You are here

Provider: Mersey Care NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 5 April 2019

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

  • We rated well-led for the trust overall as outstanding. We rated safe, effective, caring, responsive and well-led as good across mental health and learning disability services. For community health services, we rated caring and responsive as good and safe, effective and well-led as requires improvement. When aggregating overall trust ratings we did not include the ratings of community health services. This is because the trust only acquired these services recently, some as late as April 2018, and CQC has the discretion to give trusts an allowance of up to 24 months before including newly acquired services that are considered to be failing in the ratings aggregation.
  • We rated ten of the trust’s twelve mental health and learning disability core services as good, one as requires improvement and one as outstanding. In rating the trust’s mental health and learning disability services, we took into account the previous ratings of the seven services not inspected this time.
  • We rated two of the trust’s community health services as good and three as requires improvement.
  • The trust had a clear vision and set of values. The trust’s strategy had been developed with involvement from staff and external stakeholders. There was a clear emphasis on quality improvement (striving for perfect care), a culture of learning, and integrated care services delivered at local level. The trust had a strong presence in the local community. Leaders had the right skills and abilities to run services providing high-quality sustainable care. Trust governance and management of risk was effective. The vast majority of staff that we spoke with felt valued.
  • Staff had the right qualifications, skills, training and experience to keep people safe from abuse and avoidable harm and provide the right care and treatment. Staff followed best practice in medicines management. They kept detailed records of patients’ care and treatment. Staff reported and managed incidents well. Ward staff participated in the trust’s restrictive interventions reduction programme and were proactive in anticipating and deescalating conflict with patients.
  • Services provided care and treatment for patients’ physical and mental health needs in line with national guidance and best practice. Staff of different grades and disciplines kept their professional skills updated and worked together to benefit patients. Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion and respect. Patients and carers were involved in decisions about care and treatment. Patients’ individual preferences were reflected in how care was delivered. Patients of mental health and learning disability services were also involved in the running of the trust. Staff acted on patients’ feedback.
  • The trust planned and provided services in a way that met the needs of local people. Services treated concerns and complaints seriously, investigated them and learned lessons from the results. Trust ward environments were adapted for the specific needs of their patients. This included cultural, dietary, disability and mental health needs.

However:

  • There were not always enough staff in all services.
  • A number of mental health wards provided dormitory accommodation rather than private rooms.
  • Staff compliance with mandatory training in a minority of services was low.
  • In some community health services, the trust could not be assured that controlled drugs had been destroyed safely.
  • Waiting times for psychological interventions were very long in community mental health teams, and two of the team bases were not accessible to wheelchair users.
  • Staff working in community health services did not all participate in relevant audits to monitor care quality.
  • Trust leaders had worked hard to engage staff in the newly-acquired community health services, but there was still some evidence of a minority of staff not feeling supported or comfortable to raise concerns.
Inspection areas

Safe

Good

Updated 5 April 2019

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

  • Staff had the right qualifications, skills, training and experience to keep people safe from avoidable harm and provide the right care and treatment. The trust provided mandatory training in key skills to all staff and in most cases made sure everyone completed it. Mandatory training included infection control, moving and handling, health and safety and fire safety.
  • Staff understood how to protect patients from abuse and worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff followed good practice in infection control.
  • Services followed best practice when prescribing, giving, recording and storing medicines. Clinic rooms in inpatient areas were clean and well-stocked. Monitoring of patients’ physical health following rapid tranquilisation had improved in acute mental health wards for adults of working age.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and in most cases easily available to staff providing care.
  • Services managed incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with teams and with the wider services.
  • Inpatient environments all had risk assessments in place. Staff were aware of any ligature anchor points and took action to mitigate risk to patients who might try to harm themselves.
  • Staff on mental health and learning disability wards participated in the trust’s restrictive interventions reduction programme. They were proactive in anticipating and deescalating conflict with patients. They used restraint safely and only as a last resort.

However:

  • Staff compliance rates for role-specific mandatory training in one of the community mental health teams was low.
  • In community end of life care and community health services for adults, destruction of controlled drugs was not always in line with legislation and trust policies and procedures. Staff compliance with a number of mandatory training topics was poor and equipment was not always serviced in line with manufacturers’ guidance.
  • Staff in community health services for children and young people did not monitor or record the cleaning of equipment.
  • Community health services for adults and acute mental health wards for adults of working age did not always have enough staff.
  • Staff in community health services for adults and community mental health services could not always easily access patients’ electronic records.
  • In community dental services, there was not a consistent procedure or protocol for the hoisting of patients.

