All inspections: Humber Teaching NHS Foundation Trust

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

Staff identified risks for children and young people from referral, whilst on waiting lists and whilst in treatment. They put plans in place to decrease or mitigate the risks; this included crisis plans where appropriate. Parents, carers, young people and other professionals knew what actions to take if there was a deterioration in health. Staff responded appropriately and promptly if this occurred.
Staff knew how to protect children and young people from abuse. They recognised when people were suffering from significant harm. Staff had good relationships with external teams to assess holistic needs and if required, knew how to make safeguarding referrals.
Teams included a full range of specialists required to meet the needs of children and young people. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multi-disciplinary team and with external organisations to provide additional support.
Staff treated children and young people with compassion, kindness, respected their privacy and dignity and understood individual needs. They actively involved them and their families and carers in care decisions. Children, young people and their parents or carers had good opportunities to provide feedback on the service and be involved in service developments.
Staff offered flexible times and locations for appointments including weekends and evenings. They responded promptly and appropriately when contacted by children, young people or their parents and carers and took positive steps to encourage those who found it difficult to engage.
Managers were experienced and had good knowledge of the service. Staff felt supported and valued; they felt able to contribute to service improvements and raise concerns if needed. Governance systems ensured information was shared effectively amongst teams and with external organisations.

However:

The service had long waiting lists above the NHS constitution of 18 weeks. This was mostly in Hull for the attention deficit hyperactivity disorder pathway.
Room space was limited in the Beverley location in East Riding.

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

We rated well led for the trust as good. We rated effective, caring, responsive and well led as good across mental health and learning disability services. We rated safe as requires improvement.
We rated nine of the trusts 11 mental health services as good and two as requires improvement, and whilst the rating for acute wards for adults of working age and psychiatric intensive care units remained as requires improvement, the safe key question was now rated as good. In rating the trusts mental health and learning disabilities as good we considered the previous ratings of services not inspected this time, and deviated from the ratings principles.
We rated two of the core services as good that we inspected this time. Mental health crisis and health based place of safety services were rated as requires improvement at our last inspection in 2017 and was now rated good in all key questions.
Six GP practices which had been inspected were rated as good in all key questions.
The adult social care location at Granville court was inspected and rated in January 2018 and was rated as good in all key questions.
The trust had a clear vision, strategy and vision. Staff knew and understood the trust’s vision, values and strategy, had opportunity to be involved of the development of these and understood how achievement of these applied to the work of their team. The trust board and senior leaders had the appropriate range of skills, knowledge and experience to perform its role.
Staff felt respected, supported and valued amongst their local teams. Staff knew and understood the trust’s vision and values and their behaviours reflected these.
Staff treated patients with compassion and kindness. They largely respected patients’ privacy and dignity and supported their individual needs. Staff understood how to protect patients from abuse and were trained to do so. Feedback we received from patients was positive. Friends and family test results were consistently positive.
Staff were aware of what incidents they should report as adverse events and were and generally managed them well, they also knew what should be reported, their duty in reporting these and in meeting the requirements of the duty of candour.
Patients could now access a mental health bed in a timely manner when in crisis. This meant that a bed was available when needed and that patients were not moved between wards unless this was for their benefit.

However:

We rated community health services for adults as requires improvement in safe, effective and well led. This was the third inspection where this core service has been rated as requires improvement, and at this inspection effective has gone down one rating from good to requires improvement. This has led to an overall rating in community health services as requires improvement.
There was improvement at our last inspection in the forensic and secure services leading to a rating of good over all. This improvement has not been sustained and has now been rated as requires improvement in safe and well led.
Despite there being a programme of board visits to clinical areas and board members reporting that significant engagement was undertaken with staff, some staff reported that board members were not visible and staff did not always feel supported or listened to.
Staff did not feel they were always consulted properly about changes to services. There were not always enough staff in all services.
The electronic patient records system was slow and staff had developed paper records so they could access details about patients if they could not access the system when needed. The information that teams kept about patients in paper records was not consistent across the service. Staff did not always record details of safeguarding concerns under the designated section of the electronic patient record.
There were some difficulties with works issues not being completed in a timely manner in the forensic services.
Children and young people were waiting over 18 weeks to receive treatment in some areas.

Our full Inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website – .

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

Staff completed and updated risk assessments for each patient and used these to understand and manage risks individually.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
Staff assessed the physical and mental health of all patients on admission. They developed individual care plans and updated them when needed.
Staff provided a range of treatment and care for patients based on national guidance and best practice.
Managers made sure they had staff with a range of skills needed to provide high quality care.
Staff from different disciplines worked together as a team to benefit patients.
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice.
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs.
Staff involved patients and those close to them in decisions about their care, treatment and changes to the service.
The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However:

Compliance with clinical supervision was low.
There continued to be difficulty for the service to access medication out of hours due to the trust’s contract with the community pharmacy.
Staff did not always have access to equipment to enable them to complete physical health monitoring whilst on community visits.
Two of the meeting rooms at Miranda house did not have obscure glass to promote privacy and dignity for patients who were completing an assessment.
Staff reported a lack of confidence in the trust to support them in raising concerns.

Our rating of this service went down. We rated it as requires improvement because:

There were not always enough staff to maintain safer staffing levels on the wards. There was a frequent reliance on occupational therapy staff to support safe staffing levels. Patient leave was often cancelled due to staffing levels.
There were not always timely responses to carry out maintenance and repairs on the wards. Showers on Ouse ward and one of the laundry rooms within the service had been out of use or awaiting repair since November 2018. Offensive graffiti on a window in Derwent ward had not been reported for repair or replacement.
Governance processes did not operate effectively at ward level and across the service. There were ineffective systems in place to monitor actions from incident investigations and learning from incidents was not routinely shared with staff.
Staff did not always document that required reviews had taken place for patients in seclusion. Whilst in seclusion, patients did not have personalised emergency evacuation plans in place.
Staff observed all visits between patients and their family members and friends. This was not individually risk assessed.
Carers did not always feel well supported, involved or informed about their loved one’s care.

However:

Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding
Staff developed holistic, recovery-oriented care plans informed by comprehensive assessments. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
Ward teams included or had access to the full range of specialists required to meet the needs of patients. Managers ensured that these staff received supervision and appraisal. Ward staff worked well together as a multi-disciplinary team and with those outside the wards who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients in care decisions.
Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharges were rarely delayed for other than a clinical reason.

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

Staff did not always develop patient care plans which were holistic, recovery-oriented and personalised. Staff did not always carry out an assessment to determine if patients needed a personal alarm. They did not always adhere to the principles of the Mental Capacity Act when patients had capacity to make decisions for themselves and they did not always complete patients consent to treatment in a timely way.

Staff did not have appropriate information for patients who identified as lesbian, gay, bi-sexual or transgender. Some of the measures the trust had taken to protect patients’ privacy and personal details were not always effective.

Governance processes were not effective in ensuring staff applied policy and practice consistently across the service and it was not always possible to tell from audit reports what improvements were required. The trust had not reviewed minimum staffing levels for the service. Staff did not feel supported or listened to by senior leaders.

Staff did not always receive timely feedback when the trust investigated serious incidents. They did not have a robust system in place to share lessons learned with staff from incidents and complaints from across the wider trust.

However:

They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.

The service provided safe care. Overall, the ward environments were safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.

Staff treated patients with compassion and kindness. They respected their dignity and understood the individual needs of patients. They involved patients and families and carers in care decisions whilst maintaining patient confidentiality.

The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.

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

There were inconsistencies in completion of risk assessments and care plans. In Scarborough and Ryedale, the appropriate templates were not yet on the electronic record and staff had not received training. Care pathways were not in place for specific conditions.
There was no caseload management tool used to determine required staffing levels. Staffing levels at Whitby were low.
Participation in audits and benchmarking was low. This had been identified at our last inspection and although the team at Whitby had started to introduce audits, others had not.
Staff were not receiving regular documented supervision and appraisal compliance was low in some areas, particularly Whitby.
Feedback from staff about leaders was mixed and there were questions about the experience of some leaders who were new in to post. Morale was variable and staff told us communication and engagement from senior management was poor, particularly with regards to the new services.
Although the community services staff were all employed by Humber Teaching NHS Foundation Trust, staff did not see themselves as part of a wider team and there was little cross team working.
Issues identified at our last inspection had not been fully addressed. Although there had been some changes made in the Whitby team, these were recent changes and needed to be fully embedded.

However:

Staff provided compassionate care and treatment to patients. Patients and their families were encouraged to be partners in their care.
The health trainers service had good outcomes and supported people to live healthier lives.
The service worked closely with commissioners to plan and deliver services to meet the needs of the local population.
Governance systems were in place, with regular meetings taking place that ensured relevant information was fed down to practitioners and up to board level.

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

The service had enough staff with the right qualifications to keep people safe from avoidable harm and abuse and to provide the right care and treatment. They identified risks and recorded actions on how they would manage, reduce or mitigate them. They had effective systems to safely store and dispense medications.
The premises used were clean, well maintained with a welcoming atmosphere. There was a variety of locations offering patients a choice of where to be seen.
The service was continually improving to provide a recovery focussed treatment system. Staff delivered psychosocial interventions to encourage a patient’s improved health and wellbeing. Peer mentors provided patients with additional support and encouragement to commence their treatment journey.
Patients felt involved in their care. The service met their individual needs and families and carers were involved if this was agreed. They were able to give feedback on the service and knew how to complain. Information relating to health, support groups and activities in the wider community was available and displayed.
Staff showed a caring and respectful attitude. They were committed in their roles and embraced the service’s vision.
Governance systems provided managers with a clear oversight of the service’s performance. They recognised and took responsibility where improvements were needed and involved patients, staff and commissioners in discussions. Managers and staff from the service were involved and committed to continual improvements

However:

Staff did not review a patient’s recovery plan or review clinical interventions in line with best practice. Interventions on recovery plans lacked detail to enable a patient to clearly understand how or when they could achieve a goal.
Staff did not have timely access to patient information agreements.

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

Governance systems and processes at team level across Whitby neighbourhood care service were not fully embedded and learning from incidents had not been fully embedded into the Whitby community teams. Record audit results showed overall 25.3% compliance. This was for Whitby hospital and did not refer only to community health services for adults.
Mandatory training completion rates did not always achieve the trust target.
There was limited evidence of a local audit programme and benchmarking being used. Appraisals across Whitby community nursing services had not been kept up to date in the previous six months and clinical supervision in the Whitby community nursing team had not been fully embedded, however managers told us they were addressing this.
There were waiting lists in therapy services. These were longer than 18 weeks and although managers could tell us the action being taken to address waiting lists, there was no action plan and this was not included on the risk register.
Morale varied across the services and staff told us there was a lack of communication between the trust and staff. There was variance in the governance systems between Pocklington neighbourhood care service and Whitby neighbourhood care service.

However:

Staff could describe the level of safeguarding training received. Staff adhered to infection, prevention and control policies such as ‘bare below the elbow’ and carried hand gel during visits. Mobile working had been implemented in some services such as community nursing and was being introduced into services such as therapy services.
Records were found to be mostly completed and staff had access to relevant policies. Policies checked during the inspection were found to be in date. Staff were aware of duty of candour and there had been two incidents at Pocklington neighbourhood care services which had been investigated and action plans produced.
Staff were able to access information through the trust intranet and told us of the different risk assessments available for use. Compliance with appraisals was 100% in the Pocklington neighbourhood care service for June and July 2017. Staff across the services were able to describe the multi-disciplinary team working in the services, for example between the occupational therapists, physiotherapists and community nursing teams.
Staff provided compassionate care and treatment to patients. Staff took time to interact with patients and feedback from patients was positive across the services visited. We observed staff introducing themselves by name to patients and speaking to them with courtesy and respect.
Managers were able to describe how they carried out service planning for the services and told us they worked closely with commissioners in service planning.
Managers were able to describe the governance arrangements at trust level and how governance was managed at locality level through to board level. Staff attended business meetings and governance meetings. Staff across Pocklington neighbourhood care service were positive about local leadership. Trust vision and values were displayed on notice boards in staff offices. Staff told us of good teamwork and a culture of openness and honesty in teams. The service had developed a quality improvement plan.

