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Provider: Lancashire & South Cumbria NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 11 September 2019

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

  • We rated the trust as requires improvement overall in safe, effective, responsive and well led. Our rating for the trust took into account the previous ratings of the core services not inspected this time. We rated two of the trust’s 14 core services as inadequate and two as requires improvement overall.
  • We had significant concerns about patient safety, privacy and dignity and the functioning of the mental health decision units within the mental health crisis services. The unit designs were not fit for purpose, they were not being used in the way intended and they persistently failed to meet the basic needs of patients. Trust leaders had failed to address these concerns following our last inspection. Full information about our regulatory response to the concerns we have described will be added to a final version of this report, which we will publish in due course.

  • Staff were detaining patients in the health-based places of safety past the expiry time of the section 136. Patients were subject to restrictive interventions without the appropriate legal safeguards in place. This practice had become routine. This had not improved since our last inspection.
  • The governance systems in place for the oversight of the health-based places of safety and mental health decision units was not effective. The trust did not have accurate or complete information in relation to patients who remained in the health-based places of safety or the mental health decision units for prolonged periods of time. Staff were not consistently reporting these breaches. This had not improved since our last inspection.
  • Due to our concerns, we used our powers to take immediate enforcement action. We issued the trust with a Section 29A warning notice for this core service. This advised the trust that our findings indicated a need for significant improvement in the quality of healthcare. We will revisit these services to check that appropriate action has been taken and that quality of care has improved.
  • The trust was not providing consistently safe care within the acute wards for adults of working age and psychiatric intensive care units. There were not sufficient numbers of suitably trained staff. Staff were not managing all risks effectively. Staff were not always following the seclusion policy, infection control practices and best practice in relation to medicines management.
  • Due to the concerns we found during our inspection of the trust’s acute inpatient mental health wards for adults of working age and psychiatric intensive care units, we used our powers to take immediate enforcement action. We issued the trust with a Section 29A warning notice. This advised the trust that our findings indicated a need for significant improvement in the quality of healthcare. We will revisit these services to check that appropriate action has been taken and that quality of care has improved.
  • The problems with the health-based places of safety and mental health decision units were symptomatic of an acute care pathway that did not function effectively. This had a direct impact on patient care. In addition to the blockages at point of admission, the home treatment teams did not have effective gatekeeping arrangements and discharges from the acute wards were delayed for other than clinical reasons. High use of out of area beds was another symptom of the problem. Community teams had unacceptable waiting times.
  • Within the community based mental health services for adults of working age, risk management plans did not contain detailed information about how to manage specific risks and the legal authority to administer medication to patients on a community treatment order were not kept with the medicine charts.
  • Not all staff were receiving supervision or an annual appraisal. This had not improved since our last inspection.
  • The trust did not have a strategy or service model for the care of people with a personality disorder. This resulted in some people with a personality disorder being admitted to an acute ward whose admission might have been avoided.

However:

  • We rated 10 of the trust’s 14 core services as good overall. We rated eleven of the trust’s core services as good for caring and the dental services as outstanding for caring. The ratings for the child and adolescent ward in all domains had improved to good. Our rating for the trust took into account the previous ratings of the core services not inspected this time.
  • Staff were kind, caring and motivated to provide the best care and treatment they could for patients.
  • On the acute and psychiatric intensive care wards, staff completed the physical observations of patients following the administration of rapid tranquillisation. This had improved since our last inspection.
  • Staff understood how to protect patients from abuse and they worked well with other agencies to do so. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.
  • Staff completed comprehensive, holistic assessments of all patients on admission/referral. Staff developed good care plans and reviewed and updated these when patients’ needs changed. They made sure that patients had a full physical health assessment and knew about any physical health problems.
  • Staff met the needs of all patients including those with a protected characteristic.
  • Staff knew and understood the provider’s vision and values and how they applied in their work. Staff morale was improving and staff were optimistic that improvements would be made under the new leadership team.
  • Team members worked well together.
  • Staff treated concerns and complaints seriously, investigated them and learned lessons from the results were shared.

Inspection areas

Safe

Requires improvement

Updated 11 September 2019

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

  • We rated one of the trust’s 14 core services as inadequate in safe, six as requires improvement and seven as good. In rating the trust, we took into account the previous ratings of the nine core services not inspected this time.
  • We had significant concerns about patient safety, privacy and dignity and the functioning of the mental health decision units which the trust had failed to address following our last inspection. The units did not have beds and should only have accommodated patients for up to 23 hours however; they were routinely being used as additional wards with patients including children, staying several days. Staff had failed to incident report these instances. Children admitted to the units did not routinely have access to child and adolescent mental health specialists.
  • Staff were not always incident reporting section 136 breaches and breaches over 23 hours in the mental health decision units. There were some environmental issues within some of the health-based places of safety which had not been addressed following our previous inspection. The mental health decision unit in Preston breached same sex accommodation guidance. Staff were not all trained in basic life support and overall completion of mandatory training was below the trust target.
  • There were staffing issues within some of the acute wards for adults of working age and psychiatric intensive care units, health-based places of safety, home treatment teams and community based mental health services for adults of working age. There was a lack of medical cover in the mental health decision units which impacted on patient’s length of stay.
  • Within the acute wards for adults of working age and psychiatric intensive care units, ligature audits were not always comprehensive. Staff were not managing risks in relation to patients smoking on the wards. Staff were not always following the seclusion policy and infection control practices. Staff within the acute wards for adults of working age and psychiatric intensive care units and the health-based place of safety at the Harbour, were not always following best practice in relation to medicines management. Staff were not all trained in basic life support and immediate life support.
  • Within the community based mental health services for adults of working age, risk management plans did not contain detailed information about how to manage specific risks. Staff did not have access to patient information that was held on the local authority electronic record system.

