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Provider: Tees, Esk and Wear Valleys NHS Foundation Trust Requires improvement

Read our full service inspection reports for Tees, Esk and Wear Valleys NHS Foundation Trust, published on 11 May 2015.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 March 2020

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

  • We rated safe as inadequate for one of the core services and requires improvement in six of the 11 core services. We rated effective as requires improvement in two of the 11 core services. We rated responsive as inadequate in one core service and requires improvement in two of the 11 core services. We rated well led as inadequate in one core service and requires improvement in three of the 11 core services. In rating the trust, we considered the current ratings of the core services we did not inspect this time. We also inspected one non-core service, a specialist eating disorder service. The eating disorder service ratings were not aggregated into the overall trust ratings.
  • We rated well-led for the trust overall as good.
  • Risks were not always managed effectively. In specialist eating disorder services risks were identified in the environmental ligature risk assessment but these did not always say how these would be mitigated. In specialist community mental health services for children and young people, patients waited long periods without contact, waiting lists were not reviewed to assess risk changes and staff did not know which children were waiting for treatment or receiving treatment. In wards for older people with mental health problems there were gaps in patient observation records and identified risks were not always mitigated.
  • Staffing did not always meet the needs of patients. Patients assessments were delayed in mental health crisis services and health-based places of safety due to lack of availability of staff. In specialist community mental health services for children and young people, there were not enough staff to meet the number of referrals, complete assessments or deliver interventions and staffing levels were disproportionate across teams. Case loads were excessively high in some teams and staff and managers had no control over caseload size. In forensic inpatient/secure wards section 17 leave was regularly cancelled on Mallard and Linnet wards due to staffing issues.
  • Medicines were not always effectively managed. In mental health crisis services and rehabilitation wards staff were not ensuring the correct temperature for safely storing medication at two locations visited. In acute wards for adults of working age and psychiatric intensive care units there was no rational for prescribing medication used 'as required’ in some patient records. In wards for older people with mental health problems the service did not use systems and processes to safely prescribe, administer, record or store medicine and didn’t always follow infection control policy when dispensing medication.
  • In some services, the poor physical environments were adversely impacting on the safety, privacy and dignity afforded to patients. There were examples of this in the health-based places of safety and CAMHS offices. In the learning disability and older people inpatient services, the trust was not achieving an acceptable standard of gender separation.
  • Equality and diversity for staff and patients was not fully integrated into all areas of the work of the organisation. This was particularly needed for people who are LGBT+.
  • Disciplinary and grievance processes were not always completed in line with trust policy. Timescales weren’t always met and there were missing documents in the grievance files. This was an issue at the last inspection and continues to be the case.

However:

  • We rated, effective and caring, as good.
  • The trust had a talented and experienced leadership team. The board was working together well to respond appropriately to the ongoing challenges following the closure of the wards for young people at West Lane Hospital. The importance of the leadership team being visible and approachable was recognised. There were well structured arrangements to visit services across the wide geographical area served by the trust.
  • The trust continued to provide leadership development for staff, a strong focus was still placed on creating a coaching culture that supported recovery and wellbeing. The trust continued with its leadership programme for staff from a black, Asian and minority ethnic background.
  • The board and senior leadership team had developed a clear strategy and staff were aware of what it was. It was evident that staff and patients had been engaged during the formation of the strategy. The trust continued to embed the strategy as it developed its ongoing operational priorities.
  • The trust had a values-based culture which was positive and open. There was a high degree of openness and transparency in the senior leadership team. Staff spoke about the positive culture during the inspections of services.
  • The trust was making increasing use of digital technology to support the delivery of services to patients. The trust was introducing a new clinical information management system (CITO) which aims to allow staff to complete key pieces of information and store them in one place and link directly to the patient record.
  • The trust engaged positively with patients, carers and staff. This included a wide range of co-production work. The trust was also extending the number of peer support workers. However, it would be helpful to have a trust strategy for user involvement to ensure this was embedded throughout the organisation.
  • Staff were skilled and supported. Compliance with mandatory training was high. Staff engagement was positive. The making a difference programme included a number of workstreams to promote a positive working experience for staff. This included initiatives to improve staff health and well-being.
  • The quality improvement programme was well embedded across the trust. There were a number of trust wide quality improvement priorities including work to increase the proportion of inpatients who feel safe on the wards.