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

Patients, carers and family members were pleased with the service. Patients felt respected and involved in their care and treatment.
The trust had introduced a number of initiatives to improve the standard of clinical governance.
Staff knew how to report incidents using the online incident reporting system.
Consultant psychiatrists and psychologists were readily available in all the services.
Staff adhered to the trust lone working policy and they had not experienced any incidents.
Staff carried out a comprehensive assessment of each patient, which included mental and physical health needs.
Staff had regular supervision and appraisals.
Staff supported patients to get involved in the local community. Bridlington service provided a therapy garden to support patients in therapeutic activities.
There was a culture of openness and transparency and good team support among the managers and staff.

However:

The trust target for six mandatory training courses had not been achieved.
Some premises were in need of refurbishment and redecoration.
The interface with prison in reach services for obtaining medical information about offenders was not working satisfactorily.
Incidents had increased and had not always been investigated and documented appropriately.
The transfer of Pocklington to a different trust had led to uncertainty and low staff morale.
Precise caseload weighting was often not carried out.

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

The service had acted upon our feedback from our previous inspections and there had been improvements in the quality of patient care. Staff had made substantial improvements.
Staff treated patients with kindness, dignity and respect. Staff understood the needs of the patients and involved them in the planning of their care. The service sought feedback from patients and carers to ensure their involvement in service development.
Staff understood the use of seclusion and it was used in line with the Mental Health Act Code of Practice and trust policy. The trust had decommissioned two seclusion rooms that were not fit for purpose.
The service had undertaken work on reducing restrictions for patients and restrictive practice was based on an individual assessment of risk and need.
Staffing levels had improved and patients had greater access to Section 17 leave and activities on the wards to aid their recovery. Staff ensured patients could attend medical appointments in the community and the physical healthcare provision within the service had improved.
Staff understood risks in the environment and used supportive engagement to manage patient risks. Staff completed risk assessments using validated tools and reviewed them regularly. Learning from incidents was shared with staff across the service.
Staff had a good understanding of the Mental Health Act and Mental Capacity Act. Staff completed documentation as required and this was monitored by the trust.
Managers had a good understanding of the service and were proactive in monitoring service delivery. The service involved clinical staff in audit to assess compliance and performance. Staff developed action plans in response to these to track improvements.
The environments across the wards had been improved. The wards were clean and well maintained, with furnishings in good order.

However:

Staff attendance at mandatory training and clinical supervision was below the trust target.
Staff did not always ensure that the appropriate monitoring was in place for patients who were prescribed anti-psychotic medication. Patients did not always have care plans in place for their physical health needs.
The trust did not ensure that all electrical equipment was portable appliance tested in line with their policy.

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

Staffing levels on the wards didn’t meet safe staffing levels and staff, patients and families told us that leave and activities were frequently cancelled. Team meetings and supervisions were not taking place regularly across all the wards.
Mandatory training rates and appraisal rates were lower than the trust target.
On Westlands, clinic checks were not allocated to a specific staff member and checks not always completed. We could not identify the frequency that controlled drugs were checked on Newbridges.
We found an inconsistent approach to recording data. We saw no clear protocol for recording discussions and actions that related to patients on the electronic records system. The electronic system did not allow for easy access to blood results. Patients care plans were of inconsistent quality; 12 care plans of 26 were generic with little patient contribution or personalisation.
Patients on Avondale and Westlands told us they did not feel safe. Informal patients on Mill View Court told us that they felt unable to leave and did not feel safe. Signs informing patients of their rights to leave were unclear. Information for patients on notice boards was out of date on Mill View Court and Avondale, and incorrect on Newbridges.
Patients were able to feedback at community meetings and directly to staff but we saw no evidence of patients being involved in makings decisions about changes to the service.
Mill View Court, Westlands and Newbridges all admitted patients to leave beds, when patients were on leave the bed occupancy rates were greater than the 85% occupancy rate recommended by the Royal College of Psychiatrists . When there were no beds available staff admitted to sofas and mattresses. Charge nurses told us that they were not always able to refuse admissions when they felt it necessary.
Staff felt there was a disconnect between the staff at ward level and the senior leadership team. Charge nurses, modern matrons and service managers were visible on the wards, although staff felt that the senior leadership team were not.
There was no risk register at ward level.

However:

Patients had clear seclusion exit plans; reviews were conducted and seclusion was ended appropriately with multidisciplinary input. Staff completed collaborative risk assessments that reflected the patients’ voice in line with trust policy.
Staff on the wards had a good understanding and knowledge of safeguarding and incidents and reported them. We saw examples that changes were being made following incidents. Staff were knowledgeable in the application of the Mental Health Act and Mental Capacity Act. Patients had access to independent mental health advocates that regularly visited the wards.
We observed kind and respectful interactions between staff and patients on the wards and found staff to be knowledgeable about patients’ needs. Patients and carers described staff as genuinely caring, respectful and working for the best interests of the patients.
Staff orientated patients and carers to the wards on admission and provided them with key information in an accessible format. Patients, families and carers were involved in care planning and risk assessments. Patients, families and carers felt confident to complain and feedback on the service and told us that they were listened to.
Staff could access interpreters and there was spiritual support on the ward for patients. On the wards there were activities and facilities suitable to the patient group. Wards were clean and staff complied with infection control guidance.
Staff planned for patients’ discharge. Patients had care programme approach meetings with care coordinators, families and the multidisciplinary team.
The service had effective mechanisms in place to monitor ward performance, including staffing, discharges, readmission and bed occupancy. Staff completed care records audits, infection control and seclusion audits. Charge nurses and ward managers were aware of the challenges within their wards and had a good understanding of their services.
Ward leaders were very proud of their staff and spoke of their teams’ resilience and pride in care given. Staff were also proud to work at the service and teamwork was demonstrated in the support the staff gave each other regardless of role. There were effective working relationships on and off the wards, including the multidisciplinary team and external organisations.

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

The service had made improvements following feedback from our previous inspections. Maister Lodge had senior nurse cover for all day shifts and agency nurses were required to have the skills appropriate to the patient group. The ward now complied with safe medicines management.
There were good patient risk assessments on each ward. The service provided a safe environment and managed risks well. Patients told us they felt safe. Risk assessments included monitoring of existing and potential physical health risks. At Maister Lodge, all patients had a bespoke risk assessment.

Staff understood that the use of restraint was a last resort. They used de-escalation and low levels of restraint to manage incidents of aggression wherever possible. Staff ensured they documented episodes of seclusion, restraint, and rapid tranquilisation in accordance with trust policy. The ward took part in the trust restrictive interventions reduction programme and reported incidents of restraint appropriately.
Patients on Maister Lodge had detailed, personalised care plans, which included information about physical health needs. Patients felt involved in decisions about their care. Staff gathered information from families and carers to produce an ‘all about me’ record for patients with cognitive impairment. This reflected a patient’s history and preferences and contributed to their care plan.
There was effective multi-disciplinary team working with regular reviews of patients care and treatment needs. We saw an improvement in staff adherence to the Mental Health Act, with detention papers and associated records completed appropriately. Staff understood the application of the Mental Capacity Act. They recorded best interest decisions including when significant decisions were made for patients who lacked capacity.
Patients, families, and carers appreciated and spoke highly about the quality of care and treatment the service provided. Staff involved patients in decisions about their care where possible. They engaged with and supported families and carers where appropriate. Staff contacted families and carers with updates on patient progress, held regular carers meetings, and invited them to reception meetings.
The service accommodated patients in local beds rather than send them out of area. When Millview Lodge was full, they admitted patients to Maister Lodge until a bed became available. Staff worked towards home discharges for patients on Mill View, implementing the correct levels of support to make this possible.
Activities were available although the way staff offered activities varied between the two wards. At Millview Lodge, staff offered group activities, in which the current patient group did not always choose to participate. At Maister Lodge, activities were ad hoc and individualised. The ward was currently implementing plans to improve the provision of activities for their patient group.
Internal changes within the service had led to a positive change in culture. Staff focused on the needs of the people using their service, providing high quality patient centred care, which reflected the trust’s vision and values. Senior managers were committed to improving the environment at Maister Lodge and promoting best practice in dementia care.

However:

The service could not always fill shifts. In particular, when increased staffing levels were required to meet changes in patient presentation. They relied on bank and agency staff and their own staff to fill shifts on a regular basis. This meant staff prioritised patient safety over individual staff clinical supervision and mandatory training needs.
The trust had redecorated Maister Lodge and replaced broken furniture nevertheless the ward required a major refurbishment to make it appropriate to the needs of the patient group. Refurbishment plans had been in place since the previous inspections in 2016. The ward expected these plans to go ahead in October 2017.
Both wards experienced delays in discharging patients. This was due to the lack of availability of suitable placements followed by delays in securing funding packages for patients.
Systems and processes for reporting supervision were not robust. The system relied on staff remembering to sign the team’s supervision chart. Ward managers completed a survey with information from the chart but received no feedback.

Our rating of this service went down. We rated it as requires improvement because:

The interview rooms used by the service were not properly maintained and were in poor condition. Chairs in the place of safety were soiled and required cleaning.
The service had not ensured that all staff had received training in adult and paediatric basic and immediate life support. Staff did not receive training in managing violence and aggression. Staff training compliance rates for five mandatory training elements and appraisal rates for staff fell below the trust targets.
None of the staff working in the service knew what a Freedom to Speak Up Guardian was or who performed this role. Two staff told us that they would be reluctant to raise concerns due to fear of retribution.
The service had not undertaken or participated in clinical audits to assess the performance of the service.
The service had escalated the high number of vacant posts to the trust risk register. Despite, the use of bank and agency staff, in six months a further 471 shifts were not filled.
Staff had difficulty accessing information quickly when needed because the electronic patient record system was used inconsistently. The trust policy meant that staff would have difficult in accessing medication for patients out of hours.
We received variable feedback from patients using the Rapid Response Service and their carers. The service had limited engagement when making changes to the service and seeking feedback on the service with patients and carers.
Patients using the place of safety were required to inform staff if they did not want their nearest relative to be provided with a copy of the information leaflet explaining their detention under the Mental Health Act.

However:

The trust had refurbished the health based place of safety at Miranda House. Mental health assessments took place promptly and the average length of stay was less than 5 hours. The place of safety had a robust policy and information pack linked to national guidance.
The Rapid Response service had a clear access and comprehensive criteria and process for the crisis, urgent and non-urgent mental health assessments of patients.
Staff completed comprehensive mental health assessments for all patients. They agreed an immediate plan of care to meet assessed needs with patients.
Managers ensured that staff received feedback from the investigations including lessons learnt, changes to practice and good practice identified.
Staff monitored the physical health of patients in the place of safety to check for acute physical health warning signs. Staff providing mental health crisis services ensured that patients’ physical health was monitored.
Staff understood their roles and responsibilities under the Mental Health Act and the Mental Capacity Act.
Observation of interactions between staff and patients showed staff treated patients with respect, compassion and acted in a supportive way.
Staff had been invited to be involved and included in changes to the service. They had also taken part in development days which had resulted in the introduction of a service development and improvement plan.
Staff had the opportunities for leadership development. Managers up to service manager levels were visible in the service and all staff felt they were approachable.

