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Provider: Leicestershire Partnership NHS 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 9 August 2019

We did not rate this inspection. The ratings from the inspection which took place in November 2018 remain the same.

This was a focused, unannounced inspection, to follow up on enforcement action we issued to the trust after our last inspection in November 2018.  We have not inspected against other requirement notices that were issued at the same time; therefore, all requirement notices from the last inspection remain in place. 

At the last inspection, we issued enforcement action because the trust did not have systems and processes across services to ensure that the risk to patients were assessed, monitored, mitigated and the quality of healthcare improved in relation to:

  • Access to treatment for specialist community mental health services for children and young people
  • Maintaining the privacy and dignity of patients and concordance with mixed sex accommodation
  • Environmental issues
  • Fire safety issues
  • Medicine management
  • Seclusion environments and seclusion paper work
  • Risk assessment of patients
  • Physical health care
  • Governance and learning from incidents.

The trust was required to make significant improvements in the following core services where we found concerns in the areas listed above:

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

  • Wards for people with a learning disability or autism

  • Long stay or rehabilitation mental health wards for working age adults

  • Specialist community mental health services for children and young people.

At this inspection, we found the following areas the trust needed to improve:

Significant improvements had been made to the environments at most wards. It was clear to see the difference the investment and improvements had made since our last visit. The majority of repairs and maintenance issues highlighted within the warning notice at the Bradgate Mental Health Unit had been fixed or resolved. A programme of work was due to start in forthcoming months, for wards yet to be refurbished. New systems were in place for staff to report any repairs or maintenance issues.

There were improvements in ligature risk assessments. All ward ligature risk assessments had been reviewed and were located on each ward together with mitigation summaries. Staff completed risk assessments that were thorough and had been reviewed following incidents.

The trust had improved how staff recorded patients physical healthcare, and monitored patients who had ongoing physical healthcare problems. The trust had recruited two registered general nurses with dedicated time to focus on individual healthcare plans at Stewart House and The Willows. There were effective systems in place to audit and monitor physical health care records.

The trust had improved medicines management. This included labelling, disposal, reconciliation and ward level audit. All wards had developed their own systems to improve medicines management in their areas. Medicine management training sessions had been undertaken with inpatient ward sisters and charge nurses.

Some improvements to address the no smoking policy at the Bradgate Mental Health Unit wards were seen. Smoking cessation had been successful across most wards in the Bradgate Mental Health Unit.The trust had re-drafted the smoke free policy following on patient and staff consultation. Patients were offered smoking cessation treatments, nicotine replacement therapy (NRT), or free vapes. 

Fire safety was much improved, with fire drills carried out regularly. An escape plan was developed with patients (PEEP) who may not be able to reach an ultimate place of safety unaided, or within a satisfactory period of time in the event of any emergency. We saw patients that needed a PEEP had a plan in place.

Some improvements were seen in seclusion documentation and seclusion environments. The trust had new seclusion paperwork implemented in May 2019. A full audit was scheduled for the end of June 2019. Improvements had been made to seclusion areas at The Willows Acacia and Maple wards.

The trust had maintained patients privacy and dignity at Short Breaks Services. The trust ceased mixed sex breaches by maintaining male and female only weeks. Patients privacy and dignity had been addressed at The Willows, Cedar and Acacia wards with changes made to male and female wards.

The trust had ensured patients privacy and dignity were maintained when receiving physical health observations at the Bradgate Mental Health Unit. Staff had set clear guidelines on where and how physical health observations were completed on wards.

The trust had significantly reduced waiting times and the total numbers of children and young people waiting for assessments. The trust had reviewed existing systems and processes identified improvements and implemented changes. Funding had been secured for increased staff with specialist skills. There had been a change in leadership and a review of key performance indicators (KPIs) with commissioners. The trust had developed new processes and redesigned and improved data validation.

