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Provider: Lancashire & South Cumbria NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 21 May to 26 May 2019

During a routine inspection

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.


CQC inspections of services

Service reports published 11 September 2019
Inspection carried out on 21 May to 26 May 2019 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 465.03 KB (opens in a new tab)Download report PDF | 3.03 MB (opens in a new tab)Download report PDF | 1.13 MB (opens in a new tab)
Inspection carried out on 21 May to 26 May 2019 During an inspection of Child and adolescent mental health wards Download report PDF | 465.03 KB (opens in a new tab)Download report PDF | 3.03 MB (opens in a new tab)Download report PDF | 1.13 MB (opens in a new tab)
Inspection carried out on 21 May to 26 May 2019 During an inspection of Community-based mental health services for adults of working age Download report PDF | 465.03 KB (opens in a new tab)Download report PDF | 3.03 MB (opens in a new tab)Download report PDF | 1.13 MB (opens in a new tab)
Inspection carried out on 21 May to 26 May 2019 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 465.03 KB (opens in a new tab)Download report PDF | 3.03 MB (opens in a new tab)Download report PDF | 1.13 MB (opens in a new tab)
See more service reports published 11 September 2019
Service reports published 23 May 2018
Inspection carried out on 8 Jan to 21 Feb 2018 During an inspection of Forensic inpatient or secure wards Download report PDF | 484.79 KB (opens in a new tab)Download report PDF | 2.11 MB (opens in a new tab)
Inspection carried out on 8 Jan to 21 Feb 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 484.79 KB (opens in a new tab)Download report PDF | 2.11 MB (opens in a new tab)
Inspection carried out on 8 Jan to 21 Feb 2018 During an inspection of Child and adolescent mental health wards Download report PDF | 484.79 KB (opens in a new tab)Download report PDF | 2.11 MB (opens in a new tab)
Inspection carried out on 8 Jan to 21 Feb 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 484.79 KB (opens in a new tab)Download report PDF | 2.11 MB (opens in a new tab)
Inspection carried out on 8 Jan to 21 Feb 2018 During an inspection of Community health inpatient services Download report PDF | 484.79 KB (opens in a new tab)Download report PDF | 2.11 MB (opens in a new tab)
See more service reports published 23 May 2018
Service reports published 20 February 2018
Inspection carried out on 4 - 5 December 2017 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 209.61 KB (opens in a new tab)
Service reports published 11 January 2017
Inspection carried out on 5 to 14 September 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 381.46 KB (opens in a new tab)
Inspection carried out on 12 to 14 September 2016 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 332.33 KB (opens in a new tab)
Inspection carried out on 13 to 15 September 2016 During an inspection of Community-based mental health services for older people Download report PDF | 387.52 KB (opens in a new tab)
Inspection carried out on 7 September and 13 to 15 September and 27 September 2016 During an inspection of Forensic inpatient or secure wards Download report PDF | 385.11 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Community health services for children, young people and families Download report PDF | 345.37 KB (opens in a new tab)
Inspection carried out on 12 to 16 September 2016 During an inspection of Specialist community mental health services for children and young people Download report PDF | 316.85 KB (opens in a new tab)
Inspection carried out on 13 to 15 September 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF | 403.52 KB (opens in a new tab)
Inspection carried out on 5 to 14 September 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 384.05 KB (opens in a new tab)
Inspection carried out on 12 to 16 September 2016 During an inspection of Child and adolescent mental health wards Download report PDF | 328.57 KB (opens in a new tab)
Inspection carried out on 12-15 September 2016 During an inspection of Community health services for adults Download report PDF | 412.67 KB (opens in a new tab)
Inspection carried out on 12 to 14 September 2016 During an inspection of Wards for older people with mental health problems Download report PDF | 338.13 KB (opens in a new tab)
Inspection carried out on 12-16 September 2016 During an inspection of Community health inpatient services Download report PDF | 337.15 KB (opens in a new tab)
Inspection carried out on 12th -15th September 2016 During an inspection of Community health sexual health services Download report PDF | 293.63 KB (opens in a new tab)
See more service reports published 11 January 2017
Service reports published 29 October 2015
Inspection carried out on 28 - 30 April 2015 During an inspection of Community health services for adults Download report PDF | 313.51 KB (opens in a new tab)
Inspection carried out on 28, 29 and 30 April 2015 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 308.67 KB (opens in a new tab)
Inspection carried out on 28 to 30 April and 1 May 2015 During an inspection of Forensic inpatient or secure wards Download report PDF | 436.62 KB (opens in a new tab)
Inspection carried out on 28 to the 30 April and 12 May 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF | 340.27 KB (opens in a new tab)
Inspection carried out on 28-30 April 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 353.98 KB (opens in a new tab)
Inspection carried out on 28 - 30 April 2015 During an inspection of Community health services for children, young people and families Download report PDF | 352.21 KB (opens in a new tab)
Inspection carried out on 27 - 30 April 2015 During an inspection of Community health inpatient services Download report PDF | 290.89 KB (opens in a new tab)
Inspection carried out on 28-20 April 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 382.13 KB (opens in a new tab)
Inspection carried out on 28 and 29 April 2015 During an inspection of Child and adolescent mental health wards Download report PDF | 341.15 KB (opens in a new tab)
Inspection carried out on 27/04/2015 – 01/05/2015 During an inspection of Community-based mental health services for adults of working age Download report PDF | 328.54 KB (opens in a new tab)
Inspection carried out on 28-30 April 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 387.22 KB (opens in a new tab)
Inspection carried out on 28th -30th April 2015 During an inspection of Community-based mental health services for older people Download report PDF | 357.81 KB (opens in a new tab)
See more service reports published 29 October 2015
Inspection carried out on 8 Jan to 21 Feb 2018