Effective

Good

Updated 5 April 2019

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

  • Services provided care and treatment in line with national guidance and best practice. Managers monitored the effectiveness of care and treatment, and used the findings to improve.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and encouraged them to complete additional training. Evidence of staff compliance with clinical supervision was improving across the trust.
  • Staff of different grades and disciplines worked together to benefit patients. They supported each other to make sure patients had no gaps in their care.
  • Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff in mental health and learning disability wards assessed the physical and mental health needs of all patients on admission. They supported patients with their physical health and encouraged them to live healthier lives. They developed individual care plans which were reviewed regularly and updated as needed.

However:

  • Waiting times for psychological interventions were very long in community mental health teams.
  • In community end of life care and acute mental health wards for adults of working age, staff did not always document patients’ capacity to consent to treatment.
  • Staff in end of life care (South Sefton) and community health services for children and young people did not participate in relevant audits to monitor care quality.
  • Staff in community health services for adults were not always accessing clinical supervision in line with trust policy.

Caring

Good

Updated 5 April 2019

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

  • Staff cared for patients with compassion and respect.
  • Staff involved patients and carers in decisions about care and treatment. Patients’ individual preferences were reflected in how care was delivered.
  • All of the patients and carers we spoke with said positive things about the trust’s services.
  • Staff in community health services for adults went the extra mile to support patients, for example ensuring patients had adequate supplies of medication, caring for additional family members and provided additional support for patients who were anxious about treatment.
  • Patients in mental health and learning disabilities were involved in the running of services.
  • Staff on wards for people with a learning disability or autism spoke to and about patients in a way that was consistent with a culture of positive behaviour support.
  • There were regular community meetings on mental health and learning disability wards. We saw that issues raised by patients had been acted on.

However:

  • Not all patients in acute mental health wards for adults of working age felt engaged in their care planning.

Responsive

Good

Updated 5 April 2019

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

  • The trust planned and provided services in a way that met the needs of local people. Service priorities were aligned to local priorities.
  • Services were accessible to all who needed them and took account of patients’ individual needs. Waiting times for most community services were good, and all local people could access an inpatient bed close to home.
  • Patients were informed of how to complain. Services treated concerns and complaints seriously, investigated them and learned lessons from the results.
  • Most of the trust’s buildings were well-furnished and promoted privacy and dignity.
  • The trust’s rehabilitation mental health wards had a clear recovery focus.
  • Psychiatric intensive care was available to patients when they needed it.
  • Environments on wards for older people with mental health problems and wards for people with a learning disability or autism had been adapted to be as safe and accessible as possible. Staff helped patients with communication, advocacy and cultural support.
  • Patients’ cultural beliefs were accommodated on mental health and learning disability wards. Patients had a choice of quality food meeting a range of dietary and cultural requirements, and access to a space to worship.

However:

  • Two community mental health team bases were not accessible to wheelchair users.
  • Acute mental health wards for adults of working age at three locations had dormitories and restricted access to outdoor space. Three wards for older people with mental health problems also had dormitories.

Well-led

Outstanding

Updated 5 April 2019

Our rating of well-led improved. We rated it as outstanding because:

Checks on specific services

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

Good

Updated 5 April 2019

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

  • Staff delivered care in line with best practice and national guidance.
  • Staff completed and updated assessments of patients, and developed care plans from these. Patients’ physical health care was routinely assessed, monitored and treated when required. Staff minimised the use of blanket restrictions and restrictive interventions and followed best practice and the Mental Health Act when restricting patients to keep them and others safe.
  • A multidisciplinary team of staff provided care to patients. In addition to medical and nursing staff, care was provided by psychologists and occupational therapists. Other specialists could be accessed when required.
  • Staff adhered to the requirements of the Mental Health Act. Staff received training about the Mental Health Act and knew how to access advice. Staff were aware of the Mental Capacity Act, and knew how it worked in relation to best interest decision making.
  • The wards were safe and clean, complied with guidance on the elimination of mixed-sex accommodation, and provided appropriate facilities for patients.
  • There was pressure on beds, but patients were usually able to have a bed when they needed one. Staff and managers regularly reviewed the availability of beds, and how current patients were progressing through their treatment plan.