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

The trust had acted upon our feedback from our previous inspection of this service and there had been improvements in the quality of patient care.
Safety was high priority for staff and the leadership team. There were measures in place to ensure the safety and quality of the service was monitored and that any changes required were acted upon in a timely manner. Patient risk was closely monitored and risk assessments updated on a regular basis. Staff protected patients by reporting incidents and raising safeguarding concerns.
Patients received effective care and treatment. Staff were trained in the Mental Health Act and Mental Capacity Act and worked to their principles. Care plans were holistic and highly personalised and contained the voice of the patient. Patient needs and wishes were clear, and all patients had a clear discharge plan.
The staff team were passionate about ensuring patients had a voice and were involved in the service. We observed staff who were kind, caring, respectful and compassionate. Staff made efforts to communicate with patients in complex circumstances and provided high quality individualised care for all patients. Patients and carers spoke highly of the service and the staff team.
The service was responsive to the needs to patients. The service was tailored to ensure each patient was treated as an individual and services were delivered according to patients’ individual needs and choices. The staff team were significantly focussed on patient discharge and had found innovative ways to ensure patients could be safely discharged from hospital settings and enabled to live fulfilling lives in the community. The service ensured that patients were able to maintain close relationships with people who were important to them.
The service was well-led. The staff team spoke highly of senior leaders and told us that they felt respected and valued. Governance systems in place ensured the safety of staff and patients. The service was focussed on continuous improvement and encouraged staff to take part in research and specialist training opportunities to enhance their skills and increase the quality of patient care. Staff spoke of a culture which was open, honest and supported them in their role.

However:

The service continued to have difficulties with meeting optimum safe staffing establishment levels.
Although the overall mandatory training rate for the service was 76%, not all staff had completed all of the required areas of mandatory training. Where the service was reliant on temporary staff, the trust did not ensure that these staff were trained to the same level of permanent staff to ensure the safety of patients.
Areas of the ward which contained ligature points were not entirely risk assessed.
The service allowed outpatients to use inpatient clinic rooms and this was not risk assessed or discussed with patients.
Staff did not always adhere to guidance in the Mental Health Act and Mental Capacity Act Codes of Practice. This meant that seclusion and long term segregation reviews were not always completed on time, and that one patient did not have a best interests meeting for a restrictive care plan.
Some areas of the units required re-decoration and were not entirely clean.

The ward relied on bank and agency staff and staffing levels were often below the required establishment. Mandatory training rates for basic life support was low and the rotas did not identify how many staff on each shift had completed life support training. Staff did not always document that they carried out checks on resuscitation equipment.
Staff did not document up to date patient risk assessments and safety plans or share information about risks consistently at their daily handovers

Our rating of the trust improved. We rated it as good because:

We rated effective, caring, responsive and well-led as good. We rated safe as requires improvement. Our rating for the trust took into account the previous ratings of services not inspected this time.

By applying the strict aggregation principles to the responsive key question the trust would be

rated as requires improvement in responsive and requires improvement overall. However, we

have decided to deviate from the aggregation rules because:

All responsive ratings in community health services, primary medical services and adult social care were good at the time of this inspection.

Of the seven mental health core services and substance misuse service that we reinspected the rating for responsive has improved, one of those to outstanding.

All of the requires improvement in responsive are linked to services that we did not reinspect, we have checked our intelligence on issues that caused our services to be rated requires improvement in responsive and identified that there had been improvement in two of these three areas.

We inspected four out of the five GP practices which the trust had acquired in the last 12 months, all four of these were rated good in all key questions.

The adult social care location at Granville Court remains rated as good.

Since our comprehensive inspection in 2016 the trust had lost two community health services due to a retendering process in early 2017. Due to the reduction in number of community health services if we now aggregated the ratings from the three core services within community health services it would be rated as requires improvement despite the community health adult core service which we inspected not changing in rating since April 2016, the responsive domain in this core service also improved. The rating for the community health services therefore remains as good and deviated from the aggregation principles.

Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.

We rated well-led at the trust level as good.

We found the following areas the trust needs to improve:

The multi-disciplinary team did not always carry out reviews for patients in seclusion within the times specified in the Mental Health Act code of practice.
Not all qualified staff were trained to provide immediate life support.
Oxygen and a defibrillator located on Derwent ward was shared with Ouse ward. There was no risk assessment of the impact sharing this equipment could have on patients in an emergency.

However we found the following areas of good practice:

The service had complied with several of the regulatory breaches identified in the warning notice.
There were adequate stocks of emergency medicines on all wards. All medicines and equipment were within the expiration date and fit for use. Staff knew where emergency medicines and equipment were located.
Staff carried out physical health monitoring following the use of rapid tranquilisation in line with trust guidance.
Patient entering seclusion had individualised seclusion care records and exit plans. Staff recorded the justification for the use of seclusion.
The service had decommissioned those seclusion rooms not fit for purpose.
The trust had introduced a new policy, which ensured that patients’ rights were protected and they were being treated in line with guidance. Staff were aware of new policies and acted in accordance with them.

Following this inspection, the CQC withdrew the warning notice and issued the trust with a requirement notice to address the outstanding issues identified.

We found the following areas the trust needs to improve:

Staff did not always carry out physical health monitoring following the use of rapid tranquilisation in line with trust guidance.
Not all qualified staff on Westlands ward were trained to provide immediate life support

On Newbridges ward, seclusion exit plans contained a blanket restriction. Patients were required to have a fixed period of settled behavior, which meant seclusion did not end at the earliest opportunity.

Clinicians did not always carry out the necessary reviews for those patients in seclusion within the timeframes specified by the trust policy.

However, we found the following areas of good practice:

The service had complied with some of the regulatory breaches identified in the warning notice.
There were adequate stocks of emergency medicines on all wards. All medicines and equipment were within the expiration date and fit for use. Staff knew where emergency medicines and equipment were located.
Patients entering seclusion had individualised seclusion care records and exit plans. Staff recorded the justification for the use of seclusion.
The service had decommissioned those seclusion rooms not fit for purpose.
Staff observed infection control principles when patients used the seclusion facilities.

Following this inspection, the CQC withdrew the warning notice and issued the trust with a requirement notice to address the outstanding issues identified.

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

patients had risk assessments in place which were reviewed regularly. Risk management was practised in daily and weekly multi-disciplinary meetings
there were good safeguarding practices in place. Staff knew how to identify abuse and raise concerns
there were lone worker protocols in place that staff understood and adhered to
staff received regular supervision and appraisal and felt supported in their role
staff assessed the physical health of patients at the initial contact and managed physical healthcare in collaboration with the patient’s GP. Shared care protocols were in place to support this
care was being delivered in line with the Mental Health Act and Mental Capacity Act
care was delivered in partnership with patients and carers. Patients and carers were involved in decisions about care and treatment. Care plans were personalised and holistic
feedback from patients and carers was positive. They described a good service with caring and skilled staff
standard operational procedures were in place to manage waiting lists. Waiting list initiative teams were being used to reduce waiting times and numbers

there were processes in place to prioritise referrals and respond to urgent referrals. Urgent referrals could be seen within either four or 48 hours
a range of information was available for patients and carers. This included information on diagnosis and available services and support.

However:

there were waiting lists in place for some teams. There were two teams with waiting times of 40 days and one team with a waiting time of 66 days.
not all teams were compliant with mandatory training
not all staff had received training on the Mental Health Act and Mental Capacity Act
there was no routine monitoring of performance for the single point of access service. However we were being told this was being considered as part of the service review
not all staff felt engaged in the service transformation programme. This meant that there was a level of uncertainty about the future and how services would work.

We rated Humber NHS Foundation trust specialist community mental health services for children and young people good because:

Patients and their parents/carers told us that staff provided positive support. Patients were visited at home as well as the local children and adolescence mental health services office. Parents/carers told us that staff had always treated them and their child with dignity and respect.

Patients felt safe within the service. Staff had a thorough understanding of the safeguarding procedures and were confident in making safeguarding referrals. Information was available for patients and their parents/carers on how to complain. The trust responded promptly when someone made a complaint.

Patients told us that staff included them in their care plan and kept their parent/carers informed. Patients were encouraged to become involved in a patient participation group and for those interested, patients were involved in the recruitment of staff.

To ensure patients had the best support possible, staff worked with other agencies to ensure they understood the condition the patient had been diagnosed as having. Staff assessed patients to determine whether they had a sufficient level of understanding to make decisions.

Staff had started a group for parents/carers of patients who had attention deficit hyperactivity disorder; feedback from the group was positive and they found it supportive. Hull children and adolescence mental health services were able to refer patients with a low mood or anxiety to a service with MIND. Patients found this to be a valuable service to them.

Staff had recognised and highlighted with their managers that the waiting time for assessments was unmanageable. In response to these concerns, extra funding was provided to ensure the backlog of referrals could be cleared and they were able to meet their 18 weeks target for assessment. A crisis team had been established to ensure children and adolescence mental health services were available 24/7.

Staff were committed to providing a good service even when they were struggling to meet deadlines for work. They understood the values of the trust and patient care was at the centre of their work.

Staff told us their managers were supportive and understood the pressures they were under.

Learning was shared throughout the organisation.

A member of staff had set up a peer support group for patients with attention deficit hyperactivity disorder and had received national recognition for the group.

However:

Patients were waiting up to 37 weeks for treatment from the date of their referral.

Not all the care plans were saw contained evidence that the patient had received a copy of their care plan.

Not all care plans had information about a patients capacity to make decisions.

Staff were not receiving supervision in line with the trusts policy.

Staff did not have access to personal alarms when having a one-to-one session with patients.

Letters sent to patients from the East Riding team informing them about a wait for services, did not contain any information about other services they might be able to access whilst they were waiting for an assessment or treatment.

We rated Humber NHS Foundation Trust’s wards for older people as requires improvement because:

The recording of medicines at Maister Lodge required improvement.
There continued to be higher use of agency staff at Maister Lodge and issues with the deployment of experienced staff /more senior clinical staff being limited especially at evenings and weekends and despite escalation these had not been addressed.
Systems were not fully in place to ensure all incidents of restraint were recorded appropriately.
Ward staff and operational managers had highlighted that staffing levels on Maister Lodge required review particularly at nights and weekends. The trust produced a plan to deal with staffing levels in June 2015. These actions were still being addressed.
The ward based audits did not pick up on issues we found on inspection such as medicines management issues.
Whilst there were plans to develop the environment of Maister Lodge, these plans had been in place for some time and, in the meantime, the quality of the environment had deteriorated.

However

Each ward provided safe environments to care for patients. There were good patients’ risk assessments in place so the risks were well managed. Patients’ physical health was monitored. Each ward was meeting same sex guidance. Patients told us that they felt safe. There was evidence of lessons learnt.
Staff wrote care plans that were of good quality; including those for people with dementia. There was effective multi-disciplinary working with daily care reviews taking place. Staff were adhering Mental Health Act. Best interest decisions were well recorded where decisions were made about incapacitated patients.
Patients were complimentary about the care they received. Patients were actively involved in their care and had access to advocacy input. Where patients could not be involved due to cognitive impairment, records showed that families were involved.
Patients could access a bed in their locality and staff were working towards helping patients on Mill View Lodge to be discharged home with the correct support. Patients’ individual needs were met. Patients had access to a range of activities. Complaints were well managed.
There were plans to improve the environment of Maister Lodge and dementia care across the trust. Teams had their own objectives. Internal changes within the trust were helping ward staff to have better links with allied health professionals involved in the care of older people.

