Lancashire & South Cumbria NHS Foundation Trust

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.

The Longridge ward team were positive and proud of the service they provided for the local community. We saw that multidisciplinary working was in place, the ward had input from therapists and a dedicated pharmacist. Access to dieticians and speech and language therapists were available and staff were positive about their working relationships.

Patient care, including managing patients nutritional needs and pain relief, were well managed.

Staff were observed talking to patients in a kind, sensitive and caring manner. Staff used the Friends and Family test as a formal tool to obtain feedback from patients or their relatives.

Staff were familiar with incident reporting procedures. The majority of staff were up to date with mandatory training. Records and medicines were appropriately audited .

Information was not readily available in different languages, staff stated they could access an interpreter as necessary.

During our inspection we visited the ward over two days as there was only one in patient on our first visit. We spoke with 14 staff, seven patients, eight relatives and we viewed seven patients medical and nursing records.

The service faced a number of challenges including staffing levels in some teams; large case loads, the fluctuating population from seasonal workers and students and the increased acuity of patients. The needs of children in the community had increased, as there were no other services to assist them.

Clinics were scheduled weekly at set times with some open and some pre-booked slots. With a lack of national guidelines for waiting times, the trust had set a preliminary nominal target of 18 weeks. Data supplied by the trust showed waiting times varied in each speciality. Overall, from April 2014 to March 2015, the average percentage of referrals waiting over 18 weeks for all services had decreased from 10% to 3% and the referral waiting the longest time reduced from 22 weeks to 16 weeks. Waiting times for patients once they had been accepted in a team were short.

Many services were being delivered from less than ideal locations that were not owned by the trust. The low number of risk assessments for clinic locations and the fact that they were not complete or comprehensive meant the potential risks were not being clearly identified or addressed.

Electronic patient records were not always accessible when connectivity was poor and access to paper based records was variable throughout all areas. Electronic templates had not been set up for all the specialities, which meant staff continued to maintain paper records, which could not be accessed across other specialities. Issues were raised in relation to “Red Books” which were not always fully completed with names and address of the children and the “Flimsy’s” in the red books were inconsistently completed and we saw evidence of poor quality of scanning of these ‘flimsy’s’ making them illegible.

Medicines were managed safely in most cases but at a school vaccination session, we observed the temperature of vaccine storage was allowed to go over the recommended range potentially affecting the cold chain storage making them unfit for use.

The trust target to achieve 90% uptake by 31 August 2015 was not yet met as the actual uptake ranged from 59% to 73% at the time of inspection with four months remaining. The vaccination and immunisation team target at 90% was not met due to a considerable amount of unreturned consent forms and low take up rates within Muslim communities declining the vaccination that contained porcine gelatine.

The vaccination and immunisation team were not always following the trust’s consent policy in relation to the Gillick competency and Fraser guidelines, which resulted in some children not being vaccinated or the parents being contacted to gain verbal consent. Young people only had a gown to protect their modesty and female students were asked if there was any chance of pregnancy in the open hall without due consideration to their privacy.

There was no routine antenatal contact by the health visiting team where breastfeeding support and advice should be given. The routine health visitor contact became part of the health visitor contract in April 2014, however, it had been agreed with commissioners that this would be introduced on an incremental scale starting with those deemed most vulnerable (ie highlighted by Children’s Centres and Midwives). It became routine in September 2014, again with the expectation that the number contacted would increase each quarter.

The coordination of Children Looked After (CLA) who were under the care of the local authority (Lancashire County Council) was a challenge especially when the child was placed out of Lancashire’s boundaries as the LCFT CLA nursing teams had to coordinate the referral, discharge and transition of the child with social services teams from all over the country to perform assessments.

Discrepancies between data held at trust and local levels regarding the uptake of mandatory training meant we could not evidence that the target of 85% attendance for mandatory training was being consistently met within the service. Data from the trust’s centralised mandatory training system showed basic life support training being at 64% at the time of the inspection. Overall compliance was 83.9% at January 2015. The local system showed that compliance rates for all modules were above the Trust’s target of 85% as at end of April 2015.

Trust records showed, as of March 2015, only 54% of all staff had received appraisals for the year 2014 to 2015.

Care and treatment, policies and procedures and mandatory training was evidence-based and followed recognisable and approved guidelines. Pain relief was administered and applied as required through medication and via specialised equipment. We observed collaboration and communication amongst all members of the multidisciplinary team (MDT) to support the planning and delivery of care.

Parents, carers and children were positive about the care and treatment provided. The NHS Friends and Family Test results showed the majority of patients would recommend the department to their family and friends. Patients felt they were afforded sufficient privacy and dignity.

Staff were compassionate, kind and respectful whilst delivering care. We observed positive interactions between staff, patients and their relatives when seeking verbal consent.

Staff clearly expressed the trust’s vision and values and portrayed positivity and proudness in the work they did. There was effective teamwork and visible leadership across the teams. There was a positive attitude and culture within children’s services with an ethos on all the services working together with best practice coming from the whole group rather than any individual.

Public and staff engagement was embedded and included initiatives such as a partnership with Hyndburn Council and Public Health Lancashire in the launch of a voluntary ban to encourage people not to smoke in Council Play Areas and working with people from the community to conduct research studies about how cultural beliefs had prevented access to healthcare. The Early Start Team felt proud and honoured to have their hard work and efforts recognised with a National Nursing Times Award.