Inspection areas

Safe

Requires improvement

Updated 3 March 2020

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

  • We rated one of the of the 11 core services as inadequate and six as requires improvement for the safe key question. This takes into account the ratings of the core services which were not inspected at this inspection.
  • Risks were not always managed effectively. In specialist eating disorder services risks were identified in the environmental ligature risk assessment but these did not always say how these would be mitigated. In specialist community mental health services for children and young people, patients waited long periods without contact, waiting lists were not reviewed to assess risk changes and staff did not know which children were waiting for treatment or receiving treatment. In wards for older people with mental health problems there were gaps in patient observation records and identified risks were not always mitigated.
  • Medicines were not always effectively managed. In mental health crisis services and rehabilitation wards staff were not ensuring the correct temperature for safely storing medication at two locations visited. In acute wards for adults of working age and psychiatric intensive care units there was no rational for prescribing medication used 'as required’ in some patient records. In wards for older people with mental health problems the service did not use systems and processes to safely prescribe, administer, record or store medicine and didn’t always follow infection control policy when dispensing medication.
  • Environments were not always suitable or managed appropriately. In mental health crisis services and health-based places of safety the environments compromised the privacy and dignity of patients. In specialist community mental health services for children and young people, premises where children and young people received care were not always safe or fit for purpose. In wards for older people with mental health problems and wards for people with learning disabilities or autism the service did not comply with guidance relating to mixed sex accommodation.
  • Staff and patients did not always have access to alarms to summon assistance. In some community older people locations alarms were not available for staff. In forensic inpatient/secure wards and long stay/rehabilitation mental health wards for working age adults not all patients had access to personal alarms.
  • Staffing did not always meet the needs of patients. Patients assessments were delayed in mental health crisis services and health-based places of safety due to availability of staff. In specialist community mental health services for children and young people, there were not enough staff to meet the number of referrals, complete assessments or deliver interventions and staffing levels were disproportionate across teams. Case loads were excessively high in some teams and staff and managers had no control over caseload size. In forensic inpatient/secure wards section 17 leave was regularly cancelled on Mallard and Linnet wards due to staffing issues.

However

  • All wards were clean, well equipped, well furnished, well maintained.
  • There was adequate medical cover across all wards including out of hours.
  • The completion of mandatory training was high, although improvements were needed in the specialist eating disorder service.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. The trust had systems in place to identify learning from safeguarding alerts and make improvements. There was a clear ‘think families’ focus across the safeguarding team and the trust.
  • Overall staff managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

Effective

Good

Updated 3 March 2020

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

  • We rated 9 of the 11 core services as good and 2 as requires improvement for the effective key question. This takes into account the ratings of the core services which were not inspected at this inspection.
  • Staff provided a range of treatment and care for the patients based on national guidance and best practice. They ensured that patients had good access to physical healthcare and supported patients to live healthier lives. In specialist eating disorder services staff used a holistic approach to care and treatment and used new evidence-based techniques to support high-quality care delivery.
  • Staff used recognised rating scales to assess and record severity and outcomes. They also participated in clinical audit, benchmarking and quality improvement.
  • Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The ward team(s) had effective working relationships with other staff from services that would provide aftercare following the patient’s discharge and engaged with them early in the patient’s admission to plan discharge.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.
  • Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.
  • The trust had an effective approach to investigating and learning from complaints and incidents. They encouraged feedback for patients and carers and used this information to inform service development.