We rated The Humber Centre forensic and secure inpatient wards as inadequate because:

Staff had limited understanding of the use of seclusion. Staff did not always use seclusion in line with the provider’s policy or the Mental Health Act code of practice. When we reviewed the seclusion records, we found that that they were not in line with hospital policy.
Emergency medicines were not available on all wards as per the provider’s policy. Staff did not fully complete medication administration records, including for some critical medicines.
Staff did not understand their roles and responsibilities and withheld patients’ incoming mail. There is no power for a medium secure hospital to withhold patients’ mail. This is not in line with the Mental Health Act code of practice.
The environment on some of the wards was in a poor state of repair. The resources needed to maintain the hospital properly were not in place. Furnishings were ripped in places, floors contained trip hazards and paint was flaking off the walls. The fixtures in some of the shower rooms were rusting, there was no ventilation and they had a musty odour. The outdoor courtyard on one ward was covered in moss and littered with cigarette butts.
Staff did not receive regular supervision in line with the provider’s policy. The trust target for staff completing their mandatory training was 75%. However, only 45% of staff had completed this at the time of the inspection. Training in the Mental Health Act was not mandatory and staff had not received training in the revised Mental Health Act code of practice.
Staffing levels did not always meet the minimum requirements to keep people safe. Staff shortages were not responded to adequately. On occasions, staff cancelled patients’ home leave and healthcare appointments due to insufficient staff on duty. One patient had been waiting at least six months to receive treatment recommended by the responsible clinician.
Mental Health Act documentation was not always complete or in order. Managers had not put good systems in place to ensure staff complied with the Mental Health Act. Staff did not regularly review and update patients’ risk assessment on all wards. Care programme approach reviews did not always happen within identified timeframes.
The management team did not monitor systems and processes to ensure patients received effective care and treatment. Not all staff understood their responsibilities under the duty of candour.

However:

Staff treated patients with dignity and respect. Staff understood the needs of the patients and involved them in the planning of their care. Each ward held regular patient meetings. Staff involved carers in patients’ reviews and held carers meetings. Carers spoke positively of the care provided by the staff.
Staff morale was good and staff felt supported by their immediate managers. Staff spoke of a supportive multi-disciplinary team and handovers were effective. The ward managers organised team days to involve staff in the development of the service.
Staff measured risk using recognised tools and used the supportive engagement policy to manage individual patient’s risk. Staff received a security induction based on the recognised principles of ‘See, Think, Act.’ Staff regularly undertook environmental risk assessments.

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

There were a number of staffing vacancies, and sickness rates among the teams were high, which put additional pressure on the workloads of other staff. Staff work-related stress assessments highlighted concerns about staff workloads.
Team managers were not using caseload weighting tools. This meant there was no tool to measure the workload and weight of each care co-ordinator’s caseload.
Large waiting lists were not consistently managed. The average number of days a patient waited between assessment and treatment in each team varied from 21 days to 204 days. This meant that all six teams were above the trust target of 14 days.
The number of staff who had completed mandatory training was below the trust target of 75 to 80% in most areas. The lowest team compliance was 22% and the highest team compliance was 48%.
Senior managers were not visible within the teams and staff told us that they did not receive feedback regarding concerns they raised. Staff in the Hull area did not feel involved in changes taking place in the area’s services.
Key performance indicator reports were not reflective of the performance monitored at team level. The reports were not always reflective of the team’s current position and did not always include data from social care staff. This meant that the teams did not always find the reports to be a helpful tool in improving performance.
There were delays in transferring care records between services. This meant a patient’s previous medical history was not always available to staff.

Clinical audits were not taking place as the trust was reviewing these. Clinical audits check the effectiveness of patient care.

However:

Patients had care plans and risk assessments that were person centred and met their needs. Staff worked closely with GPs to monitor the physical health care of patients, to ensure physical health care was prioritised.
The provider had safeguarding policies and procedures and staff could identify what abuse looked like and acted on this accordingly. Staff reported all incidents through their electronic incident reporting system.

Psychological therapies were offered in line with the National Institute of Health and Care Excellence guidelines. A full range of multidisciplinary professionals worked effectively together within the teams.
Staff followed the Mental Health Act Code of Practice and understood the principles of the Mental Capacity Act.
Patients and carers spoke positively about the care and treatment received in all of the services.
The community teams all had adequate facilities to see patients, and could access interpreters and information in different languages where there was a need.

We rated acute and psychiatric intensive care wards as requires improvement because:

All wards had ligature points. These were detailed on ligature audits. However, clear actions to mitigate against risk of ligature were not documented. Funding bids had been submitted to resolve some of the ligature risks, but not all of these had been approved.
The trust’s policy on rapid tranquilisation was out of date. Staff did not have a clear understanding of what constituted rapid tranquilisation. Rapid tranquilisation was being undertaken without the appropriate observations being carried out in line with trust policy and national guidance.
The full range of emergency medicines were not available in line with trust policy. This included medicines, which may need to be administered following rapid tranquilisation. There were out of date medications and oxygen on some of the wards.
The use of seclusion did not always follow the principles of the Mental Health Act Code of Practice. Patients did not have seclusion exit plans and seclusion was not always ended appropriately.
Staffing levels meant that patients could not always have sufficient one to one time with staff. There was a high reliance on bank and agency staff to meet staffing shortfalls. Staff did not always receive regular management and clinical supervision in line with trust policy. Training in the Mental Health Act was not mandatory and compliance with Mental Capacity Act training was low.
There was a lack of leadership from senior managers in the trust, leaving staff feeling unsupported. There was limited evidence of clinical audit being carried out. Learning from incidents and complaints was not robust and did not inform service delivery.
Blanket restrictions were in place regarding the searching of patients bags on return from leave.
Same sex guidance was not always adhered to.

However:

Most of the ward environments, including clinic areas, were clean and well maintained.
Staff treated patients with dignity and respect. Staff had an understanding of the needs of patients. Patient meetings were held regularly on the wards. Patients spoke positively about staff, although felt there were not always enough staff on the wards.
Staff felt very well supported by managers on the wards. There was a good range of professionals working within multi-disciplinary teams on all the wards.
Mental Health Act documentation for detained patients was in good order. Staff regularly read patients their rights under the Mental Health Act. All detained patients received an automatic referral to an independent mental health advocate.

We rated Community mental health service for people with learning disabilities as good because:

Staff regularly risk assessed patients whilst on the waiting list across all services. Staff weighted caseloads to ensure caseloads were not excessive. Incidents were discussed during team meetings and appropriate debriefs took place with both staff and people who used the service. Facilities at Townend Court and Four Winds were safe and suitable to use for their intended purpose.
Staff took the Mental Capacity Act into account at all services. The speech and language therapy team had devised a script to aid communication and ensure that staff gave people every opportunity to participate in capacity assessments. Patient assessments took place within 6 weeks of initial referral and prior to patients being added to the waiting list. Staff across all the services followed the National Institute of Health and Care Excellence guidance, which included recent transitions guidance. Staff had regular supervisions and appraisals were up to date. Specialist training was available and staff were keen to continue their development. Multi-disciplinary team meetings were effective across all services and decisions made were evident in people’s care files.
Patients and their family members reported they received an excellent service. Staff treated patients with dignity, respect and were supported by staff who understood their needs. Patients were involved with their care and staff used innovative methods to enable people to engage with their care.
Staff made contact with patients whilst on the waiting list and staff managed the list well. Staff prioritised urgent referrals. Information was available in various formats, interpreters were used and some staff were trained in British sign language. Team meeting minutes had a British sign language ‘sign of the week. Staff helped patients to complete patient passports and health check documents, which assisted patients when visiting or being admitted to hospital. There was a policy in place to manage complaints. Patients and their families knew how to complain.

Staff spoke highly of the local management including the care group director. Managers investigated incidents and where appropriate they made to procedures. Staff understood the trust visions and values and these were integral to the way they worked. The service had introduced iPads to assist patients to be involved in their care and care planning.

However:

Waiting lists were unacceptable with the longest wait being 94 weeks
The environment at the children’s community team for learning disabilities Victoria House was not appropriate. The building was in need of redecoration and repair. Interview rooms contained out of use equipment. Not all areas were clean. There were no fixed or portable alarms available for staff. Staff had not made a safeguarding referral for an incident witnessed at Hull community team for learning disability.
There were staff vacancies at Hull and Four Winds community team for learning disability which impacted on the length of time patients had to wait for an allocated worker.
Staff said the use of both System One and Lorenzo was difficult to manage, information on Lorenzo was not always updated. Staff working at Four Winds reported difficulties in ensuring records were updated on the day of the patient visit.
Whilst generally managers had sufficient authority to carry out their roles, they reported delays of up to four months in recruiting staff to vacancies which was as a result of the recruitment process. Some staff members reported incidents of bullying, which they felt managers had not adequately dealt with until recently.

we rated Humber NHS Foundation Trust as requires improvement because:

The pharmacist inspector found that the emergency drugs pack at St Andrew’s Place did not contain several emergency drugs. This issue has been dealt with through a warning notice issued to the trust 17 May 2016.

Patients care plans were of variable quality and did not include details of nursing interventions or care required.

Patients did not attend their recovery meetings in person. Some patients did not feel as involved in their care as they would like to be. The psychiatrist worked part time, which meant that there was limited medical cover.

Staff at St Andrew’s Place did not check fridge temperatures every day as per the trust policy and national guidance.

The trust admitted patients to the units with no clinical rationale or particular identified rehabilitation/recovery need when their acute wards were full.

However:

Staff used the trust’s supportive engagement policy to manage patients’ observation levels. This meant they engaged patients in a conversation enhancing the therapeutic relationship rather than just routinely noting their whereabouts.

Staff at both units were up to date with their personal appraisal and development reviews and received supervision in line with the trust’s compliance target. This meant that ward managers were able to support their staff’s professional development and monitor standards of care and treatment.

Patients were encouraged to take ownership of their physical health needs wherever possible. We saw evidence of self-completed health improvement profiles in patients’ records.

The service had introduced protected engagement time during the daily overlap between shifts. Staff used this time to actively engage with patients, facilitate their leave and encourage activities.

Staff treated patients with kindness and respect. Interactions between staff and patients were warm and supportive. During the morning meetings, staff were attentive and flexible to patients’ needs.

The service was piloting an outreach service aimed at supporting patients for six weeks following discharge. This helped patients make their transition from the ward to the community successfully and identified when further input was need.

The service provided meaningful activities and therapies that aided a patient’s rehabilitation and recovery. Staff regularly sought patients’ views about the type of activities they wanted to participate in.

Both units benefitted from strong local leadership that had a positive impact on staff and patients.

We rated substance misuse services as requires improvement because:

Staff were not up to date mandatory training.
Staff did not update risk assessments and management plans following changes in a person’s circumstances or following a multi-disciplinary team review.
Patients did not have care plans that were up to date, holistic, personalised or recovery orientated.
Patients had limited involvement in the care plan.
There was limited evidence that staff used psychosocial interventions in treatment.
Staff did not fully assess patients’ physical health needs.
Treatment pathways were problematic for patients resulting in longer waiting times and higher unplanned exits from treatment.
The service was clinically focussed with a lack of encouragement for recovery.
Staff were unsure of the indicators the trust used to monitor their performance.

However:

Both staff and patients felt safe.
Staff promoted harm minimisation throughout a person’s treatment.
The service had recruited peer mentors to support new patients.
The multi-disciplinary team meetings discussed all patients in detail at least every 12 weeks.
The service supported people who used image and performance enhancing substances.
Morale was high in teams and there was a good partnership relationship between trust staff and ADS staff.

We rated mental health crisis services and health-based places of safety as good because;

The service had effective systems to assess, monitor, and manage risks to people who used services.
Staff supported people who used services with their recovery with care plans that focused on the person’s needs.
There was good multi-disciplinary and inter-agency working in the crisis teams and the health-based place of safety.
Staff provided kind and compassionate care and treated people who used services with dignity and respect.
Staff supported people who used services and their carers. Family members were involved in the person’s care where appropriate and according to the person’s wishes.
There was a clear pathway for people to access services including those people who referred themselves to the crisis teams.
There were a low number of complaints from people who used the crisis teams and health-based place of safety.
Staff were committed to providing good quality care in line with the trust’s vision and values.