However:

  • Our rating for safe on the child and adolescent ward went up to good.
  • Staff understood how to protect patients from abuse and they worked well with other agencies to do so.
  • Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restrictive interventions as a last resort when attempts at de-escalation had failed.
  • On the acute and psychiatric intensive care wards, staff completed the physical observations of patients following the administration of rapid tranquillisation. This had improved since our last inspection.
  • Overall, staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff understood the duty of candour.

Effective

Requires improvement

Updated 11 September 2019

  • We rated one of the trust’s 14 core services as inadequate for effective, four as requires improvement and nine as good. In rating the trust, we took into account the previous ratings of the nine services not inspected this time.
  • Lengths of stay within the mental health decision units regularly breached the 23 hour timescale whilst patients waited for an in-patient bed. The remit and functioning of the units was not understood within the trust and they were not used effectively to reduce in-patient admissions.
  • The trust did not have a personality disorder strategy or model of care for patients with a personality disorder to keep their inpatient admissions to a minimum. Staff within the acute services did not receive training in learning disability, autism or personality disorder even though they were caring for patients with these needs.
  • The trust policy for section 136 did not reflect all relevant legislation and the Mental Health Act Code of Practice and the trust’s policy for implementing the Mental Capacity Act and obtaining authorisation for Deprivation of Liberty did not give an accurate definition of the meaning of capacity within the Act.
  • Staff within the health-based places of safety and mental health decision units did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice. Patients were detained past the expiry of section 136 and subject to restrictive interventions without appropriate legal safeguards in place. This had not improved since our last inspection.
  • Within the adult community mental health teams, the legal authority to administer medication to patients were not kept with the medicine charts. We were not assured that patients on community treatment orders had their rights read in accordance with the Mental Health Act and Code of Practice.
  • Not all staff within the crisis service, acute services and community adult mental health teams were receiving supervision in line with the trust’s policy and not all staff in the crisis service had received an annual appraisal. Team meetings were not regularly taking place on all wards. This had not improved since our last inspection.

However:

  • Staff completed comprehensive, holistic assessments of all patients on admission/referral.
  • Staff made sure that patients had a full physical health assessment and knew about any physical health problems. Health promotion was evident throughout the trust.
  • All patients had a care plan and staff regularly reviewed and updated these when patients’ needs changed.
  • Team members worked well together. Staff from different disciplines worked together as a team to benefit patients. Teams had access to the full range of specialists required to meet the needs of patients.
  • Staff within the child and adolescent wards and dental services used recognised rating scales to assess and record severity and outcomes. They also participated in clinical audit, benchmarking and quality improvement initiatives.

Caring

Good

Updated 11 September 2019

  • We rated one of the trust’s 14 core services as outstanding for caring, eleven as good, one as requires improvement and one as inadequate. In rating the trust, we took into account the previous ratings of the nine core services not inspected this time.
  • Within the dental services, patients and those close to them were continually positive about the way staff them and they reported that staff went the ‘extra mile’.
  • Across all services staff understood and respected the individual needs of each patient and supported them to understand and manage their care, treatment or condition.
  • Overall, staff ensured that patients had easy access to advocates when needed.
  • Overall, staff informed and involved families and carers appropriately.
  • Staff were kind, caring and motivated to provide the best care and treatment they could for patients.
  • Within the child and adolescent ward, staff and patients had worked together to produce an impressive, large wall display to remind patients of ten key rights when attending care programme approach meetings.

However:

  • The mental health decision units did not provide privacy, maintain the dignity or promote the recovery of patients. Some patients had slept on reclining chairs for up to 10 days whilst they waited for a bed. Patients were dissatisfied with their treatment on the units. Food options were limited. There were fridges and freezers located in the lounge where patients slept which were noisy. Staff did not make sure patients could access advocacy services. Patients and carer feedback opportunities were limited.

Responsive

Requires improvement

Updated 11 September 2019

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

  • We rated one of the trust’s 14 core services as inadequate for responsive, two as requires improvement and eleven as good. In rating the trust, we took into account the previous ratings of the nine core services not inspected this time.
  • The acute care pathway did not function effectively and services were not able to meet demands. Gatekeeping arrangements within the home treatment teams were not effective and they did not provide a 24 hour service.
  • There were significant blockages within the system which directly impacted on patient care throughout services. There were not always beds available for patients in the catchment area. The use of out of area beds was high. Patients stayed on the mental health decision units and in the health-based places of safety for excessive lengths of time due to no bed being available for them to be transferred into. The mental health decision units were not fit for purpose and they persistently failed to meet the basic needs of patients.
  • Discharge was delayed for other than clinical reasons on the acute wards, this included waiting for appropriate accommodation for patients to be discharged to.
  • Patients referred to community mental health teams had unacceptable waits even those assessed as urgent. The service had long waiting lists. Service users waited too long to be allocated to a care coordinator and for appointments with consultant psychiatrists. In Lancaster and Leyland there were patients waiting for up to 12 months for transfer to community mental health teams from home treatment teams.
  • The trust did not have effective local arrangements for young people who were detained under section 136 of the Mental Health Act.
  • On Scarisbrick ward, there were four two-bed dormitories, beds were separated by curtains. This meant patients did not have their own space and privacy protected in their bedroom.

However:

  • Staff met the needs of all patients including those with a protected characteristic.
  • Staff treated concerns and complaints seriously, investigated them and learned lessons from the results were shared.
  • Within the child and adolescent ward, staff planned and managed discharge well by liaising with services that would provide aftercare and were assertive in managing the discharge care pathway. As a result, patients did not have excessive lengths of stay and discharge was rarely delayed for other than a clinical reason.

