Updated 22 June 2022
We carried out this unannounced inspection of Leicestershire Partnership NHS Trust because at our last inspection we rated two mental health services provided by this trust as inadequate, four mental health services and one community health service as requires improvement. We rated the trust as inadequate for well-led overall.
At this inspection, we visited the two mental health services previously rated inadequate and one mental health service previously rated as requires improvement.
We also inspected the well-led key question at provider level for the trust overall.
At this inspection, two of the three mental health services we inspected improved overall. We rated all three mental health services inspected as requires improvement overall.
At this inspection the overall ratings for mental health services stayed the same in safe, effective and responsive, which we rated as requires improvement. Caring stayed the same, rated as good. The rating for well-led in mental health services, improved to requires improvement.
At this inspection the well-led provider rating improved from inadequate to requires improvement.
We inspected three mental health inpatient services because of the ratings from the previous inspection. All three service inspections were unannounced.
We inspected all key lines of enquiry in all domains (safe, effective, caring, responsive and well-led) in two services. These services were:
- acute wards for adults of working age and psychiatric intensive care units and
- long stay or rehabilitation wards for working age adults.
We inspected all key lines of enquiry in two domains (safe and well-led) in a third service. This was:
- wards for people with a learning disability or autism.
We also assessed if the organisation is well-led and looked at areas of governance, culture, leadership capability and improvement. Our inspection approach allows us to make a judgement on how the trust’s senior leadership leads the organisation and the provider level well-led rating is separate from the ratings of the services we inspected.
We did not inspect the following core services previously rated as requires improvement:
- community health inpatients services
- community based metal health services for adults of working age
- mental health crisis services and health-based places of safety
- specialist community mental health services for children and young people.
We did not inspect the following core services previously rated as good:
- forensic inpatient or secure wards
- child and adolescent mental health wards
- wards for older people with mental health problems
- community based mental health services for older people
- community based mental health services for people with a learning disability or autism
- community health services for adults
- community health services for children and young people, and
- community end of life care.
We are monitoring the progress of improvements to services and will re-inspect them as appropriate.
In rating the trust overall, we took into account the current ratings of the 12 services not inspected this time.
Our overall rating of this trust stayed the same. We rated them as requires improvement because:
- The trust leadership team had not ensured that all requirements from the last inspection had been actioned and embedded across all services. This meant some fundamental standards were not being met. This included environmental improvements, shared sleeping accommodation, response times to maintenance issues, care planning and access to relevant therapies in certain services. Improvements were noted in some wards in core services but not all. Senior leaders in core services we inspected, had not maintained oversight of improvement across all wards of their services.
- In two of the core services inspected, the environment had not been well maintained. This was highlighted in the previous inspection. Maintenance teams did not undertake repairs in a timely way and not all areas used by patients were clean. Some patients continued to share bedroom spaces in dormitories, and personal belongings were stored on the floor because of limited storage provided by the trust.
- Not all patients on acute wards for adults of working age could summon help from staff if required. There was no patient alarm access in four ward areas, including the dormitories. Following inspection, the trust submitted an action plan to review access to call alarms.
- In all three services, not all staff were up to date with mandatory training. Staff who delivered training had been redeployed away from training during the COVID-19 pandemic, but face to face training had restarted and not all staff who had out of date training had rebooked.
- Staff had not managed all risks to patients in services. Staff did not always follow trust policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff on the acute wards were not consistent with searching patients upon return from unescorted leave as some patients had managed to take lighters onto four of the wards. The service did not have a system in place to monitor the number of lighters each ward held. This was an issue highlighted at our inspection in 2018. At the Willows, six out of 19 patient’s risk assessments had not been updated. At the Agnes Unit, staff did not always record the physical health of patients who had been given rapid tranquilisation. In addition, staff did not record the maximum dose of medications a patient could have in any 24-hour period.
- Patient access to psychology and occupational therapy was less than expected on acute wards and rehabilitation wards due to the number of staff vacancies in therapy positions. The lack of psychology was an issue highlighted at our 2018 inspection.