However:

  • Staff did not always keep accurate records. In wards for older people with mental health problems people mental capacity and best interest decisions were not recorded clearly. In mental health crisis services and health-based places of safety individual care plans were not clearly developed or updated and interventions didn’t correspond with care plans. In specialist community mental health services for children and young people care plans were not always recorded to demonstrate holistic, person centred and recovery focused care and consent to share information was not well recorded. In acute wards for adults of working age and psychiatric intensive care units care plans did not reflect assessed needs and were not personalised.
  • Some areas of training were not available to some staff and records were not always kept. In wards for older people with mental health problems training for dementia was not recorded.
  • Recording of supervision rates was low on some wards although staff said they received regular supervision.

Caring

Good

Updated 3 March 2020

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

  • We rated nine of the 11 core services as good and one as outstanding for the caring key question. This takes into account the ratings of the core services which were not inspected at this inspection.
  • Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • Overall staff involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. They ensured that patients had easy access to independent advocates.
  • Overall staff informed and involved families and carers appropriately.
  • We rated ten of the 12 core services as good, one as outstanding and one as requires improvement for the effective key question. This takes into account the ratings of the core services which were not inspected at this inspection.

However

  • Staff did not always maintain confidentiality or secure information about patients in wards for people with learning disabilities or autism.

Responsive

Requires improvement

Updated 3 March 2020

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

  • We rated one of the 11 core services as inadequate and two as requires improvement for the responsive key question. This takes into account the ratings of the core services which were not inspected at this inspection.
  • Privacy and dignity of patients was compromised in some areas. Some observation disturbed patients. Some environmental issues such as windows not having the ability to be covered and CCTV compromised privacy. Some patients were still sharing dormitories although plans were underway for these to be replaced.
  • Meaningful activity was not always available. On Willow ward we found little evidence of meaningful activity.
  • Discharge planning was not always clear in one service. In long stay/rehabilitation mental health wards for working age adults care plans had no longer term formulation for discharge.
  • Access to services differed across the localities. In some services there were delays and long waiting lists to access the service.

However

  • Staff managed beds well. This meant that a bed was available when needed and patients were not moved between wards unless this was for their benefit. Patients placed out of area were returned as soon as a bed was available in their local area.
  • The wards mostly met the needs of all patients who used the services - including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support.
  • Staff mostly planned and managed discharge well. They liaised well with services that would provide aftercare and were assertive in managing the discharge care pathway. Although some patients had excessive lengths of stay the service was working continuously to find suitable placements.
  • The design, layout and furnishings of the ward / service mostly supported patients’ treatment, privacy and dignity. Most patients had their own bedroom with an en-suite bathroom and could keep their personal belongings safe. There were quite areas for privacy.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from results, these were mostly shared with the team.

Well-led

Good

Updated 3 March 2020

Our rating of well-led at core service level went down. We rated well led at core service level as requires improvement because:

  • We rated one of the 11 core services as inadequate and three as requires improvement for the well led question. This takes into account of those core services not inspected at this inspection.

  • In the crisis and health-based place of safety and wards for older people there were a number of governance processes that did not operate effectively, and risks were not managed well. These issues included the documentation of risk and risk management, safe management of medicines and privacy and dignity in the health-based places of safety

  • There were delays in patient assessments and treatment in the health-based place of safety due to the availability of doctors. The multi-agency arrangements in place to support the operations of the health placed places of safety were not always effective to ensure that patients’ needs were always being met. We found delays to treatment because approved mental health practitioners were not available in a timely manner.
  • There were not enough staff in specialist community mental health services for children and young people to meet the needs of the children and young people and caseloads were excessively high in some teams. There were long waiting lists in this service and the children and young people on these lists were not reviewed in relation to risks and managers did not know which children were waiting for treatment or which were receiving treatment.
  • Environments in the specialist community mental health services for children and young people were not always safe or fit for purpose in York, Selby and Redcar. However, the trust had active plans to rectify some of these issues.
  • In the wards for older people staff did not consistently participate in local clinical audits. Local audit schedules varied across teams and where staff did engage in local audit it was unclear whether staff always acted on findings or fed these up to management. Local audits failed to pick up areas of concern found in relation to rapid tranquilisation.