Well-led

Requires improvement

Updated 11 September 2019

Our rating of well-led went down. We rated it as requires improvement because:

  • We rated two of the trust’s 14 core services as inadequate for well led, one as requires improvement and eleven as good. In rating the trust, we took into account the previous ratings of the nine core services not inspected this time.
  • Trust leaders had not addressed the failings within the acute care pathway despite being aware of these issues. Senior managers had not identified and improved the quality of the service. There were significant problems with the performance of the governance framework throughout the pathway.
  • We had significant concerns about patient safety, privacy and dignity and the functioning of the mental health decision units which trust leaders had failed to address following our last inspection.
  • The governance systems in place for the oversight of the mental health decision units was not effective. It was practice for patients, including children, to remain on these units over the 23 hour limit within the statement of purpose and CQC registration condition. Breaches were not consistently reported by staff. This meant the trust did not have complete data relating to the breaches. This had not improved since our last inspection.
  • Trust leaders had failed to ensure that patients were not being detained in the health-based places of safety past the expiry of the section 136. Patients were subject to restrictive interventions without the appropriate legal safeguards in place. This practice had become routine. This had not improved since our last inspection.
  • Environmental issues within some of the health-based places of safety had not been addressed following our previous inspection.
  • Staffing issues within some of the acute wards for adults of working age and psychiatric intensive care units, health-based places of safety, home treatment teams and community based mental health services for adults of working age had not been effectively addressed.
  • Staff were not always providing consistently safe care within the acute wards for adults of working age and psychiatric intensive care units. Staff were not always following the seclusion policy, medicines management policy and infection control practices.
  • Staff were not consistently managing risks in relation to patients smoking on the wards.
  • Staff were not always receiving appraisals, supervision and training required in line with trust policy.

However:

  • Trust leaders and staff we spoke with demonstrated a motivation and commitment to implementing the improvements and changes needed. Staff were optimistic they would be supported in doing so under the new leadership team and by their immediate managers.
  • Despite the challenges some staff faced, morale was improving, and staff were committed to providing the best care they could. All staff demonstrated a positive culture of being open and honest.
  • Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff demonstrated these with patients, carers and team members in the interactions we observed.
  • Overall, staff felt respected, supported and valued. They felt able to raise concerns without fear of retribution.
  • There were effective systems in place to identify learning from incidents, complaints and safeguarding alerts and make improvements.
  • Staff responded to and managed complaints effectively.
  • There was a robust audit programme in place to monitor compliance against trust policies and best practice guidance.
  • Staff felt that leaders were approachable and visible.
  • Governance processes operated effectively within the child and adolescent ward and across the dental services where performance and risk were managed well, and quality improvement was embedded.
Checks on specific services

Community-based mental health services for older people

Good

Updated 11 January 2017

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

• There were safe lone working practices which were standardised across each of the localities. This promoted staff safety when visiting patients’ homes. Staff had manageable caseloads which helped to promote staff keeping patients safe. Referral information was coordinated and actioned quickly to minimise risk. Care plans had crisis care plans to inform patients and carers on what to do in crisis. Patients’ records contained comprehensive risk assessment and were stored securely on the electronic patient record.

• Staff were up-to-date with mandatory training. Staff had regular supervision and there was a new structured appraisal process which had quarterly review intervals. The new appraisal included key objectives and the trust’s visions and values.

• Teams had effective multidisciplinary working in the delivery of care and treatment. There was good interagency working with voluntary and third sector organisations. Staff took action to ensure that patients’ physical health needs were monitored and treated.

• The service had good systems to ensure the Mental Health Act was followed where patients were on a community treatment order. Staff had a good understanding of the Mental Health Act and Mental Capacity Act.

• There was a process in place so that patients on a community treatment order were informed about the availability of the independent mental health advocacy service and had their rights read to them.

• Patients spoke highly about the care they received from the staff within each of the older adult services. Patients told us about staff going the extra mile to support patients. Patients and those close to them were involved in the decisions around care and treatment.

• Access to services was coordinated through a single point of entry in each locality. There were some waiting lists but these were within the guidelines from the standard operating procedure of the service delivery timescales. This meant that teams were meeting the targets expected of them.

• There were low numbers of complaints and these were well managed. The service received 238 compliments within the last 12 months.

• Staff understood the trust’s vision and values. Teams were well-led by committed managers and staff felt respected and supported. Effective managerial operational meetings took place where incidents were discussed, team performance was reviewed and staffing and sickness in teams was considered. There was a commitment to service improvement to meet the needs of different patient groups.

However:

• The Fylde Coast rapid intervention and treatment team had changed their operational hours as a result of vacancies and safe staffing levels.

• The services were not routinely undertaking fire drill testing at each of the team localities.

• The executive management team were not fully visible and in some cases staff did not know who they were.

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

Inadequate

Updated 11 September 2019

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

We have taken enforcement action against this service which has limited ratings for some key questions to inadequate. We have issued a section 29A warning notice to the trust with improvements that need to be made by 20 December 2019.

  • The service did not provide safe care. Four ward environments were not safe and clean and ten ward environments did not protect patients’ privacy and dignity. The wards did not have enough nurses. Medicines were not always managed safely.
  • Staff did not receive training in how to best meet the needs of people with a personality disorder, learning disability or autism. Staff did not create specific care plans for patients with epilepsy or moving and handling needs.
  • Managers did not ensure staff received training, supervision and appraisal.
  • A patient had been detained at the Orchard without the safeguards afforded by the Mental Health Act or Mental Capacity Act; 12 detained patients had been given medication that had not been included on the relevant consent to treatment documentation; the trust’s Mental Capacity Act and Deprivation of Liberty Safeguards policy did not give an accurate definition of the meaning of capacity within the Act.
  • The service did not manage beds well. A bed was not always available locally to a person who would benefit from admission and there was a very high demand for the beds and an ineffective strategy to manage those demands.
  • The service was not well led, and the governance processes did not ensure that ward procedures ran smoothly.
  • The service had not addressed two regulatory breaches from the inspection in 2018 and had a further regulatory breach that was also a breach in 2016.

However:

  • Staff were passionate about their role and were caring and supportive towards patients. Staff understood and implemented safeguarding procedures.
  • Staff were now receiving appraisals and conducting observations post rapid tranquillisation of patients, these were regulatory breaches at the inspection in 2018.

