• Organisation
  • SERVICE PROVIDER

Leicestershire Partnership NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

All Inspections

12 April 2022

During an inspection of Mental health crisis services and health-based places of safety

We carried out this unannounced focused inspection of adult liaison psychiatry services as part of a system wide inspection of Urgent and Emergency Care provision in the Leicester, Leicestershire and Rutland Integrated Care System. Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, the Care Quality Commission undertook a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care.

Adult liaison psychiatry services are provided by Leicestershire Partnerships NHS Trust (LPT), the mental health trust in the Leicester, Leicestershire and Rutland Integrated Care System. Adult liaison psychiatry services are delivered by the mental health trust across three acute hospital sites at Leicester Royal Infirmary, Leicester General Hospital and Glenfield Hospital. At this inspection, we looked at adult liaison psychiatry services at the Leicester Royal Infirmary site. We looked at how the adult liaison psychiatry service affected patient flow, admissions to hospital and discharges from the Leicester Royal Infirmary hospital as part of the system wide healthcare.

The adult psychiatric liaison service provides assessment and treatment for adults between the ages of 16 to 65, who experience mental health problems in the context of physical illness. Adult liaison psychiatry is categorised under Mental Health Core service of Mental Health Crisis and Health Based Places of Safety (HBPoS), as it is provided by the mental health trust, Leicestershire Partnership NHS Trust.

This was a focused inspection. We did not rate this inspection. We looked at the domains of safe, effective and responsive and we did not inspect all of the key lines of enquiry. We did not inspect the whole core service.

We inspected adult psychiatric liaison services as part of Mental Health Crisis and Health Based Places of Safety core service. We did not inspect the following areas of this core service:

  • Crisis Resolution and Home Treatment teams (CRHT)
  • Health Based Places of Safety.

We did not rate this service at this inspection. The previous rating of requires improvement remains. We found:

  • Staff working for the adult psychiatric liaison team developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients.
  • Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • The service did not exclude patients who would have benefitted from care. The team engaged with patients who found it difficult or were reluctant to engage with mental health services.
  • There was a full complement of staff with no vacancies.
  • All areas were very clean, fresh smelling and fit for purpose. All assessment rooms had good visibility.
  • Staff we spoke with were proud to work within the adult psychiatric liaison team and proud to show us the work they did and the service they provided. They were constantly looking at ways to improve their work and the patient experience of the service.

However, we noted one issue that could be improved:

  • We found the average wait times for patients presenting with a mental health crisis or specific mental health needs were between 1.5 hours and 1.9 hours. This was because the EDU ‘batch’ refer sending four or five referrals at a time rather than when they arrive. We were aware the local commissioning groups had not set targets for wait times.

How we carried out the inspection

We spoke with six members of staff including matrons, team leaders and mental health practitioners and reviewed all the assessment areas the adult psychiatric liaison team uses. We reviewed data and documentation including three patients’ care records and risk assessments.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We did not speak to any patients using the service at the time of the inspection.

28 February 2022

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

We carried out this unannounced focused inspection because at our last inspection in 2021, we had concerns about the quality of services and issued enforcement action. At this inspection we assessed what work the Trust had undertaken, as a result of the enforcement action we issued. The Trust was required to make significant improvements in some key areas.

We did not inspect all key questions in all domains because this inspection was undertaken specifically to assess progress the Trust had made to meet legal requirements after the last inspection. We are monitoring the progress of improvements to other key lines of enquiry in other services following the inspection in 2021 and will re-inspect them as appropriate.

The action we told the Trust to take following the last inspection were:

  • to improve ways in which patients could call for help in an emergency
  • to take action to eradicate shared sleeping arrangements (dormitories).
  • to improve ways in which patients’ privacy and dignity were protected.

We inspected some but not all key question in the domains of safe, effective, caring, responsive and well led in one service. The key questions inspected were in relation to the areas of concern in the enforcement action we took following the last inspection.

At this inspection, we visited the following service:

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

We re-rated the ‘Safe’ and ‘Responsive’ key question only at this inspection. The ‘Safe’ key question rating improved from inadequate to requires improvement. The ‘Responsive’ key question rating improved from requires improvement to good. Other key questions not inspected at this inspection will be addressed at future inspections.

Effective, Caring and Well-led were not re-rated.

The overall rating of requires improvement for acute wards for adults of working age and psychiatric intensive care units remains the same.

The Trust overall rating of requires improvement remains the same.

The Trust have met all actions required in the enforcement action issued at the last inspection.

We found:

  • On Watermead and Thornton wards, all patients now had a way to summon help in an emergency. Across all wards at the Bradgate Mental Health Unit (BMHU), all patients had now been risk assessed for a wrist worn personal alarm, which could be used to summon help in an emergency. A paper-based risk assessment form was now in place for every patient which showed staff had considered the need for a wrist worn alarm. The form included the patient’s involvement in the decision. Where patients had declined an alarm, staff documented this decision. Patients who wore wrist alarms, knew how they worked.
  • Fixed alarms in toilets and bathrooms were now insitu.
  • The Trust had completed major environmental works to eliminate shared sleeping arrangements (dormitories), in the timeframe outlined in their action plan. One ward remained with shared sleeping accommodation (dormitories) at the time of our inspection. However, this ward (Aston) was relocating to a newly refurbished, single occupancy bedroom ward so that refurbishment could start. This meant, all wards at the Bradgate Mental Health Unit (BMHU) would be single occupancy.
  • Patients had sufficient space to store personal belongings. Every bedroom had a floor to ceiling wardrobe and a chest of drawers. Every patient had access to lockable storage and additional storage space in separate room on the ward.
  • Staff were aware of the importance to protect patients’ privacy and dignity. Every bedroom door now had a permanent sign which reminded staff to knock before entering.

However:

  • Staff did not routinely upload paper-based risk assessments for patient wrist alarms into the patient’s electronic care record as per Trust policy.
  • Staff had not consistently completed care plans in the electronic patient record for those patients who wore wrist alarms.
  • Staff did not test the wrist worn alarms or fixed room alarms regularly on all wards and record the outcome as per Trust policy.

How we carried out the inspection

We carried out this inspection to follow up on enforcement action we issued at the last inspection in 2021. These concerns were in relation to some of the key questions of Safe, Effective, Caring, Responsive and Well led. Therefore, our report does not include all the information usually found in a comprehensive report. We have only re-rated the ‘Safe’ and ‘Responsive’ key questions for one service.

The rating of ‘Safe’ improved from inadequate to requires improvement. The rating of ‘Responsive’ improved from requires improvement to good. All other key questions were not re-rated.

The overall rating of requires improvement for this service remains the same.

The Trust overall rating of requires improvement remains the same.

During our inspection, our inspection team carried out the following activities across wards:

  • interviewed 11 staff including charge nurses, healthcare assistants and two senior managers
  • spoke with 14 patients
  • visited six wards of seven wards and reviewed the environment and bedroom spaces
  • reviewed governance systems and processes in place to deliver safe care and treatment
  • reviewed minutes of team meetings, MDT meetings and board papers and reviewed a range of policies, procedures and other documents relating to the running of the service
  • reviewed 35 care records, including risk assessments and care plans.

What people who use the service say

One patient told us how well balanced the system was to assess if patients needed a wrist band alarm. They told us the process was not discriminatory or had a hierarchy that singled out patients who needed an alarm. They told us they felt having an alarm was accepted by all. And made them feel safe. Another patient told us they had been risk assessed twice for a wrist band and had declined but understood the purpose of the wrist alarms. One patient on Aston ward said their visitor had not been given an alarm to wear. One patient told us they had agreed to have an alarm but could decide when they wore it; it depended on how they felt each day.

Some patients reported agency staff still did not knock on their bedroom doors.

25 to 27 May 2021, 2 June 2021, 29 June 2021, 5 to 6 July 2021

During a routine inspection

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.

However:

  • 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.

11, 12 and 17 June 2019

During an inspection looking at part of the service

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.