However:

  • On five of the nine wards, most of the patient bedrooms contained more than one bed. This meant that patients had to sleep in the same room as a stranger.
  • Maintaining safe staffing levels was an ongoing challenge, as there were difficulties in recruiting qualified nurses and in some areas healthcare assistants.
  • All the trust sites were non-smoking, but patient smoking was allowed/tolerated in outdoor areas and doorways. This was inconsistent with trust policy, and management of smoking was an ongoing concern for staff.
  • Staff did not record or always explain to patients who were not detained under the MHA that they had the right to leave the ward whenever they wished.
  • Staff monitored patients on high dose antipsychotic therapy, but this was not consistently recorded and implemented by staff.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 5 April 2019

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

  • The service had worked to implement improvement regarding problems noted in the previous inspection. Ligature assessments were completed and up to date. We saw that mixed sex accommodation guidelines were being followed. The units themselves were clean and well furnished, with furniture appropriate to a rehabilitation setting. Staffing figures showed that more staff had been employed, and that safe staffing levels were prioritised. Risk assessments were completed and updated regularly. The service followed the trust guidance regarding no force first, this being evidenced by the minimal use of restraint in the service. Medication management was audited and noted to be of a high standard during the inspection.
  • Care plans were holistic, personalised, and patient-centred with patient involvement. Physical health monitoring was on-going at the service, starting on admission, and related to individual patient needs. Psychology input was available at the service, with multi-disciplinary input that guided therapy. We attended a psychology group meeting, and saw good interaction and patient involvement. Supervision and appraisals were taking place at the service, and staff told us that input from such sessions was helpful. Staff were trained in the Mental Health Act and the Mental Capacity Act, and we saw that both Acts were being implemented within the service, with access to administrators and consideration in care records of patient rights.
  • Patients told us they were happy at the service, and felt safe. We were told that staff were kind, helpful, and always available. Carers spoke highly of the service, stating that their relatives’ difficulties had improved since being admitted. Patient experience survey results were very positive, with 100% approval for many of the aspects reviewed. The inspection team saw good interaction between staff and patients, and a willingness by staff to be courteous, respectful, and helpful during this interaction.
  • The service looked to discharge dates for patients from the first ward review, and worked towards meeting those dates. At the time of the inspection, there were no delayed discharges in the service. Delays to discharge were often not down to clinical problems, but due to external factors beyond the scope of the service. Patients could access bedrooms at any time and there was safe storage for valuable items in each room. There were many different activities available seven days a week, and patients were encouraged to take part. There was lots of information available to patients and carers regarding treatments, rights, smoking cessation, advocacy, and volunteer work for patients.
  • Leadership training was available to managers in the service, and staff told us they felt that management on each unit were approachable and considerate. The trust visions and values were apparent throughout the service: signs and posters giving information were on each unit, and staff told us they were aware of the values and tried to bring them to the ward environment. An electronic dashboard of information regarding performance was available to managers, outlining service performance, and managers used this information to take the service forward, improving the patient experience. The brain injury rehabilitation unit was due to accept accreditation to a national brain injury charity, after being assessed over a period of time.

However:

  • Some care plans contained jargon, language that might confuse patients.

Community-based mental health services for adults of working age

Requires improvement

Updated 5 April 2019

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

  • There were long wait times for patient access to psychological interventions.
  • Staff compliance rates for role-specific mandatory training were low.
  • The service was going through a migration of one electronic system to another. New staff could not easily access the previous electronic record system.
  • Park Lodge and Moss House were not accessible for wheelchair users and the disabled toilet at Moss House was not fit for purpose.

However:

  • There were no waiting lists for assessment by the community mental health service.
  • Risk assessments and audits of the environment, including infection control, were done regularly and were up to date.
  • Patients had robust, person centred care and treatment plans including physical health assessments. They were involved in the decision making about their care and treatment.
  • Serious incidents were being reported and managers were able to feed into the trust risk register. The service had a variety of ways that risks, concerns, complaints and lessons learnt were being communicated to staff.
  • The service had robust multidisciplinary and interagency teamworking.
  • The service provided a variety of information regarding community events, treatments and care services available for patients, carers and families.
  • Staff were trained in and had a good understanding of the Mental Health Act and the Mental Capacity Act. The service had policies and procedures in place and staff had access to support.
  • There was good leadership and the service encouraged learning and continuous improvement ideas from staff, patients, families and carers.