We saw the trust had developed oversight and a vision on how to improve the nine key areas identified by the warning notice. The trust had launched its "Step up to Great" approach, which identified the vision and priorities for the year. Two external governance reviews had been commissioned and undertaken. One review was in response for the delivery of actions for the 2018 CQC inspection. A further review was an examination of processes and procedures within the trust for reporting investigations and learning from serious incidents requiring investigation. The trust provided newsletters, quarterly serious incidence bulletins, regular emails from matrons about incidences and lesson learnt.

However:

Some areas at Bradgate Mental Health Unit required further improvements to the environments. Response times to maintenance request were variable. Whilst there had been some improvements, the process for reporting repairs and issues varied across the wards and a time lag existed for repairs being completed.

New positions such as medicines administration assistants and link nurses to support wards were in place in certain areas, but ward staff still described irregular pharmacy visits and a lack of pharmacy oversight in medicines management.

We found evidence that patients, at the Bradgate Mental Health Unit, and in some instances, staff, smoking in ward areas. Staff told us patients were concealing lighters and cigarettes and bringing them onto wards. There were inconsistent practice around conducting searches on patients. Team meetings were not regular, or didn't take place.The sharing of lessons learnt remained inconsistent across some wards.

We looked at 20 sets of seclusion records and from 17 records, staff were not recording seclusion, in line with the Mental Health Act Code of Practice. Some seclusion rooms had environmental concerns at Belvoir and Griffin units, and Watermead wards.

The waiting list had increased for those children and young people waiting for the start of treatment, following assessment. Demand for neurodevelopment assessments remained high. The trust had long term plans to address this.

Inspection areas

Safe

Requires improvement

Updated 9 August 2019

Environment

We found during inspection that:

Significant improvements had been made to the environments at most wards. The majority of repairs and maintenance issues highlighted within the warning notice at the Bradgate Mental Health Unit had been fixed or resolved. A further programme of works for older wards were due to commence. Bosworth will complete in July 2019 with works to Aston and Thornton due to commence in August 2019 (for completion in March 2020). Two property managers were appointed with responsibilities for acute, forensic, and rehabilitation wards. New systems were in place for staff to report any repairs or maintenance issues.

There were improvements in ligature risk assessments. The trust used the Manchester ligature audit tool to assess the environment for ligatures in inpatient areas. All ward ligature risk assessments had been reviewed by health and safety staff, ward sisters and matrons. Ligature risk assessments were located on each ward, identified all risks together with mitigation summaries. Colour coded displays identified "heat spots" and photographs of rooms ensured staff were are aware of potential ligature anchor points. Ligature risk assessments and ward mitigation plans were held locally and on a central electronic data base. Ligature audit spot checks were ongoing on wards.

Three newer staff did not know about the ward ligature audits, but explained what ligature points were.

Risk assessments of patients

Risk assessments of patients had improved. Staff completed risk assessments that were thorough and had been reviewed following patient incidents. Some staff groups had received training around patient risk assessments.

Medicines Management

The trust had improved medicines management. All wards had developed their own systems to improve medicines management in their areas. Medicine management training sessions had been undertaken with inpatient ward sisters and charge nurses. A regular programme of spot checks of ward clinic rooms were ongoing and required further time to embed learning. Most medical equipment including blood monitoring and blood pressure equipment had been calibrated to ensure it worked correctly.

Fire safety 

Improvements to address patients smoking on the ward were seen. The trust had re-drafted the smoke free policy following on patient and staff consultation. Patients were offered smoking cessation treatments, nicotine replacement therapy (NRT), or free vapes for seven days. Patients could then purchase vapes on the ward. Smoking cessation had been successful across most wards in the Bradgate Mental Health Unit. No-smoking posters were designed and displayed at the Bradgate Mental Health Unit. The trust had organised the removal of discarded cigarettes and regular and ongoing upkeep in Bradgate ward gardens.