19 Nov to 23 Nov 2018

During a routine inspection

  • We rated well-led as inadequate, safe, effective, and responsive as requires improvement and caring, as good. In rating the trust, we took into account the previous ratings of the ten core services not inspected this time. We rated the trust overall for well-led as inadequate. At this inspection, we rated two core services as inadequate, two core services as requires improvement, and one core service as good. Therefore, overall, eight of the trust’s 15 services are now rated as good, five as requires improvement and two as inadequate.
  • We found a high number of concerns not addressed from the previous inspections. We found significant issues with trust level governance, oversight of environments, a failure to address keys issues and a lack of pace with delivering essential improvements. Overall, the pace of change in planning and converting plans into action across the trust was disappointingly slow.
  • The trust had not fully articulated their vision for how they operated as a trust. The trust had several strategies, a vision and corporate objectives, but they did not underpin all policies and practices. The trust lacked an overarching strategy which everyone within the trust knew. Staff and senior leaders could not articulate the trust’s direction of travel and how this was co-ordinated. There was a lack of understanding in teams how their own plans, visions and objectives connected with the trust’s vision.
  • We were not assured that the trust risk register clearly documented action taken or progress of action, within agreed timescales. Many of the actions listed included plans to review process, establish an approach, or to develop areas. We felt this contributed to senior staff views that pace of change in the trust was slow. The trust’s Board Assurance Framework (BAF) was lengthy, was combined with a corporate risk register and had overdue actions. Due to the lack of a trust overarching strategy, the BAF did not provide an effective oversight against strategic objectives, gaps in control and assurance.
  • We had serious concerns about the trust’s oversight of ward environments and safety of patients within those areas. Since our 2017 inspection, the trust had not fully ensured that clinical premises where patients received care where safe, clean well equipped, well maintained and fit for purpose. We found concerns with the environment in all five core services we inspected.
  • Medication management across four of the five services we inspected was poor, despite reported trust oversight and audit. We found serious concerns with medication disposal, storage, labelling and management of controlled drugs.
  • Staff did not record seclusion well. Considerable numbers of records we reviewed during our inspection, were of a poor standard, with substantial and important clinical reviews missing, as recommended by the Mental Health Act Code of Practice.
  • Risk management in services required improvement. Staff did not effectively complete risk assessments for patients, manage a smoke free environment, or share information about incidents or share learning from incidents within teams, across services or between services in the trust.
  • In most services, we were concerned with the lack of evidence in care plans which showed patients and carers had been consulted and involved in their care. Staff did not routinely complete detailed, person centred, individualised or holistic care plans about or with patients. Staff in four of the five services we inspected did not document patient involvement in their care. Staff had not routinely recorded whether they had given patients copies of their care plans and we saw this in a considerable number of patient records we sampled. Patients and carers confirmed in most services they had not received copies of care plans. Community meetings and patient involvement in the services did not always take place. Therefore, patients were not always actively engaged in decisions about service provision or their care.
  • We found concerning evidence of long waiting times for assessment in specialist community mental health services for children and young people. Whilst staff monitored patient’s risk on the waiting lists, the length of time to wait was of concern, in addition to the services’ lack of oversight and management of this issue. This left patients without access to treatment when they needed it most.
  • The dignity and privacy of patients across three services we visited was compromised. The trust did not always manage the admission of patients into mixed sex environments well. Staff used strategies to maintain patient’s safety which had an adverse effect on their dignity and privacy. Staff carried out physical observations in public areas in one service, and staff did not always record or explain why some observations of patients were required.
  • Staff did not always feel connected to the wider trust. Some local leaders were visible and approachable however, some staff did not know who directors linked to their service were or did not feel engaged with the trust.
  • The trust lacked a framework for co-ordinating, endorsing and therefore learning from the very many positive quality projects taking place. The teams we spoke with, felt the trust board did not set clear timescales or direction on how to move their projects forward.
  • The trust had a limited approach to patient involvement. We found this across core services and within senior teams. We would expect patient involvement to be embedded at all levels of the trust, across as many departments as possible, in planning, review, evaluation and delivery. The trust mostly used surveys to gain feedback and we saw limited evidence of face to face engagement with patients about service delivery and improvement.
  • There were issues within the trust of a bullying culture despite evidence that staff knew the trust values. Some teams told us about a lack of teamwork, best practice was not shared amongst services and regular meetings did not take place in some services.
  • The trust’s pace for implementing equality and diversity initiatives across the organisation needed improvement. This was particularly relevant to protected characteristics. The trust supported a BAME network (black and minority ethnic) however, given the diversity of the geographical area of the trust, they had not significantly developed its agenda or work streams since our last inspection.
  • Supervision and appraisal compliance of three teams fell below 75%. The trust did not provide data to demonstrate medical staff appraisal compliance.

However:

  • Despite the issues we found with storage, disposal, labelling and controlled drugs, the trust had made improvements to prescribing of medication and had successfully implemented e-prescribing processes trust wide. Services had supplies of emergency medication available and this was accessible to staff. Staff in some services completed care plans with detailed information on allergies, and risks around medication.
  • The number of incidents reported by the trust had decreased since the last inspection and serious incident figures remained comparable. The trust had robust systems in place which allowed staff to effectively report incidents. The patient incident team carried out a review of serious incident reporting and made changes to improve the reporting process, categorise incidents in a better way and improved reporting of safeguarding. The group established a deliberate self harm and suicide group in the last year to oversee specific incidents of this nature.
  • Mandatory training compliance for trust wide services was 91% against the trust target of 85%.
  • We heard from most teams, positive examples of teamwork and multidisciplinary working within teams and services, and with external agencies and key stakeholders.
  • Many staff we spoke with knew who their chief executive was and mentioned them by name. Staff gave examples of initiatives such as the chief executives’ blog and the presentation of the valued star award. We were pleased to hear about the trust’s investment in well-being events and initiatives for staff, such as ‘valued star award’, choir, yoga and time out days.
  • Detention paperwork for those detained under the Mental Health Act was detailed and followed procedures. Staff knew and understood their role in compliance with the Mental Health Act and Mental Capacity Act.
  • Staff showed caring attitudes towards their patients. We saw numerous interactions between staff and patients with very complex needs and staff managed extremely challenging situations with knowledge and compassion. Staff demonstrated a respectful manner when working with patients, carers, within teams and showed kindness in their interactions. Patients and carers gave positive feedback about the caring nature and kindness of staff and made positive comments about the positive therapeutic relationships they had with their loved ones.
  • The trust had robust governance structures and they had assured any potential gaps or overlaps had been considered. The trust had a variety of measures in place to ensure that processes and reporting to board were not delayed. Every team we spoke with knew who they reported to and what to report.
  • We heard positive reports of senior staff feeling able to approach the executive team and the board. Local leaders were visible and had the skills and knowledge to perform their roles. The trust delivered programmes for staff to develop into senior roles and had a clear career development programme for nursing staff.
  • Engagement and joint planning between departments was well developed. The trust encouraged staff at most levels of the organisation to develop and deliver ideas for service delivery, improvement and innovation. We heard many examples of interesting innovation projects and work that staff groups had done which impacted on and improved patient care.
  • The trust had made progress in oversight of data systems and collection. Staff were aligned to services to manage data and we have seen improvements in recording and monitoring of supervision and appraisal, improvement in managing risks of those on waiting lists in specialist community mental health services for children and young people and in training data.

9 Oct to 21 Nov 2017

During an inspection of Community health services for adults

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.

9 Oct to 21 Nov 2017

During an inspection of Community-based mental health services for adults of working age

  • 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.

9 Oct to 21 Nov 2017

During an inspection of Specialist community mental health services for children and young people

  • The rating had improved from the November 2016 inadequate rating. Managers had introduced a specialist child and adolescent mental health traffic light system, a red, amber and green rating tool for managing risk. In addition to this, risk assessments were comprehensive and reviewed as per the trust policy, six monthly or after risk incidents. Staff reviewed young people’s risk at every appointment and recorded this in the case notes. Managers had introduced a duty clinician to manage caseload sizes and reduce patients’ risks. The service was meeting the target for initial assessment within 13 weeks of referral with a compliance of 99%. However, 323 were waiting for their first appointment through the access team, to complete a core mental health assessment. There were no children who had waited more than a year for treatment.
  • The clinic rooms across sites had all the equipment calibrated. Therefore, staff could ensure accurate measures of blood pressure were being recorded. Across the teams, we found up to date ligature audits in place. At the Valentine Centre improvements had been made to the storage of cleaning materials.
  • Since the last inspection the service now had a Section 136 suite that met the standards set out in the Royal College Standards. The 136 suite is a place of safety for those who have been detained under Section 136 of the Mental Health Act. A children’s adolescent mental health crisis service had been developed and commenced in April 2017.
  • We observed clinicians working with young people were skilled and very positive. There was regular and effective multidisciplinary working. Staff provided psychological therapies as recommended by NICE such as group work and cognitive behavioural therapy. Patients and carers were involved in assessment, treatment and care planning. There were clear treatment pathways.

9 Oct to 21 Nov 2017

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

  • The wards tried to book regular bank and agency staff so they knew the ward and patients, to provide continuity of care.
  • Staff kept risk assessments up to date and carried out comprehensive assessments which were holistic and recovery focused.
  • Staff were kind, compassionate and respectful towards patients.

9 Oct to 21 Nov 2017

During an inspection of Mental health crisis services and health-based places of safety

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.

9 Oct to 21 Nov 2017

During a routine inspection

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

  • We rated safe, effective, responsive and well led as requires improvement and caring as good. We rated the four mental health core services as requires improvement and community health services for adults as good. In rating the trust, we took into account the previous ratings of the core services we did not inspect on this occasion.
  • We rated the trust as requires improvement for well led.
  • The environment in some services was poor, not well maintained and not kept clean. The acute mental health wards had broken facilities which had not been repaired in a timely manner and we found dirt in some areas on one ward. The environment in specialist community mental health services for children and young people, and community based mental health services for adults of working age was not suitable, did not promote safe practice and was not well maintained. The environment in the crisis service did not ensure confidentiality as rooms were not sound proofed and conversations could be heard outside the room.
  • Staffing levels did not meet requirement in some community teams. There was a high vacancy rate of 12.9% for band 5 and 6 nurses in community based mental health services for adults of working age, 18.9% for band 5 and 6 nurses in crisis service and 17.3% across community health services for adults.
  • Patients were not always safeguarded. Patients waiting for their appointment in community based mental health services for adults of working age had access to a room unsupervised which held items which could cause harm. Patients waiting for their appointment in the specialist community mental health services for children and young people used a shared waiting room with the learning disabilities adults’ services. This could pose a risk as patients were unsupervised in this area.
  • We identified medicines management issues, including out of date medication in the acute mental health wards and fridge temperatures were not monitored in community based mental health services for adults. The policy for rapid tranquillisation was not in line with national guidance.
  • Staff held high caseloads in community based mental health services for adults of working age, an issue which had been recognised by the trust and placed on the risk register. Waiting times and lists remained of concern, and this had been identified in the previous inspection. There were a high number of patients on the waiting list for treatment in the specialist community mental health services for children and young people. The waiting times in community based mental health services for adults of working age were long and breached targets. A high number of outpatient appointments were cancelled. The psychiatric outpatients was responsible for 2094 of the breaches, with city east reporting the highest of these breaches at 429.2
  • Not all patient records showed a full assessment of need, including physical health needs or up to date care plans. Care plans were not always holistic and person centred.
  • Staff were not always recording their supervision on the electronic system so we could not be assured they were receiving it regularly.
  • The acute mental health wards had two and four bedded dormitories which did not promote privacy and dignity. Patients returning from leave from the acute mental health wards were not assured of returning to their original ward. This reduced continuity of care.
  • The governance processes had not picked up the issues around repairs, medicines and cleanliness.
  • The quality of some of the data was poor. Staff could not rely on performance reports being accurate. Some local managers were keeping their own records to ensure performance was monitored.