Child and adolescent mental health wards

Good

Updated 11 September 2019

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

  • The service provided safe care. The ward environment was safe and clean. The ward had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary 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. They followed good practice with respect to young people’s competence and capacity to consent to or refuse treatment.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. Staff actively involved patients and families and carers in care decisions, where possible, including working together to produce an impressive wall display to remind patients of ten key rights when attending care programme approach meetings.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

  • While staff ensured that they were recording most of safeguards relating to seclusion, we found one example where staff had not recorded that parents or carers were informed of one seclusion episode.
  • There were a small number of minor issues picked up in our clinic check including some stock medication exceeding suggested amounts and some unnecessary clutter. This was due to the recent change from two wards to one ward and staff were aware and working on these.
  • While detention papers had been checked by the receiving nurse and scrutinised by an administrator, on three out of four relevant records, we did not find evidence of medical scrutiny to make sure the clinical grounds for detaining patients were made out.
  • Staff were discussing patients’ religious needs with them but, in one record, these discussions were not fully reflected in the patient’s care plans. Care plans could provide more detailed information about patients’ education status and needs. The education provision was limited but this was beyond the full control of the trust.

Community-based mental health services for adults of working age

Requires improvement

Updated 11 September 2019

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

  • The service could not demonstrate that it managed risks to service users effectively. Although staff assessed risk well, the resulting risk management plans did not address all risk identified and were vague and not personalised. Staff did not have access service user information that was held on the local authority electronic records system.
  • There were unacceptable waiting times for service users to be assessed, to be allocated to a care coordinator and for appointments to see consultant psychiatrists.
  • Staff supervision rates had been low over the last 12 months.
  • Systems were still not in place to ensure that the corresponding legal authority to administer medication to patients subject to a community treatment order were kept with the medicine chart and reviewed by nurses administering medication. We were not assured that service users on Community Treatment Order were being read their rights at regular intervals in accordance with the Mental Health Act and code of practice.
  • Staff did not have access to information that was held on the local authority electronic record system. Telephone calls from service users often went unanswered.
  • Senior managers did not respond promptly to failings within the service. Issues were not identified and addressed causing significant shortfalls to many aspects of service user care.

However:

  • Clinical premises where service users were seen were safe and clean.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the service user. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of the service users. Managers ensured that these staff received training and appraisals. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood and discharged their roles and responsibilities under the Mental Capacity Act 2005.
  • Staff treated service users with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The criteria for referral to the service did not exclude service users who would have benefitted from care.

Community dental services

Good

Updated 11 September 2019

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

  • Staff had good access to training to support their roles. Managers had oversight on mandatory training levels. Staff had a good awareness of the need to protect patients from abuse and neglect and there were systems in place to support them. Premises and equipment were clean and well maintained. The service followed best practice guidance on the decontamination and sterilisation of used dental instruments. Staff had a good awareness of the incident reporting process. Incidents were investigated and where necessary the patient was fully informed, and an apology given in line with the duty of candour.
  • The clinicians provided care and treatment tin line with current nationally recognised guidance. There was an effective use of skill mix within the service including dental therapists and dental nurses with extended duties. Staff worked with other healthcare professionals in the best interest of patients. Staff had a good understanding of the importance of obtaining and documenting consent and were fully aware of their responsibilities under the Mental Capacity Act 2005.
  • Staff cared for patients with kindness and compassion. During the inspection we received feedback from 35 patients. They told us that staff were friendly, helpful calm, kind and patient. We witnessed positive interactions between staff and patients throughout the inspection. The service carried out the NHS Friends and Family Test. Between June 2018 and June 2019, the service received 2379 responses. Of these responses 99% of patients would either highly recommend or recommend the service to friends and family. Staff from one location were due to receive an award for obtaining 1435 responses between June 2018 and June 2019.
  • The service took into account patients individual needs. All locations which we visited were fully accessible for wheelchair users and those with limited mobility. They had access to wheelchair tippers. There was access to translation services and arrangements for patients with sight and hearing loss. The service dealt with complaints promptly, positively and efficiently.
  • There were clearly defined roles and responsibilities within the service supported by an effective management structure. Governance arrangements were well embedded and there were clear lines of accountability. Morale within the service was good and staff spoke proudly and passionately about the service which they provided. The service actively monitored and managed risk well. The service engaged well with staff, patients, external stakeholders and other healthcare professionals well in order to continually improve the service.

Mental health crisis services and health-based places of safety

Inadequate

Updated 11 September 2019

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

We have taken enforcement action against this service which has limited ratings for some key questions to inadequate.