Fire safety was much improved. We looked at six fire drills reports and found fire drills were carried out regularly. The trust fire safety management policy was revised to include information about general emergency evacuation plans and personal emergency evacuation plans (PEEPS). An escape plan was developed with patients who may not be able to reach an ultimate place of safety unaided or within a satisfactory period of time in the event of any emergency. The need for a PEEP was added to patients admission check list and handover agenda. We saw patients that needed a PEEP had a plan in place.

Seclusion environments and documentation

Some improvements were seen in seclusion documentation and seclusion environments. The trust had new seclusion paperwork implemented in May 2019. A full audit was scheduled for the end of June 2019. Improvements had been made to seclusion areas at The Willows Acacia and Maple wards. 

Maintaining privacy and dignity of patients and concordance with mixed sex accommodation

The trust had maintained patients privacy and dignity at Short Breaks Services. The trust revised the statement of purpose for emergency requests for Short Breaks Services. Managers liaised with families and rebooked breaks to ensure no breaches. Letters were sent to families to explain the rationale. The trust ceased mixed sex breaches by maintaining male and female only weeks. There have been no breaches since 11 February 2019.

Patients privacy and dignity had been addressed at The Willows, Cedar and Acacia wards. The trust had made changes to the wards in consultation with patients, families, carers and staff. Acacia was now an all-female ward and Cedar was an all-male ward. Changes were completed by 29 April 2019.

The trust had ensured patients privacy and dignity was maintained when receiving physical health observations. Ward staff at the Bradgate Mental Health Unit had met together and set clear guidelines on where and how physical health observations are completed on wards. Guidance posters were displayed on wards.  

However:

There was variability in how staff reported maintenance requests and response times for repairs at Bradgate Mental Health Unit. For example, on Watermead ward staff reported 32 light bulbs in need of repair before Christmas. Most light bulbs were repaired in batches in March, however some lights were still not working. Despite the new maintenance systems some staff still followed the old maintenance process.

On Watermead ward the ligature audit did not include anti-barricade features. Ashby ward had anti-barricade fixtures and fittings but there was a small gap on some doors which could be a potential ligature point and was not on the ligature risk assessment. The ward manager said they would take immediate action.

The trust had been creative in their recruitment strategy; with new positions such as medicines administration assistants and link nurses to support wards in certain areas, but ward staff still described irregular pharmacy visits and a lack of pharmacy oversight in medicines management.

Some patients were still smoking in ward areas. We visited six wards at the Bradgate Mental Health Unit and saw cigarette ends in ward gardens, except on Aston ward. Patients were concealing lighters and cigarettes and bringing them onto wards. There was inconsistent practice around conducting searches on patients, not all staff had security wands to search patients. Some staff on Watermead ward were smoking outside the female ward door area, and patients saw this.

We looked at 20 sets of seclusion records and from 17 records, staff were not recording seclusion, in line with the Mental Health Act Code of Practice. Some seclusion rooms had environmental concerns at Belvoir and Griffin units and Watermead wards.

Effective

Requires improvement

Updated 9 August 2019

Physical Healthcare

We found during inspection that:

The trust had improved how staff recorded patients physical healthcare, and monitored patients who had ongoing physical healthcare problems. Patients records showed physical health care plans and 72 hour checks in place. The trust had recruited two registered general nurses with dedicated time to focus on individual healthcare plans at Stewart House and The Willows. There were effective systems in place to audit and monitor healthcare records.

Caring

Good

Updated 9 August 2019

We did not inspect this domain during this inspection.

Responsive

Requires improvement

Updated 9 August 2019

Access to treatment for specialist community mental health services for children and young people 

We found during inspection that:

The trust had significantly reduced waiting times and the total numbers of children and young people waiting for assessments. The trust had reviewed existing systems and processes identified improvements and implemented changes. Funding had been secured for increased staff with specialist skills including locums, a service manager, clinical leads, nurses, psychologist, and allied health professionals.There had been a change in leadership and a review of key performance indicators (KPIs) with commissioners. The trust had developed new processes and redesign and improved data validation. 