However:

  • The trust had addressed the issues regarding the health based place of safety identified in the previous inspection.
  • The process for monitoring patients on the waiting list in specialist community mental health services for children and young people had been strengthened since the last inspection.
  • Care planning had improved in the crisis service.
  • There was an effective incident reporting process which investigated and identified lessons from incidents which were shared in most teams.
  • Patients and carers knew how to complain and complaints were investigated and lessons identified.
  • Staff were kind, caring and respectful towards patients. Most patients spoke positively about their care and said they were involved. Patients had access to advocacy.

14-18, 24 November 2016

During a routine inspection

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.

The trust needs to take steps to improve the quality of their services and we found that they were in breach of seven regulations. We have issued seven requirement notices which outline the breaches and require the trust to take action to address. We will be working with them to agree an action plan to improve the standards of care and treatment.

We rated the trust as requires improvement overall:

  • Whilst there had been some progress since the last inspection in 2015, the trust was not yet safe, fully effective or responsive.

  • We had concerns about the safety of some of the facilities where care was delivered. The environmental risks in the health based place of safety identified in our previous inspection remained. The trust had not met all the required actions to reduce and mitigate ligature points across wards following the previous inspection in March 2015. The trust had not fully addressed the issues of poor lines of sight in wards. Due to this staff could not observe all parts of wards due to their lay out and the risk had not been mitigated. The trust was not fully compliant with same sex accommodation guidance in two acute wards, the short stay learning disability service and rehabilitation services.

  • Some facilities lacked essential emergency equipment. In the health based place of safety resuscitation equipment and emergency medication were not available and staff had not calibrated equipment to monitor patient’s physical health. The community therapy rehabilitation unit at Hinckley did not have a defibrillator in the unit for staff to use in an emergency despite staff having been trained how to use one.

  • Some wards and community teams did not store or manage medicines safely. There were no pharmacy services within the community mental health teams or crisis team. This could have resulted in an increased risk of incorrect safe and secure handling of medicines and unsafe practice in relation to the administration and prescribing of medicines. We identified concerns around the storage of medicines in community hospitals, with missing opened or expiry dates across all hospitals. Patients’ own controlled drugs were not always managed and destroyed appropriately. We identified that in community mental health teams, wards and community inpatient hospitals, fridge temperatures were not recorded correctly; either single daily temperature readings were recorded rather than maximum and minimum levels or temperatures were not recorded on a daily basis. This did not demonstrate a consistent temperature, had been maintained to assure the safety and efficacy of the medicines.

  • Some wards and community teams had low staffing levels, or an absence of specialist staff, and this had an impact on care.Staffing levels remained low at the Bradgate mental health unit. To ensure that safer staffing levels were met they used regular bank or agency staff to achieve the required amount number of staff for the wards to meet the needs of the patients. However, they did not always meet the required skill mix for the nursing teams. Despite considerable effort with recruiting new members of staff for community inpatient areas, 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. The majority of community mental health teams did not meet the referral to initial assessment and assessment to treatment times. The child and adolescent mental health (CAMHS) community team’s caseloads were above the nationally recommended amount, although young people had a care co-ordinator. The community adult team caseloads varied. People that were referred to the service were waiting for a care co-ordinator to be allocated. Due to the large caseloads in community health service, the number of visits that were required was not always manageable. The trust had identified the lack of psychological therapies for patients, and support and training for staff, on their risk register. This had been identified during the last Care Quality Commission inspection in 2015. We remain concerned that a significant period had passed and the trust had not improved access to psychology for patients and staff. At our last inspection we raised concerns that an insufficient number of nursing staff in community health services for adults had received appropriate statutory and mandatory training. At this inspection we found compliance levels with this type of training were still below the trust’s target.

  • The trust was not meeting its target rate of 85% for clinical supervision. Sixty per cent of staff working in the mental health services had attended supervision and 64% of staff working in community health inpatient services.

  • Record keeping was poor in some services. Within mental health services the quality of care plans was variable. Some care plans were not holistic, for example they did not include the full range of patients’ problems and needs. Care plans did not always consider the patient views, and were generic did and not all were recovery focussed. Patients in four services across the trust reported that they had not been involved in the planning of their care and had not received copies of care plans. Within the end of life service 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.

  • Staff demonstrated poor understanding of some aspects of the Mental Capacity Act. We found that there were still errors within the staff’s application of the Mental Capacity Act. Staff did not ensure that mental capacity assessments and best interest decisions were consistently documented in care records. When staff deemed a patient lacked capacity there was no evidence that the best interest decision-making process was applied. There was little evidence that staff supported patients to understand the process, no involvement of family or independent mental capacity advocate in most mental capacity assessments. This meant that patients could have been deprived of their liberties without a relevant legal framework. Managers did not have oversight of these issues. Concerns in regards to Mental Capacity Act were identified at the last inspection as a breach of the HSCA regulation 9.

  • Staff did not always maintain the privacy and dignity of patients. Staff in the community adult mental health teams did not protect patients’ dignity or privacy. During the depot clinic staff did not close privacy curtains when patients were receiving depot injections. On Bosworth ward patient privacy was compromised when staff and patients entered the clinic room during examinations because there was no privacy curtain in place. On Ashby ward, the shower rooms did not have curtains fitted. This was a breach of the patients’ privacy and dignity to patients as staff might be required to enter the shower rooms to check patients were safe. The trust confirmed that these were reinstalled after the inspection had taken place.

  • The trust could not always provide a bed locally for patients who required admissions to its mental health wards. Bed occupancy rates were above 85% for community health inpatient wards. Beds were not always available for people living in the trust’s catchment area. This meant patients had been placed outside of the trust’s area. We saw that patient numbers exceeded the number of beds available on wards. Therefore there were no beds available if patients returned from leave. To address this deficit the trust moved patients that required an acute bed to a rehabilitation bed which was not clinically justified or met the needs of the patients. The trust was not commissioned to provide female psychiatric intensive care beds. Therefore, if a female needed a psychiatric intensive care unit they were sent out of area.

  • The trust did not ensure that they meet set target times for referral to initial assessment, and assessment to treatment in the majority of teams. This impacted on patients requiring care. Adult community health patients did not always have timely access to routine appointments. We found a total 40 breaches of the six week referral and seven breaches of the five day urgent referral. At the time of inspection, there were a total of 647 children and young people currently waiting to be seen in specialised treatment pathways. 87 of the total patients had been waiting over a year to begin treatment. The longest wait was 108 weeks for four patients to access group work or outpatients. In community based mental health teams for older people five of six services breached national targets from referral to assessment. The learning disability community team had not met the six week target for initial assessment on average it was six days over. The adult community therapy team did not meet agreed waiting time targets. Between August 2015 and July 2016 the trust had a total of 372 delayed discharges.

  • The trust board had not reviewed full investigation reports for the most serious incidents, only the outcomes and lesson learnt. This meant board members were not able to monitor the trust’s assertions that there were strong systems and processes in place for identifying and reporting serious incidents, including deaths, or monitoring whether reviews and investigations were completed fully.

However:

  • We rated the caring domain for the community health families, young people and children service as outstanding due to staff approaches to family and patient care utilising or creating tools to assist children to understand their condition or prepare for treatment. Feedback from those who used the families, young people and children services was consistently positive.

  • The trust had made some improvements in response to the previous CQC inspection undertaken in March 2015.This included removing some ligature anchor points in the acute mental health wards.

  • Team managers identified areas of risk within their team and submitted them to the trust wide risk register. Serious incidents were thoroughly investigated and outcomes and lesson learnt were discussed in a variety of clinical governance meetings. Managers shared the outcomes and lessons learnt from incidents, complaints and service user feedback at regular staff meetings, where meetings took place. Emails and the trust intranet also provided staff with this information. Lessons learnt were shared across the organisation via emails and the intranet. Staff had been trained with regards to duty of candour and in line with the trust policy. The trust had a major incident policy to deal with any major incidents or breakdown in service provisions. Potential risks were taken into account when planning community health services.

  • In CAMHS community teams waiting times from referral to initial assessment was less than 13 weeks. The service was meeting its target in this area. This had improved since the last inspection in March 2015.

  • Overall, the trusts compliance rates for mandatory training was 87%.

  • We reviewed 267 case records and found that, generally, staff completed detailed individualised risk assessments for patients on admission. Care records showed that physical health examinations were completed upon admission and there was ongoing monitoring of physical health across the trust. The majority of care plans were up to date. Care and treatment was mostly planned and delivered in line with current evidence.

  • Staff actively participated in clinical audits. The services used recognised outcome measures and monitoring measures to help assess the level of support and treatment required. The trust had well-developed audits in place to monitor the quality of the service. The trust used key performance indicators/dashboards to gauge the performance of the team. These reports were presented in an accessible format.