Community health services for children, young people and families

Good

Updated 5 April 2019

We have not previously inspected this service. We rated it as good because:

  • Services were found to be good for safe, effective, caring, responsive and well led.
  • The service had effective strategies for identifying, managing and reducing risk, learning and improving when things went wrong.
  • There were sufficient numbers of competent and experienced staff to reduce the risk of harm to patients.
  • The service used best practice guidance to inform the delivery of care and ensured treatment was based on evidence based practice.
  • Staff within the service demonstrated good levels of commitment to patient care and they adopted holistic patient and family centred care. Patients and families believed the care provided was good.
  • The service planned and delivered care based on the identified needs of the community it served, but also built the service around the individual needs of patients. Staff were proactive in their approach to establishing the individual needs of patients.
  • There was an exceptional family focused approach to care delivery and staff had extensive knowledge about their patients.
  • The service was well led by effective and enthusiastic managers, who were aware of risks to the service and were capable of tackling difficult issues head on with a view to service improvement.

Wards for older people with mental health problems

Good

Updated 5 April 2019

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

  • We rated all key questions as good.
  • Improvements in the clinical environment and medicine management had been made since our last inspection.
  • Medicines were now managed safely. Equipment was now cleaned and recorded. Clinic fridge temperatures were also now monitored. Environments had been suitably adapted to meet the needs of patients with dementia. There were enough rooms to accommodate activity and therapy sessions.
  • Compliance with supervision, appraisals and mandatory training had improved, including basic life support, immediate life support, moving and handling and dysphasia training. Staff were now appropriately trained and supported for their roles.
  • Risk assessments and care plans had been completed for all patients and reflected patients’ lives and interests. They were personalised, holistic and recovery-oriented. Staff had developed a tool to support patient and carer involvement. Families and carers were involved in care planning and discharge planning.
  • The food was of good quality and drinks and snacks could be accessed 24 hours a day. Cultural beliefs were accommodated, including special diets.
  • Staffing levels and skill mix on each ward were appropriate to meet the needs of patients.
  • The service was now notifying the Care Quality Commission of Deprivation of Liberty Safeguards authorisations for patients. Mental Health Act and Mental Capacity Act policies and procedures were followed by staff.
  • There were effective systems and processes in place to drive quality improvement and safety. Incidents were reported and acted upon. Complaints were managed well and information fed back to patients.
  • Managers had the necessary skills and resources to ensure patient care was of good quality.
  • Staff felt respected by senior managers and morale had improved. Staff treated patients, their families and carers with kindness, privacy, dignity, respect, compassion and support. There were good relationships between patients, staff and carers.

However:

  • There was dormitory bedroom accommodation on three wards. Beds were separated by curtains. This impacted on patients’ privacy and dignity.

Community end of life care

Requires improvement

Updated 5 April 2019

We have not previously inspected this service. We rated it as requires improvement because:

  • Although the priorities for the service were aligned to the North West Palliative Care Network, the service did not have an overall strategy or workable plans to turn it into action.
  • Although the trust had undertaken service reviews across several community services, this had not been undertaken for the Liverpool palliative care team at the time of our inspection. A service review had been undertaken for the South Sefton palliative care team, an action plan had not yet been implemented to make improvements where needed.
  • There was not always evidence that controlled drugs had been destroyed after a patient had passed away, in line with legislation as well as trust policies and procedures. Records indicated that there was no evidence of this on two out of eight occasions. Additionally, a recent care of the dying audit that had been completed in June 2018 indicated that there was only evidence that controlled drugs had been destroyed on 62% of occasions.
  • The service had suitable equipment but had not always looked after it well. Records indicated that only 67% of syringe drivers in the South Sefton area had been serviced in line with manufacturers’ guidance. This meant that there was an increased risk that equipment would malfunction while being used.
  • The service had not planned to review all expected patient deaths before the time of our inspection. This meant that there was an increased risk that areas for improvement had been missed. However, the management team informed us that a new process had recently been implemented so that all expected deaths could be reviewed.
  • Not all staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Patient records indicated that consent to treatment had not always been documented in line with trust policy.
  • Although staff informed us that the palliative care team were responsive when support was needed, the service had not monitored compliance with the service’s policy to triage urgent patients within four hours as well as triaging all other patients within 24 hours and undertaking a clinical review within 72 hours. This meant that it was unclear if these targets had been achieved consistently.
  • Although there was evidence that staff had provided emotional support to patients and relatives to minimise their distress, records indicated that not all relatives had been offered bereavement support after a patient had passed away. We found that there was no documented evidence of this being undertaken on nine out of 11 occasions. In addition, a care of the dying audit that had been undertaken in June 2018 had identified that only 45% of relatives had been offered bereavement support.