Some staff used an electronic records system called ‘ECR’ where as others used a paper based system. The ECR system required more time to complete details and entries made had to be transferred to other systems which increased the risk of errors and extra work for staff. Incorrect entries made on the ECR system could not be amended by the author and had to be amended by the information technology staff which complicated the process and could explain why trust figures for reporting documentation issues was high. Staff used computerised ‘tablets’ enabling them to source or store information when visiting patients which although useful and speeded up processes when connectivity was poor patient visit lists could not always be accessed. This issue had been added to the trust’s risk register which showed it had been identified as problem.

Staffing levels were managed with low levels of sickness and few vacancies however, the managers had not taken a systematic approach to quantify the staffing levels and acuity of caseloads and neither had been reviewed for some time. Despite good practice we found that some teams had been recently reconfigured and there appeared to be limited integration. There were limitations with staffing in some areas which meant that services stopped if staff were on leave. Despite this, longer term staffing issues had been identified in some areas and recruitment plans were in place to address future challenges.

Patients with minor injuries were triaged by staff who were not clinically trained. It was noted that no staff had advanced paediatric life support despite offering services to children over 1 year however this requirement would be dependent on the number of children seen. These concerns were raised with the trust before the inspection was completed and the trust responded with a full review of the service.

We found extended waiting times for the Chronic Fatigue Service and podiatry and there was not always good use of available space or adequate wheelchair access in clinics.

The community services for adults were delivered by staff who were committed and enthusiastic about their roles. We saw evidence that staff took the time to familiarise themselves with patients and were welcoming and helpful. They were also supportive to each other.

In most of the services provided, people received appointments in a timely way. Clinics were visibly clean, tidy and organised. People expressed that whilst sometimes they had to wait to be seen in clinic, they felt the standard of care was good and the staff were friendly. This was reflected by the low levels of complaints received.

Staff were familiar with reporting procedures despite few having reported an incident recently. Most staff were up to date with mandatory training and felt proud to work for the Trust. Records and medicines were stored correctly in most areas and audits were completed at intervals.

We found that Lancashire Care Foundation NHS Trust was providing a high quality service regarding end of life care (EOL). It was delivered by passionate staff who gave patients and their families compassionate care were however there were areas for improvement in the effective domain.

Caseload numbers had continued to increase but shortages were addressed through additional hours by staff and the use of agency staff when required and patient needs were being met. The decreased skill mix of staff had been recognised and changes to work patterns were being discussed. Staff worked with hospices, hospitals, GPs and specialists for advice when needed. The hospice team provided specialist advice and support as requested, coordinated and planned care for patients at end of life in the community. The trust had also not appointed a board member with a specific lead role for end of life care to ensure executive scrutiny.

The trust had developed an EOL framework and an advanced care plan but these were still in draft form and yet to be embedded. The nursing staff were working with primary and secondary health care professionals to adopt nationally recognised best practice tools, including the gold standard framework, preferred place of care, the priorities for care for the dying person and advanced care planning to replace the Liverpool care pathway. It was evident the trust were trying hard to achieve partnership working despite the difficulties of different services being provided under different trusts. However, the timeline of this improvement was slow as this should have been implemented in July 2014.

Staff appraisals were completed however there were inconsistencies in staff supervision. Staff spoke positively about the support they were given by seniors and management within end of life care although staff were not aware of who the trust lead for end of life was.

A review of the data showed there was a shortfall in monitoring systems in place to ensure the trust delivered a good quality EOL service. It was from discussions with patients, relatives, staff and observations that highlighted the commitment and passion staff of all grades had to provide good end of life care. Staff involved patients and their relatives in their care where possible and treated them with kindness, respect, compassion and dignity.

We rated the community based services for people with learning disability or autism as ‘Good' because:

• The services had reliable systems, processes and practices in place to keep patients safe and safeguard patients from abuse. There was an openness and transparency about safety. Staff understood their roles and responsibilities to raise concerns and report incidents and near misses.

• Individual and environmental risks were monitored and managed appropriately. In most teams comprehensive risk assessments were carried out by staff for patients who used the service; risk management plans were developed in line with national guidance.

• There was a holistic approach to assessing, planning and delivering care and treatment to patients. Patient’s individual care and treatment was planned using best practice guidance. Outcomes were monitored to ensure changes were identified and reflected to meet patient’s needs.

• Consent practices and records were monitored and reviewed to improve how patients were involved in making decisions about their care. Staff requested patient’s consent to care and treatment in line with the Mental Capacity Act.

• Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff were supported by means of supervision and appraisal processes, to identify additional training requirements and manage performance.

• Feedback from patients who used the services was positive, regarding how staff treated patients and their families. Patients were treated with dignity, respect and compassion whilst receiving care and treatment. Patients and the ones who were close to them were involved in their care decisions.
• Planning and delivery of service took patient’s individual needs and circumstances into consideration. Access to care and treatment was timely. Waiting times, delays and cancellations were minimal and managed appropriately.

• The services managed complaints and concerns effectively; they listened to patient’s concerns with a view to improve the services being provided.

• The services had good structures, processes, and systems in place to manage current and future performance and ensure quality to drive improvements. The information used in reporting, performance management and delivering quality care was timely and relevant. Performance issues were escalated to the relevant monitoring committee and the board through clear structures and processes.