However:

The waiting list had increased for those children and young people waiting for the start of treatment, following assessment. Demand for neurodevelopment assessments remained high. The trust had long term plans to address this.

Well-led

Inadequate

Updated 9 August 2019

Oversight and governance

We found during inspection that:

We saw the trust had developed oversight and a vision on how to improve the nine key areas identified by the warning notice. The trust had launched its "Step up to Great" approach, which identified the vision and priorities for the year. Two external governance reviews had been commissioned and undertaken. One review was in response for the delivery of actions for the 2018 CQC inspection. A further review was an examination of processes and procedures within the trust for reporting investigations and learning from serious incidents requiring investigation. Heads of Service had reviewed governance processes within the remit. A full review of trust committees terms and reference were underway.

The trust provided newsletters, quarterly serious incidence bulletins, regular emails from matrons about incidences and lesson learnt.

However:

There was variability in sharing of lessons learnt across the acute wards and PICU units. Some teams had regular team meetings, other teams cancelled team meetings due to work pressures.

Checks on specific services

Community health services for adults

Good

Updated 30 April 2018

Our rating of this service improved. We rated it as good because:

  • We rated safe, effective, caring and responsive as good and well led as requires improvement
  • Patients were protected from avoidable harm and abuse, systems were in place to investigate incidents and concerns and staff received suitable training in safety systems. Risk assessments were completed and care plans implemented to keep patients safe and promote wellbeing. The service had plans in place to manage service disruption and major incidents.
  • The service used evidence based, best practice guidance throughout its policies and procedures and ways of working. Clinical audit was taking place and learning was shared across the service. Staff were suitably trained with the relevant knowledge and skills to carry out their work, had regular appraisals and had access to the information they needed to perform their duties. Multidisciplinary team work both internal and external to the service was effective and patients were supported to make informed decisions about their care.
  • Patients were supported, treated with dignity and respect and involved as partners in their care. They told us that staff were kind and caring.
  • Services and care were planned with the local population in mind and to address the individual needs of patients. Facilities had been adapted to improve access and systems were in place to support the most vulnerable. Patients knew how to make a complaint or raise a concern and complaints were taken seriously.
  • A new leadership structure had been introduced since the last inspection and had not yet fully embedded in the service. Leaders were motivated and developing their skills to address the current challenges to the service. Staff support systems were in place and there was a drive to engage with staff. Governance structures were in place and risks registers were reviewed regularly.

However:

  • The service still had challenges in recruiting sufficient staff which meant that the service, in particular community nursing, was understaffed at times impacting on staff satisfaction and compromising patient care.
  • Staff did not always have time to attend clinical supervision sessions and patient information systems were inconsistently utilised and did not always enable effective working.
  • Patient outcomes were not routinely collected so the quality of the clinical care being delivered could not be measured or benchmarked.
  • There were long waiting times from initial referral to being seen in some clinics and services although these had improved in some areas since the last inspection.
  • The community nursing service could not measure its performance in relation to response times for unplanned care.
  • The leadership, governance and culture did not always support the delivery of high quality person centred care.
  • Staff satisfaction varied greatly across the service with some staff feeling devalued.

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

Inadequate

Updated 27 February 2019

The summary for this service appears in the overall summary of this report.

Wards for people with a learning disability or autism

Requires improvement

Updated 27 February 2019

The summary of this service appears in the overall summary of this report.

Specialist community mental health services for children and young people

Requires improvement

Updated 27 February 2019

The summary for this service appears in the overall summary of this report.

Long stay or rehabilitation mental health wards for working age adults

Inadequate

Updated 27 February 2019

The summary for this service appears in the overall summary of this report.

Community-based mental health services for older people

Good

Updated 27 February 2019

The summary of this service appears in the overall summary of this report.