However:
The health-based place of safety was not fit for purpose. There was a lack of provision to adequately maintain people’s privacy, dignity, and confidentiality. There were apparent risks, which meant that the health-based place of safety compromised the safety of people who were detained under Section 136 and staff.
There were gaps in staffing which meant appointments for people who used the crisis teams were sometimes cancelled or re-arranged. Assessments for people detained under Section 136 at the health-based place of safety were sometimes delayed.
Mandatory training and appraisal compliance was low overall across the crisis teams and health-based place of safety and did not meet the trust’s mandatory training targets.
The service used paper and electronic systems of care recording, which meant comprehensive information relating to people who used services was not easily accessible.
The systems to provide feedback to staff following incidents and audit activity in the crisis teams and health-based place of safety were not robust.

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

Staff did not always identify and assess known risks to the health, safety and welfare of patients and have plans in place to manage these. Where plans were in place, staff did not always review these in response to incidents. Potential environmental risks on some units had not been fully assessed and mitigated.
Staff did not always follow procedures in relation to possible safeguarding concerns involving patients. Staff had not referred some incidents that met the threshold to the safeguarding team. There was no rationale as to why not.
Staff did not always log all incidents that met the reporting criteria as set out in trust policy on the trust’s incident reporting system. There was inconsistency between incidents that were reported.
There was a lack of overall review at service level of interventions such as restraint and seclusion. Informal debriefs took place in response to incidents and staff reflected on what could be done differently in future.
There were shortfalls in some mandatory training compliance and the service had not met the trust target. The areas where fewest staff had undertaken training were the Mental Capacity Act training, safeguarding and equality and diversity.
There was no clear structure about what additional competencies and skills staff should have in order to support patients with learning disabilities and associated conditions. This included skills and training staff needed to support patients with their mental health.
Incidents were not being assessed and routinely monitored at management level. This was due to a backlog. Therefore, risks in relation to the service were not being effectively identified and acted upon. This had been an ongoing issue and there was no information as to how this was going to be addressed.
Care plans did not always reflect patients’ holistic needs. In most, it was not clear what treatment plan patients were working towards. There was a lack of clear objectives and goals for recovery and progress towards these. Multi-disciplinary working was not fully embedded as part of patients’ treatment and recovery although this was gradually improving.
Staff used several separate systems to record patient information which meant there was a risk of important information being overlooked.

However:

Patients and carers spoke highly of the staff and said they were treated with kindness and respect. They said they felt safe, were able to have one to one time with staff and would speak out about any worries or concerns they had.
Staff involved patients in contributing to their own care plans and carers told us they were involved in these. The units were calm and staff were good at reassuring patients and managing behaviour.
Staffing had recently improved at the service. Patients were able to have escorted leave and activities as planned. Patients received support with their physical health.
There were systems in place in relation to admission and discharge planning. The service was proactive in working with other organisations.
Staff undertook ward based learning and had regular meetings. There had been previous shortfalls in staff receiving supervisions and appraisals but this had improved.
Senior managers had a clear vision for the future of the service. Staff said managers were very approachable and that the team was supportive.

Overall rating for this core service Good

We rated the community urgent care services as good because:

Patients were assessed on presentation to Minor Injury Units (MIUs) using recognised assessment tools. Staff carried out risk assessments in order to identify patients at risk of harm.

Care pathways and care plans were in place for those patients identified to be at high risk, to ensure they received the right level of care through the care pathways. Assessments were undertaken at presentation to MIUs and discharge and evaluation completed on the clinical effectiveness and support provided during treatment.

Risk assessments, treatment plans and test results were completed at appropriate times during a patient’s care and treatment and we saw these were available to staff enabling effective care and treatment. There were appropriate and effective systems in place to ensure patient information was co-ordinated between systems and accessible to staff.

MIUs were accessible for wheelchair users and had systems in place for people with hearing and visual impairment. We saw appropriate equipment to ensure effective care was available. Risks to the safety and welfare of patients were identified and managed.

Discharge and referral pathways and effective multidisciplinary working practices were in place across MIUs.

The trust had formal nurse staffing review processes in place and had a staffing establishment based upon agreed methodology.

Patients were positive about the care they had received and we observed care being provided in a compassionate way. Throughout our inspection we observed that patients were treated with compassion, dignity and respect. Support was available to meet the needs of different people, for example patients living with a dementia and learning disabilities.

Senior managers had a clear vision and strategy for MIUs. The vision and strategy had been communicated to all staff. The trust had a commitment to a people centred approach.

Clinical governance meetings were held and this process had identified a significant risk of workforce gaps in the minor injury units and a reduction in staff compliance with mandatory fire training.

Leadership of the service was good, there was good staff morale and staff felt supported. Staff meetings identified good practice and were held regularly and during the inspection it was clear that there was a culture that supported improvement.

However:

The nurse vacancy rate within community health services in urgent care was 16% and the sickness rate was 8%. Staff were working extra shifts and agency staff were employed to cover these and ensure continuity of the service. Workforce gaps in the minor injury units had been identified by the trust as a risk and shifts were covered by a reliance on internal bank and agency staff.
Mandatory training compliance for community health services in urgent care was 51% and not meeting trust compliance targets. In particular, Mental Capacity Act training had the lowest completion rate of 39% and a reduction in staff compliance with mandatory fire training had been identified as a risk.

Overall rating for this core service: Good

Overall, we rated community end of life care as good. This was because:

People were protected from avoidable harm and abuse. Although there were very few incidents reported, staff understood and fulfilled their responsibilities to raise concerns and report incidents. We found that learning from incidents was shared across teams and staff we spoke with were aware of the duty of candour.
We found that staff we spoke with were aware of their responsibilities and took a proactive approach to safeguarding. Mandatory training was above the trust target overall, although there was low levels of compliance in some core subjects.
We found that medication processes used by all teams kept patients safe. Access to equipment in people’s homes was good and the trust had systems to ensure timely delivery. Patient care records were mostly completed to a high standard. Staff adhered to infection prevention and control guidelines and the trust had robust systems in place for managing risks including major incident planning.
We rated effective as good because people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Patients were receiving advice about pain relief, nutrition and hydration.
There was participation in relevant local, national and some international audits. The gold service framework was embedded across the locality. Staff were highly qualified, received timely appraisals, clinical supervision and were supported with further professional development. There was evidence of multi-disciplinary working across all teams. Consent to care and treatment was obtained in line with legislation and guidance, including the mental capacity act 2005.
We rated caring as good because feedback we received from patients and those close to them was consistently positive about the way staff treated them and we observed consistently sensitive, caring and compassionate staff.
Staff were highly motivated and inspired to offer care that was kind, promoted people’s dignity, and involved them in planning their care. We saw staff providing detailed explanations of procedures and thorough assessment of all needs and reassurance. Patients were supported emotionally. All staff were very responsive to the psychological needs, of not only patients but also those close to them.
We rated responsive as good because services were planned and delivered in a way that met the needs of the local population. We saw that staff respected the equality and diversity of patients and their families. The needs of vulnerable people were taken into account when planning and delivering services and team worked collaboratively to provide this. Patients were able to access services in a responsive and timely way. In addition to this, there were no complaints about patients receiving end of life care.
We found that services were well led because the teams providing end of life care had a clear strategy, vision and values, driven by quality and safety. Senior staff were visible and supportive to staff and patients. All staff we spoke with said that senior staff were very approachable. Leaders were actively engaged with staff, people who used services and their representatives and stakeholders.
We witnessed the culture within teams as being team focused and positive. All staff we spoke with told us that they worked as part of a team and felt supported within their service. We saw good examples of positive staff and patient engagement.
We saw numerous examples of innovation that the teams had been involved in. There was a strong focus on continuous learning and improvement at all staff levels. New care group structures had recently been introduced. Plans to ensure that governance processes were embedded were being introduced by senior staff in the service.

However, we also found that:

Some policies were out of date.
Some teams in community hospitals were not using the appropriate care pathway ‘caring for me advanced care plan’ for end of life patients.
Low numbers of staff had attended mental capacity act training.
Not all risks were identified on the care group or corporate risk register, for example out of date policies. Some identified risks had no evidence of mitigation to reduce the risk despite being on the register for many months.

Overall rating for this core service: Good

We rated community inpatient services as good because:

Patients were positive about the care they received. We saw staff being respectful towards patients, and making sure that they were treated with dignity. Patients were involved in decisions about their care where possible.

There was evidence to show that staff recorded and reported incidents, and completed risk assessment and risk management plans. Staff were familiar with the systems in place to report incidents that may affect the safety, health and welfare of patients and with the reporting system. Regular meetings to discuss lessons learned from incidents took place.

Patient risks were assessed and plans developed to reduce them. Patients with individual needs were given the support they required. In addition, members of staff were identified as leads in learning disabilities and dementia.

Staff were trained in safeguarding and mental capacity procedures, and were able to apply and discuss these appropriately.

Complaints were handled in line with the trust’s policy.

Information was displayed information about the trust’s vision and values and staff demonstrated they understood and put these in to practice.

Services at Whitby Hospital had recently transferred to the trust (April 2016) and staff told us they had been communicated to well and kept informed of developments affecting the service. Performance information for this ward was not yet available through the trust.

There were temporary arrangements in place at Withernsea Community Hospital to provide medical cover for the ward and the trust had advertised a tender to contract medical cover for the ward.

However, although wards worked well together as a multidisciplinary team, there was limited access to therapy support at Withernsea Community Hospital. This affected the discharge of some patients.

There were also problems with accessing medicines through the local pharmacy services out of hours.

Overall rating for this core service: Good

Overall, we rated the service as good because:

Throughout the inspection, we observed staff delivering care to children and their families in clinic settings and in their own homes. We saw staff treat children and families with dignity and respect at all times. They were sensitive to the children’s needs, demonstrating kindness and compassion. We observed good relationships between the staff and patients and their carers.

The service reported incidents and there were examples of changes in practice as a result of lessons learnt from incidents, for example, immunisation practices. There was shared learning as a result of serious case reviews.

Staff received appropriate safeguarding training and had access to regular safeguarding supervision as required by national guidelines. Staff also undertook clinical supervision and received statutory and mandatory training. There were opportunities to access additional training to support their work with children.

The service used an electronic record keeping system. This provided staff with up to date information about children, including safeguarding concerns. It allowed staff to share information with other practitioners in a timely way. The electronic system for patient records also allowed the service to monitor commissioned targets and patient outcomes.

Children’s services used a range of evidence based systems and risk assessments to deliver appropriate care and promote patient outcomes. Staff had additional training opportunities. The service had implemented electronic record keeping in all areas, other than speech and language and occupational therapy, where it was being rolled out. This provided staff with up to date information about children, including safeguarding concerns. It allowed staff to share information with other practitioners in a timely way. The electronic system for patient records allowed the service to monitor targets and for teams to take action when commissioned targets and patient outcomes were not being met.

There was integrated care between other agencies and services were planned to meet the needs of children and families.

However:

There was a lack of staff and public engagement. This was a breach of regulations in the previous inspection and, although some improvement had been made, it continued to be a breach.

Services did not have a programme of auditing to measure and improve the quality of care. Children were waiting over 18 weeks for speech and language therapy services. Action plans were in place to reduce the waiting lists.
The trust had a children’s strategy, but staff were not aware of this and the trusts future vision of 0-19 services. There was limited engagement with identifying risks and reporting incidents by all the staff groups. Staff across the services were not clear about governance arrangements. There was a disconnect between the trust overview of training figures and the training figures recorded at team level.