During a routine inspection

Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating. Our rating of the trust went down. We rated it as requires improvement because:

  • We rated three of the trust’s core services that we re-inspected as requires improvement overall. We rated safe and effective as requires improvement overall and well-led at trust level as requires improvement. In rating the trust, we took into account the previous ratings of the core services not inspected this time.
  • The trust continued to experience significant challenges recruiting and retaining staff in some core services. This resulted in a reliance on the use of agency and bank staff to ensure patients were kept safe. Managers and matrons worked clinical shifts. They reported this had impacted on their ability to ensure that staff accessed appraisals, supervision and mandatory training in line with trust policy on some wards. Compliance rates were particularly low on some wards. This had not improved since our last inspection.
  • Staff did not always monitor patients following the use of rapid tranquilisation on the acute and psychiatric intensive care wards. This had not improved since our last inspection.
  • The trust did not have a robust mechanism in place to capture compliance with supervision. This meant that the trust did not have adequate oversight of this and there was a reliance on managers reporting compliance.
  • On the child and adolescent ward, staff did not always have time to spend with all patients due to high levels of staff observation required for some patients. Activities did not always take place. Staff did not always interact proactively and positively with patients. There were delays in repairing broken doors which negatively impacted on the environment. Staff did not review all adverse incidents and debriefs and lessons learnt did not always take place. Staff morale was low and they did not feel supported by senior managers within the trust.
  • Due to high bed occupancy, staff could not always admit people detained under section 136 of the Mental Health Act within 24 hours, the time limit set out in the Mental Health Act. This occurred when patients had been assessed as needing hospital admission, but there were no beds available.
  • The crisis support units were intended to accommodate patients for up to 23 hours. However; patients who required admission were sometimes held in the unit for several days and nights because there was no bed available on an admission ward. This resulted in patients having to sleep in a reclining chair because the crisis support units did not have beds.

However:

  • We rated caring and responsive as good overall.
  • The trust’s visons and values were embedded across the trust.
  • Board members had good oversight and understanding of the key priorities, risks and challenges faced by the trust and actions in place to mitigate these.
  • There was a robust and realistic strategy for achieving the priorities and developing good quality, sustainable care which had been developed with external stakeholders.
  • The trust ensured that cost improvement plans did not compromise patient care.
  • Risks identified on the board assurance framework and corporate risk register reflected those we found in core services.
  • Patients were generally positive about the care and treatment they received from staff.
  • The quality of risk assessments and care plans was of a good standard overall.
  • Staff were open and transparent in reporting safeguarding issues and incidents.
  • Complaints and incidents were investigated by a dedicated team. Reports were of a good standard and there were systems in place to share learning.
  • The trust met the fit and proper person’s requirements.
  • Staff had access to performance dashboards to monitor progress and improve service provision. The trust had a robust audit programme in place.
  • Medicines management, infection control management and monitoring of the Mental Health Act was good across the trust.
  • Despite the challenges staff faced due to the increased acuity of patients, staffing issues and increased demand for beds in some core services, staff remained committed and motivated to providing the best care possible and improving services for patients.
  • Staff felt supported by their immediate and local senior managers and matrons.