However in the Lancaster team, risk information was not consolidated into a single overarching risk assessment and management plan for individual patients. We found that there were variations in the multi-disciplinary make up of teams in different teams; some teams did not have good access to psychiatrists, occupational therapists, or speech and language therapists. The recording of patient information did not optimise the sharing of patient data between staff of differing services and teams. GPs were not given regular updates regarding any plans specific to patient care such as treatment interventions or information about patients being discharged from the teams.

We rated The Lancashire Care NHS Foundation Trust as good because:

There was an open and transparent approach to the treatment of people who used services that allowed for identification of safeguarding issues or inefficient practice. Staff prioritised the safety of people using the service and also the safety of people working for the trust. The staff showed knowledge of procedures and requirements that helped maintain their safety.

Staff assessed risk in observance of national guidelines, to the benefit of people who used services.

Care plans were of a high standard. The care plans were thoughtful and fluid, changing as and when needed. Whilst the treatment of people who used services was seen as holistic, it was also person-centred. Team management and governance monitored the completion of care plans through routine audits.

Staff demonstrated a good understanding of the Mental Capacity Act 2005 (MCA). In the multi-disciplinary meeting we attended, a person’s capacity was considered in every situation and discussed. Of the 23 care plans reviewed it was seen that capacity was addressed. However, this was not in a uniform format. Capacity assessments had been carried out only when staff had identified an issue with the capacity of a person who used the service. It was at this time a full capacity assessment was carried out. Staff received training in the MCA and there was an on-going training schedule to ensure they remained skilled.

People who used the service were positive about it, with no adverse comments received during home visits, or in telephone conversations with them or their carers. Staff were observed treating people who used the service and their carers with dignity and respect. People who used services felt that they had been personally involved in the development of their care plans.

Staff were able to manage the development of the service they provided. They took into account the opinions and considerations of people who used the service and where possible other staff. This allowed treatment to be provided in an effective and timely manner. The managers of the individual services were supported by senior managers in this measured and effective approach.

The physical space of four of the five health-based places of safety (HBPoS) we visited provided safe, clean environments to assess people. However, the layout and location of the HBPoS at the Scarisbrick Centre at Ormskirk General Hospital compromised patient safety and the bathroom door at the Orchard had no observation panel.

The premises at Hope House were not fit for purpose.

Risk assessments completed with the police were not present on 40% of the records we looked at.

The HBPoS were staffed by nurses from the adjacent acute wards when people were brought to the suite. There were concerns about whether the staffing establishment at the Orchard could support management of the HBPoS safely.

At the Orchard, the door to the bathroom lacked an observation panel, which meant people’s privacy was compromised. The handle on the entrance door created a ligature point which compromised people’s safety. The manager assured us this was due to be corrected. In the meantime, risk was mitigated through observation.

The HBPoS at the Harbour had clear windows which compromised patients’ privacy, dignity and confidentiality.

Interview rooms and clinic rooms used by the mental health crisis services (MHCS) were clean, well maintained and safe environments.

Staffing levels and skill mix within the MHCS meant they were able to meet the needs of people accessing the crisis services.

Uptake of mandatory training was in line with trust policy.

Staff carried out risk assessments of patients on initial contact and updated this regularly.

People referred to the MHCS were usually seen within four hours of referral.

MHCS staff worked closely with people on the adult acute wards to provide intensive home treatment and facilitate early discharge.

Safeguarding arrangements were in place and took account of both adult and children's safeguarding. Staff knew how to make a safeguarding alert and showed good understanding of safeguarding issues.

There were good personal safety protocols in place including lone working practices.

There were clear policies and procedures covering all aspects of medicines management. At Hope House, documentation relating to medicines was not being completed consistently.

Staff told us that the impact of the trust implementing a smoke-free policy was putting staff and other patients at risk as people were not following the policy.

There was an incident reporting system in place. Staff understood their responsibilities in relation to reporting incidents. Managers analysed incidents to identify any trends and took appropriate action in response. For a reported incident we looked at, it was not clear whether a root cause had been established.

Across the teams, there was a general understanding of the regulation relating to the duty of candour.

Staff were de-briefed and supported following serious incidents. Debriefing included input from a psychologist. Actions from incidents were discussed in team meetings and at individual supervision to ensure lessons were learnt.

We found examples of excellent practice in disseminating information. At Pendle House, we saw an electronic ‘notice board’ accessible to all staff that included an SUI ‘action tracker’ that showed shared learning and good practice.

Staff carried out an initial assessment that focused on people’s strengths, self-awareness and support systems, in line with recovery approaches. This usually took place within 24 hours.

At the HBPoS, a comprehensive assessment and physical health check was undertaken when people were brought in by the police under section 136 Mental Health Act 1983 (MHA).

Care plans were centred on the person’s identified needs. They demonstrated knowledge of current, evidence-based practice.

We found evidence that demonstrated the teams implemented best practice guidance within their clinical practice. At Pendle House, we saw an electronic ‘notice board’ accessible to all staff that flagged up best practice guidelines.

People’s physical health needs were considered alongside their mental health needs. One team held a regular clinic for people to attend.

We saw some examples of excellent practice which meant people were able to stay in the community. All the MHCS carried out home-based clozaril titration. People did not have to be admitted to hospital when they were prescribed clozaril as staff carried out monitoring in the person's own home.

People who used services were enabled to participate in the activities of the local community so that they could exercise their right to be a citizen as independently as they were able to.