  • We had significant concerns about patient safety, privacy and dignity in the Trust use of mental health decision units. These units were intended for short stay, under 23 hours, but were now routinely being used as additional wards. The accommodation was not designed for this and patients were sleeping in reclining chairs in shared lounges for up to 10 days. Because these units had not been designed to accommodate patients for long periods, there were issues with food availability, bedding and linen, private space to change clothes and no safe places to store possessions. One decision unit, at Preston, was a mixed sex facility where men and women were sleeping in the same lounge. This is in breach of same sex accommodation guidance where service users in mixed sex accommodation are expected to have individual bedrooms or bed areas which are solely for one gender. Additionally, we had concerns about the use of mental health decision units for patients under 18 years old. In the last 12 months, 13 children were admitted to the decision units at Preston and Blackburn, although three are noted as multiple events so the admissions figure is higher. This practice was of concern because the trust did not recognise under 18-year olds as children. Admissions of children to these units was not incident reported. Children in mental health decision units did not routinely have access to child and adolescent mental health specialists. Staff were not sufficiently guided to consider risks relating to children and their placement alongside adults.
  • Full information about our regulatory response to the concerns we have described will be added to a final version of this report, which we will publish in due course’.
  • We had significant concerns about patients detained without lawful authority once the detention period under section 136 had ended. For patients who had been assessed as needing further detention under the Mental Health Act, they were not able to leave. Staff had been advised to assess capacity and that patients were then detained “in their best interests”, but this is not a lawful deprivation of liberty. The Mental Capacity Act cannot be used to authorise detention in this way. Some patients had recommendations completed for detention under the Mental Health Act, so appropriate means of detention were already being utilised. The applications were not completed as there had not been a bed identified in a specific hospital. This situation had deteriorated since the last inspection in 2018. This requires significant improvement as patients were being deprived of their liberty without a legal framework in place for this.
  • We also had significant concerns that governance systems in place for the oversight of the 136 suites and stays over 23 hours in mental health decision units were not effective. The trust data was incomplete in relation to patients who remained in section 136 suites and admissions over 23 hours to mental health decision units.
  • As a result of these concerns, we have issued the trust with a warning notice to make significant improvements.
  • In the Preston 136 suite and the home treatment team offices at Ormskirk, there were issues in relation to maintenance of the buildings. The 136 suite at Preston had a shower room which had evidence of mould growing and cracked tiles. This had been identified at a previous inspection but not addressed. In Ormskirk, there was a hole in the ceiling in the waiting area. The reception office floor was cracked. Ventilation in reception and in the interview rooms was poor.
  • Across all the teams, there were issues with staffing, despite staff now being recruited specifically to work in 136 suites. Staff were not all trained in basic life support and overall completion of mandatory training was below the trust target. Staff were not receiving regular supervision of their work.
  • Gatekeeping arrangements were not effective. Gatekeeping arrangements were not always made with a home treatment team assessment and monitoring of these patients was often over the phone rather than face to face.
  • Home treatment teams did not have sufficient flexibility to offer a full 24-hour service. In Lancaster and Leyland there were patients waiting for up to 12 months for transfer to community mental health teams. This impacted on the teams’ abilities to work more proactively, for example, in seeing patients on wards to facilitate early discharge or admission avoidance work. Only one home treatment team provided any input into inpatient services in terms of early discharge or diversion.
  • Actions in relation to complaints were often recorded as an apology being offered or expectations managed, but there was no evidence of investigation of systemic issues and wider changes.
  • Our findings from the other key questions demonstrated that governance processes did not operate effectively at team level and that performance and risk were not managed well. We were not assured that the trust was collecting meaningful data to understand the scale of the issues apparent across this core service. The risks associated with prolonged stays in section 136 suites and decision units were not recognised.

However:

  • The home treatment teams included or had access to the full range of specialists required to meet the needs of patients under their care, including clinical psychologists and occupational therapists. Staff working for the home treatment teams provided a range of care and treatment interventions that were informed by best practice guidance and suitable for the patient group.
  • Staff in all services were generally described as discreet, respectful, and responsive when caring for patients.

Forensic inpatient or secure wards

Good

Updated 23 May 2018

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

  • Patients using the service told us that they were treated with dignity and respect and described the staff as caring and helpful. We observed that staff took time to communicate with patients in a respectful and compassionate manner and patients were empowered to become active participants in their care.

  • All patients underwent a thorough assessment of need, care plans were holistic and recovery oriented and included physical health assessments, these were completed in collaboration with the patients, progress was regularly reviewed.

  • Regular multidisciplinary meetings were held and attendance by outside agencies was encouraged. Families and carers were involved in this process where appropriate. Advocacy services were accessible and available to support patients.

  • The hospital followed national guidelines on cleaning standards and monitoring procedures to provide and maintain a clean and appropriate environment to prevent and control healthcare associated infection. The wards were clean and tidy and there was an established cleaning regime. All clinic rooms were fully equipped. Emergency equipment was accessible to all and was maintained appropriately. Medicines were dispensed and stored securely and audits undertaken to ensure safe practice.

  • The ward environments were subject to constraints in observation. These were effectively managed and risks mitigated with the use of observation and individual risk management planning. Regular environmental quality checks were conducted and patients were able to discuss and resolve environmental issues in community meetings.

  • Electronic rostering was used to support staff management and staffing was reviewed regularly to ensure there was enough staff with the relevant skills to deliver safe patient care. Patients were supported by a skilled multidisciplinary team of staff which included nursing, psychiatric, psychological, occupational and dietetic support. Treatment practices were based on nationally recognised guidance.

  • Any identified spiritual needs and cultural requirements were supported and families and carers groups were active in the service.

  • Safeguarding processes were in place which reflected national guidance, and understood by all staff. There was a clear structure of reporting and responsibility for safeguarding adults and children. Any concerns relating to adult and child protection were communicated to the relevant protection agencies.

  • Restrictive practices were reviewed regularly and patients were involved in the process. Regular patient surveys and community meetings informed improvements in patient care across the hospital.

  • Staff were trained in and had a good understanding of the Mental Health Act and Mental Capacity Act. Staff followed local procedures and support was available from mental health act administrators. Patients were given information and support to ensure appropriate representation and aid understanding of their rights.

  • There was an established governance structure with a defined hierarchy of reporting and decision making within the service. There were clear systems of accountability and senior managers were actively involved in the operational delivery of the service. There was a clear statement of visions and values, staff knew and understood the vision, values and strategic goals of the service.

  • Staff we spoke with were positive about their roles and were positive about service development. Staff felt able to raise concerns without fear of victimisation and spoke positively about the organisation. They told us that they felt valued, had input into the service and were consulted and involved in service quality developments.

However:

  • Most non-refrigerated medicines must be stored at less than 25°C to ensure they remain effective. Ambient room temperatures in two clinic rooms regularly exceeded this temperature.

  • Key access to the seclusion room on some wards was limited and staff described some difficulty finding key holders to access these rooms.