Overall rating for this core service: Requires Improvement

We rated services for community adults as requires improvement, because;

Staffing levels were below established levels throughout many parts of the service.
Mandatory training compliance was below the trust target levels.
Safeguarding training compliance was below the trust target levels.
We found inconsistent practice across teams with regard to record keeping.
Some Neighbourhood Care Teams did not have access to basic equipment.
There was no organised clinical audit plan for the service and a lack of audit activity.
Compliance with Mental Capacity Act training was below trust target levels.
Mental health records were stored on a separate computer system and community staff told us that this could cause problems in providing care to some patients.
Some services, such as speech and language therapy and pulmonary rehabilitation, had lengthy waiting times in excess of 18 weeks.
Neighbourhood Care Teams were not meeting performance targets for triage.
We saw a lack of evidence to show that learning from complaints was shared across the service.
Some services did not have a service specification in place.
Staff told us that they did not always feel part of the wider trust or that there was an awareness in senior leaders of the role of community services.
Staff told us that they did not feel valued or supported by senior staff.
We did not see a consistent approach to delivering care between different Neighbourhood Care Teams.
There was a lack of public and staff engagement in the service.

However;

Medicines were appropriately managed and stored.
Staff were able to record and respond appropriately to patient risks.
The service performed better than the national average in providing harm free care.
We saw good examples of evidence based practice.
Staff had access to and underwent regular clinical supervision.
We saw good examples of MDT working and coordinated care pathways.
We saw good examples of audits of patient outcomes being monitored in therapy services.
Patients and families told us that they received compassionate care and that staff supported their emotional needs.
We saw evidence that patients and families were involved in care planning.
We observed staff providing compassionate and supportive care in home and in clinic settings.
We observed staff maintaining the privacy and dignity of patients when providing care.
Services were planned to meet the needs of the local population, such as the provision of out of hours district nursing.
Staff were able to account for the needs of people in vulnerable circumstances in delivering care.
Staff had access to interpretation services.
Staff valued the support and dedication of their immediate managers.
We saw good examples of innovative practice.
All staff we spoke to told us that there was a patient centred culture.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We rated Humber NHS Foundation Trust as requires improvement overall because:

The trust used restrictive interventions and practices in its mental health services in ways that did not comply with best practice or with the Mental Health Act 1983 and its code of practice. Staff did not have the proper safeguards in place when they subjected patients to seclusion or long-term segregation. Seclusion rooms and places of safety did not meet best practice guidelines.The trust policy on rapid tranquilisation was not up to date and staff did not always record its use or undertake the procedure safely. In particular, they did not always undertake the appropriate physical health checks.Staff restrained patients in a prone (face-down) position but did not always report it.Staff in forensic services still supervised all patients when they opened their mail - two years after being told that this was inappropriate.
The trust did not always assess risks to patients and take action to eliminate or reduce them. It did not have effective systems and processes to support learning from incidents of harm or risk of harm across the organisation and to prevent them happening again.
Staff vacancy rates were high in some services and a number of teams were operating below agreed staffing levels.This was a particular problem in mental health crisis services, the health-based places of safety, the five district nursing teams and seven community health services neighbourhood care teams.
The trust did not ensure that its staff undertook basic training or received support for personal development.Staff compliance with training that the trust had deemed mandatory was only 61%; well below the trust’s target of 75%. Fifty per-cent of staff had not received recent training in the Mental Capacity Act.The trust had kept a central record of how many staff had received recent training in the Mental Health Act but all of the training had not been recorded.The trust scored below the national average in the 2015 NHS staff survey on the number of staff reporting that they had been appraised in the last 12 months.
Senior managers had not updated or put into effect a number of important policies and procedures that should have ensured a consistent approach to providing safe, caring, effective and responsive services. Their approach was, at times, chaotic. The trust’s mechanism for assuring and improving the quality of care was not consistent at team, service and trust board levels. However, there was some good practice in teams in each service except acute admission wards.
Although the trust had made significant progress since our previous comprehensive inspection in addressing concerns about services for children, young people and families and in community health services, they had failed to make the same progress in mental health services.

However

The trust had a duty of candour policy dated December 2015. The policy guided staff understanding of the duty be open and honest with patients when things go wrong with care and treatment, giving them reasonable support, truthful information and a written apology. The trust was adhering to the principles of duty of candour.
The trust provided good checklists and forms to ensure that correct papers were available on the wards for each detention under the Mental Health Act. Detention papers showed that there had been appropriate medical and administrative scrutiny to ensure that where patients were detained under the Mental Health Act, each detention was supported by a full set of well-completed detention papers. The section 17 leave forms (covering arrangements for leave for patients detained under the Mental Health Act) were completed, with clear conditions.
Across all services we visited, we observed positive interaction between staff and patients. We saw that patients were treated with kindness, dignity and respect, and were supported. Staff were committed to their roles and compassionate about the patients they were caring for.

The provider needs to take significant steps to improve the quality of its services and we find that it is currently in breach of regulations. We served the trust with a warning notice, giving the trust until 14 June to produce an action plan describing how it would improve services. The trust produced the plan before the deadline.

The warning notice related to three main issues:

Arrangements for overseeing and improving the use of rapid tranquilisation were not effective and on occasion staff used rapid tranquilisation of patients inappropriately.

Seclusion and long-term segregation of patients was not in line with the Mental Health Act code of practice. Monitoring checks were not effective and the senior team and staff did not ensure that safe care was being provided to patients in seclusion.
In forensic services, staff supervised all patients when opening their mail rather than supervision being based on individual risk assessments. Arrangements for monitoring patients’ mail were inappropriate.

We will be working with the trust to assist them in improving the standards of care and treatment

The patient on Ullswater ward was admitted 23 months ago as an emergency placement, which was supposed to be for a period of three weeks, until a permanent future placement was ready for him.This placement subsequently became unavailable and he had remained in the seclusion room whilst alternatives were looked at.
On the day of our visit, the seclusion area on Ullswater had an acrid smell of urine and we could see by observing in the seclusion room that there was food splattered on the walls
The trust policy on seclusion was dated 2011 and was due for review in 2014. The current policy was out of date, as it did not take account of the requirements of the Code of Practice, which came into effect in April 2015.
We were unable to find any evidence that attempts to create a structured routine were being tried for the patient on Ullswater.
There was no care plan in place to address this patient’s personal care. There was no exit plan for termination of seclusion for the patient on Ullswater.
On Ullswater, the medical review documentation referred to “continue with plan”, but we were unable to find where the seclusion plan was recorded and staff were unable to source this for us.
Whilst we were told that the arrangements for reviewing the patient’s seclusion on Ullswater were agreed by the MDT, we were unable to locate where this was recorded. There was clear evidence available in the patient’s file that medical reviews were occurring once in every 24 hour period. However, we were unable to find evidence that the reviewing of this patient’s seclusion met the requirements of either seclusion or longer term segregation as outlined in the Code of Practice.
Staff told us that it was difficult to persuade the patient on Ullswater to take a shower and that he was currently refusing to do so. There was no care plan in place to address this patient’s personal care or physical cleaning of the environment.
Staff expressed concerns about the physical health of this patient because of the time he spent kneeling and the fact that he was kneeling in urine some of the time.
We reviewed the notes of the patient secluded on Ullswater ward. There was limited information available within the files about this patient’s likes, routines, and means of expression.
On Ullswater we were informed that the multi-disciplinary team (MDT) had agreed the frequency of medical and multi-disciplinary reviews, but we were unable to find where this had been documented. We were also unable to conclude that the reviewing of this patient’s seclusion met the requirements of either seclusion or longer-term segregation as outlined in the Code of Practice.
The trust did not have a longer-term segregation policy despite having two patients in seclusion one on Ullswater and one on Swale ward. who would meet this definition. Reviews of their ongoing need for seclusion were agreed by the MDT and did not appear to meet the procedural safeguard requirements of the Code of Practice for either seclusion or longer-term segregation.

However:

We undertook a further visit on the 10 December 2015.By that time, the provider had opened up a further seclusion room for the patient to allow him to be moved into a different room to facilitate deep cleaning of the rooms and to encourage him to use the shower.Care plans were in place for his management in seclusion and he had care plans for his activities, his personal hygiene, his environment, his physical health, his nutrition, his snacks, his communication, his routine, managing his violence and aggression, his activities and his family contact.Staff had begun to implement these care plans.
The physical layout of the seclusion rooms on Ullswater and Swale met the requirements for of paragraph 26.109 of the Code of Practice.
We were informed that the views of his carers were constantly sought, although we were unable to speak to them. That the independent mental health advocate (IMHA) was involved and included in all meetings to discuss this patient’s care and treatment

Humber NHS Foundation Trust Child and Adolescent Mental Health Services (CAMHS) provide specialist assessment and treatment services to children and young people up to the age of 18 years who are experiencing significant emotional or mental health difficulties. These services are community based and there are no inpatient services commissioned. Children and young people requiring an inpatient bed are referred out of area or in an emergency admitted to an adult ward. We found that the trust had not followed the required notification system to CQC when the latter had taken place.

The CAMHS services had recently undergone a period of review and transformation and were part way through the introduction of a new model when we inspected. The staff told us that as a result, some staff were unclear about their roles and what was expected of them and there was a lack of job descriptions. We found that the staff team were unsettled and wanted some processes and procedures to be clearer. Staff also said that they received inconsistent advice from managers and had not felt involved in the consultation about the changes.

There were long waiting lists and staff told us that they were struggling to cope with the increased demands for CAMHS services. Staff felt anxious about their workload and the growing waiting list to receive a service. We saw that the trust risk register reflected the capacity and demand issues relating to the service and an action plan was in place. However, the impact of heavy caseloads meant that that staff were not completing some processes, for example reporting incidents.

Children and young people, their families and carers told us that CAMHS services made a difference and often helped them learn how to manage their difficulties once they were allocated a worker. They told us that staff were respectful and caring and we saw that staff were committed to providing a good service and were motivated to provide safe and effective services for children and their families.

Staff undertook thorough risk assessments using a variety of assessment tools.

Staff on the community inpatient wards at East Riding and Withernsea Community Hospitals were dedicated to providing a high quality service to patients. This was reflected in the comments made by patients and their relatives.

We found that care on the wards at both hospitals was safe. There was evidence to show that staff recorded and reported incidents, and completed risk assessment and risk management plans. Patient risks were assessed and plans were developed to reduce them. In addition, there was a daily multidisciplinary review of patient risks and their progress, to make sure that planned care was still relevant and that patients were making suitable progress.

The trust had set up a dashboard to monitor the quality of care provided. It also provided clinical skills training for staff, as well as additional managerial support. There were temporary arrangements in place at Withernsea Community Hospital to provide medical cover for the ward. Interim arrangements were also in place at East Riding Community hospital. However, the trust had advertised a tender to contract permanent medical cover for the ward.

The care patients received was effective. We saw that regular audits were undertaken and that any issues identified were addressed or escalated. Staff completed assessments for all patients, if appropriate, and recorded the outcomes in their care records.

While both wards worked well together as a multidisciplinary team, there was limited access to therapy support, especially at Withernsea Community Hospital. This affected the discharge of some patients. There were also some problems with accessing medicines through the local pharmacy services.

Patients and their relatives were all positive about the care they or their relative received. We saw staff were respectful towards patients, and made sure that they were treated with dignity. Patients were involved in decisions about their care where possible, for example, taking part in the multidisciplinary team meetings. We also saw staff took families’ needs into consideration.

Patients with individual needs were given the support they required. In addition, members of staff were identified as leads, for example, in diabetes, learning disabilities and dementia. Staff were trained in safeguarding and mental capacity procedures, and were able to apply and discuss these appropriately. Discharge was discussed with patients on their admission. Staff updated patients if their discharge was going to be delayed, and the reasons for this. Any complaints were handled in line with the trust’s policy.

Both hospitals displayed information about the provider’s vision and values and staff demonstrated that they understood these. Staff were aware of the structure of the organisation and said that they were supported by their matrons, senior staff and, at East Riding Community Hospital, the service manager. Both of the wards had risk registers, however the completion of the register at Withernsea Community Hospital was inconsistent.