  • Nursing staff interacted with patients in a caring and respectful manner. They remained positive when engaging patients in meaningful activities. Staff responded to patients’ needs discreetly and respectfully. Patients were positive about their care and treatment and said staff were caring and understanding and respectful. Patients told us that staff listened and empathised with them. Patients reported that they felt safe on the wards.

  • The trust provided patients with accessible information on treatments, local services, patients’ rights and how to complain across all services. Patients we spoke with knew how to complain. Staff supported patients to raise concerns when needed. Staff received feedback on the outcomes on investigation of complaints via their managers. Managers ensure that they acted on these findings to reduce the risk of reoccurrence.

14 - 18 November 2016

During an inspection of Community end of life care

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.

14 – 18 November 2016

During an inspection of Community health services for children, young people and families

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.

14-18 November 2016

During an inspection of Community health inpatient services

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.

14-18 November 2016

During an inspection of Community health services for adults

We rated community health services for adults as requires improvement because

  • The trust had not made sufficient progress in addressing the concerns raised at the previous inspection in March 2015. Following this inspection the trust were required to ensure teams were adequately staffed to prevent impacts on staff workload and ensure staff completed mandatory training in line with trust requirements.Insufficient progress had been made against these notices.

  • The service had not delivered timely care to a significant number of patients. Service planning was not being managed in a systematic way. The high demand for services, high levels of staff sickness and staff vacancy rates had not been managed effectively. This had a negative impact on the delivery of urgent nursing care, continence services and non-urgent therapy care.

  • Nursing staff had large caseloads. The number of visits was not always manageable. This impacted on the time available for staff development and training. In five of the six community nursing teams attendance on some mandatory training courses was below 70%.

  • Staff morale in some teams was low, with high levels of stress. Some staff found there was insufficient time to complete their visits within the working day. There was limited time available for staff to attend specialist courses to enhance their knowledge.

  • Data could not be relied upon to measure service performance or improvement.Data collection and interpretation did not include key pieces of information for example number of delayed or missed visits. The electronic data held by the trust was currently being validated with large numbers of visit records not closed on the database.

  • The services did not have a strategy and there were no service plans. There was no process in place for learning from other organisations which provided similar services or to share this service’s best practice.

However:

  • Patients were happy with the care they received and were very complimentary about the staff who cared for them. We observed care being delivered in a kind and caring way, by staff who demonstrated compassion and experience.

  • Care and treatment was planned and delivered in line with evidence based guidance and standards, and systems were in place to ensure trust policies reflectedthe latest guidance

  • The single point of access made contacting the service easy for both patients and health professionals and enabled referrals into the service to be triaged and assigned from one central point.

  • The integrated therapy and nursing teams and the primary care coordinators in conjunction with the night service had clear focus on keeping patients safe and well in their own homes.

  • Complaints were well managed to ensure a timely response and aid learning.

14-18 November 2016

During an inspection of Community-based mental health services for adults of working age

We rated community based mental health services for adults of working age as requires improvement because:

  • Access to the service was delayed due to variable caseloads and waiting times.

  • There was no medicines management input from pharmacy within the community based mental health services for adults of working age.

  • A dual paper and electronic recording system meant that some information was not accessible to all of the staff that might need it.

  • 56% of individual care plans were not up to date, personalised or holistic.

  • The patients did not consistently have their physical healthcare monitored or recorded, unless there were identified problems.

  • Not all of the patients felt involved in their care planning and not all had a copy of their care plans.

  • Staff were not meeting targets for the assessment and assessment to treatment of urgent referrals and six week routine referrals.

  • There were waiting lists of up to 18 months for psychology and up to 40 weeks for other treatment within the personality disorder service.

  • Staff were not meeting the trust’s target compliance rate for annual appraisals and mandatory training.

However:

  • Lessons were learned from feedback and complaints from patients. Managers changed practice because of this.

  • Staff reported incidents, which were discussed and reviewed by line managers within the teams. Incidents were on the agenda at the clinical governance meetings. Staff were adequately supported and debriefed following incidents and could access further support if required.

  • Staff held multidisciplinary team meetings weekly and these were attended by a range of mental health professionals. There was detailed discussion and consideration of patients and carers’ needs. Staff routinely referred patients to access additional support for employment, housing, benefits and independent mental health advocacy.

  • Some patients told us that staff were polite and respectful and willing to go the extra mile in supporting them.

  • There was evidence of leadership at local and senior level. Staff told us their managers were supportive and senior managers were visible within the service.

14 - 18 November 2016

During an inspection of Mental health crisis services and health-based places of safety

We rated Leicestershire Partnership NHS trust as requires improvement because:

  • Environmental risks in the Health Based Place of Safety (HBPoS) identified in our previous inspection remained.

  • The HBPoS had no designated resuscitation equipment and emergency medication and shared equipment with acute wards. We found out of date and non-calibrated equipment located within a cupboard in the health-based place of safety. The HBPoS did not have access to a dedicated clinic room.

  • The HBPoS had poor visibility for observing patients.

  • HBPoS and crisis resolution and home treatment (CRHT) team toilets were not visibly clean

  • The HBPoS did not have designated staff provided by the trust.

  • Risk assessments were completed during the initial assessment at the CRHT team. However, they were not updated regularly or following an incident.

  • In all instances police transported the patient to the HBPoS. This does not comply with the guidance from the Royal College of Psychiatrists.

  • The CRHT team did not have lockable bags to transport medication to patients’ homes; staff told us they transported medication in their handbags.

  • Patients using the CRHT team had limited access to psychological therapies and there were no psychologists working within the CRHT team.

  • Care records for patients using the CRHT teams were not holistic or personalised.

  • Staff did not document physical health checks for patients detained under section 136 in the HBPoS.

  • Records in the HBPoS did not clearly indicate if patients had their rights explained to them.

  • Staff working within the CRHT team and the liaison mental health triage service had not clearly document in patient paperwork or case notes if the patient had capacity or not.

  • With the exception of the liaison psychiatry service and the mental health triage car, managers were not supervising or appraising staff within the trust’s supervision policy.

  • A new quality dashboard had been introduced in September 2016 after it was established that the previous system was incorrect, meaning all data submitted prior to September 2016 was incorrect.

  • Mandatory training that fell below 75% included adult immediate life support, adult basic life support, safeguarding children level 3 and fire safety awareness.

However:

  • Mental health crisis services and health-based places of safety had an overall mandatory training compliance rate of 82%.

  • Lone working policies and procedures were in place for staff to follow to ensure patient and staff safety.

  • Staff were de-briefed and supported after a serious incident; we saw that incidents were a standing agenda item for team meetings and were discussed with staff.

  • Teams met assessment target times.

  • Trust staff working within the had remote access to electronic systems used by the trust.

  • Staff considered and supported patients with their physical health needs in CRHT and the liaison mental health triage service.

  • Patients who accessed the CRHT team told us that they felt their wishes and needs were taken in to consideration, staff could be accessed quickly and they felt safe when visiting the Bradgate Mental Health unit.

  • Carers told us they had regular contact with the CRHT team and they were kept involved with their loved one’s care.

  • Staff were passionate about their roles and enjoyed working with the client group.

  • Staff followed up on all people seen in by phone, post or face to face to help with any ongoing issues such as housing or benefits.

  • We saw evidence of discharge planning in care plans written by CRHT staff.

  • Staff working within criminal justice and liaison services and triage teams had good morale and worked well with internal and external colleagues.

14 – 18 and 24 November 2016

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

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

  • The trust had made improvements to the clinical environments but had not met all the required actions following the previous inspection of March 2015. Improvements to the inpatient wards included updating seclusion rooms, removing some ligature anchor points and replacing garden fencing. However, ligature points remained. Wards had high numbers of hydraulic style patient beds that were a risk to patients with histories of self-harming behaviour. The trust had begun the process of replacing some beds with more suitable options for the patient group. However, we were concerned that ligature risks remained in these bedrooms. Some wards and patient areas had blind spots, where staff could not easily observe patients. We found damaged fixings on one ward; that posed a risk to patients.

  • The trust did not have seclusion rooms on all wards. This meant staff transferred patients to wards that had seclusion rooms when needed. This could pose a risk to patients and staff.

  • The trust had high numbers of vacancies for registered nurses. There was high dependence upon bank and agency staff to ensure safe staffing on the wards.

  • Patients did not have access to psychological therapies, as required by the National Institute for Health and Care Excellence (NICE).

  • Staff were not in receipt of regular supervision in order to discuss training needs, developmental opportunities or performance issues. Ward teams did not hold regular team meetings. Ward matrons told us they shared outcomes from incident investigations in team meetings for shared leaning. Therefore, the trust could not be sure staff received information to support best practice and change in a timely manner. The trust had not ensured all staff had received training in immediate life support. The trust could not be sure that all staff

  • Staff were not always recording room and fridge temperatures in clinical rooms and out of date nutrional supplement drinks had not been appropriately disposed of.

  • The trust experienced high demand for acute inpatient beds. Patients could not always access a bed in their locality when needed and the trust moved patients between wards and services during episodes of care and following return from leave. Staff moved acute patients to the rehabilitation wards when acute beds could not be located. The trust could not ensure continuity of care for these patients.

  • The trust had no psychiatric intensive care unit (PICU) for female patients. Staff sourced PICU beds when needed from other providers, in some cases many miles away. The trust was not commissioned to provide a female PICU and have identified the need with their commissioners. The trust admitted male patients to female areas of the mixed wards when male beds were unavailable. This was in breach of the Mental Health Act Code of Practice guidance on mixed sex accommodation. We noted, however, that staff maintained close observation when this occurred and considered this less stressful for patients than sourcing out of area beds.