Community health inpatient services

Good

Updated 23 May 2018

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

  • Staff knew how to report incidents and these were discussed at monthly team meetings.
  • The staffing levels had improved since the last inspection to between 90% and 100%. Staff followed a formalised flow chart of actions to be taken if there were instances of sickness.
  • Infection control and prevention audits were regularly undertaken.
  • Records we saw were comprehensive, patient centred and used recognised assessment tools for monitoring pain, nutrition, hydration and skin condition.
  • The service participated in National Institute for Health and Care Excellence audits such as the use of waterlow scales and end of life care.
  • The service continued to have input from pharmacists, a physiotherapist, occupational therapist, integrated therapy technician and speech therapy. With the introduction of the community frailty service staff ensured there was improved joint working and more timely access to their services.
  • Staff had access to training and development and there were nurse links for tissue viability, end of life care, dementia, falls and infection control. Healthcare support workers were about to enrol on the associate practitioners course which would enable them to enhance their practical skills.
  • Patients were very positive about the care they received and we saw patients were treated in a professional and caring manner.
  • At the last inspection management of the risk register was found to be poor. We found the risk register was now up to date, reviewed monthly and actions taken where needed.
  • Patient outcomes were collected and monitored using the national hip fracture audit and national Parkinson’s audit.
  • There was good leadership at ward level and above. Staff spoke highly of their line managers and told us they felt listened to.

However:

  • There were still two registered nurse vacancies to be filled. These were being advertised at the time of the inspection.
  • At the last inspection some staff were unsure of their future due to a lack of direction and strategy for the service. We found the service had made inroads into developing their service and there remained six members of staff on six temporary contracts. Further work was needed to ensure these contracts were made substantive.

Community mental health services with learning disabilities or autism

Good

Updated 11 January 2017

We rated community based services for people with a learning disability or autism as good because:

  • Person-centred therapeutic interventions were being delivered to patients to support them to achieve improved independence and wellbeing.
  • Interactions between staff and patients demonstrated personalised, collaborative, recovery-oriented care planning.

  • Comprehensive risk assessments for patients were completed and reviewed and clear crisis plans were in place where patients were assessed as

  • Staff had a good understanding of the principles and application of the Mental Capacity Act.
  • Patients were protected and safeguarded from avoidable harm and incidents were appropriately reported.

  • Patients’ individual care and treatment was planned and best practice guidance was implemented, ensuring outcomes were monitored and reviewed.

  • Staff had knowledge and skills to deliver effective care and treatment and staff received support and supervision from their managers and peers.

  • Patients and their carers were positive about the care and treatment they received and staff behaviours were responsive, respectful and caring. Staff involved patients and their carers in the care and treatment they received.

  • Managers were able to provide information into the governance meetings and staff received regular feedback from these meetings. They were kept up to date about their team’s performance.

  • The management and governance arrangements within the directorate were effective and teams were able to feed information about risk into the risk register.The trust had identified 38 items on their risk register in relation to learning disability and autism community services and these were being reviewed and monitored by the trust.

However;

  • There were gaps in the mandatory/essential training that staff should have received and not all staff had received an appraisal.

  • Commissioning arrangements meant that the staffing skill mix and provision of psychiatric cover across the trust was variable.

  • Information about complaints, concerns and compliments was not adapted to meet the needs of some patients with a learning disability.

  • An audit of antipsychotic prescribing in people with a learning disability identified that there was action required against standard three of a quality improvement programme-prescribing audit. There were no clear dates for the action plan implementation following the audit.

Community health services for children, young people and families

Good

Updated 11 January 2017

Overall, we have judged that community health services for children, young people & families is “Good”. This is because:

  • Staff knew how to report incidents and reported receiving feedback in a number of ways. Staff could describe incidents that had been reported and identified actions taken in response.

  • The trust had implemented “Risk sensible” approach safeguarding training for all practitioners in the children and families network. This assisted with the identification of risk and enabled effective communication with social care colleagues using a common language.

  • Paper and electronic records we reviewed were completed to a good standard and included relevant patient information including name, address, date of birth as well as care plans, referrals and safeguarding information as appropriate.

  • All clinical areas we visited were visibly clean. We observedhandwashing and infection control practices in home visits and at a baby clinic, appropriate cleaning of equipment between patients and use of personal protective equipment.

  • Caseloads in universal services for children and young people were weighted to ensure a standardised approach to decision making across the trust and the weighting of each child was clearly identified on the electronic care record (ECR).

  • The service used National Institute for Health and Care Excellence guidelines to determine care and treatment. Health visiting and school nursing teams worked to deliver the Healthy Child Programme and two of the five contacts were delivered using the Ages and Stages evidenced based screening tool.

  • Health visitors used tablet computers to access records and document contacts while in clinic settings or during family visits. The use of internet software allowed staff from across bases to connect in to daily huddles without the need to travel and ‘Chat Health’ was being introduced across the school health service which allowed students and parents to contact the school health service by telephone and text in a confidential and accessible manner.

  • We observed several examples of multi-disciplinary working during our inspection, in both health and education settings, with clinicians collaborating to support the planning and delivery of care to children, young people and their families.

  • Contacts we observed showed information provided to children and families was clear and tailored to the individual child. Families were offered choice regarding their child’s care and given the opportunity to ask questions. Families engaged with the Children’s Integrated Therapy and Nursing Service were involved in writing their child’s care plan.

  • The Children’s Integrated Therapy and Nursing Service staff arranged joint visits to families to reduce the need for attendance at multiple appointments and health visitors in the West Lancashire area had returned to individual allocation of community clinics to promote continuity for families in response to service user feedback.

  • The Family Nurse Partnership was offered in the Preston and Burnley area to first time mothers aged 19 years and under to improve health, social and educational outcomes. Identified liaison health visitors were in post to provide support and advice to families placed in a refuge and safeguarding specialist nurses worked in partnership with other agencies to provide health assessment, advocacy and support for children and young people involved with the youth offending team or identified as being at risk of child sexual exploitation.

  • The Clinical Director for the children and families network provided a monthly quality and performance report to the Quality and Safety sub-committee and performance was monitored against a variety of targets and data. Staff we spoke with were aware of the key performance indicators relevant to their role and individual performance was reviewed in monthly one to one meetings with their line manager.

  • We observed strong leadership from team leaders and managers and staff spoke positively about the team leaders, describing them as visible, accessible and supportive. Monthly team meetings took place to ensure staff received information and feedback regarding incidents and complaints and were kept informed of developments within the trust.