However:

  • The service provided care and treatment based on national guidance. This included the Supporting Care Improving Outcomes guidance (National Institute for Clinical Excellence, 2004), End of Life Strategy (Department of Health, 2015) as well as the Care of Dying Adults in the Last days of life (National Institute for Clinical Excellence, 2017).
  • Staff of different kinds worked together as a team to benefit patients. Members of the palliative care team worked well alongside staff, both internally and externally.
  • Staff cared for patients with compassion. Both members from the district nursing and palliative care teams were committed to providing high quality and compassionate care.
  • Patients and relatives who we spoke with told us that the care and treatment delivered had been of a high standard. Comments included ’we are extremely happy with the care that we are getting’ and ‘we are more than happy, we can’t fault it and that staff are very helpful’.
  • Most managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The palliative care team were very proud of the work that they had done. They were focused on providing the best possible care and meeting the needs of the people that used the service.

Wards for people with a learning disability or autism

Good

Updated 5 April 2019

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

  • We rated all key questions as good.
  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability and/or autism and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • 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 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. They involved patients and those close to them in decisions about their care and about the service. Staff spoke to and about patients in a way that was consistent with a culture of positive behaviour support.
  • The ward promoted privacy and dignity for patients. The service was accessible to all who needed it. Arrangements to admit, treat and discharge patients were in line with good practice. Staff helped patients with communication, advocacy and cultural support.
  • Managers had the right skills and abilities to run a service providing high-quality sustainable care. Managers promoted a positive culture that supported and valued staff. The ward used a systematic approach to continually improving the quality of its services.

Community health services for adults

Requires improvement

Updated 5 April 2019

This is the first time we rated this service and we rated it as requires improvement. We rated it as requires improvement because:

  • The service did not always have the right number of staff although staff had the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse to provide the right care and treatment.
  • There was a lack of clinical supervision in some services and competency based training was not always carried out.
  • Some equipment necessary for carrying out treatments was not always available.
  • Controlled medications were not always destroyed and disposed of in line with Trust policy and procedures.
  • A number of Trust policies and procedures were out of date.
  • Some staff told us that there was a lack of visibility of senior and middle management.
  • Some staff told us that they were reluctant to speak up to the ‘freedom to speak up champions’ due to previous experiences.

However:

  • The Trust planned and provided services in a way that met the needs of local people and worked well with external organisations.
  • The service primarily used electronic patient records. Patient records were easily accessible by staff working in all community teams. Staff could access records using electronic devices in patient home and on computers based in clinic areas.
  • Records were clear, legible and information collated was in chronological order.
  • Staff from different specialities worked together collaboratively to benefit patients and their families.
  • The service controlled infection risk well and infection rates were low.
  • The service managed incidents well. Staff recognised incidents and reported them appropriately. There was a positive culture around the reporting of incidents and lessons learnt were shared with the whole team.
  • The service provided care and treatment based on national guidance and evidence based care.
  • The service had a clear vision and strategy in place. The service knew what it wanted to achieve and workable plans to turn it into action.

Community dental services

Good

Updated 5 April 2019

This service has not been inspected before. We rated it as good because:

  • Staff were qualified and had the necessary skills to carry out their roles and provide safe treatment to patients.
  • Infection control processes followed nationally recognised guidance.
  • Premises and equipment were clean and well maintained.
  • Staff reported incidents and accidents, these were investigated and acted upon to reduce the chance of re-occurrence. Learning from incidents was disseminated to all staff in the service through the “Notification of Clinical Improvement” system
  • Staff were aware about issues relating to safeguarding and there were systems in place to refer children and vulnerable adults.
  • Staff provided care and treatment based in line with nationally recognised guidance.
  • There was an effective skill mix at the service to assist with the ever-increasing complexity of patients. Staff worked together as a team and with other healthcare professionals in the best interests of patients.
  • Staff understood the importance of obtaining and recording consent. They had a good understanding of their responsibilities under the Mental Capacity Act 2005.
  • Staff cared for patients with compassion. We observed staff treating patients with dignity and respect. Feedback from patients was positive. Patients commented staff were kind, helpful, friendly and caring.
  • The service considered patients’ individual needs. Reasonable adjustments were made to ensure patients could access dental care.
  • The service dealt with complaints promptly, positively and efficiently.
  • Leaders had the skills and ability to support high quality care. Staff told us that management were visible and approachable.
  • The team worked well together and supported each other.
  • There were systems and processes in place for identifying risks and planning to reduce them.
  • Staff engaged with patients, external stakeholders and other healthcare professionals to continually improve the service.