  • The acute service contained large numbers of beds in ‘bed bays’ accommodating up to four patients. Patients experiencing mental health crisis and distress did not have access to a fully private area in these environments. Curtains separated patients’ bed areas and the rooms were not secured to allow free access; meaning that patients could have their property removed by other patients. The provider supplied lockers on the wards; however, these were not large enough to contain all possessions and patients did not hold keys.

  • On one ward, female shower rooms did not contain shower curtains. This did not protect the privacy and dignity of patients when staff undertook observations. On many wards, the trust had not supplied sufficient numbers of lounge and dining chairs to accommodate all patients and some wards did not have sufficient quiet rooms for care and treatment or for patients to receive visitors.

  • Staff completed care plans for patients. However, staff did not consistently record patients’ views in their care plan or ensure they had received a copy. Patients did not have access to regular community meetings where they would discuss ward issues and concerns. When community meetings occurred, staff did not include details of outcomes to evidence change.

However:

  • Senior managers were aware of the bed pressures in their acute and PICU service and had raised concerns with their commissioners.

  • The trust had made improvements to the clinical environments since the last CQC inspection. For example, Ashby, Aston, Bosworth and Thornton Wards had been converted to single sex only accommodation to ensure compliance with the Department of Health and Mental Health Act 1983 guidance on mixed sex accommodation. The trust had begun replacing hydraulic beds on the wards and had agreed plans for the replacement of further hydraulic beds across the site over a four-year period. Improvements had been made to the seclusion facilities, and further improvements were planned across the service to improve patient experience and promote privacy and dignity.

  • The trust had completed ligature risk assessments across all wards, detailing where risks were located and how these should be managed. Staff had access to quick guides in their clinical areas to ensure they were aware of how to manage risks. Wards employed additional healthcare support workers to meet patient needs when needed. Staff maintained a presence in clinical areas to observe and support patients.

  • Staff received robust and detailed shift handovers, including information on patient risks, observation levels and physical healthcare concerns and how these were to be managed. Staff were provided with relevant information to care for patients safely.

  • Staff completed detailed individualised risk assessments for patients on admission and updated these regularly and after incidents. Staff completed Mental Health Act 1983 (MHA) paperwork correctly and systems were in place for secure storage of legal paperwork, advice and regular audits.

  • The trust employed registered general nurses (RGN) to assist with assessment and management of physical healthcare needs for patients. Wards had good evidence of multi-disciplinary team working, enabling staff to share information about patients and review their progress

  • Staff were caring, compassionate and kind towards patients. We observed many examples of staff treating patients with care and compassion. We saw staff engaging with patients in a kind and respectful manner on all of the wards. Staff were visible in the communal ward areas and attentive to the needs of the patients they cared for. Overall, patients were positive about the care they received and had access to advocacy services on all wards. The trust had a dedicated family room for patients to have visits with children. This environment was pleasant and well equipped. Patients had the use of their mobile phones on the ward. The trust had a patient involvement centre, which was pleasant, well-equipped and supported involvement from friends and family.

  • Staff consistently demonstrated good morale. There was highly visible, approachable and supportive leadership.

14-18 November 2016

During an inspection of Community mental health services with learning disabilities or autism

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.

14 - 18 November 2016

During an inspection of Specialist community mental health services for children and young people

We rated specialist community mental health service for children and young people as inadequate because:

  • Staff managed high caseloads and reported low morale.

  • Care plans reviewed were not personalised, holistic or recovery orientated.

  • The trust reported a 10% increase in the number of referrals received into the CAMHS service.

  • There were delays in staff delivering treatments to young people and young people following assessment. We found multiple internal waiting lists where the longest wait for young people was 108 weeks. There were significant waiting times for a range of further assessments and treatments including psychology, school observations, psychiatric opinion and group work.

  • Four young people told us they felt involved in developing their care plan however, they had not received a copy.

  • Staff did not always record or update comprehensive risk assessments.

  • Cleaning products in a cupboard in the waiting area was unlocked, which posed a risk to the young people.

However

  • Environments were visibly clean and welcoming.

  • Staff reported they felt supported by their colleagues and managers.

  • Young people and their carers spoke positively about the CAMHS service.

  • Staff had received specialist child safeguarding training and were able to make referrals when appropriate.

14 - 18 November 2016

During an inspection of Wards for older people with mental health problems

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.

14 -18 November 2016

During an inspection of Community-based mental health services for older people

We rated community based mental health services for older people as requires improvement because:

  • When we checked care records, we found variable implementation of the Mental Capacity Act. Staff did not record consent to treatment, and capacity to consent and best interest’s decisions when these were needed. Staff received Mental Capacity Act 2005 and Deprivation of Liberty Safeguards Some staff did not demonstrate a good understanding of the Mental Capacity Act.

  • Staff did not assess and record the risks posed by medicines stored in patents’ homes. For example, for adepot injection,a slow-release slow-acting form of medication. Not all medicine records included allergy information.

  • Care plans were generalised, not person centred or recovery focused. Risk assessments were brief, did not always contain sufficient information and were not updated regularly.

  • At West Leicestershire there was a lack of psychology input.

  • Patients and their carers were not involved in care planning and care programme approach (CPA) reviews. Staff told us they involved patient’s carers but there was little evidence of this in care records. Patients told us they did not have access to a copy of their care plan.

  • The trust set target times from referral to initial assessment against the national targets of 28 to 42 days. Five of the six services in this core service were in breach of these targets.

    Managers identified the breach in these targets and had plans in place to reduce them and had highlighted this risk on the risk register.

  • Staff received supervisions and appraisal. However at South Leicestershire clinical supervision take-up was low at 73%.

  • There were not enough registered staff at City West and this was identified as a risk on the service risk register. However, managers had identified funding for two agency nurses to start work the week following the inspection.

  • Staff told us there were no service information leaflets available. We saw information in the service reception areas about older people’s care. Patients occasionally attended the service. Staff usually met patients in their homes or in the community.

  • At Melton, Rutland and Harborough and Charnwood there was a lack of audits and little focus on quality and improvement.

However:

  • The waiting areas and interview rooms where patients were seen were clean and well maintained.

  • Staff were up to date with mandatory training. Staff had a good knowledge of safeguarding.

  • There were appropriate lone working procedures in place.

  • There was a duty worker system in place which meant the service was able to respond quickly to escalating risks if necessary.

  • Some staff used tools and approaches to rate patient severity and monitor their health.

  • Staff received appropriate induction.

  • There was good multi-disciplinary working within the teams and good communication with other organisations.

  • Staff treated patients with kindness, compassion and respect.We saw staff spend time talking to and their carers. Patients told us that appointments usually run on time and they were kept informed when they do not. Staff provided patients and carers with information in a way that they understood.At City West, City East, and South Leicestershire patients and their carers reported “outstanding” and “good care”.

  • There was access to interpreters and staff were aware of how to access them.

  • There was good staff morale. Staff felt well supported and were able to raise concerns with their line manager and were listened to.

  • At Melton, Rutland and Harborough, City East and City West CMHT’s m

  • At City West in conjunction with the young onset dementia assessment service staff developed a digital app for younger who were developing dementia.

14 - 18 November 2016

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated long stay/rehabilitation mental health wards for working age adults as requires improvement because:

  • The environment in some areas was very poor, particularly at Stewart House. There was a lack of storage at Stewart House, the utility/laundry room was used to store cleaning equipment. Clinic room temperatures were very hot, although one thermometer was above a radiator so would not give an accurate reading. The room used to administer medication on Arran ward at Stewart House was not appropriate; the room was a bedroom and still had a toilet in. There was no fridge to keep medicines cool when required. The old kitchen at the Willows was not fit for purpose and poorly equipped but was being used by occupational therapy. The ovens were old and the dials were not visible and cupboards were broken. There were no vision panels on patient bedrooms. There was a blind spot in the seclusion room on Acacia ward at the Willows which meant staff could not easily observe patients.

  • Men using the laundry had to pass women’s bathroom and bedrooms. The 30 bed unit at Stewart House was mixed sex and there were no doors to lock between the male and female sections.

  • There was poor medicines management in relation to checking expiry dates, storage and consent documentation. Staff who were unclear of the process for rapid tranquillisation did not have a reminder of the process to follow. Wards did not have a list of stock items.

  • There had been periods of understaffing. Staffing levels were not consistent across the two sites. There were high vacancy rates.

  • Record keeping at Stewart House was disorganised. Staff used a mixture of paper and electronic records which were not easy to follow. We found loose papers in records. There were problems with access to the electronic system owing to ongoing building works. There was no evidence of patient involvement recorded in some of the notes.

  • Mental Health Act documentation was not always up to date on the electronic system. The paperwork was difficult to find and not consistent. Staff were confused about Deprivation of Liberty standards and paperwork was incomplete. Capacity assessments were unclear. Detention renewal paperwork had been signed by a doctor prior to them seeing the patient.

  • Local audits were not completed regularly. Team managers could not be assured of local performance around record keeping, care planning and patient involvement.

  • Acute patients had been sent to rehabilitation wards inappropriately.

  • Staff were not aware of the trust’s visions or values.

  • There was a high staff sickness rate reported and managers did not always follow the managing sickness policy.

However

  • Recruitment was in progress for 10 new healthcare support workers. The senior occupational therapist was trying to recruit to vacant occupational therapy posts. Support workers were being trained in phlebotomy to improve timely blood testing. There was a floating qualified unit coordinator to oversee the service requirement at the Willows. Staffing numbers were met but not always the right skill mix.