- Two core services did not promote patient centred care in all aspects of care delivery. In rehabilitation wards, staff did not always develop and review individual care plans. Not all care plans reflected patients’ assessed needs, or were personalised, holistic and recovery oriented. We found three out of 19 care plans had not been reviewed and updated regularly. On acute wards, not all informal patients knew their rights.
- Staff did not consistently promote dignity and respect as expected in all services. Curtains were missing from bed spaces and staff did not wait for an answer from patients before entering rooms on acute wards. On rehabilitation wards, staff did not care plan the needs of a patient with protected characteristics. In two services, staff were not always caring towards patients.
- The trust had not responded in a timely way to eliminate shared sleeping arrangements (dormitories). On four wards in acute wards for adults of working age, there were shared sleeping arrangements for patients. The trust was told to address the arrangements for eliminating dormitories at our last inspection in 2018 and work had started on one ward in March 2021. Whilst there was a plan to eradicate the dormitories across the trust, there were delays to the timetable and patients continued to share sleeping accommodation which compromised their privacy. Following inspection, the trust submitted an action plan to review shared sleeping arrangements.
- Managers did not successfully cascade information down to all ward staff in acute mental health services. Staff we spoke with were unaware of incidents and learning on other wards across acute wards for adults of working age; this was highlighted as an issue at our inspection in 2018. In the same service, managers did not always review incidents in a timely way.
- Governance systems and processes, and the strategy of the organisation had been extensively reviewed since our last inspection but was not fully embedded into services. Some managers had access to key performance data and could respond to areas of improvement, but this was not consistent in all aspects of care delivery and across all services. For example, issues found in risk assessments, care plans and environmental concerns had been addressed in some services, but not all since our last inspection.
- In July 2019, the new trust board formed a buddy relationship with a mental health and community health service NHS trust in Northamptonshire (Northamptonshire Healthcare NHS Foundation Trust – NHFT) following the previous inspections in 2018 and 2019. This became a formal group working partnership in April 2021. A new chief executive was appointed as a shared role between the two trusts. The trust had made significant improvements to develop a strengthened vision and strategy.
- Following the appointment of a new chief executive a new trust board was formed. We noted how much time the new executive team had invested in making and implementing improvements during the COVID-19 pandemic.
- The Step up to Great strategy identified key priority areas of focus which were linked to the trust’s vision.
- Governance processes had improved since our last inspection and operated effectively at trust level to ensure that performance and risk were managed well. There were clear responsibilities, roles and systems of accountability to support good governance and management.
- A positive culture had developed since our last inspection. Staff told us they felt happy and enjoyed their work. There was good staff morale in services. Staff felt respected, supported and valued and we heard how well the trust supported staff during the COVID-19 pandemic. Leadership behaviours were fostered, and development of staff was encouraged. There was an extensive wellbeing offer available to staff.
- Engagement with external stakeholders had significantly improved since our last inspection. The trust had key roles in the development of health and social care system working, and collaboration with other care providers to improve provision of mental health services. The trust ensured that people who used services, the public, staff and external partners were engaged and involved in the design of services.
- Equality diversity and inclusion matters had been a focus of the new trust leadership team.
- Medication management had improved significantly across the services. There were improved systems and processes to manage storage, disposal and administration of medications.
- Services had complied with guidance on eliminating mixed sex accommodation. Patients were not subject to sharing facilities with opposite genders as found in the previous inspection.
- Infection prevention and control (IPC) was well managed and monitored and services were responsive to deal with frequent changes in IPC requirements during the pandemic.
- Seclusion environments were not an issue of concern at this inspection. Staff documented seclusion well in most services, compared to our last inspection.
- Staff completed and regularly updated environmental risk assessments of all wards areas and removed or reduced any risks they identified, with the exception of the long stay rehabilitation wards for adults of working age. Staff followed procedures to minimise risks where they could not easily observe patients.
- Patient involvement in planning care was now in place and the voice of the patient in changes to services had been considered.
- There was a good working relationship between the Mental Health Act (MHA) administration team and the wards, community teams and the executive team. This had continued during the pandemic.