Inspection carried out on 12-16 September 2016

During a routine inspection

We rated the trust as ‘good’ overall because:

  • eleven of the thirteen core services we inspected were rated as good overall

  • staff treated patients with respect, care and compassion

  • staff communicated with patients in a way that was appropriate to patients’ individual needs

  • patients told us that staff treated them well and were responsive to their needs

  • patients had been involved in service development

  • despite the staffing challenges the trust faced, there was evidence to demonstrate that services were committed to minimising the impact this had on patient care

  • staff completed timely and comprehensive assessments for all patients including risk and physical health needs

  • the board had strategic oversight of potential risks which could impact on their ability to deliver services and had actions in place to mitigate these

  • the trust had a dedicated team to investigate serious incidents, all of whom had additional qualifications in root cause analysis.

  • staff were knowledgeable about their responsibilities in relation to reporting safeguarding concerns including to external agencies

  • most care plans were of good quality with evidence of patient involvement

  • services were being delivered in line with national guidance and best practice

  • the trust was compliant with the workforce race equality standard and was acting to understand and close the gap between treatment of white staff and those from Black and minority ethnic backgrounds

  • staff built and maintained good working relationships with agencies and stakeholders external to the trust

  • the trust had established systems in place to support the administration and governance of the Mental Health Act and Mental Capacity Act.

  • the trust’s strategy had been developed with the population’s specific health needs in mind

  • the trust had a dedicated equality and diversity lead to ensure the protected characteristics of the population were considered

  • the trust had identified that some wards did not meet the needs of the patient groups and had plans in place to move these to more appropriate buildings

  • arrangements for children and young people transitioning to adult mental health services had improved since our last inspection

  • the trust had a clear vision, supported by six values. The trust’s strategy was embedded across the four clinical networks

  • the trust’s board and council of governors understood their responsibilities. There was a clear framework by which the trust was held accountable for its actions

  • each clinical network had a clear, effective governance structure ‘from board to ward’

  • the trust had a number of established methods to promote engagement and communication with staff.

However:

  • in community health services for children and young people, not all safeguarding cases were being supervised and the trust safeguarding team was not routinely copied into referrals made to children’s social care

  • in the community child and adolescent mental health service, not all patients had an up to date and current risk assessment in their care record

  • in the acute wards and psychiatric intensive care units, significantly less than 75% of staff were trained in life support

  • the trust policy did not adequately deal with all the requirements of nursing patients in long term segregation in line with the Code of Practice

  • staff were not always providing person centred care to patients on a community treatment order

  • there were problems with the quality of care plans on Elmridge ward, in child and adolescent community mental health services and in community health services for adults

  • compliance with supervision and appraisal was below 75% in some services

  • the trust did not notify CQC of applications for Deprivation of Liberty Safeguards in more than 75% of cases between January 2015 and February 2016

  • there was a high demand for mental health beds, which meant that some patients were either being placed out of area or requiring intensive support from community teams

  • within the community health services for adults, staff did not do all that was reasonably practicable to mitigate the risks of patients developing pressure ulcers on their caseload.

Inspection carried out on 28-30 April 2015

During a routine inspection

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

We found that the provider was performing at a level that led to a rating of ‘requires improvement’ overall.

Following consultation with a range of staff and stakeholders, the trust had recently developed a new governance structure from board to senior management level to support the implementation of its five-year strategic plan. The structure was in its infancy and, as such, was in the process of being embedded in practice. It was configured to provide an effective mechanism for senior managers and the trust board to have strategic oversight and an informed understanding of the quality agenda, financial performance, operational issues and risks relating to the trust.

However, the governance structure from senior management level to ward level was in the process of being developed and was still in draft form at the time of our inspection. There was not an effective, existing governance structure in place across the four clinical networks. This had resulted in a disconnect between the four clinical networks which limited opportunities for shared learning across the networks. The trust acknowledged that there needed to be a common approach across the four networks to effect alignment with the refreshed governance arrangements and the assurance requirements of the corporate level structure needed to be clearly articulated to be embedded appropriately.