However:

  • The service did not have a consistent procedure or protocol for the use of hoists to assist patients with mobility difficulties to access dental chairs.
  • Staff told us that they felt “a bit frazzled” because of staffing issues. Staff worked hard to ensure that high priority clinics were not cancelled.
  • The policy supporting the use of the “Notification of Clinical Improvement” system had not been updated since 2002.
  • “Notification of Clinical Improvements” were only sent to one individual. This would pose a problem if this member of staff was ever away for a long period of time.
  • Individual results of the X-ray audit were not disseminated or discussed with dentists.

High secure hospitals

Good

Updated 19 October 2017

We rated high secure services at Ashworth Hospital as good because

:

  • Wards were clean and well furnished. Mirrors and closed circuit television cameras were used to ensure that patients and staff were safe and monitored on every ward. Staffing was being managed by ward managers and matrons, using a safe staffing system, and we were informed that 53 new staff had been recruited to the trust and would soon be ready to join the teams. National policies relating to night time confinement and long term segregation were being followed. Medication management followed guidance, and the introduction of an electronic prescription system had improved monitoring. Incidents were reported and appropriate actions were taken to deal with these incidents.

  • Care plans were comprehensive and holistic across the service. Staff involved patients in the development of their care plans and gave copies of care plans to patients when the patient agreed to accept them. Staff were able to access further specialist training from external bodies, up to and including masters level qualifications. The care records indicated that staff paid as much attention to patients’ physical healthcare as they did to patients’ mental health. The provider had recruited psychologists to the service.This improved the patients’ access to effective psychological therapies. All patients were detained under the Mental Health Act.Staff across the service adhered to the guidance in the Mental Health Act Code of Practice. However, the trust Mental Health Act policy referred to an out of date Code of Practice; the trust was using the current Code of Practice. The Mental Capacity Act was applied across the service, and we saw evidence of capacity assessments in care records.

  • Interaction between patients and staff was seen to be of a high standard, empathic and professional. Patients told us that staff treated them with kindness and respect. We observed a patient forum and saw excellent interaction between staff and patient representatives, with matters discussed openly and with due consideration for all. We spoke with carers of patients and were told that, generally, they were positive about the service. Some carers raised points that we looked further into, and were assured that the service was acting in the best interest of patients. Patient viewpoints were listened to and helped to define the service.

  • The service was adhering to national recommendations regarding times for referral and assessment of patients. Wards were updated and refurbished on a rolling basis, as older wards were redecorated and improved. Forster ward had recently closed and re-opened as Newman ward, the new ward being appreciatively more modern than the old ward. The service had plans in place for patients from different cultures and countries, considering food, treatment and religious aspects.

  • The trust visions and values were embedded in the service. All staff knew of the values of the trust, and the direction the trust wanted to move. We saw evidence of senior staff involvement in the service, including at chief executive level. Staff were involved in clinical audit; the service itself had been involved in a number of audits in the 12 months prior to the inspection. Ward managers felt they had the authority to do their job. Staff told us that morale on the ward was quite high, but it would improve more when new staff joined the teams.

Forensic inpatient or secure wards

Good

Updated 27 June 2017

We rated forensic inpatient/secure wards (medium and low secure) as good because:

  • All wards had a ligature risk assessment in place. Security procedures that were in place for accessing the wards met the needs of each individual service and the level of security required.
  • Clinic rooms were functional; medical devices were checked regularly and serviced and calibrated annually. Physical health was monitored routinely, and patients had access to a GP twice weekly if this was required.
  • Risk assessments and care plans were in place for all patients. These were up to date and reflected the patients’ needs. The majority of patients told us that they had been offered a copy of their care plans.
  • Incidents were reported through the trust’s electronic incident reporting system. Staff received feedback on incidents and complaints through staff meetings and quality practice alerts.
  • Staff used National Institute for Health and Care Excellence guidance to guide their practice, and used recognised rating scales to monitor patient outcomes.
  • Staff received supervision and annual work performance appraisals. Staff felt skilled and competent to perform their role and had lots of opportunity for additional training should they wish to develop their skills further.
  • We observed positive and supportive interactions between patients and staff, which showed that staff treated patients with dignity and respect. Patients told us that staff were respectful and caring.
  • The independent mental health advocate was available on thewards, and supported patients in ward rounds and with their concerns. Community meetings took place monthly.
  • A referrals meeting took place weekly across the medium and low secure wards to review all referral, discharges and movements between the services.
  • Both diversionary and occupational activities took place on the ward seven days a week. The majority of patients told us that the food was good, and they had access to hot and cold drinks throughout the day and could have snacks. Both units had a multi faith room and could access spiritual leaders to support their patients’ cultural and spiritual needs. There was disabled access on both sites.
  • Staff were aware of the vision and values of the organisation. Staff felt that there was a high presence of the matrons within the low and medium secure services.
  • There were good governance systems in place for monitoring compliance with staffing sickness, mandatory training and appraisals. The ward managers felt that they had enough authority to perform their role and had access to key performance indicators, which helped to monitor the performance of their teams.
  • Staff morale was good and there was evidence of good team working. Staff were able to provide feedback on their services through team meetings. They were also invited to send any feedback to the trust chief executive.
  • All the wards were part of the quality network for forensic mental health peer review initiative.