- The trust had robust arrangements in place for the receipt and scrutiny of detention paperwork. The scrutiny process was multi-tiered, which included the nurse, Mental Health Act administrator and medical scrutiny. The trust had developed checklists to assist staff with the receipt and scrutiny process.
- There had been only one out of area placement over 14 months. This was a significant improvement since our last inspection which reported 171 out of area placements lasting between two and 192 days. In rehabilitation services, staff had effective working relations with the new rehabilitation community transition support team created in response to the pandemic to facilitate faster discharges from the wards.
- Services treated concerns and complaints seriously, investigated them and learned lessons from the results. Managers shared the outcome of complaints with their ward teams.
- The trust board, heads of departments and senior leaders had access to the information they needed to manage risk, issues and performance across the trust.
How we carried out the inspection
During the inspection, our inspection teams carried out the following activities across 11 wards in the services:
- reviewed 64 care records
- reviewed 53 medication records
- interviewed 73 staff and 13 managers
- interviewed 35 patients
- spoke with 15 family members or carers of patients
- checked 5 clinic rooms
- attended 5 meetings
- observed 10 episodes of care
- reviewed the mental health act detention papers of 23 patients and seclusion records of 10 patients, and
- received 41 comment cards from patients that were available for patients to complete during the time of our inspection.
During our well-led inspection, we spoke with 32 senior leaders of the organisation and looked at a range of policies, procedures and other governance documents relating to the running of the trust.
You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
What people who use the service say
On Heather ward patients said that there was not enough ventilation on the wards. The matron opened some vault windows via a remote. They later told us that this had been an ongoing concern for around five years. Two patients told us they had experienced cancelled leave, and numerous staff confirmed that facilitating escorted leave had been difficult at times which had led to either a cancellation, or where possible delayed leave. Three patients told us of times when staff had been rude, threatening and disrespectful towards them.
We spoke with five informal patients at the Bradgate Mental Health Unit who were unaware of what they could and could not do as an informal patient. One patient told us they did not know they could leave the ward to seek medical attention. Beaumont ward did not have a poster displayed around informal patients and rights as a patient had ripped it down.
Two patients we interviewed on Ashby and Heather wards told us that staff did not always knock on their bedroom doors before entering. One patient on Thornton ward told us that while staff did knock, they did not wait for a response before entering, which had resulted in staff walking into their room while they were changing their clothes, compromising their privacy and dignity.
One patient told us that staff had been rude, threatening and disrespectful towards them, which a relative also confirmed. One ward matron told us that a patient had recently alleged that a staff member had assaulted them. Ward matrons were looking into these alleged incidents.
One patient on Watermead ward told us that a staff member had ignored them when they had asked them for a sandwich.
Six further patients across Beaumont, Ashby and Heather wards told us that not all staff were caring or respectful. One patient on Heather ward claimed that they had previously watched a staff member walking past a distressed patient and did not seek to reassure them or ask what was wrong.
We spoke with five patients on long stay or rehabilitation wards; they told us they felt very well supported, and staff and were kind, caring, and respectful. One patient told us there wasn’t enough to do at the Willows. Another patient said on their comment card they did not see enough of the occupational therapist.
We spoke with nine patient families and carers. Some families and carers told us that the service was not responsive, telephone calls to the service were not returned. Not all families and carers knew they could attend virtual ward meetings and care programme approach meetings. Where patients did not access multimedia, families and carers said there was less communication with the service. Some families’ carers said that the meals were unhealthy.
One family member told us their relative could be challenging but they felt they were well cared for. Another relative said their relative was a “changed person” since going to the Willows and they were able to go home last Christmas. A family member spoke about enjoying regular meetings in the service gardens with their relative. Families and carers said the wards were clean.
One patient at Stewart House told us other patients made comments around their protected characteristics and staff had not care planned the needs of the patient.
The trust also collected feedback from patients in a variety of ways, including surveys, iPads, community forum meetings and the Friends and Family Test. The trust told us patients across mental health inpatient wards had commented positively about their experience of care. Patients said staff who cared for them were knowledgeable, professional and friendly.