The MHCS at Hope House had carried out development work analysing how to optimise home treatment. They had looked at reducing or avoiding admissions and out of area treatment.

Staff had an annual appraisal which included setting objectives for personal development and they received regular clinical and managerial supervision. Staff were knowledgeable and committed to providing high quality and responsive care.

The MHCS had access to a range of mental health disciplines required to care for the people using the service. There was effective multi-disciplinary team working.

The MHCS had established positive working relationships with other service providers. They worked with them to plan people’s transition between services in a holistic way.

There was a joint agency policy in place for the implementation of section 136 of the Mental Health Act which had been agreed by the local authorities, police forces and ambulance service.

The development of the HBPoS and joint working arrangements with the police reduced the numbers of people being assessed in police cells.

Use of the Mental Health Act 1983 (MHA) and the Code of Practice was good. We found evidence to demonstrate that the MHA was being complied with.

The teams were compliant with the requirements of the Mental Capacity Act 2005 (MCA). Staff took steps to enable patients to make decisions about their care and treatment wherever possible.

Staff were kind, caring and compassionate and supportive of people using the service.

When we spoke with people receiving support they were generally positive about the support they had been receiving and the kind and caring attitudes of the staff team.

We accompanied staff visiting people who used the service and it was clear that they had a good understanding of people’s needs.

Care plans were developed with the person using the service. People were offered a copy of their care plan. They were able to decide who should be involved in their care and to what degree.

Carers’ assessments were offered to people when appropriate.

Advocacy services were available.

People had access to information in different accessible formats. Interpreting services were also available if necessary.

The referral system enabled anyone to refer into the service, including self-referral from people or their carers. This meant that people were empowered to access help and support directly when they needed to, 24 hours a day, seven days a week. Access to crisis care was not delayed by having to access it through the accident and emergency department, for example.

The MHCS worked well with the adult acute mental health wards to prevent inappropriate admissions to inpatient beds. They ensured that people did not stay in hospital longer than necessary and promoted early discharge.

The MHCS worked within the principles of the recovery model. This meant they focused on helping patients to be in control of their lives and build their resilience so that they could stay in the community and avoid admission to hospital wherever possible.

The MHCS ensured arrangements for discharge from hospital were considered from the time people were admitted, to ensure they stayed in hospital for the shortest possible time.

The HBPoS at Burnley and the Orchard held teleconferences three times a day regarding bed availability.

Assessments had always been completed well within the 72 hours required by the MHA and Code of Practice but not always within the trust’s four hour target. We did not identify any additional or arbitrary restrictions when people were placed in the HBPoS.

Staff were committed to provided care which promoted people’s privacy and dignity and focused on their holistic needs.

People's diverse needs were integrated in policies and proactively taken into account when devising protocols. This meant that meeting people's diverse needs was embedded in practice.

Complaints were well managed. At Hope House in particular, the MHCS was proactive in their approach to gaining feedback from people who used the service.

Staff knew the trust’s vision and values and were able to describe how these were reflected in the team's work.

We saw records of staff appraisals that embedded the trust's vision and values.

Morale was high in the teams we visited. Staff showed a clear commitment to providing the quality care which individuals needed.

There were initiatives in place that supported staff morale and wellbeing. We saw a piece of work analysing the main reasons for staff sickness absences and considering how these could be addressed.

Staff felt well managed locally and mostly had high job satisfaction. They understood the trust whistleblowing policy and reported they felt able to raise concerns without fear of victimisation. Information supplied before the inspection indicated a culture of systemic bullying; however, we found no evidence of this.

Staff were encouraged to discuss issues and ideas for service development within supervision, business meetings and with senior managers.

Staff understood their responsibilities in relation to the duty of candour and their role in the process for any future incidents where patients experienced harm.

There was outstanding commitment to quality improvement, innovation and development.

The staffing establishment in the MHCS had been increased following a scoping exercise that looked at the staffing levels necessary to meet the needs of people who used the service, based on agreed trajectories.

At Hope House, a dedicated member of staff contacted everyone who had been discharged from the service in the previous two weeks to ask their opinions. We found that this information was discussed and used effectively to improve the service.

There were systems in place to monitor the service in order to improve performance. Audits were carried out on the use of section 136 and the use of HBPoS.

We gave the overall rating for community-based services as requires improvement because:

• The number of staff that had not completed mandatory training was below expected levels. This had the potential to put people who use the service and staff members at risk.

• There were concerns expressed by staff and reflected in the services risk register over the capacity of teams.

• We identified concerns over the transition of young people from CAMHS. The trust had a protocol in place however this was not being followed consistently and was out of date.

• We identified concerns over the ability of services to manage young people when they transfer from CAMHS at the age of 16. The trust recognised these issues. Actions had been agreed and a CQUIN target was associated the delivery of the action plan.

However:

• Services were being delivered in line with adherence to the Mental Health Act 1983, the Code of Practice and the Mental Capacity Act 2005. Capacity was being assessed on admission and was reviewed as required. Appropriate risk assessments and paperwork was in place for individuals on community treatment orders. Staff displayed a good knowledge of both the MHA and MCA. However the level of staff training on these areas was below expected standards.
• Systems were in place to monitor and manage risk. Escalation procedures for urgent referrals were in place. Assessments were carried out in a timely manner, reviewed and reflected in care plans. Safeguarding was embedded within the service. Staff displayed a good understanding of their roles and responsibilities in this regard.
• Feedback from people who use the service was positive. We observed people who use the service being treated in a respectful manner and with a caring and empathetic approach. We saw evidence of involvement in their care and decisions over treatment. Where families and / or carers were involved their opinions and views were also reflected. However it was not clear that people who use the service were routinely offered a copy of their care plan.
• Processes were in place to monitor performance. Regular governance meetings were held and performance data was on display in teams. Teams used a Quality SEEL tool to assess performance and generate improvement. However there were no KPIs in place for the single point of access services. We were told these were being developed.