  • The safeguarding team were not routinely being copied in to referrals made to children’s social care. This meant that managers did not have an accurate picture of safeguarding activity across the trust.

  • Safeguarding supervision was practitioner-led and delivered in a group setting where each practitioner would bring one case to discuss. While safeguarding specialist nurses were available to provide telephone advice and team leaders were available for ad hoc support, this meant that not all safeguarding cases were subject to objective, critical reflection.

  • At the time of our inspection the antenatal contact was not being delivered consistently to all pregnant women in the trust. Staff and managers told us that there were delays receiving information about patients accessing antenatal care from local acute providers and this was recorded on the trust risk register.

  • Annual appraisal rates for non-medical staff in community health services for Children, Young People and Families was 73%. Compliance rates in individual teams ranged from 29% (6 out of 15 staff) in the Blackburn with Darwen CITNS team to 100% in the 0-19 South Ribble East team (19 staff).

  • From January to August 2016 referral to treatment times for occupational therapy consistently missed the 92% standard averaging 73% in this time period.

  • From January to August 2016 referral to treatment times for speech and language therapy  consistently missed the 92% standard averaging 89% in this time period.

Specialist community mental health services for children and young people

Good

Updated 11 January 2017

We rated Lancashire Care NHS Foundation Trust specialist community child and adolescent mental health services as good because:

  • All parents and young people said staff were welcoming, caring and respectful and listened to them. They found the service helpful and described positive change that had occurred after contact with the service. Parents could easily contact staff and found the teams responsive to their needs.

  • Governance structures were in place to monitor performance targets and risk. Key performance indicators were used to assess the effectiveness of the service offered to young people. Most teams met the trusts target of 18 weeks waiting time from referral to assessment. Issues affecting waiting times such as staff performance, sickness and vacancies were monitored and addressed promptly. 

  • Staff employed by the service had good compliance with mandatory training, supervision and appraisals and had opportunities for specialist staff training and development. Child and adolescent mental health services had a range of suitably qualified staff who offered a choice of therapies to young people and their families.

  • Staff had a clear understanding of the trusts safeguarding procedures. Safeguarding systems were in place to support staff in the safeguarding process and monitor safeguarding incidents across the trusts children and families network. Staff had a good understanding of issues of consent and Gillick competence in their work with young people.

  • Staff had a good understanding of National Institute of Health and Care Excellence guidance and other national guidance. Nine evidence based care pathways had been developed and were in the process of being introduced across the service.

  • Staff described effective communication and referrals between services, such as local schools, social workers, GPs and health visitors. Systems were in place to support young people transitioning to adult services. The effectiveness of these systems was subject to ongoing review.

  • Information about how to complain was readily available to young people and their families. Complaints were dealt with promptly and monitored across the children’s and families network. Parents, young people and staff were aware of the independent advocacy service. Child friendly posters and the trusts website gave comprehensive advice on how to access independent advocacy services.

  • Staff felt valued and supported by their colleagues and were aware of the senior management team within the trust.

However:

  • Not all young people had an up to date current risk assessment present in their care records. This meant young people were at risk of receiving care that did not take into account identified risks.
  • The service did not collate quality measures in relation to primary reason for referral making it difficult to assess condition specific waiting times in line with National Institute of Health and Care Excellence guidance.

Community health services for adults

Requires improvement

Updated 11 January 2017

Overall, we have rated community health services for adults as “Requires Improvement”. This is because:

  • We were not assured that all lessons learnt were being identified in the root cause analysis investigations we reviewed or areas identified for improvement were being monitored.

  • In the Integrated Nursing Teams (INTs) in Chorley and South Ribble, and Blackburn with Darwen localities, we found 18 out of 20 patients records where patients had died, that did not have an end of life care plan in place.

  • In Chorley and South Ribble INTs and the treatment room service, there were not always care plans in place for problems that had been identified. We found incomplete assessments, wound evaluation charts not updated at least fortnightly in line with the trust management of wound’s policy, and not all entries had the time of entry documented.

  • Data for mandatory training and appraisal rates provided by the trust was not as accurate and up to date as data held at team level.

  • An audit had been performed to monitor storage of medicines and had reported issues with clinic room temperatures not being monitored which we observed at the time of our inspection and we were not assured that clear actions and improvements had been made. When staff had raised issues with the temperature recordings being high in clinics and treatment rooms, as per the trust policy, no action had been taken.

  • The Integrated Nursing Teams (INTs) were not using a staffing acuity tool and of the seven INTs we visited we found two that mentioned the use of a caseload weighting tool. Since our previous inspection the trust had been reviewing potential tools and had analysed activity data to inform a new model of care. Due to on going transformation work at the trust, the business case for staffing against activity had been placed on hold.

  • We requested documentation audits specifically for the INTs and were informed by the trust that the INTs had not participated in a documentation audit for the 12 months prior to our inspection. Documentation issues had been highlighted in root cause analysis investigations in relation to pressure area care.

  • The trust data identified that a total of 575 pressure ulcers had developed whilst patients were on the services caseloads. There were 13 of these that deteriorated which suggest that once a pressure ulcer developed care and prevention strategies were implemented to prevent any deterioration. We were not assured that prevention strategies were put in place to prevent the development of pressure damage. During our inspection we found care plans and risk assessments were not always in place or updated and this was also identified as part of a root cause analysis investigation.

  • Systems in place to ensure staff were safe at the end of an evening shift were not always followed.

However:

  • The trust had a range of mandatory training available to staff and staff compliance met the trust target of 85%.

  • Staff had an annual appraisal where learning needs were identified. The trust provided opportunities for staff to develop which included placements at education establishments. Developmental roles for band five nurses had been implemented for staff wanting to develop into leadership roles. This also assisted the trust to develop and recruit senior nurses from within their own workforce.

  • There was good evidence of services and disciplines working together to improve services for patients and included: the intensive home support service, the discharge planning team, the Care Home Effective Support Service (CHESS) Team and the diabetes service.