  • Patients felt safe and said they were checked regularly by staff. Patients described being cared for, respected and treated with dignity. Notes reflected caring and compassionate view of patients. Staff were quick to sort out requests and problems for patients. We observed positive interactions between patients and staff

  • There were low levels of restraint and staff tried other methods to de-escalate before restraining patients. There was an effective incident reporting system.

  • Staff carried out physical health checks on admission.Ongoing physical healthcare was provided by a local GP who visited two days a week and was available in case of an emergency.

  • There was a range of large therapeutic areas and rooms for art therapy plus other interventions.

  • Leadership had been strengthened at Stewart House. Staff acknowledged directors’ visits.

14 - 18 November 2016

During an inspection of Wards for people with a learning disability or autism

We rated wards for people with learning disabilities as requires improvement because :

  • The short stay services did not comply with the guidance on the elimination of mixed sex accommodation. There were no separate female bedroom areas and no gender specific toilets or bathrooms. Bathrooms and toilets were specified for which gender depending on who was resident at the unit at the time. This was done by sliding signs to the door as needed.
  • Shifts were not always covered with sufficient staff, or with staff who had the appropriate qualification and experience for the role.
  • Staff were not supervised in line with the trust's policy. The overall average compliance rate for supervision of staff in the learning disability wards was 46%.
  • Staff did not adhere to the Mental Capacity Act Code of Practice and the five principles of the Act. Capacity assessments were not decision specific. Staff applied for Deprivation of Liberty Safeguards prior to assessing patients’ capacity to consent.

However:

  • Staff completed and regularly reviewed and updated comprehensive risk assessments.

  • Staff completed extensive and detailed care plans. Patients were involved in the writing of their care plans and their views were reflected in the plans. Staff used "my care plan" documents to obtain patients’ views on their care. Plans were shared with family and carers.

  • Staff were kind, caring and compassionate and treated patients with dignity and respect. Patients felt safe.

  • Staff reported morale was good, they worked well together and supported one another.

14-18 November 2016

During an inspection of Child and adolescent mental health wards

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.

14 - 18 November 2016

During an inspection of Forensic inpatient or secure wards

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.

9-13 March 2015

During an inspection of Mental health crisis services and health-based places of safety

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

  • Some medication was out of date and there was no clear record of medication being logged in or out. There were no recorded regular temperature checks of the medication cupboard.
  • The health-based place of safety did not meet some aspects of the guidance of the Royal College of Psychiatrists. For example, furniture was light and portable and could be used as a weapon. Designated staff were not provided by the trust. This meant the police very often had to care for detained patient for the duration of the assessment.
  • Information needed to deliver care was not always readily available when people using community mental health teams presented in crisis out of hours.
  • People using the service had limited access to psychological therapies and there were no psychologists working within the service.
  • Staff had not received any specialist training on crisis intervention. Administrative staff had not received specific mental health awareness training to assist them when taking calls for people who were acutely unwell and in crisis.
  • There some gaps in staff receiving regular supervision.
  • Target times had been set but the speed of response to referrals was not analysed and used to determine whether they were meeting targets. People using the service may not be able to get the speed of telephone response they needed in a crisis.
  • There was no performance data dashboard to gauge the performance of the service. However, the service was collecting data. A dashboard of key performance indicators was being developed.
  • Staff knew who the most senior managers were in the organisation but these managers had not visited the service and staff had no contact with them. Staff felt supported by their immediate managers but felt disaffected with trust senior management.
  • Staff treated people who used the service with respect, listened to them and were compassionate. They showed a good understanding of peoples’ individual needs.
  • The trust had set safe staffing levels and these were followed in practice. Cover arrangements for sickness, leave and vacant posts were in place.
  • The needs of people who used the service were assessed and care was delivered in line with their individual care plans. Risks to people who used the service and staff were assessed and managed.
  • Multi-disciplinary teams and inter-agency working were effective in supporting people who used the service.

9 to 13 March 2015

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

Overall we rated this core service as ‘requires improvement’ because:

  • Whilst staff were working hard to identify and manage individual risks, some ward environments were unacceptable. Improvements were needed to make them safer, including reducing ligatures, improving lines of sight and ensuring the safety and dignity of patients.
  • Some wards did not meet the Department of Health and Mental Health Act Code of Practice requirements in relation to the arrangements for mixed sex accommodation.
  • The acute wards for adults of working age had not complied with all of the required actions following the previous inspection of September 2013.

However:

  • We found that staff across the service were committed to providing good quality care to the patients and showed care and compassion. We found positive multidisciplinary work and observed staff were supporting patients.

9 - 13 March 2015

During an inspection of Substance misuse services

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.

09 to 13 March 2015

During an inspection of Child and adolescent mental health wards

We rated the child and adolescent mental health wards as ‘requires improvement’ because:

  • We had concerns about the environment but noted the service was due to move locations within two weeks.
  • We received mixed feedback about staffing levels and several staffing reported concerns. There was use of bank and agency staff.
  • We found a patient being nursed in the low stimulus area and their liberty was restricted. We could not find records for seclusion or evidence of regular reviews taking place as per trust policy.
  • There had been several serious incidents (SI) within this service in the last year. Examples were given regarding learning from these. However three staff said that information from incidents and learning points was not always fully shared.
  • Supervision, appraisals and training compliance did not always meet the trust standard.
  • Some actions were required to ensure adherence with the Mental Health Act.
  • Admission to the unit was agreed with commissioners. Inpatient and community staff reported difficulties with getting inpatient beds. Often patients were admitted to hospital out of the area especially if they need a more intensive support. Some patients had to be admitted to adult wards in the last year.
  • The trust had systems for promoting, monitoring and responding to complaints. Two patients and a carer gave feedback indicating the systems were not always robust.
  • Staff morale appeared low. Six staff expressed concerns about the proposed move and some said the trust had not communicated information to staff effectively.

However:

  • Patient had individualised risk assessments. Assessments and care planning took place for patients’ needs. Assessments took place using nationally recognised assessment tools and staff provided a range of therapeutic interventions in line with National Institute for Health and Care Excellence (NICE).
  • Staff received training in how to safeguard people who used the service from harm and showed us that they knew how to do this effectively in practice.
  • Staff knew how to report any incidents on the trust’s electronic reporting system and could raise concerns for the trust risk registers. We saw an example of an SI investigation and also action taken from lessons learnt. The trust had systems for staff to raise any concerns confidentially.
  • Patients reported they were treated with dignity and respect. Staff communicated with patients in a calm, professional way and showed an understanding of patient’s needs. Staff involved patients in the ward review and community meetings. A carers group was available to give support.
  • Patients had opportunities to continue their education.
  • Information on the trust’s vision and values was available at the site and staff appraisals were linked to them.
  • Consultations with staff and the public had been undertaken to gain feedback on the proposed move of wards. Comprehensive relocation action plans were available.
  • There was evidence of actions taken to improve the quality of the service. For example, ‘patient-led assessments of the care environment’ (PLACE) were completed.

9 March – 13 March 2015

During an inspection of Community-based mental health services for older people

We rated community-based mental health services for older people as good because:

  • There was an effective duty system in place to provide rapid access to support. There was an on-call rota system for access to a psychiatrist 24 hours a day.
  • Staff had a good knowledge of safeguarding and incident reporting. There were robust lone working procedures in place.
  • There was evidence of lessons learnt from incidents being shared with the team.
  • Comprehensive assessments were being carried out and information was stored securely, except for one location and arrangements were in place to address this. There was a skilled multi-disciplinary team able to offer a variety of therapies.
  • Staff were up to date with mandatory training and had regular supervision and appraisals.
  • Staff were consistently caring, respectful and supportive. All the people who used services and the carers spoken to were happy with the service they had received and spoke positively about their interactions with staff.
  • There were key performance indicators set for time from referral to assessment and where these were not being addressed action had been taken. The duty system enabled urgent referrals to be seen quickly. There was good access to interpreters and signers when needed.
  • There was evidence of items being submitted to the trust risk register where appropriate. Staff spoke of feeling supported by team leaders and team leaders felt supported by their managers.

However:

  • Staff demonstrated a good knowledge of the Mental Capacity Act and consent however this was not routinely documented in care records.
  • Care plans did not always reflect a person centred approach and people who used services and their carers were not routinely involved in CPA reviews.
  • Staff morale was low and they felt disempowered in some areas. Staff identified this was due to the management of change process and current work being undertaken by an outside organisation to identify more effective ways of working.

9 – 13 March 2015

During an inspection of Community mental health services with learning disabilities or autism

We rated learning disability and autism community services as good because:

  • There were systems for lone-working in place including a ‘red folder’ process that kept workers safe.
  • Staff had good knowledge of safeguarding processes and risk assessments were generally detailed, timely and specific.
  • There was clear evidence that staff learnt from incidents and had forums for information exchange to occur as and when needed.
  • Staff were positive about the level of support they received, including regular supervision and line management.
  • Flexible working arrangements allowed staff to work effectively in teams, particularly when there were not enough staff in some professional groups such as speech and language therapists, occupational therapists and psychologists.
  • Staff demonstrated good knowledge of the Mental Capacity Act 2005.
  • Practice development and embedding practice was good, for example, where dementia mapping was adapted to learning disabilities.
  • The people who used services, carers and relatives we spoke with were all positive about the service they received. Staff were described as putting people who used services first and being person-centred.
  • Crisis and relapse care plans were in place for the people that used services.
  • Staff were dedicated and passionate about the work that they undertook.
  • Staff would still work with people who were on waiting lists so that they received some level of service.
  • People knew how to make a complaint as this information was provided in welcome packs.
  • Interpreters were used when working with people who did not have English as a first language.
  • One Community Learning Disability Team had developed an educational awareness raising event to prevent hospital admissions due to dehydration.
  • The nurses we spoke with had specialist interests, including mindfulness and dementia.
  • Teams were responsive and dealt with high levels of referrals.
  • Staff mostly felt positive about their managers and said that the services provided were well-led.
  • Staff felt that they had opportunities to develop and were supported to undertake further study.
  • Many staff knew the Trust values and were aware of the Chief Executive Officer. They were able to talk about the effectiveness of ‘Listening in Action’ events which aimed to improve the quality of services.

