guidance. Each team was made up of the full range of disciplines, who were regularly supervised and supported to undertake appropriate training. Staff demonstrated a good understanding of the MHA and MCA. Urgent referrals were seen quickly and non-urgent referrals within acceptable timescales.
• The trust had effective governance procedures in place. Key performance indicators were used to gauge the performance of individual teams, and staff had the ability to submit items to the directorate and trust risk registers. Staff spoke highly of their managers and their supportive teams. Staff were open and transparent with patients when things went wrong. Some teams were involved in innovative research programmes. Whilst a wide range of information leaflets were available at each site we visited, these were not available in a range of formats or languages.

Overall we rated this core service as ‘good’ because:

• We received positive feedback from patients about the care they received and found that staff across the service were committed to providing good quality care to the patients.
• We found positive multidisciplinary work and observed that staff were caring, compassionate and supported patients.
• Patients received regular one to one time with staff
• The bed management system was effective, ensuring that patients receive timely access to services when they required it.
• The leadership was visible and proactive on all of the wards.

However:

• Staff had assessed ligature points on all wards. However, the low level of staff at night on Poplar ward meant that patients could potentially access ligature points without the notice of staff.
• The clinical rooms for Oak 1, Oak 2 and Oak 3 wards were not fit for purpose and did not comply with infection control guidance.
• The nursing and medical staffing levels on Springbank ward were poor.
• There were a number of concerns relating to Mental Health Act 1983, specifically consent to treatment (Section 58) and practice which amounted to seclusion.

We gave an overall rating for community based mental health teams for adults of working age as good because:

• The teams worked to a lone working practice protocol. Staffing levels were safe and recruitment was in progress for vacancies. Staff were trained in and aware of safeguarding requirements and showed they used the referral process. Staff had received and were up to date with mandatory training. Caseloads were managed and re-assessed regularly and were discussed in supervision.
• There was an effective incident reporting system in place and there was learning from serious incidents. All staff knew how to report an incident.
• Risk assessments were recorded and updated regularly. Comprehensive assessments were completed in a timely manner. Care records showed personalised care which was recovery oriented. Physical healthcare needs were considered during assessment and during treatment. Outcome measures were used to evaluate the effectiveness of care and treatment. The teams were looking at how to implement other outcome measures for all disciplines. Medicines were managed safely and there was learning from medication incidents.

• Staff were respectful and caring when they spoke with people. People said they felt involved in their care planning and treatment and this was documented in the care record.

• Teams were meeting the five day standard for seeing urgent referrals and the eight weeks for routine referrals. Actual times for adult locality teams were 3-4 days for urgent and 3-4 weeks for routine. The Peterborough locality team provided extra clinics to address a large number of unmet referrals to ensure waiting time targets were met.

• Managers monitored performance and addressed any issues. Staff had received appraisals and said a new format had recently been introduced to improve structure. All staff said they could raise issues with their manager if required and action would be taken. Clinical and managerial supervision was taking place. Staff knew who the senior managers and executive directors were. Staff were aware of the trust’s vision and values and could describe them. They had met the chief executive and executive and non-executive directors. They said they felt supported by the board members and senior management. Staff said they had raised issues with the chief executive and felt they had been heard and action had been taken. Staff said morale had improved greatly over the last 12-18 months, since the trust had re-organised services and improved leadership and accountability.

However:

• There was no evidence medical equipment, such as weighing scales and blood pressure monitoring machines had been checked and re-calibrated according to the manufacturer’s instructions. Apart from Peterborough locality where equipment had been recently calibrated.
• Buildings did not have alarm systems fitted in rooms where staff saw people. The Huntingdon team were in the process of fitting alarms. Wisbech and Peterborough locality teams had personal alarms for use in the building. The buildings for the early intervention teams (CAMEO), Huntingdon and Peterborough locality team also required re-decorating in areas. The buildings for the CAMEO teams and Huntingdon locality team did not provide sufficient space to see people. People had to travel distances for appointments at Wisbech because of geographical area. The south CAMEO team base had no separate reception in a shared building. People were escorted around the outside of the building to access the waiting room. The trust has an estate strategy to look at alternatives.
• The locality teams did not have direct access to the system providing results of blood tests, which might cause a delay in clinicians being able to adjust medication or arrange for further tests if required.
• Consideration of mental capacity assessment was not always recorded.
• The early intervention teams had moved to a two year model of engagement from a three year model. The NICE (National Institute for Health and Care Excellence) recommendation is a three to five year model.
• There was no policy for failed visits or for when people did not attend appointments. Although staff were able to describe how they risk assessed and tried to engage with people.
• Staff reported a delay in referrals reaching the early intervention teams because of the introduction of the assessment and referral centre (ARC). Staff in the locality teams also told us about the need to improve the ARC process. A review of the role of ARC was underway. Staff reported carers’ assessments were taking four to six weeks unless urgent. Young carers were also assessed, working with CAMHS staff. Carers could access money from social care when eligible.

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 Cambridgeshire and Peterborough NHS Foundation Trust as good overall because:

• Services were effective, responsive and caring. Where concerns had arisen the board had taken urgent action to address areas of improvement.
• Staff treated people who used the service with respect, listened to them and were compassionate. They showed a good understanding of people’s individual needs.
• Admission assessment processes and care plans, including for physical healthcare, were good.
• The board and senior management had a vision with strategic objectives in place and staff felt engaged in the improvement agenda of the trust. Performance improvement tools and governance structures were in place and had brought about improvement to practices.
• Morale was found to be good in most areas and staff felt supported by local and senior management. There was effective team working and staff felt supported by this.
• The trust had undertaken positive engagement action with service users and carers.
• A good range of information was available for people and the trust was meeting the cultural, spiritual and individual needs of patients.
• The inpatient environments were conducive to mental health care and recovery.
• The bed management system within adult and older people’s services was effective.
• Information systems were in place to ensure effective information sharing across teams.
• Services were using evidence based models of treatment and made reference to National Institute for Health and Care Excellence (NICE) guidelines.
• The trust had an increasingly good track record on safety in the previous 12 months. Effective incident, safeguarding and whistleblowing procedures were in place. Staff felt confident to report issues of concern. Learning from events was noted across the trust.
• The trust had met its targets required under the Department of Health’s ‘Positive and Proactive Care: reducing the need for restrictive interventions’ agenda. There had also been a decreasing level of restraint and seclusion in the previous 12 months.
• Medicines management was effective and pharmacy was embedded into ward practice.
• Arrangements were in place to ensure effective use of the Mental Health Act and Mental Capacity Act
• There was a commitment to quality improvement and innovation.

However:

• We had some concerns about restrictive practice in some areas of the trust. However, the trust was engaging in work to reduce these episodes. In addition not all environments where people were secluded were appropriate.
• Staffing issues in some community children’s teams and acute services were affecting waiting targets.

• There were clear arrangements for ensuring that there was single sex accommodation on the majority of wards. However, improvement was needed to ensure that arrangements for managing mixed sex accommodation at Maple 1 ward were followed to ensure the privacy of patients.

• There were ligature points in some inpatient services and observation should be improved in some areas.
• Not all patients had easy access to psychological therapies.
• Consent to treatment procedures needed improvement.