We rated wards for older people with mental health problems as requires improvement because:

• On ward 22, Department for Health guidance on same sex accommodation as well as the MHA Code of Practice was not being followed, as access to reach bathroom and toilet areas meant patients had to walk through communal areas occupied by either sex, which opened out onto the main ward communal area.
• The wards did not have current and up to date ligature risk assessments and environmental risk assessments had not been completed on ward 22. The CQC have received assurance that the trust have put in place actions to address these issues with an action plan in place to complete the ligature risk assessments on each ward.
• Ward 22 had identified insufficient levels of nursing staff on duty during the day from January 2015 – March 2015. Bronte, Wordsworth and Dickens wards also identified this during March 2015.
• On ward 22 patients were unable to summon assistance throughout the ward as alarm call bells were not fitted in most of the patient areas. However, a push button (anti-ligature) staff alert system was installed in all unobservable areas (toilets and bathrooms).
• We identified concerns about staff not receiving mandatory training; both of which increased risk to patients and staff.
• On ward 22, we observed staff placing aprons around most patients without any explanation or asking the question if they wanted an apron around them. This meant that some patients were not treated as an adult. We also saw blinds were not used in the male dormitory to protect patients’ privacy and dignity as staff and visitors when entering the ward area were able to see into this area.
• Governance structures and performance management did not always operate effectively to assure staff had completed their mandatory training. The governance structures in place for the older adult wards were in their infancy and had not been fully embedded.
• The trust used high numbers of bank and agency staff on their wards.
• Individual wards were able to submit items onto the trust risk register in relation to staffing issues however, on ward 22 the trust had not addressed the deficit of replacing permanent staff. The risks described by the staff on ward 22 were not understood by their managers/leaders.

However we also found

• Staff demonstrated they understood safeguarding procedures and incident reporting; and we saw that debriefing and support was available to all staff, after a serious incident had taken place.
• Patients had up-to-date risk assessments in place that were regularly reviewed. The wards they were on sought to create an environment that reduced restrictive practise.
• On admission to a ward, patients had a comprehensive assessment of their needs, and systems were in place to asses and monitor physical health and nutritional needs.
• Patient information was available to staff, it was stored securely, and was readily accessible. Staff used this information to effectively plan people’s care and make sure that when patients were discharged, all necessary and relevant information was available.
• There was evidence of staff following guidance and best practice; an example of which was their reviewing the use of antipsychotic medication for dementia.
• Staff were observed being responsive and respectful to patients, and demonstrated that, where possible, patient were participating in the planning of their care. A review of patient notes also showed that advanced decisions were recorded for some patients.
• Patients were supported and encouraged to maintain their independence.
• Staff sought feedback from patients and carers, and openly shared information on what they had done in response to the feedback.
• The wards provided activities for patients during the week and at weekends; and made adjustments for people (both patients and ward visitors) who had physical disabilities.
• Complaints processes were clear and staff demonstrated they actively responded to issues raised by patients and their carers.
• Staff demonstrated that they knew the organisations visions and values, and were supportive of them. They also knew who their senior managers were and said that that they had a visible presence on the wards.

We rated child and adolescent mental health inpatient wards as good because:

• Motivated and supported patients with care, dignity and respect, so patients felt supported and described positive relationships.
• Involved patients and their families in decisions and had access to good information to make these decisions.
• Comprehensively assessed patients’ needs, included consideration of clinical needs, mental health, physical health and well-being and involved patients in developing their own care plans
• Held multi-disciplinary staff meetings to discuss and review patients’ needs, to make sure patients received the best possible coordinated care and treatment.
• Offered patients activities and education.
• Monitored patients’ physical healthcare, with links to GP surgeries to respond to any continuing physical health needs.
• Planned for discharge from admission (and discharge was rarely delayed).
• Used a systematic approach to discharge, using routine outcome measures to measure patients’ progress and time their discharge process.
• Implemented best practice guidelines – such as routine outcome measures to plot patients’ progress and experience (and had taken part in Royal College of Psychiatrists' Quality Network for Inpatients (QNIC) reviews).
• Gave patients the opportunity to give feedback about the service and listened to that feedback.
• Told patients how to raise a complaint or concern, and had investigated and responded to concerns and complaints.
• Reported, investigated, and responded to ward incidents, using clear processes to safeguard young people.
• Assessed the number of child and adult beds available in the trust, and responded to this by increasing beds and at times placing patients in adult wards to ensure they received the care and treatment they needed promptly.