Mental health crisis services and health-based places of safety

Requires improvement

Updated 30 April 2018

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

  • We rated responsive and well led as requires improvement, and safe, effective and caring as good.
  • Interview rooms were unsafe. They did not have alarms or vision panels in the door. They contained items which could pose a danger to staff and patients.
  • Staffing levels were below the expected level. The vacancy rate for the service was 12.9% and for band 5 and 6 nurses was 18.9%.
  • The quality of the data produced was poor and staff needed to correct the data when reports were produced.
  • The service was not meeting its performance targets.

However:

  • The trust had addressed the issues previously identified with the health based place of safety.
  • Care plans were up to date and holistic.
  • There was effective communication between the service and other healthcare professionals.
  • Staff received regular managerial and group supervision.

Community-based mental health services for adults of working age

Requires improvement

Updated 30 April 2018

  • Staff treated patients with respect and maintained dignity.
  • Staff felt supported by their managers and received regular supervision and annual appraisals.
  • There was effective multidisciplinary working. Staff monitored those patients on the waiting list regarding risk levels.
  • Staff had been given lone worker safety devices to ensure their safety.

Child and adolescent mental health wards

Good

Updated 8 February 2017

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

  • The ward had clear lines of sight in the main areas of the ward. In the dormitories, observation mirrors were situated so that staff could observe patients without having to disturb them.

  • The ward had an up to date ligature risk audit, staff mitigated the risks on the ward by observing patients. Staff mitigated the risks posed in the garden area by accompanying patients when they wanted to access the garden.

  • The ward had sufficient staff to provide care and treatment to patients.

  • Staff followed the trust policy on seclusion. Data provided by the trust showed there were four episodes of seclusion from February 2016 to July 2016. Staff monitored the ongoing condition of any secluded patient.

  • 100% of staff were trained in how to safeguard children from harm. Staff informed us there was a safeguarding lead to refer to when guidance was needed.

  • Staff updated risk assessments and individualised care plans regularly. Patients had their own copies of care plans and were involved in their care plan reviews.

  • A psychologist led weekly reflective practice sessions to help staff think about the best way of helping the patient on the ward.

  • Patients’ reported staff treated them with dignity and respect. Staff interacted with the patients’ in a positive way and was respectful to them.

  • Patients knew how to formally complain and could attend daily community meetings where they could raise any issues of concern.

  • Staff said morale was good and they felt supported by their managers.

However:

  • The service used a computer record system that differed from the rest of the trust. Other professionals within the trust could not access this system. Staff said the system was difficult to use and this had affected the information recorded in patient’s notes.

  • Staff and carers said that when a patient was discharged, it was difficult to allocate them to a community CAMHS worker.

  • Patients said they got bored at the weekends, as there were fewer activities on offer.

Community mental health services with learning disabilities or autism

Good

Updated 8 February 2017

We rated community based services for people with learning disabilities or autism as good because:

  • Staff worked well as a team and morale was high. Multi-disciplinary team meetings took place on a regular basis. 89% of staff had attended their mandatory training; 92% of appropriate staff had received training in safeguarding adults and 90% of staff had completed safeguarding children training.

  • There were good systems for lone-working which included a code word that staff used when they required assistance. Staff said this made them feel safe whilst visiting patients at home or whilst undertaking activities with patients in the community.

  • Staff undertook comprehensive assessments and developed high quality care plans. The assessment and resulting care plans were personalised, holistic and recovery focussed. Staff made individualised risk assessments which were regularly updated and followed best clinical practice. Staff managed their caseloads effectively; they discussed their caseloads during multi-disciplinary team meetings as well as in supervision. The teams did not have waiting lists for care coordinators at the time of inspection.

  • Staff treated patients with kindness, dignity, and respect. Staff allowed patients time to respond to questions and did not try to hurry them. We spoke with six patients who all told us that the staff were very kind and looked after them well.

  • The teams were able to respond quickly when patients or carers telephoned with problems. We spoke with carers; they all stated that staff responded well when they contacted the service.