However:

  • Inconsistencies in record-keeping for the Autism Outreach services as some records were missing, but others were of an acceptable standard.
  • Safeguarding notes for one person using the Autism Outreach service could not be located creating a potential risk.
  • Resuscitation bag, defibrillator and fire drill checks in the CAMHS LD service were not recorded.
  • Some records were over more than one database/system which could make locating information a problem.
  • Waiting lists for psychological services were high and currently on the Trust’s risk register.
  • Reductions in social service provision had led to an increase in referrals to the Community Learning Disability Teams.
  • The transition from the CAMHS LD service to adult teams was not always timely and, therefore, did not follow best practice. The Trust should ensure that the transition is in line with best practice in future.
  • The perception of staff that learning disabilities services were a low priority for the Trust since they had moved into the adult mental health directorate.
  • The Trust had a number of unfilled positions being covered by long-term bank staff. This meant that some staff felt insecure.

9 - 13 March 2015

During an inspection of Forensic inpatient or secure wards

We gave an overall rating for forensic/secure wards of requires improvement because:

  • Ligature risks had been identified in bedrooms, bathrooms and toilets but there was no clear action to address all of the identifed risks
  • The seclusion rooms had known blind spots but no action had been taken to reduce them. The bed in the seclusion room on Phoenix was too high and a patient had used it to climb up to windows and to block the viewing pane
  • Care plans and risk assessments did not show staff how to support patients. Staff were inconsistent in updating the Historical Clinical Risk Management (HCR-20) assessments.
  • Staff did not demonstrate a good understanding of the Mental Health Act (MHA) and Mental Capacity Act (MCA). Patient’s capacity to consent to their treatment had not been assessed in some cases
  • Patients’ physical health was checked on admission but patients did not have access to a GP for ongoing monitoring or treatment of their health
  • The telephone for patients’ use was situated in a corridor and did not provide patients with sufficient privacy
  • We identified that staff did not always take a person centred approach to care and did not always take positive risks when this might have been indicated
  • The forensic services staff said they felt lost and did not know where they were going strategically

9 – 13 March 2015

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated Leicestershire Partnership NHS Trust long stay / rehabilitation mental health wards for working age adults as requires improvement because:

  • Arrangements for medication management did not keep all patients safe which meant that some patients did not receive the follow-up care they should have received and some patients received medication that was not covered by consent documents
  • The systems that manage patient information (electronic and paper files) did not support staff to deliver effective care and treatment in line with the Mental Health Act
  • The granting of Section 17 leave for patients detained under the Mental Health Act at Stewart House did not follow the Trust’s documented procedure (dated September 2014) and also contravened the Mental Health Act Code of Practice (2008 and 2015)
  • Consent to Treatment could not be easily established for a number of patients because the documentation could not be located by staff

However:

  • Patients told us that they were satisfied with the care they received and we observed warm, positive interactions between staff and patients
  • The Willows had good systems in place to collect, monitor and act upon patient feedback
  • Managers were able to demonstrate that they took poor staff performance seriously and they were actively dealing with this
  • Morale amongst staff we spoke with was generally good and staff were clear about their roles and responsibilities

9 - 13 March 2015

During an inspection of Community health services for adults

Overall rating for this core service Good

We rated Community health services for adults as good because:

  • The community healthcare services provided by Leicestershire Partnership NHS Trust were judged to be good. We did not identify any significant community wide areas for improvement but did find many exemplary services provided by the trust. These included the Older People’s Unit at Loughborough Hospital, the Hand Injury Service, the splitting of planned and unscheduled community nursing services with a single point of access, podiatry and the specialist management of long term conditions.
  • Patient outcomes for people using trust services were very good and the trust was able to demonstrate that their services had a positive impact through good data collection and review mechanisms.
  • The trust had a culture of promoting staff learning and development and encouraged staff to share best practice and innovation. Staff told us the trust was a good place to work.

09 -13 March 2015

During an inspection of Wards for older people with mental health problems

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

  • Wards provided safe environments where patients felt secure. Patients’ needs were assessed and monitored individually. There was good physical health care and good therapeutic treatment and activities. Wards for people with dementia had dementia-friendly elements; particularly the activity rooms and there was commitment to build on this. Assessed risks were well-managed and staff showed a good awareness of individual needs and how to respond to them. Staff showed a good awareness of patient rights.
  • Patients were full of praise for staff and the care and support they offered. They and their carers were kept informed and involved in their treatment and care.
  • Staff interacted with patients in a responsive and respectful manner at all times and showed a good understanding of individual needs. Where English was not the first language of patients, the service provided interpreters. The service was proactive in ensuring the welfare and well-being of patients and in ensuring suitable activities. There was a good level of occupational therapy input and good support to help maintain patients’ physical health. Staff showed high levels of motivation and morale, felt part of a positive team and felt well supported and trained.

However:

  • There were no records of capacity being assessed for patients’ consent to treatment, and no clear evidence of best interests decisions being agreed.
  • We noted a box for discarded needles being left unattended in a communal area. This practice stopped once we drew attention to it.
  • There were delays in maintenance and repairs in some areas.

9 to 13 March 2015

During a routine inspection

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.

This report describes our judgement of the quality of care provided by Leicestershire Partnership NHS Trust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by Leicestershire Partnership NHS Trust and these are brought together to inform our overall judgement of Leicestershire Partnership NHS Trust.

We rated Leicestershire Partnership NHS Trust as Requires Improvement overall because:

  • Not all services were safe, effective or responsive and the board needs to take urgent action to address areas of improvement.
  • While the board and senior management had a vision with strategic objectives in place, staff did not feel fully engaged in the improvement agenda of the trust.
  • Morale was found to be poor in some areas and some staff told us that they did not feel engaged by the trust.
  • We found that while performance improvement tools and governance structures were in place these had not always brought about improvement to practices.
  • We had a number of concerns about the safety of this trust. These included unsafe environments that did not promote the dignity of patients; insufficient staffing levels to safely meet patient’s needs; inadequate arrangements for medication management; concerns regarding seclusion and restraint practice: insufficient clinical risk management.
  • We were concerned that information management systems did not always ensure the safe management of people’s risks and needs.
  • Some staff had not received their mandatory training, supervision or appraisal.
  • A lack of availability of beds meant that people did not always receive the right care at the right time and sometimes people were moved, discharged early or managed within an inappropriate service.
  • We were concerned that the trust was not meeting all of its obligations under the Mental Health Act.

However:

  • Overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.
  • Staff showed us that they wanted to provide high quality care, despite the challenges of staffing levels and some poor ward environments. We observed some very positive examples of staff providing emotional support to people.
  • Procedures for incident management and safeguarding where in place and well used.

9-13 March 2015

During an inspection of Community-based mental health services for adults of working age

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

  • There were risk assessments and plans in place to keep people and staff safe.
  • Staffing skill mix was appropriate to need overall.
  • There were safe lone working practices embedded in practice.
  • There was good multi-disciplinary working within the teams.
  • There were effective methods for obtaining feedback from service users and carers and feedback was acted upon.
  • Staff were caring and committed to providing high quality care and showed a person-centred approach.
  • Staff received regular supervision and most had received an appraisal in the last 12 months.
  • The local managers monitored the environment for staff, carried out local audits and checked performance of staff on a regular basis.
  • People we spoke with said they had received a good service.

However:

  • Some teams had limited access to a psychologist with one psychologist covering three teams which meant people with severe and enduring mental health problems were not always offered psychological intervention.
  • There were different recording systems in place, for example paper records and electronic records, different professional kept separate files. Staff told us they will move to a new electronic system in July 2015 which will be the same as other areas in the trust. Until then there is a danger information is not shared or fully available to all staff seeing a person.
  • The IAPT service was not meeting the Key Performance Indicators (KPIs) set by commissioners in relation to ‘access targets' - meaning they were not getting the expected quota of referrals per population head.
  • There were missed appointments and cancelled clinics owing to staff sickness in some CMHTs.

9 to 13 March 2015

During an inspection of Specialist community mental health services for children and young people

We rated the community mental health services for children and adolescents overall as ‘requires improvement’ because:

  • We had concerns about how environmental risks at CAMHS community sites were being assessed and managed.
  • There had been several serious incidents (SI) within this service in the last year and it was not clear that learning from investigations and actions consistently took place to prevent recurrence. For example relating to assessment of ligature points at Westcotes.
  • There had been an  increase in the number of CAMHS referrals over the last two years. This impacted on staff’s ability to assess and treat young people in a timely manner.
  • Across teams risk assessments were not always completed and updated. Some care plans had not been updated and physical healthcare checks were not routinely documented in young people’s notes.
  • There could be risks posed by the use of different recording systems across teams as staff may not all have access to all records.
  • There was a risk that staff did not receive adequate support or that their capability was not reviewed. Effective multi-disciplinary team working and joint working did not always take place across services.
  • Staff at the PIER team had not received recent Mental Health Act training.
  • The recording of discussions and assessments with people regarding consent to treatment was not always documented.
  • There was a risk that young people may not get assessed out of hours in a timely manner by staff with CAMHS experience
  • We found that there were often delays in hospital beds being identified with some people placed out of area away from their family, friends and community.