However:

  • At the Scott Clinic, the sluice on four of the wards was located within the patient laundry room. This did not apply good infection control principles for clean and dirty areas.
  • Patients that were secluded at the Scott Clinic could potentially see the computer screens in the staff office which could cause a breach of confidentiality.
  • The ward staffing levels meant there were not always enough staff on duty to meet the needs of the patients; patients and staff told us that leave often had to be rescheduled.
  • The drug detection dog attended all the wards on a frequent basis. We felt that this practice was overly restrictive on low secure wards.

Substance misuse services

Good

Updated 27 June 2017

We rated substance misuse services as good because:

  • All the services we visited were tidy and well maintained. The furniture was in good repair and the clinic areas were clean and well organised. Staff understood infection control procedures.

  • Staffing levels and skill mix were planned and reviewed to keep patients safe and meet their needs. There were effective procedures for escalating concerns about staffing levels. There were effective handovers to ensure staff were aware of the risks to patients.

  • There were clearly embedded systems, processes and standard operating procedures to keep patients safe. The staff knew how to look for signs of abuse and how to make a safeguarding alert if necessary. This meant that patients were protected from avoidable harm.

  • Managers encouraged openness and transparency about safety. Staff knew what to report and how to report it. They understood their responsibilities relating to the duty of candour.
  • In most cases, patients’ needs assessments included consideration of clinical needs, physical and mental health and wellbeing, and nutrition and hydration needs.
  • Staff planned care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Links to best practice guidance were available on the trust’s website.
  • Patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.
  • Staff respected patients’ diverse needs. Patients were supported, treated with dignity and respect, and involved as partners in their care. There was a visible person centred culture.
  • Patients were involved and encouraged to be partners in their care and in making
  • decisions, with any support they need. Staff spent time talking to patients so that they understood their care, treatment and condition.
  • Staff took into account the needs of different groups so that they met patients’ needs.
  • Patients understood how to complain or raise a concern. Staff took complaints and concerns seriously. They listened and responded to in a timely way.
  • The service was transparent and open with stakeholders about performance. Information was used to support effective decision-making and drive improvement. Staff reported and reviewed information on patients’ experiences alongside other performance data.
  • Staff felt respected, valued and supported. They were committed to their roles and enjoyed working with the patient group. They described a strong and supportive team.
  • Managers supported staff to work in innovative ways. They encouraged staff to discuss issues and ideas for service development.

However:

  • At the Windsor Clinic, the fire risk assessment was out of date and actions had not been completed.
  • Not all patients had a comprehensive risk management plan that staff reviewed regularly.
  • Care records were not always comprehensive and holistic. They did not always take account of patients’ views. Some were not recovery focused and were not reviewed regularly.
  • Systems for audit and review in relation to care records were not always effective.
  • Some care records did not contain individual plans for unexpected exit from treatment.

Community-based mental health services for older people

Good

Updated 14 October 2015

We rated the community based services for older people as ‘Good' overall because:

  • People had their needs assessed, care planned and delivered in line with best practice.
  • Multi-disciplinary teams managed the referral process, assessments, on-going treatment and care. This included care navigators who support people with dementia.
  • Common assessments and pathways for post diagnostic support for people with dementia had been agreed across mental health, acute and specialist NHS trusts.
  • People who used services had timely access to care and treatment.
  • There were systems in place to triage referrals based on the individual needs of people who used the service. Services were planned and delivered to meet people’s needs in a person centred way, taking their cultural needs into account.
  • Each team was well led by committed managers.
  • Each team had team objectives which helped guide staff and teams.
  • Two out of three of the memory clinics were accredited as excellent, with the Royal College of Psychiatrists’ memory services network accreditation project.

