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Provider: Leicestershire Partnership NHS Trust Requires improvement

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 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.


CQC inspections of services

Service reports published 27 February 2019
Inspection carried out on 19 Nov to 23 Nov 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 19 Nov to 23 Nov 2018 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 19 Nov to 23 Nov 2018 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 19 Nov to 23 Nov 2018 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 19 Nov to 23 Nov 2018 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 27 February 2019
Service reports published 30 April 2018
Inspection carried out on 9 Oct to 21 Nov 2017 During an inspection of Community health services for adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 9 Oct to 21 Nov 2017 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 9 Oct to 21 Nov 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 9 Oct to 21 Nov 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 9 Oct to 21 Nov 2017 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 30 April 2018
Service reports published 8 February 2017
Inspection carried out on 14-18 November 2016 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Inspection carried out on 14-18 November 2016 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
Inspection carried out on 14 - 18 November 2016 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)
Inspection carried out on 14 - 18 November 2016 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Inspection carried out on 14 - 18 November 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 14-18 November 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
Inspection carried out on 14 – 18 and 24 November 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 14 - 18 November 2016 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)
Inspection carried out on 14-18 November 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 14-18 November 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 14 - 18 November 2016 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)
Inspection carried out on 14 - 18 November 2016 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 14 -18 November 2016 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)
Inspection carried out on 14 - 18 November 2016 During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on 14 – 18 November 2016 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
See more service reports published 8 February 2017
Service reports published 10 July 2015
Inspection carried out on 9-13 March 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 9 – 13 March 2015 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)
Inspection carried out on 9-13 March 2015 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 9 – 13 March 2015 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)
Inspection carried out on 9-13 March 2015 During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on 09 -13 March 2015 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 9 to 13 March 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Inspection carried out on 9 - 13 March 2015 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)
Inspection carried out on 9 - 13 March 2015 During an inspection of Substance misuse services Download report PDF (opens in a new tab)
Inspection carried out on 09 to 13 March 2015 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Inspection carried out on 9 – 13 March 2015 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
Inspection carried out on 9-13 March 2015 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
Inspection carried out on 9 March – 13 March 2015 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)
Inspection carried out on 9 to 13 March 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 9-12 March 2015 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 9 - 13 March 2015 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
See more service reports published 10 July 2015
Inspection carried out on 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.

Inspection carried out on 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.

Inspection carried out on 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.

Inspection carried out on 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.

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.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


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.