However we also found that staff were:

• Staff at the Platform described secluding patients in an extra care area, but they had not followed the Mental Health Act code of practice guidance of what actions to take when secluding a patient. For example, one seclusion record out of the five reviewed had no evidence of who started and who ended seclusion. Three records did not have 15-minute recordings of the patient’s progress. There were medical reviews in some records but it was unclear when the medical review took place. The Mental Health Act code of practice guidance helps protect patients' rights and ensures patients detention is lawful.
• Information provided by the trust demonstrated poor compliance with annual staff appraisals by teams. An annual appraisal enables the staff to review staff competency and ensure their development at work. In addition, at the Junction compliance with clinical and management supervision was low. Clinical supervision enables the managers to assess the quality of staff's work.
• Staff told patients detained under the MHA 1983 their rights and gave access to an advocate. However, at the Junction staff did not know the agreed and allowed medication under the MHA. This meant staff that may administer medication not permitted under the MHA.
• We found the ward action plan resulting from the health, safety and environmental audit at the Platform did not include the impending changes to the environment and was unclear about when actions would be completed. Following two patients attempting to harm themselves by hanging using fixed points in the lounge ceiling where they could attach something.
• Staff had completed their basic and intermediate life support skills but one member of staff was unconfident about using the handled suction machine. Also, some equipment in the clinic room had passed the expiry date for use.

We rated forensic inpatient/secure wards as “requires improvement” because:

The physical environments of Calder, Fairsnape, Greenside and The Hermitage wards needed improvement. There was significant damage to Calder and Greenside wards. On Calder, Fairsnape, Greenside and The Hermitage wards there were ligature risks present. However, there were plans in place to address all of the issues associated with the physical environment and ligature risks, and a programme of work was underway.

Seclusion facilities on Calder, Fairsnape, Greenside wards were poorly equipped.

Bleasdale, Elmridge, Mallowdale, Fellside, Forest Beck, Marshaw, Dutton, Whinfell and Langden wards were in good condition and presented safe, clean and pleasant environments, Fairsnape and Fairoak needed some updating and Calder, Greenside and The Hermitage were in a poor condition. However, we found Greenside and Calder wards were not clean and hygienic.

The trust had legitimately implemented a no smoking policy at Guild Lodge in January 2015. We found this was not consistently applied across the site. We found evidence of patients smoking on wards despite staff enforcing the policy, while others at Guild Lodge were not. This resulted in staff on site dealing with smoking-related incidents differently as some staff allowed patients to bring smoking materials into the site while others did not. In addition staff on wards told us where the ban was being enforced there had been an increase in incidents as a direct result of the ban.

Patients were treated with dignity, respect and kindness and staff were dedicated and enthusiastic about involving patients in their care, However we received mixed comments from patients we spoke with and from comment cards we received gave mixed views about patients’ experience of dignity, respect and support. Concerns were raised about escorted leave and activities being cancelled, understaffing, unsafe patient mix on some wards, and the poor quality of food. Patients also complained about the no smoking policy, blanket restrictions on mobile technology and disrupted sleep owing to the practice of 15 minute observations at night for all patients in medium secure wards. Complaints during a 12 month period prior to the inspection showed patients had complained about issues including concerns about safety on wards, availability and quality of food, cancellation of leave, and staff behaviour.

Patients did not have privacy for phone calls as public phones were located in communal areas and not all had a hood.

Patients and staff raised concerns about the quality of food and special diets were not easy to access. Religious needs were not always met in a timely manner even though there were spiritual care facilities on site.

Patients frequently experienced cancellations to escorted leave and activities. Staff were regularly called away to the phase one services to deal with incidents, so were not available to patients to support leave or engage in activities.

There was no learning from complaints about the food and cancellation of activities and leave. This resulted in patients raising concerns with us during the inspection.

All patients were subjected to searches on return from off-site leave owing to smoking-related risks and a recent serious incident. However, this policy would not be appropriate for low secure or step-down services without individual risk assessment.

Patients complained about the blanket restrictions in place on access to mobile devices, social media and communication technology (IPADs, computers, mobile phones). Patients described their need to make contact with family and friends. Patients on Fellside and Forest Beck step-down wards were permitted to have non-SMART mobile phones.

Because of the rural location of Guild Lodge local public transport was limited. Staff often booked the trust’s pool cars to support patients with off-site activities and leave. However, when the cars were diverted for use elsewhere, such as medical appointments, activities were cancelled.

Activity plans on Dutton ward showed patients received below 25 hours per week of meaningful activity. Leaving the site boundary to smoke was regarded as an activity. However, on other wards patients were offered between 13 and 21 hours of meaningful activity per week. The notes of the service user group meetings showed cancelled activities and leave were common complaints. The occupational therapy team said the main reason for activities being cancelled was transport being diverted at the last minute for use at appointments. Staff told us they would try to re-arrange leave when activities were cancelled, however, in the women’s service, the occupational therapist helped to cover leave and activities when there were staff shortages.

Review of meeting notes on Marshaw ward confirmed that leave was cancelled owing to staffing issues. Staff on Marshaw ward said they did not have time to facilitate activities, and activities were inconsistent and not structured. On Fellside, Elmridge and Mallowdale wards, activities and leave were frequently cancelled because staff were diverted to other wards in response to incidents or understaffing.

There were good religious facilities on site and religious leaders could be invited to Guild Lodge upon request. For example, an Imam often visited a Muslim patient. However, access to religious facilities was inconsistent. Two patients said they found it difficult to access religious services. In one case, the lack of response to a patient’s request led to a serious incident.

Patients and staff on most wards raised concerns about the food describing it as poor quality. There was dissatisfaction with the two day advance ordering process, especially for patients with acquired brain injury. While catering for special diets was provided, for example, vegetarian, halal, and altered consistency, it was described as ‘hard to get’ and ‘same’. An example was given of a service user receiving the same halal microwave meal every day.