The lack of a clear structure from senior management level to ward level had also resulted in a disconnect between the board and the four clinical networks. This was shown by the number of environmental issues we found across services that compromised the safety of patients. The board was not aware of these issues, which were not in line with best practice guidance and the Mental Health Act (MHA) Code of Practice (CoP).

These included:

  • One older people’s ward that breached same sex accommodation guidance.

  • A number of seclusion rooms, a health-based place of safety, and the use of ‘Extra care Areas’ in the adult mental health service and that child and adolescent mental health service (CAMHS) that were not compliant with the Royal College of Psychiatrists’ standards and the Mental Health Act Code of Practice.

  • A number of maintenance and cleanliness issues in the forensic services and a lack of infection control audits in community CAMHS.

  • There were a number of wards and services which had furnishings or fittings that had ligature risks (places to which patients intent on self-harm might tie something to strangle themselves). Some of these ligature risks had not been identified through local audits.

  • Many of the children’s services were being delivered from locations that were not owned by the trust. These locations were not suitable environments for the services they were delivering.

  • The low number of risk assessments for clinic locations and the fact that they were not complete orcomprehensive meant the potential risks were not being clearly identified or addressed.

  • Connectivity for IT in the community was hindering a full move to electronic records and creating additional work for the staff converting paper records into electronic ones.

The trust had experienced challenges with staffing levels due to the relocation of some wards to the newly opened Harbour service, which was being proactively managed. However, in some other mental health services, staffing levels were not adequate or staff were not suitably qualified to meet patients’ needs.

In the community health services there were challenges including substantive staffing levels not being met in most children’s teams, although adult’s teams were better staffed. This was due to large case loads, the fluctuating population from seasonal workers and students, and the increased acuity of patients.

There was a gap in service provision for young people aged 16-18 years old. We identified a number of issues of concern in relation to the child and adolescent mental health services provided by the trust in the community. This included the lack of an appropriate transitional pathway for patients moving from CAMHS to adult services.

In the community health services, service redesign had led to restructuring of teams, which had brought smaller teams together. However, the leadership of these changes appeared to be restricted to band 7 clinical managers with minimal support in some areas from managers above this level. This demonstrated a lack of connection between service delivery and the board. The lack of supervision for band 7 allied health professional (AHP) clinical managers for two years and the lack of visibility of management above service integration managers in the district nursing service further demonstrated a lack of strategic support and control.

We found compliance with compulsory training, appraisals and supervision was inconsistent across all services and the trust was not meeting its own targets.

The trust had introduced a ‘smoke free’ initiative across all services in January 2015. This was not being consistently implemented, which had led to increased risks in some areas.

The trust was committed to reducing restrictive practices including the use of prone restraint, which was demonstrated by their strategy on this.

The trust was transparent and open in its approach to safeguarding and reporting incidents. We found evidence of the trust’s commitment to improve how it responded to complaints. However, we found that learning from incidents, complaints and the sharing of learning needed to be embedded and shared consistently across services.

Adherence to the principles of the Mental Health Act and its associated Code of Practice was good throughout the trust.

Medication management was good, with the exception of one community health services team where we found issues with the storage of vaccines and another team where medication recording issues were identified.

Patients’ care and treatment needs were assessed using a holistic approach that included a comprehensive physical health needs assessment. A range of evidence-based assessment tools, outcome measures and adherence to best practice guidance was evident in the care and treatment staff delivered. Care was provided with a multidisciplinary approach.

Staff delivered care in a responsive, caring manner and strived to ensure patients’ cultural and diverse needs were met. People had access to translation services.

The trust engaged with people including carers in the planning of service development initiatives.

There were some issues that impacted negatively on how responsive some services were. This was due to long waiting lists and ineffective care pathways. Waiting times were showing an improving trend in children’s services. In other community health services waiting times were reasonable except for chronic fatigue service appointments, which were much worse than the expected six weeks, with an average waiting time of 60 weeks.

The trust participated in several internal and external audits to drive improvements, including the quality SEEL (a quality initiative focusing on Safety, Effectiveness, Experience and Leadership).

In the teams, local leadership was generally visible and strong. Most staff understood the trust’s visions and values. Executive management visibility in the community health services was low, although staff felt listened to and supported by local managers. Staff clearly expressed the trust’s vision and values and portrayed positivity and pride in the work they did.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

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


Organisation Review of Compliance


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.