  • Staff were given opportunities to expand their knowledge and develop their roles. They could undertake both internal and external training and were able to give feedback on service development.

However:

  • Three out of 18 staff interviewed said that supervision was irregular.

  • All the team leaders we interviewed said there were internal waiting lists for patients who had been initially assessed to access profession specific treatments.

  • The service had not met the six week target for initial assessment, on average patients were seen six days over the target date.

  • Access to rooms to undertake activities in the community for people with autism had been reduced.

  • Patients were not always involved in the planning of their care. Five out of 25 care records showed that patient involvement had not been recorded.

  • The walls in patient areas at the child and adolescent mental health team were visibly dirty in places and rooms were sparsely furnished.

Forensic inpatient or secure wards

Good

Updated 8 February 2017

We rated the forensic inpatient/secure services as good because:

  • Phoenix ward had clear lines of sight for staff to observe patients. However, Griffin did not. Managers had plans in place to address this issue. However, no time frame was set for the work to be completed. Managers completed ligature audits which highlighted what mitigation was in place to reduce the risk for patients.

  • Staff completed comprehensive assessments which included physical health checks and the majority of patients had completed risk assessments. Staff ensured that these were updated regularly.

  • Staff used the mental health clustering tool, which included Health of the Nation Outcome Scales (HoNOS) to assess and record severity and outcomes for all patients. Advanced Directives had been introduced to enable patients to make decisions now about their long term care.

  • Managers had a recruitment plan in place to increase the number of substantive staff for the service. Managers ensured they used regular bank staff to achieve the required safer staffing levels and to promote continuity of care of patients. 83% of staff received mandatory training. Managers ensured they monitored their staff’s compliance with mandatory training using a tracker system. 78% of staff had completed their annual appraisal. Managers ensured they monitored the reporting and recording of incidents and complaints. They provided feedback to staff via monthly ward meetings, MDT meetings supervision and handovers.

  • Patients gave positive feedback regarding the care they received. Patients were able to access hot and cold drinks any time during the day. Patients could approach staff at night to request them. Staff interacted with patients in a caring and respectful manner. Staff we spoke with demonstrated their dedication to providing high quality patient care.

  • Wards had well equipped clinic rooms with appropriate equipment which staff regularly checked.

  • The average bed occupancy was low. The service did not have any out of area placements, readmissions or delayed discharges. Staff worked with both internal and external agencies to coordinate care and discharge plans.

  • The trust had a range of information displayed on the ward and the hospital site relating to activities, treatment, safeguarding, patients’ rights and complaint information.

However:

  • The service had seven vacancies for qualified nurses and three for non-registered nurses.

  • There was a blanket restriction. On Phoenix ward patients were not allowed access to the garden. However, this was a temporary restriction due to the building works and patient safety.

  • Clinical supervision rates were low. 42% of staff on Phoenix ward and 27% Griffin ward had received clinical supervision. Managers did not ensure that the staff were receiving regular clinical supervision and had not met the trust target compliance rate of 85%. Staff morale on Griffin ward was low due to the announcement of the ward’s closure upon the completion of works on Phoenix ward.

  • Staff explained to patients their rights under the Mental Health Act on admission and routinely thereafter, although we saw this was not always documented in the patients’ care notes.

  • Clinic rooms were overstocked with medications. Nursing staff did not have a stock list to randomly check medication which meant they could not reconciliation check.

  • The phones on each ward were in communal areas; the phone on Griffin ward had not been moved since the last inspection, although it had a privacy hood installed. There was a mobile phone in the ward office that patients could use for private calls, for example to a solicitor.

  • Patient views on the quality of the food were variable.

Community health inpatient services

Requires improvement

Updated 8 February 2017

We rated community health inpatient services as requires improvement because:

  • Despite considerable effort with recruiting new members of staff, staffing was the top concern for all senior nurses and there was still a significant reliance on agency staff to fill shifts which could not be covered internally. Senior nurses mitigated risk where they could which included switching an agency staff member with a trust member of staff if two agency staff worked together. However, we saw evidence this was not always achieved.