Patients in Guild Lodge made 65 complaints in the twelve months prior to the inspection, which was the highest number of complaints throughout the trust. Patients made complaints about a wide range of issues including concerns about safety on wards, availability and quality of food, cancellation of leave, and staff behaviour. Complaints were fully considered. Outcomes included written apologies to patients, improving patients’ understanding of policies and practices, adding issues and outcomes to Guild Lodge’s share the learning document, improving information, guidance and publicity, and supervision of staff.

In September 2013, the CQC asked the trust to review the environment of the seclusion room shared by Whinfell and Bleasdale wards. The building works had finally commenced to address these concerns at the time of our inspection. At this inspection, we noted delays in responding to maintenance and cleanliness on the Calder, Greenside and The Hermitage wards.

Security systems and processes for the site were good and staff had a good understanding of safeguarding policies and practice.

There were comprehensive assessments and care plans in place, with a strong focus on good physical health care needs, with good access to a range of health services such as GP, specialist diabetic nurse, and podiatrist.

Staff understood their responsibilities under the Mental Health Act and patients were regularly informed of their rights. Guild Lodge was utilising recovery-based models of care such as My Shared Pathway and Recovery Star, though implementation was inconsistent across the wards.

There were good multi-disciplinary working practices in place on most wards and medicines management was in line with good practice. The women’s service was operating a gender-informed model of care, which was regarded positively by patients and staff.

There was a range of facilities and activities available on and off-site, although access was limited when there were staffing shortages. There were ward-based activities and access to outside space for most wards.

We found examples of wards managed by committed managers with strong visions and values for example, the women’s service operated a gender-based model of care, and the men’s rehabilitation/step down ward (Fellside) strongly promoted hope and independence to patients. Management were accessible and supportive but this was not consistent across all services.

All wards received performance reports showing a range of data including compliance with mandatory training, sickness absence levels, and complaints.

The service was working in partnership with UCLAN (The University of Central Lancashire) on research into the involvement of patients and families in violence prevention and management.

We rated the acute and psychiatric intensive care units (PICU) services as requiring improvement.

Not all staff were adequately trained to deal with patients in seclusion. We observed use of the seclusion facilities on the two psychiatric intensive care units Byron and Keats and whilst there were care plans in place and staff observing, we found that 20 episodes of seclusion had not been entered into the log on Byron ward. On a follow up visit to Keats ward we found that there had been inaccurate recording of the seclusion start time and when mandatory reviews had been carried out including medical reviews, as per seclusion policy.

Due to the relocation of acute and psychiatric intensive care units to the Harbour, the trust lost a significant number of experienced and qualified staff. This had resulted in significant issues with recruitment and high levels of sickness. Staff recently recruited had not received all their mandatory training and inductions. Some new staff were working on wards before receiving uniforms, or even name badges.

The Trust introduced a no-smoking policy in January 2015.This had been implemented inconsistently. Some wards turned a ‘blind eye’ and others enforced the policy to the letter. This resulted in difficulties for staff because patients witnessed and heard of others smoking. In addition staff on wards where the ban was being enforced, told us there had been an increase in incidents as a direct result of the ban. We witnessed several such incidents during our inspection.

Staff told us that patients admitted to wards on an informal basis could not leave the ward until a doctor had seen them. Staffing concerns meant people sometimes had to wait to see a doctor. Patients told us this meant they could not go out for a cigarette and, at times, had to wait for a number of hours.

The quality of care plans throughout the trust was inconsistent. We saw care plans at one unit were particularly personalised, holistic, and recovery focused. However, in other areas care plans we reviewed were brief and impersonal, and were neither holistic or recovery focused.

Patient records did not always record patients’ views and it was not clear whether patients received a copy of their care records. We found the majority of records reviewed at the Royal Blackburn Hospital did not contain patient views or evidence that patients had been given copies of their care plans.

We did find that a ligature point had been identified at the wards in the Harbour when the windows of the quiet room were opened into the internal courtyard. Some wards had locked the doors however other wards were not aware of the risk. This was escalated to the management team whilst on inspection.

Although the trust had a training schedule in place, staff had not completed all their mandatory training. We examined training records of 193 staff employed and we found only 22 (11%) had completed the required training. Furthermore, we found some staff employed in the trust who had not completed any of the mandatory training.

Information provided by the trust showed staff had not received the expected supervisions and appraisals. Although staff we spoke with told us they had received some supervisions and appraisals these were not carried out in line with the trust policy.

Therapy sessions were held in areas outside the ward. This limited who had access to the sessions. Patients without leave could not attend and patients with leave could only attend if there were enough staff to escort them. Problems with staffing levels meant often there were not enough staff to provide escorts.

We also noted:

Throughout the trust we saw positive interactions between staff and patients. Staff treated patients courteously and with appropriate dignity and respect. Patients’ dignity was protected wherever possible and we found medications were administered privately, in treatment rooms where possible.

Patients told us they were involved in decisions about their care and were encouraged to participate in meetings to develop and manage their care and discharge.

The trust had access to interpreters which they used for patients with communication difficulties or for those for whom English was not their first language. This allowed everybody to be involved in care planning and understand what was expected.

All the wards we visited had information boards which showed patients and their visitors the staff who worked on the wards and also the different uniforms they might see.