We saw outstanding user involvement initiatives with significant service user involvement and community engagement, including by people with dementia. This was particular apparent in Central Liverpool. This included:

  • the work of the service user reference forum.
  • service users and staff working as partners to be involved in developing apps to assist their memory, reminiscence and daily functioning and working with businesses to make them 'dementia friendly'
  • partnership work with Everton Football Club.

People were exceptionally positive about the care they received.

However, there were vacancies within teams which meant that some staff had to manage caseloads greater than they usually would. Care navigators were managing large numbers of people. We did not see significant impact on patients from these; managers were looking to address these by recruiting staff and working with commissioners.

Some risk assessments for people using the service were over 12 months old. Lone working practices did not always fully ensure staff safety. Staff were not always proactive in following up on updates on safeguarding processes. There were minor issues with equipment in the clinic room at Central Liverpool older people’s CMHT

Community mental health services with learning disabilities or autism

Good

Updated 14 October 2015

We rated this core service as good because:

•The service had developed clear, evidence based clinical pathways to support effective assessment, treatment and management of clinical needs. The teams worked effectively and collaboratively with other services to ensure continuity and safety of care across teams, including involvement of external agencies. We found that there were inconsistencies between the localities we visited, in relation to caseload management and service delivery. This meant that people may have a different experience of care or outcome of treatment, depending on where they receive their care. However, the community learning disabilities teams worked hard to meet the varied demands on the service despite challenges they faced at times with limited resources.

•People who used the service were treated with kindness, respect and dignity. Individuals were positive about the way staff treated them and were involved in the planning of their care. Clinician`s kindness, expertise and skills within the teams were highly regarded by all carers and patients we spoke with. The staff we met ensure  the people who use the service at the centre of what they did.

•The service operated an open referral system and had capacity to respond in a timely manner. The teams were confident that they all worked within the assessment targets agreed by the trust, however the systems in place to monitor compliance with waiting and response times did not appear to accurately reflect this. The teams worked flexibly to meet individual`s needs and worked closely with a number of different agencies to meet their needs, promote community involvement and social inclusion.

•The trust had a system to identify and monitor quality and safety of the services they provided. However, there were concerns with accuracy of recording and quality of data to monitor compliance with waiting and response times. There were not effective systems in place to monitor referrals, waiting lists, unmet need and the potential impact of gaps in service provision. There was a clear system in place to report incidents. However, we were concerned about the lack of comprehensive investigation into a serious incident affecting a member of staff last year.

• The community learning disabilities service was undergoing a comprehensive review of service delivery, local team performance monitoring and management structures, as part of the service re-design.Some teams, for example, both of the Asperger`s teams, and the administrative teams, did not have a line manager. Meeting structures were not in place which would support effective oversight monitoring across the whole service, for example, there were no management meetings or administration meetings in place. Most staff were concerned that there could be reduced learning disability representation within the senior management team with the restructuring.

•We saw good examples of local leadership from the team managers we met. Staff told us that they felt well supported by their team managers and were able to raise concerns and contribute to service development. The service manager and modern matron showed a good understanding of the current challenges for this service and staff.

Mental health crisis services and health-based places of safety

Good

Updated 14 October 2015

We rated the health based places of safety as good overall because:

  • There was evidence of good inter-agency working including shared forums for reviewing issues, strategic meetings, addressing continued service improvements and positive relationships within the operational services.

  • Joint protocols were in place across Merseyside police, Mersey Care NHS Trust, the acute hospital trusts, local authorities and ambulance services involved in the detention, assessment and conveyance of people detained under section 136 of the Mental Health Act.

  • Joint procedures included a 10 step pathway for all involved in the process of section 136 to follow. The police used a traffic light rating system to support joint decision about remaining at the assessment or leaving.

  • There was a designated health-based place of safety in the city for children under the age of 16 years.

  • There had been no detentions of anyone subject to section 136 to police cells within Merseyside in the previous 12 months.

  • There was a culture of continued development. This included the street car initiative and the development of a heath-based place of safety within adult mental health inpatient services. There was also the implementation of employing health care assistants within accident and emergency services to provide one to one support for people detained under section 136.

However

  • The section 136 room at Aintree University Hospital did not provide a safe and a suitable environment for the assessment of patients detained under section 136 of the Mental Health Act (MHA) 1983 and there was a privacy and dignity issue at the Royal Liverpool University Hospital as the toilet door had been removed for safety reasons.

  • There were some considerable waits for section 136 assessments to be concluded. The reason was not clearly recorded in all the instances.

  • All of the forms that we reviewed required multi-agency input to record each stage of the 10 step care pathway retained within the A&E departments were incomplete.