  • Staff were open about their poor understanding around the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Our observations during inspection confirmed that staff knowledge and practical application of their knowledge was inconsistent despite training on their electronic learning systems.

  • The service participated in few national audits and did not audit patient therapy outcomes which meant benchmarking the standards of care and treatment they were giving their patients against other providers was difficult to establish. The service did however, complete local audits and produced action plans for improvement in care.

  • All hospitals were running at a high bed occupancy level of above 85% which national data has linked to increased risk of bed shortages as well as an increase in healthcare associated infections.

  • The service had 175 delayed discharges between August 2015 and July 2016, which accounted for 43% of the trusts total delayed discharges. The most common reason for delayed discharges was due to family choices which were beyond the control of the trust. However, delay in paperwork completion was also responsible for a large proportion of delayed discharges.

  • Staff were unaware of any service specific strategic direction. This had previously been identified on the CQC inspection in March 2015.

  • Concerns about high bed occupancy, record keeping and delayed discharges were identified in the March 2015 inspection and had not been sufficiently addressed.

However:

  • The electronic prescribing system which the trust had implemented supported the safe administration of medicines to patients, with staff reporting very few medication errors as a result of this.

  • The feedback from patients and relatives was mainly positive about the staff providing care for them. Comments included terminology such as ‘marvellous’, ‘wonderful’ and ‘excellent’. All patients told us staff respected their privacy and dignity.

  • The introduction of activities co-ordinators at Coalville Hospital had improved the patient’s experience on the ward and increased the activities that were conducted on a day to day basis.

  • Staff told us they enjoyed working at the trust and thought they all worked well as a team. We saw evidence of good team working during our inspection.

Wards for older people with mental health problems

Good

Updated 8 February 2017

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

  • The wards complied with the Department of Health 2015 guidelines on single sex accommodation.

  • Patients reported that they felt safe.

  • The use of restraint was low and staff used it as the last resort and if verbal de-escalation had not been successful.

  • Managers had a system in place for tracking and learning from safeguarding incidents and other reportable events.

  • Managers used a tool to identify and review staff numbers in accordance with need.

  • Staff completed detailed risk assessments for patients on admission and reviewed them regularly after incidents.

  • Staff were observed to be caring and responsive to patients.

  • Staff monitored patients’ physical health regularly from the point of admission.

  • Care records were up to date and holistic.

  • There was a range of treatment and activity delivered by skilled and experienced staff.

  • Patients and carers knew how to complain.

  • Staff described managers as supportive and approachable.

  • Staffs were dedicated, passionate and patient focused.

However:

  • Managers did not ensure that staff completed Mental Capacity assessments in line with the Act.

  • On Kirby ward there was no evidence of Section 132 rights read on detention in 54% of records reviewed.

  • There was minimal evidence of patient involvement in care plans.

  • Between August 2015 and July 2016, there were 60 delayed discharges across the service.

  • There were no dedicated visiting rooms.

  • At times, there were insufficient qualified nurses on shift.

  • Clinical supervision was not taking place regularly across the service.

Community end of life care

Good

Updated 8 February 2017

We rated end of life care services as good overall because:

  • The trust had worked collaboratively with local partners to develop an end of life care strategy for the region as a whole which had incorporated a health needs analysis.

  • Patients were protected from avoidable harm by sufficient staffing and safeguarding processes.

  • Staff recognised and responded to the changing needs of patients with anticipatory medications readily available and care needs assessed and reviewed appropriately.

  • Staff followed infection and prevention control practices and the community inpatient wards were visibly clean. Specialist equipment needed to provide care and treatment to patients in their home was appropriate and fit for purpose so patients were safe.