An electronic incident reporting system was in place, however staff’s understanding and reporting of incidents was inconsistent across the teams. We were not assured that all incidents were reported appropriately.

We found hygiene and cleanliness, the environment and equipment were well managed.

There were three systems used to record patient information. There was duplication and a risk of transcription errors. We found that in records reviewed, information had not been fully transcribed and found transcription errors in some records.

Staffing and caseloads varied across the teams. There was no robust, embedded system to determine appropriate staffing and caseload size, particularly for community nurses.

Staff had access to evidence-based guidance and we saw this was followed in practice.

There was limited participation in clinical audit. The trust’s clinical annual audit plan for 2013/14 detailed no audits for community nursing with the exception of the trust’s record-keeping audit. Therapy staff in East Yorkshire told us they did not have time to conduct any audit activities.

Staff were competent and worked well in multidisciplinary (MDT) teams. We saw evidence of coordinated integrated care pathways, in particular mental health services and telemedicine services were provided by the Community Services team in partnership with Hull and East Yorkshire Hospitals NHS Trust.

Staff treated patients with dignity, compassion and respect. Patients and their carers and families spoke positively about the care and treatment they received. They also felt involved in their care and supported with their emotional needs. We found limited information about bereavement and counselling services to support patients or their relatives. However, the trust was in the process of addressing this.

Referral to treatment times for podiatry in Hull and the East Riding of Yorkshire pulmonary rehabilitation service was 28 weeks and 19 weeks respectively against targets of 18 and 10 weeks. Service specifications were not in place for some services such as the occupational therapy and the speech and language therapy service. This meant staff were not clear about the service they should be providing in their areas.

Some community nursing teams were below the 100% target for the proportion of preventable or urgent referrals seen within four hours. Some teams were also not meeting the targets regarding initial and follow-up visits to patients.

Staff adopted a flexible approach to the delivery of care to patients, who could be referred to the services in a variety of ways. There were systems in place to support vulnerable patients.

Complaints were managed effectively, but feedback was not consistently shared to help staff learn from them.

Senior staff clearly expressed the trust’s vision and values and they were positive and proud of the work they did. However, staff at more junior levels were uncertain about the vision and strategy.

There was effective teamwork and visible leadership across most teams apart from therapy staff who felt under-represented at a corporate level.

Systems were in place to disseminate information about quality and risk such as quality circle meetings. Local risk assessments were available and updated.

Staff spoke positively about local leadership of services. Feedback from patients was gained in an ad hoc manner.

We saw examples of innovative work across many teams in the trust.

The services we inspected were provided for children, young people and families, and included health visiting, school nursing (including special school nursing), speech and language, occupational and physiotherapy among others.

We found that there were processes to ensure children and young people were safeguarded and staff had an excellent knowledge of child protection. However, we found a large number of documents had not been scanned onto the electronic record quickly enough. This meant that members of the multidisciplinary team could not access all the available information. We asked the trust to take urgent action at the time of our inspection and made another unannounced inspection. We found that, while most of the scanning had been undertaken, there was a significant amount outstanding in one area. However, summary information was available on the electronic system and we were assured that other professionals, for example GPs, were not reliant on receiving the information via the electronic record. This reduced the risk to children, young people and their families.

We were concerned that some services, such as school nursing and health visiting, had high caseloads. However, caseload figures provided by the managers were not consistent with those provided by clinical staff. School nurse ratio to secondary schools was in excess of Royal College of Nursing guidance, which affected their responsiveness to children’s and schools’ needs. Staff told us they worked in silos and ‘on the hoof’ due to their work pressure.

Services were effective and we found good examples of multidisciplinary working to ensure national care programmes, such as the Healthy Child programme, were implemented. The service also performed well for child immunisations. We saw many examples of compassionate care provided by staff, which gave children and families the opportunity to be involved with planning their care while maintaining their privacy and dignity.

Care was not always responsive to people’s needs because of the lack of some services, and because they had lengthy waits to see some specialists, such as speech and language therapists.

The service was not well-led as not all staff were sure of the vision or strategy of the service they worked in. We spoke with staff across services who were upset at their workload and lack of support from some managers within the service. We had significant concerns about the service.

We found patient records were complete and accurate. There were enough staff, with the right mix of skills to meet patients’ needs. However, while equipment used was safe and well maintained, it was not always available quickly enough for patients to use at home.

The processes for managing risk and measuring quality were not used consistently across the teams involved in end of life care. Not all staff understood the procedures for, or knew how to, report incidents. Information about patient safety was not communicated well and did not encourage learning or improvement by staff.

The trust no longer used the Liverpool Care Pathway for the Dying Patient (LCP). A replacement had been developed, but this had not been used yet. This meant that staff were inconsistent in the way they completed end of life care records as they did not have a universal end of life care pathway. The trust participated in national and local clinical audits.

Staff providing end of life care had the right qualifications and worked as part of a multidisciplinary team. However, they did not always meet their targets. Staff completed mandatory training and appraisals to assess performance were undertaken, however this was inconsistent and did not meet the trust’s own acceptable levels.

Information about how the end of life care services were performing was not always available and was not monitored or reviewed effectively to drive improvements.

Staff treated patients with dignity, compassion and respect. Patients and their relatives spoke positively about their care and treatment. Staff also kept patients and their relatives involved in their care and supported their emotional needs. While there was limited information about bereavement and counselling services for patients and their relatives, the trust was in the process of addressing this.

Patients could access care close to home and at any time. However, access to specialist staff was limited out of hours and on weekends. There were no clear guidelines for community nurses to refer patients to the Macmillan nurses. However, processes for admitting, transferring and discharging patients were effective across the services. The inpatient ward also had sufficient capacity to make sure that patients could be admitted quickly and receive the right level of care. There were systems in place to support vulnerable patients.

Complaints about the end of life care services were also managed effectively, but they were not always shared with staff to help learning.

The trust’s vision and values were understood and supported by staff. Staff worked well in teams and the leadership was clearly visible.

Systems and processes were in place to provide safe care and support for patients. There were processes in place to recognise and investigate incidents relating to patient safety. However, there were some inconsistencies in staff members’ application of these systems and this could have resulted in the under-recording of incidents. The staffing levels and skills mix were sufficient to meet patient needs and on bank holidays and weekends extra staff were scheduled to work. However, there were occasions where the Hedon service was closed because the trust was unable to fully staff the service due to unplanned staffing issues. The service was then delivered from another centre. Equipment used to provide the service was well maintained. However, patients were not always protected from the associated risks with medicines because staff were not always properly following the monitoring systems to ensure the medication was stored at safe temperatures.

There were effective systems and processes to ensure patients received professional and competent care in accordance with national guidelines. Clinical staff understood and participated in clinical audits. Staff carried out their roles competently and worked well as teams. With respect to mental health and community nursing we found that patients received good and well coordinated care.

Staff were positive and proud of the work they did. There was effective teamwork and visible leadership at service level during the day but during the night on site, there was not a member of staff with overall responsibility. Clinical teams felt fully supported but some driver technicians did not. Patients’ experience had not been sought for 2013/14.

The Crisis Home Treatment services provided by Humber NHS Foundation Trust aim to provide care and treatment for people experiencing a severe mental health difficulty in their own home to prevent the need for hospital admission. They also help people to be discharged from hospital early, where suitable.

We found that these services were delivered safely. Learning about incidents and accidents was shared through team meetings and handovers.

The teams operated a Single Point of Access (SPA) referral system. The SPA used a ‘risk-rated matrix’ to prioritise new referrals to ensure that people received the level of support they needed, based on urgency of their need and associated risk factors. The teams had a clear care pathway which focused on assisting people in their recovery.

Care plans we looked at were centred on the needs of the individual and reflected the use of current, evidence-based practice. There was good partnership working within the multi-disciplinary team and with external stakeholders such as GPs, voluntary agencies and specialist mental health teams.

There were some differences in the level of service that was provided to people by the two teams, due to one serving a urban community and the other a rural one. This meant that people receiving support from the Hull team could be visited at home up to four times a day, whereas some people receiving support from the East Riding team living in remote areas were only visited once a day when more frequent visits were preferred.

Staff told us they felt well-supported in their roles, and felt able to raise concerns and report incidents.

Staff had a positive, learning and transparent culture and they were committed and motivated to continually improve and develop the services.

Humber NHS Foundation Trust provides a psychiatric inpatient intensive care unit and health based places of safety. We spoke with staff and managers involved in using the area, looked at the policies and records relating to use and looked at the environments of the hospital based places of safety.

We checked whether the hospital staff and managers were meeting their responsibilities under the Mental Health Act and adhering to the Mental Health Act Code of Practice, especially in relation to the use of section 136.

People at the Miranda House health-based place of safety, were kept safe and assessed quickly. However, there were significant delays in medical and Approved Mental Health Professional (AMHP) assessments at Buckrose ward at Bridlington & District Hospital. We found that staff were working within the Mental Health Act (MHA) 1983 Code of Practice. We also saw that staff attempted to inform people of their rights when they arrived at the hospital-based place of safety.

We found the environment provided privacy and dignity for people on the PICU and in the health based place of safety by adhering to the MHA Code of Practice guidance on gender separation in order to ensure sexes had a choice of not mixing in communal areas. We found good multi-agency working and good multi-disciplinary team working.

At the PICU, people told us that care from staff was good and that they felt safe. People were admitted to the services nearest their home. Care plans were holistic and focused on the individual. People had access to good information and activities. However, whether people were granted section 17 leave, depended on the number of staff available.

Staff reported incidents and the lessons learnt were embedded into practice. Staff also understood their responsibilities in terms of safeguarding, as well as their role and purpose in providing care. Staff told us that they were well-led and had supervision with line managers and training to ensure they had the right skills.

Humber NHS Foundation Trust provides secure inpatient mental health services for adults aged 18 to 65 years old.

Overall, people who used the services said that they felt safe. Staff understood how to escalate and report any concerns. They also assessed, monitored and managed the risks people posed very well.

The wards were clean and welcoming, and the standard of decoration was generally very good. There were systems in place to assess and monitor the safety of the environment. However, we found ligature risks in one seclusion room and on some doors.

The majority of people told us that they were happy with their care, and felt supported and well-cared for by staff. The multidisciplinary teams worked well together to plan and deliver care, and there were some excellent examples of how staff engaged and included people, for example in developing their care plans. Staff also involved people in wider service development initiatives, such as staff recruitment.

We were concerned about the use of restrictive practices that were not related to people’s clinical risks, with ‘blanket policies’ in place on some wards. For example, we saw staff conducting random searches and supervising people opening their post. On one low secure ward, people were escorted in the garden area because it was shared with a medium secure ward, but this practice was not based on clinical risk. On another ward, we found that there were no toilet facilities within the seclusion room, which compromised people’s privacy and dignity. In addition, there were no interview rooms on two of the wards.

Section 17 leave had been cancelled on Ouse and Derwent wards because there were not enough staff.

People told us the quality of food at the Humber Centre was very poor. This had been raised a number of times, but had not been resolved. Managers we spoke with told us that the food provision at the Humber Centre was currently being reviewed.

The service had some governance structures in place, which were used on all the wards.

Humber NHS Foundation Trust provides long stay, rehabilitation inpatient mental health services for adults aged 18 to 65 years old.

People who used the services said that they felt safe. Staff understood how to escalate and report any concerns. They also assessed, monitored and managed the risks people posed very well.

The wards were clean and welcoming, and the standard of decoration was generally very good. There were systems in place to assess and monitor the safety of the environment. However, we found ligature risks on some doors within St Andrews Place.

All the people we spoke with told us that they were happy with their care, and felt supported and well-cared for by staff. We found the care staff provided to be outstanding. The multidisciplinary teams worked well together to plan and deliver care, and there were some excellent examples of how staff engaged and included people, for example in developing their care plans.