  • People who used the services were able to ask questions, discuss care, and were involved with decision making. The services received positive comments about the staff and the care provided and patients were treated with dignity and respect.

  • There was evidence of delivering services to meet patient’s needs. There had been a review of the community matron service which identified the need for specialist Chronic Obstructive Pulmonary Disease (COPD) services and rapid access to care to prevent hospital admissions. There was evidence of multi-agency and patient focus groups to inform delivery of services which resulted in a more integrated approach to service delivery via the intensive home support service.

  • Podiatry services had implemented a one stop assessment for patients who may require nail surgery which resulted in a reduction of additional appointments for patients and an increase in podiatry staff availability. The service had direct access to a vascular surgeon where they could arrange urgent appointments and the service could order diagnostic tests prior to the patient attending the appointment to enable the consultant to have sight of all information at the time of consultation.
  • Staff felt supported and listened to and there was professional forums for nurses and allied health professionals.

Wards for older people with mental health problems

Good

Updated 11 January 2017

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

  • The ward layout was well planned in the Harbour services: the layout used space to good effect. At Hurstwood ward, space was at a premium but utilised well. Hurstwood ward was due to close in December 2016 and a new location with more space was planned. Any ligature points were assessed and mitigated for, and reflected in the trust risk register. Staffing had been improved by the use of the safecare system, allowing shortfalls to be identified and covered. Wards were clean and well furnished. Patients had comprehensive risk assessments completed. Any incidents on the wards were reported and dealt with effectively.
  • Care records were holistic, comprehensive and showed evidence of patient and carer involvement. Patients could access psychological interventions across the service. National guidelines were being followed. Physical health care was given strong consideration, and was monitored on all patients. The Mental Health Act and Mental Capacity Act were implemented and monitored effectively: regular audits and a centralised team ensured detained patients had their rights explained properly and regularly. However, it was noted that mandatory training figures for the wards did not match the figures provided by the trust and the system of core and effective training was confusing. We also saw that supervision and appraisals were being done for staff but all wards agreed that they needed to improve this aspect. Records showed that planning was in place for regular supervision and appraisals.
  • Staff were seen to interact in a professional and caring manner with their patients, with time and attention being given to all. We saw activities with patients that showed consideration for mental state and abilities, and staff were able to make the activities meaningful. Patients told us that generally, they were happy with the service, and comment cards from carers were mostly positive.
  • Ward staff actively tried to ensure discharge to appropriate locations were completed in a timely manner. Facilities at the Harbour site were excellent, and Wordsworth and Bronte wards used a mock ‘pub’ and a mock ‘café’ in the outdoor area for patients to relax. Hurstwood ward did not have a designated outdoor space for patients, but they were regularly taken into the hospital grounds to relax and get fresh air. The planned replacement location had a large outdoor area for patients so they did not have to be taken off the ward. Ward facilities were designed with disabled access, ensuring that wheelchairs could be used freely on the wards, and bathrooms had brightly coloured equipment so patients could easily identify facilities. The service only upheld seven complaints out of 24 complaints in the 12-month period from April 2015 to March 2016.
  • Staff knew and upheld the values of the trust: there was lots of evidence on each ward explaining trust values for both staff and patients. Staff knew who their senior managers were, and a non-executive director had recently spent a shift on a ward within the service as a support worker to experience life on a ward. Quality reports compiled by the trust showed that the service was actively monitoring physical health, record keeping, mental health and observations, with good results. Wordsworth and Bronte wards had recently taken part in a human rights project with a university faculty; the results were not known at the time of the inspection.       

Community health sexual health services

Good

Updated 11 January 2017

We rated  Community sexual health services as '

Good' overall because:

  • The service had recently come through a period of change, due to sexual health services being tendered across Lancashire. The procurement process and mobilisation of new teams created some obstacles and challenges for the staff and also some changes in the services systems. Despite this, we found a committed competent staff group who were patient focussed.
  • We found good processes in place to reduce the risk of abuse and avoidable harm in the service.

  • We found a good incident reporting culture where staff were clear on what to report and who they should report to.

  • The service had a good safety record; Incidents of harm in the service were low.

  • The staff, including managers and clinicians, told us their services were safe and took pride in their own professionalism and ability to make decisions about risk.

  • Electronic notes were clear, concise and care planning processes were evident.

  • The buildings were well maintained with adequate access and good infection control measures were in place.

  • We found adequate staffing numbers with a wide range of skills which matched patient need.

  • The service followed British Association for Sexual Health and HIV Guidance on the assessment and treatment of patients.

  • The service had good multi-agency relationships which matched the holistic needs of patients.

  • Staff in teams felt they were effective in their jobs and patient surveys showed similar findings.

  • The staff showed empathy and concern and were caring to the people they treated and understood the anxieties of patients in relation to sexual health treatment

  • There was an interpreter service available for patients whose first language was not English.

  • Patients consented to treatment and were informed about their treatment and were actively involved in decisions about their care, which included choices about date of appointments.

  • The service had flexible opening times including evening and weekends to cater for its population and also good dispersal of satellite services for easy access.

  • Managers showed good leadership and supported staff to deliver high standards of care.

  • Managers and clinicians had put good governance systems in place which managed risk effectively.

However,

  • Whilst the staff showed high levels of safeguarding knowledge we also found some inconsistency in recording of safeguarding training, due to the amalgamation of new staff groups and a change of specification.

  • Due to the recent change in service specification the teams had little in the way of quantitative or qualitative information which would have evidenced how effective they were.

  • We found the team in North Lancashire had experienced problems in obtaining new accommodation and this had a negative effect on morale amongst staff. The staff in the team highlighted that the Transfer of Undertakings (Protection of Employment), process had been stressful. In some cases staff were still being slotted into positions in the team. We found concern amongst the staff in the North Lancashire team that management were not as high profile and “hands on” in their service, when compared to counterparts based in Preston and Blackburn.