  • Staff demonstrated commitment to delivering high quality end of life care for their patients. There was a strong, person-centred culture. Staff treated patients with compassion, dignity and respect. Patients and their relatives felt involved in the care provided. Patients’ social, emotional and religious needs were met and relatives valued the emotional support they received.

  • Services were planned and delivered in a way that met the current and changing needs of the local population. The needs and preferences of patients and their relatives were central to the planning and delivery of care with most people achieving their preferred place of care. Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

  • We saw evidence of multidisciplinary working, with staff, teams and services at this trust and external organisations working in partnership to deliver effective care and treatment.

  • There was strong local leadership on the community inpatient wards and in the community. Staff told us they felt supported by their line managers, ward managers and matrons.

However:

  • There were inconsistencies in the quality of completion for do not attempt cardiopulmonary resuscitation (DNACPR) forms, in the quality of admission paperwork within medical records and in the use of the ‘Last Days of Life’ care plans. This had been raised as a concern in the March 2015 inspection and had not been sufficiently addressed.

  • There was an unstructured, non-mandatory approach to formal end of life training for community hospital staff.

  • Concerns were raised regarding the fast-track process and appropriateness of admissions to hospital by the out of hours GP service.

  • We did not have assurance service leads had good oversight of the risks relating to this service as staff were not always recording incidents, the service was unable to identify incidents specific to patients at the end of life and concerns relating to the out of hours GP service were not formally recorded.

Community health services for children, young people and families

Good

Updated 8 February 2017

We rated families, young people and children services as good because:

  • There were systems in place for reporting incidents and the service was able to demonstrate learning and sharing following incident investigations. However, staff told us they had little experience of incident reporting within the community children’s services.

  • Safeguarding was a high priority with regular safeguarding reviews within each area of speciality and established systems for supporting staff dealing with distressing situations.

  • Staff followed infection control practices and maintained equipment through regular servicing.

  • Patient records were electronic, up to date and available to the multidisciplinary team to enable an integrated approach to care and treatment.

  • Staff were trained appropriately within their speciality and new staff were supported to gain experience and skills.

  • Children and young people felt listened to in a non-judgmental way and told us they felt respected. We observed positive interactions between staff and children and the use of age appropriate language. The school nurses used technology to communicate with young people.

  • The service employed care navigators to help families and carers negotiate their journey through the various services provided.

  • There was an established five year strategy and vision for the families, young people and children’s (FYPC) services and staff innovation was encouraged and supported. Staff expressed pride in their ability to work as a team and managers told us they were proud of achievements. Staff were included in service developments and involved in ‘listening into action’ projects for service improvement.

However:

  • There was a lack of reporting and monitoring of informal complaints, meaning the service was unable to monitor and recognise themes of concern with the children’s service.

  • The service is not appropriately commissioned to provide sufficient school nurses to meet the standard service recommendations of one nurse per secondary school and its associated primary schools.

  • The medical and senior leadership provision within the looked after children service did not meet the professional requirements outlined in the intercollegiate document for this provision.

Substance misuse services

Updated 10 July 2015

We do not give an overall rating for specialist services. However, we found:

  • The service was not safe. There were insufficient systems in place to monitor prescriptions. There were examples of people not being seen within service guidelines whilst receiving large doses of prescribed medication.
  • The service was not effective. While they made appropriate assessments and were responsive to changing needs, NICE guidelines were not used to ensure best practice and that multi-agency teams worked well together.
  • The service was not well led. There was a clear vision for the service which staff understood. However there were significant problems with key areas of governance in relation to the management of prescriptions.

However:

  • The service was caring. Staff interacted with people in a positive way and were person centred in their approach.
  • The service was recovery focused and had developed pathways with other agencies to build on recovery capital for people who used the service. People felt they had benefited from the service and told us how caring staff were.
  • The service was responsive. The opening hours were flexible to accommodate the needs of the people who use services and there was protected time within the open access services to assess people who were referred to treatment.
  • The work in neighbourhoods reduced travel for people and reduced barriers for people to gain support.