However:

  • Staff referred to having reflective practice peer meetings when they were concerned about the risk to a young person.
  • Staff received training in how to safeguard people who used the service from harm and showed us that they knew how to do this effectively. Staff knew how to report any incidents on the trust’s electronic reporting system.
  • Assessments took place using nationally recognised assessment tools and staff provided a range of therapeutic interventions in line with National Institute for Health and Care Excellence (NICE) guidelines where staffing allowed this.
  • Regular team meetings took place and staff told us that they felt supported by colleagues.
  • Most people and carers gave positive feedback about staff. Staff gave examples of working with people with diverse needs considering their ethnicity, gender, age and culture.
  • PIER staff reported having good links with universities and colleges regarding students needing early intervention services.
  • Staff described various ways in which they received information from the board and other governance meetings.

9-12 March 2015

During an inspection of Community health inpatient services

Overall rating for this core service Requires improvement l

We rated community inpatient services as requires improvement because:

  • Staffing was on the risk register for many of the locations we visited. Significant vacancy rates and high sickness levels put additional pressure on substantive staff. While staffing numbers were usually maintained, there was a high reliance on agency and bank staff to achieve this. At Rutland Memorial Hospital shifts were covered by using more than 20% temporary staffing. The quality of clinical supervision was variable across the trust. The trust confirmed community hospital staff were expected to undertake four clinical supervision sessions across the year. Staff told us they worked as a team and enjoyed their jobs.
  • Bed occupancy for the last two quarters of 2013/14 was around 89%. Overall community hospital occupancy rates for March 2015 were 94%, which reflected bed pressures in the local region. It is generally accepted that when occupancy rates rise above 85%, it can start to affect the quality of care provided to patients and the orderly running of the hospital. The trust confirmed the service line was contracted to provide bed occupancy at 93%. The trust recognised this was not an appropriate target and was working with commissioners to negotiate a more appropriate target.
  • Patient records across community inpatient services were not always completed fully.
  • We saw patients were treated with kindness and compassion. However, there were some instances when patients’ privacy and dignity were not respected. Patients were mostly very happy with the care provided by staff; however some patients told us they did not like being woken at 6am and going to bed early.
  • The quality of data was variable, for example training statistics were not always reliable.
  • Patients were frequently not discharged when ready due to transport problems or difficulties putting care packages in place. The trust confirmed contracts for patient transport and local authority care packages were monitored and work was ongoing with partner organisations to improve services for patients.

However:

  • Discharge planning was considered as part of board rounds although discharge planning paperwork was not used consistently.
  • Staff felt they had good local leadership and felt the governance was better with the introduction of a service line.
  • There were processes in place for reporting and learning from incidents. Staff were given feedback after incidents had been reported.
  • We found good multidisciplinary working on wards

9-13 March 2015

During an inspection of Community end of life care

Overall rating for this core service Requires Improvement l

We rated this core service as requires improvement because:

  • Staffing levels were adequate at the time of our inspection but staff told us that they had been short staffed for some time and that there were a number of vacancies. Staff told us that the trust were recruiting for their vacancies and they hoped to have a full complement of staff in the coming months.
  • Mandatory training provided to Advanced Nurse Practitioners did not cover end of life care, and these professionals received little support from trust doctors with a specialism in palliative care. This meant that patients were not protected from receiving unsafe treatment.
  • Following the national withdrawal of the “Liverpool Care Pathway” the trust has developed an alternative care plan; however this has not yet been implemented.
  • Staff were unable to show us evidence of clinical audits or the basis of evidence based practice in end of life services.
  • Computer systems were not shared across GP surgeries so information sharing did not happen effectively.
  • Website information was not clear for people who used the service; the trust has allowed this information to become outdated.
  • We saw that Advanced Nurse Practitioners were completing Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms having completed their training to do so; however we saw that these forms were not countersigned by a doctor or consultant. The trust confirmed after our inspection Advanced Nurse Practitioners used a DNACPR form which had been agreed within NHS East Midlands.
  • The service was responding to complaints and implementing systems following these, however the trust waited for these complaints to prompt improvements in the service. The trust had no auditing system to measure performance in order to improve the service.
  • Staff explained that the figures collected around preferred place of death were collected as these were requested by the clinical commission group (CCG), although these figures were collected for services in the community; the ward based palliative care figures were not collated.
  • Services based in community hospitals did not admit patients close to weekends due to issues with verification of deaths over weekends, and the access to doctors.
  • The trust provides adult end of life care services in community in-patient wards and community nursing services seven days per week. However staff did not appear to be fully aware of services provided and told us there were plans to implement a seven day service in end of life care.
  • The trust had no end of life strategy as the previous one had expired and no replacement had been developed.
  • The trust confirmed staff delivering end of life care were involved in bi-annual record keeping, safeguarding and clinical supervision audits. However there was no evidence of clinical audits or monitoring of the service in order to improve care provided to patients and staff were unable to talk about this to inspectors.
  • Staff received little support from trust specialist doctors in palliative care and contacted the local hospice run by a charity for support.

However:

  • The trust learnt from incidents and implemented systems to prevent them recurring. Staff were aware of the reporting policy and procedure and could give examples of when this was carried out.
  • Records were stored securely and well managed by staff to ensure that sensitive information about patients was protected.
  • Medication management systems were in place and followed to ensure that medicines were stored safely. Where patients took medicines home with them, staff ensured that they understood their use and storage.
  • We saw that consent was gained from people in relation to their care and future wishes.
  • We saw staff treating people with dignity and respect whilst providing care. Staff empathised where a person had a negative experience and offered support where necessary.
  • Staff at St Luke’s Hospital had arranged bi-monthly meetings to involve patients and visitors in the news and actions happening on the ward.
  • Palliative care nurses conducted holistic assessments for patients and provided advice around social issues, for example, blue badges for disabled parking.

9-13 March 2015

During an inspection of Community health services for children, young people and families

Overall rating for this core service Good

We rated this core service as good because:

  • Incidents and near misses were reported and learning from these was shared.
  • There were appropriate arrangements in place for the safe management of medicines. The “cold chain” processes to ensure optimal conditions during the transport, storage, and handling of vaccines was outstanding.
  • Staff had the right qualifications, skills, knowledge and experience to do their job. They were supported to have training to help them to develop additional skills and expertise.
  • Care and treatment of children and young people was planned and delivered in line with current evidence based guidance, standards and best practice. Consent to care and treatment was obtained in line with relevant guidance and legislation.
  • There were good examples of collaborative team working and effective multi-disciplinary and multi-agency working to meet the needs of children and young people using the service.
  • Feedback from those using the service was positive about how they were treated by staff and about how they were involved in making decisions with the support they needed.
  • Services were planned and delivered in a way that met the needs of the local population, for example the Diana Service and the Family Nurse Partnership.

However:

  • Waiting times for referral to initial assessment appointments were good, although patients experienced delays for community paediatric clinic follow up appointments.
  • The school nursing service was understaffed and consequently there was an adverse impact on outcomes for children and young people and on staff morale. Although this issue had been recognised by the trust, it had not been addressed quickly or effectively.
  • Some key outcomes for children, young people and families using the service were regularly below expectations. Outcomes of care and treatment were not always consistently or robustly monitored.
  • The risks and issues described by staff did not always correspond to those reported to and understood by their leaders.
  • Staff were positive about the support they received from their local leaders and managers but were less connected with senior leadership and management teams in the children, young people and families services.
  • Staff did not always feel actively engaged or empowered. When staff raised concerns or ideas for improvement, they felt they were not always taken seriously.

9 – 13 March 2015

During an inspection of Wards for people with a learning disability or autism

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

  • There were not always enough staff who were suitably qualified and experienced to safely meet patients’ needs.
  • Mobility and healthcare equipment took up space in The Gillivers and 3 Rubicon Close. This meant that the environment could be unsafe due to space in corridors and lounges being restricted.
  • Some risk assessments had not been reviewed regularly at The Grange.
  • Staff did not always use the Mental Health Act and the accompanying Code of Practice correctly.
  • Records about the use of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) were inconsistent. Staff were not aware of how this might affect the safety and rights of the patients.
  • Some staff did not receive regular supervision or annual appraisals.
  • Staff had limited opportunities to receive specialist training.
  • In 3 Rubicon Close, it was not clear that information about providing physiotherapy to a patient had been communicated to all staff.
  • The short breaks service was primarily set up to meet the needs of relatives and carers. There was no funding for staff to provide activities so patients had limited access to activities of their choice during their stay.
  • Two patients’ discharges were delayed at The Agnes Unit because the commissioners could not find specialist placements.

However:

  • Restraint was used only as a last resort.
  • Medicine management practices were safe.
  • Staff received training in safeguarding and knew how to report when needed.
  • All incidents that should be reported were reported.
  • Multi-disciplinary teams and inter agency working were effective in supporting patients. Best interest meetings were held where it had been assessed that a patient lacked the capacity to consent to a decision.
  • Staff were very caring and sensitive to patients’ needs. Staff had a good understanding of patients’ needs. Patients’ families and carers were positive about the care provided.
  • Patients were supported to meet their religious and cultural needs. Interpreters were available.
  • Staff knew the vision and values of the trust and agreed with these. They were reflected in the objectives of local teams.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

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

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