We found a care plan for one person who was admitted informally to St Andrews Place stated ‘Leave to be agreed with the MDT (multidisciplinary team)’. This practice did not comply with the Mental Health Act Code of Practice because it did not reflect the person’s lawful right to leave the ward at any time, and could lead to the person being detained unlawfully.

Staff at St Andrews Place assisted people to prepare meals however; we found they had not received training in basic food hygiene. There were no plans in place for staff to receive this training.

The service had some governance structures in place, which were used on all the wards.

Humber NHS Foundation Trust provides substance misuse services, which are located across East Riding.

As part of this inspection of substance misuse services, we visited East Riding Specialist Drug Service, the Inpatient Alcohol Treatment Unit, and East Riding Partnership.

Overall, there was a high standard of individual-centred care which was assessed, planned and delivered individually.

There was an emphasis on recovery and staff were passionate about what they did.

Staff morale was very high and teams worked well together, especially when there was partnership working with the Alcohol and Drug Service and the clinics with the inpatient detoxification ward. Staff were proud of the care they delivered and felt supportive of, and supported by, their colleagues, management and the wider trust.

There were good facilities which were well-maintained, safe and secure.

Services were safe and effective with clear reporting procedures and systems in place to ensure staff were able to learn from incidents.

Humber NHS Foundation Trust delivers adult community-based services in partnership with the local authority. Services include: the recovery intervention team; the adult community recovery and psychological team; and the psychosis service for young people in Hull and East Riding (PSYPHER).

Staff were aware of safeguarding policies and knew how to protect people from abuse, as well as who to contact in the safeguarding team. Staff had also received training on incident reporting. Safeguarding and other incidents were discussed in team meetings and supervision sessions.

The trust’s risk register identified capacity issues within community teams. There were high referral rates and long waiting lists ranging from 80 to 120 people in some areas. The trust told us that there were plans to try and reduce this risk. Staff told us that they had high caseloads and that it was difficult meeting demand. They also said that this resulted in them working overtime. Documentry information provided by the trust showed that some staff had high case loads.

We found that staff assessed people using a range of risk assessments, including the Galatean Risk Screening Tool (GRIST), recovery plans and care plans. People told us that they received good care, and that the multidisciplinary teams worked well together.

Community teams stated they had to print out information about people as there were three different electronic systems in use. This meant that there was a risk that information might be out of date.

Humber NHS Foundation Trust provides acute inpatient mental health services for adults aged between 18 – 65 years based on five hospital sites.

Overall people who used services told us they felt safe on the acute admission wards. The wards were locked and not all informal users of service knew they had a right to leave.

Ligature points were risk managed. Staff reported incidents electronically and learnt lessons from them. Staff were aware of what to do in relation to safeguarding procedures.

People using services had care plans although there was little evidence of the meaningful involvement of people who use services. For example they were not written in consultation with and in the person’s voice and people did not have much awareness of them.

Risk assessments and risk plans were in place. The trust’s Recovery Star model was routinely used and people were attending Care Programme Approach (CPA) meetings. Physical health assessments were undertaken and physical health care plans were in place. We found some restrictive practices for people who were not-detained under the MHA. This included taking leave of and lack of access to the internet. There was confusion about what contraband articles could or could not be brought in to the wards.

People spoke positively about the care they received. Staff were clear about their role and purpose and spoke positively about the support they received. There was good multi-disciplinary working. Leadership at ward level and Board level was visible.

Humber NHS Foundation Trust provides assessment, treatment and care for people aged 65 years and older, who have a mental health problem of a functional (such as depression or anxiety) or organic (such as dementia) nature.

We found that there were appropriate safety and safeguarding procedures in place, which included a ‘Blue Light’ reporting system. All the staff knew about the safeguarding procedures and there were good links with the local safeguarding team. Staff reported incidents and we saw incident reporting forms on the Datix IT system.

Risk assessments were undertaken using GRiST (the Galatean Risk and Safety Tool) and the outcomes were used to inform all the care plans. The multidisciplinary teams worked well together and held weekly meetings.

The trust used a single point of access referral system. This meant that people were directed to the right service. However, there were long waiting lists and shortages of permanent staff. As a result, bank and agency staff were used, who were not always knowledgeable about the people using the services.

Carers and families were involved in care planning, and all the people using the service had received assessments of their physical health. There was also good communication between the intensive home care team and the community mental health teams for older people.

Staff had received training in communicating with people with dementia. This provided them with the skills and knowledge which helped ensure people received care and support that met their needs. The staff we spoke with were also aware of the national dementia strategy ‘Living well with dementia’ and NICE (National Institute for Clinical Excellence) guidelines on the care and treatment of people with dementia.

Staff were helpful and understanding, and treated people with respect. Recovery Star plans were person-centred and involved people’s carers and families. People also had access to support from advocacy services, and the trust held support groups for carers.

Staff told us that they were unclear about the trust’s vision and strategy, which left them worried about their future. They also told us that they did not receive regular clinical supervision.

Generally, arrangements for monitoring the Mental Health Act were in place and audits were carried out. People were also given their rights under the Mental Health Act, because some people using services may have difficulty retaining this information staff need to consider how often the information about their rights should be repeated.

Humber NHS Foundation Trust provides a range of inpatient and community services for people who have a learning disability (LD) or autism. These include community team learning disabilities (CTLD) services, Willow and Lilac inpatient assessment and treatment units, and Ullswater Ward, a forensic learning disabilities medium secure unit. The services are based at The Grange in Hull, Townend Court in Hull, Four Winds in the East Riding of Yorkshire and The Humber Centre for Forensic Psychiatry in East Yorkshire.

The trust had an effective system in place for reporting safety incidents. Staff knew about their responsibilities for reporting incidents and knew how to report them. There was also a system in place to make sure that incidents of potential or actual abuse were reported to the local authority safeguarding teams.

The service compiled and reviewed safety information from a range of sources including incident trends, safeguarding information and complaints.

Seclusion rooms at Willow assessment and treatment unit and Ullswater Ward were not fit for purpose and put people at increased risk. Staffing levels to maintain close observations were difficult at times on Ullswater ward. We found the noise levels of closing doors in corridors on Ullswater Ward could have a potential impact on people who required a low stimulus.

The service used evidence-based best practice and professional guidelines when people’s needs, however assessment tools being used such as GRIST were not specific to learning disabilities.

There were issues with IT systems in place for example psychiatrists had not received training in the electronic SystmOne , which resulted in hard copies of information being made available , this had the potential risk of outdated information being in circulation.

Staff in the community and inpatient services worked well together to make sure that the service met people’s needs. However Mental Health Act documentation was not always completed correctly. We identified common themes including staff not documenting people acting as statutory consultees in case records and outcome of capacity assessments not being recorded. People detained under the MHA also had access to an independent mental health advocate. We found that staff required further training in relation to the application of the Mental Capacity Act and DoLs.

People who used the service were positive about the staff and the care they received. Everyone we spoke with was happy with the way staff treated them, particularly in regards to kindness, dignity and respect.

The service had a safe and effective system in place to for managing referrals and there were some concerns about the management of waiting lists for CAHMS learning disability servcies. Access to some therapies was delayed, For example there was an eight month waiting list for psychology services.

Staff told us that they received information about the vision and strategy of the trust and were aware of the impact that had on their role. However staff did not have regular access to managerial and clinical supervision.

Staff also told us that there was a good working relationship within the team and with the management, including the chief executive and chairman.

Improvements had been made based on people’s feedback about the service.

Humber NHS Foundation Trust provides mental health, learning disability and community health services in the East Riding of Yorkshire and mental health, learning disability and some therapy services in the city of Hull, to nearly 600,000 people. It also provides some services to parts of North and North East Lincolnshire and North Yorkshire, as well as some specialist services to people from other parts of the country. The trust provides mental health forensic services to patients in the wider Yorkshire and Humber area.

Board members and senior managers were clear about strategic and key issues. Nonetheless their visibility, and the extent to which staff felt engaged and supported by them, varied considerably. Staff in some services considered themselves well-led but in the children and therapy teams, and older people’s and CAMHS services, staff were less engaged with the trust’s vision and strategy and least confident in its leadership.

We had concerns about the safety of some services provided by the trust and significant concerns in regards to the child and adolescent mental health services (CAMHS). These were linked to the capacity and demand pressures evident in some services and the impact that this had on staff working within these services. There was concern about the potential / actual impact on the quality of care experienced by patients who accessed these services. The trust risk register noted capacity and demand pressures within some services, and some action had been taken to address longer waiting times through appointment of temporary workers in community nursing services. This had been funded by commissioners and the budget for these posts was non-recurrent.

The capacity and demand pressures meant that there was too much work for staff to do and were particularly evident within the CAMHS, older people and community mental health team services. Although some action had been taken to mitigate the risks of high case loads and long waiting lists, controls were not in place to ensure effective monitoring of those patient referrals classed as routine and placed on a waiting list following telephone triage.

We identified restrictive practices in relation to the care provided to patients accommodated within the acute admissions ward but not detained by the Act (informal patients). These wards had locked doors to maintain security however not all informal patients were advised of their right to leave the ward. A system was in operation that required informal patients to sign confirmation of their agreement not to leave the ward for the first seven days of their admission.

There was inconsistency in reporting practice. Staff demonstrated varying ability and awareness of how to identify and consider serious incidents, incidents, near miss incidents and risks and what to do with that information. We were concerned there was inconsistency in how individual teams learnt from incidents and how information was shared following incidents across the organisation.

We found the care provided to people in the majority of services was evidence based and focussed on the needs of the patients. We saw some examples of very good collaborative work and innovative practice. However staff’s ability to cope with the capacity and demand for services, had a negative impact on delivery of care and treatment;

Despite examples of person centred care, we found occasions where delivery of care was not focussed on the specific care needs of the individual patient. For example, staff at the Humber Centre routinely searched patients and asked them to open personal mail in their presence. This was in the absence of such instruction or documented reason, within the patient’s individual care plan.

Whilst there was evidence of audits, and reference to NICE guidance, this was not consistent across the trust; there was limited evidence of outcomes being monitored to show how effective care was.

We were concerned about the effectiveness of communication between professionals. This problem was compounded by the use of various operating systems, both electronic and paper, to record and store patient information. Although summary information was available, we found delays in scanning paper records onto the electronic system, including records relevant to the safeguarding of children and attendance at minor injury units, at two out of fourteen clinics. We also identified potential risks for duplication and/or transcription errors when updating electronic records from paper records and potential risks of staff delivering care whilst in possession of out-of-date information. We brought these concerns to the attention of the trust at the time of the inspection visit.

Most of the facilities we visited were in a good state of repair and well maintained. The mental health seclusion suites at Derwent and Ullswater, were an exception as these were not in a good state of repair. We also identified ligature points within these suites that posed a risk to patients who were suicidal. The trust recognised that the seclusion suites did not meet the required standard. Capital funding to upgrade these facilities had been agreed in the current year capital funding programme.

The majority of people who use services told us they had positive experiences of care. Patients, families and carers felt well supported and involved with their treatment and staff displayed compassion, kindness and respect at all times.

We found staff to be hard working, caring and committed. Many staff spoke with passion about their work and were proud of what they did. However, some staff were not aware of the values or future direction of the organisation they worked for. In some services such as CAMHS and older people's services, staff felt disconnected from the wider organisation, including lack of direct consultation in strategic planning and development of services.

The majority of staff were up-to-date with mandatory training. However, whilst staff received training on the Mental Capacity Act as part of the mandatory training programme, their knowledge and application of this training was variable. Clinical supervision arrangements were in place across the organisation, however the quality of these was variable.

Across the trust, we found pockets of patient engagement, but this was not consistent or coordinated and the trust had not yet started using the friends and family test. The trust policy in respect of patient engagement was out to consultation at the time of this inspection.

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.

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.

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.

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