We have judged the service as requires improvement because:

• The systems in place to monitor and manage patient risk were not robust. Moss View had a ligature risk audit, which related to the HDRU only. The audit was of poor quality as it was not comprehensive, itemised or specific. A ligature risk audit identifies places to which patients might tie something to strangle themselves and plans actions to mitigate the risks to the patient. Staff were not alert to the ligature risks on the CRU as the ligature points had not been identified and there was no formal management plan in place.

• Insufficient staffing levels on HDRU had been identified and noted on the local risk register. Shifts were filled to the required staffing level by redeploying staff from the CRU to the HDRU and through the regular use of bank staff.

• The service did not meet the Department of Health guidance on same sex accommodation. On the HDRU, there was an adaptable area that could provide either additional female or male beds depending on ward composition. At the time of our visit this area was mixed gender having a female bedroom next to a male bedroom. Individual pods on the CRU had been mixed gender on occasions. We observed male and female patients freely accessed each other’s pods, the communal IT equipment was located in one of the female pods and there was no separate female lounge

• We found restrictive practices in place. All kitchen knives on the unit were locked away and patients on the CRU did not have a key to lock their rooms when leaving them. These practices were not based on individual patient risk assessments

• Compliance with clinical supervision and yearly appraisals for nursing staff was poor. This meant that nursing staff did not receive the appropriate support and professional development needed to carry out their duties effectively and managers were unable to review their staffs’ competency or assess the quality of staff performance.

• Local governance structures to support the delivery of care and to monitor quality assurance were not well established as there had been changes to the location and structure of the rehabilitation wards in the past year. Staff did not always feel supported in their roles.

However, the unit was clean and well maintained. Medical staff received regular supervision, ensuring that lines of communication and support were in place. Staff had good knowledge of safeguarding procedures and were confident in applying trust policy. Physical restraint was rarely used as staff were confident in the use of de-escalation techniques. Patients’ physical health needs were routinely monitored and acted upon appropriately. Multi-disciplinary team meetings and handovers allowed the exchange of professional opinion and suggestions for onward treatment. Psychological therapies were available. Patients who used the service said that staff engaged with them in a caring, kind and respectful manner. A strong therapeutic relationship between staff and patients was evident. Patients using the service were given opportunities to be involved in decisions about their care. Patients had access to complaint forms and community meetings to discuss their concerns.

We rated specialist community mental health services for children and young people as requires improvement because:

• Children and adolescents had to long waits for appointments. For example, Chorley and South Ribble CAMHS had a waiting time of 29 weeks from referral to assessment for non-urgent cases. Following the initial assessment by staff, young people had to wait 24 weeks to see a psychiatrist, 18 weeks to see a psychologist, 10 weeks for family therapy and 54 weeks for an autistic spectrum disorder assessment.
• We found that the transfer of young people to adult mental health services was not working effectively. There was no current protocol for staff to follow and inconsistency in practice.
• Neither of the CAMHS teams had an up-to-date environmental risk assessment to ensure the environments posed no potential risks to young people or children.
• Too few staff had completed mandatory training, which had the potential to put young people at risk. Also, Lancaster CAMHS had only completed 50% of staff appraisals, and the trust could not give figures for the Chorley and South Ribble service.
• CAMHS staff were unavailable outside of normal working hours, to assess young people with mental health problems at Lancaster, Blackpool and West Lancashire A&E departments as this is not currently commissioned to be provided by Lancashire Care. This meant that young people might wait as long as three days to be seen by a specialist at a weekend.
• Team leaders had no consistent system to monitor the uptake of clinical and management supervision of staff. Evidence of a monitoring system was provided by the Lancaster and Morecambe team, however there was no evidence available for Chorley and South Ribble team. Clinical supervision is an important tool for checking that young people have received the appropriate care and treatment.
• Staff assessed, managed, and reviewed risks to young people daily but recorded information inconsistently. They did not know the trust’s risk assessment policy. This meant staff might have difficulty when reviewing the records, to locate and identify potential risks.

Although we found inconsistences in approaches to service provision, newly appointed managers had made changes to improve services. For example:

• The trust significantly changed the management structure in the three months before the inspection. It had brought in new staff to introduce systems to monitor compliance and improve services; and employed four new staff to reduce waiting lists.
• The trust used comprehensive performance monitoring and risk registers, to identify and respond to organisational risks. Staff had the ability to submit items to the risk register. The trust had systems in place to monitor the quality of the services and drive improvements.
• Staff understood processes to safeguard young people, reported incidents and investigated them. Team leaders told staff about outcomes and learning from incidents.
• Staff delivered care and treatment based on young people’s needs. Staff understood and addressed the type of problems presented by the young person and their families. They worked collaboratively with the young person and their family and always sought their agreement.
• Staff had a good knowledge of the Mental Capacity and Mental Health Act.
• The clinical staff had participated in clinical audits, to look at whether the services had met National Institute for Health and Care Excellence (NICE) guidelines in December 2014 for depression and attention deficit hyperactivity disorder.
• Staff felt well supported by the team leaders. Staff followed the trust's values of teamwork, compassion, integrity, respect, and intelligence when carrying out their work.
• Professionals involved in the clinical care of young people held case review meetings when they felt it was necessary to discuss and explore the options for care and treatment.
• Young people and families knew how to make a complaint or raise a concern about the service and staff had responded to these.