Humber Teaching NHS Foundation Trust

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