However:

  • Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff,
  • Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution.
  • Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.
  • Teams had access to the information they needed to provide safe and effective care and most used that information to good effect. 

Checks on specific services

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

Good

Updated 3 March 2020

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly.

However:

  • There were variations in the monitoring and recording of supervision. Although staff said that they were having regular supervision five wards reported under 70% compliance.
  • Ensuite bathroom doors had been removed as an interim measure to keep patients safe. The trust was correctly trying to find a more permanent solution to this issue.

Specialist eating disorders service

Good

Updated 3 March 2020

We rated it as good because:

  • The service provided safe care and treatment for patients under its care and there were enough nurses and doctors to facilitate this. The ward environment was safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices and managed medicines safely.
  • The staff team included or had access to the full range of specialists required to meet the needs of patients. Managers ensured that these staff had access to training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward including community teams who would have a role in providing aftercare.
  • Staff developed comprehensive holistic, recovery-oriented care plans which were informed by a comprehensive assessment which involved a number of professionals. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

  • Though there were clear processes for reviewing incidents and complaints, the awareness of three of the staff we spoke with about lesson sharing was limited.
  • Though risk management plans were captured through individual patient risk assessments, the ligature risk assessment used by the service did not include management plans for each risk or detail contingencies respectively on the ward ligature risk assessment.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 3 March 2020

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

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed.
  • The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.

However:

  • Patients on Talbot ward did not have access to call alarms although the trust told us these would be installed during January 2020.
  • At the Orchards, patients could not access take home medication when they went on leave unless it had been planned.
  • On Oakwood it was not clear how staff identified medicines when the shelf life had been reduced due to high fridge temperatures.
  • On Oakwood and Talbot wards, some patient care records contained the wrong ward names.
  • At the Orchards, patients could not operate the vistamatic window from inside the room. This meant their privacy and dignity may be compromised.
  • On Willow ward, we found little evidence of therapeutic activity.
  • On Willow ward, care plans focused on patients’ immediate support needs with no connection to a longer-term formulation of what was necessary for discharge.

Mental health crisis services and health-based places of safety

Requires improvement

Updated 3 March 2020

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

  • Staff did not effectively manage risk to patients. In 13 of the 18 care records that we looked at risk assessment and risk management records were brief and generic, staff were not always making use of the safety summary section of the care record,
  • Staff were not managing the safe storage of medication effectively at two locations we visited,
  • In 13 of the 18 care records that we looked at it was not clear that staff had developed individual care plans and updated them when needed,
  • We found that there were delays to assessment of patients admitted to health-based place of safety because of staff availability,
  • There were several issues that compromised the privacy and dignity of patients being admitted to health-based places of safety,
  • A number of governance processes did not operate effectively,
  • The multi-agency arrangements in place to support the operations of the health placed places of safety were not always effective.

However:

  • Staff working for the mental health crisis teams provided a range of care and treatment interventions that were informed by best practice guidance and were suitable for the patient group. They ensured that patients had good access to physical healthcare.
  • Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care.
  • Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition,

Wards for older people with mental health problems

Requires improvement

Updated 3 March 2020

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

  • Staff did not consistently act to manage or mitigate risks identified for patients and this had not been identified or addressed through governance processes.
  • There were gaps in patient observation records, so it was not clear if observations had taken place. We found examples of where staff were not mitigating risks in line with the environmental risk assessments, such as locking rooms to prevent patient access to keep them safe.
  • Improvements were needed to maintain fire safety. Some patients did not have personal emergency evacuation plans and some actions related to fire risk assessments were not completed in a timely manner.
  • Some patients did not have a documented risk assessment completed prior to taking section 17 leave.
  • The service did not use systems and processes to safely prescribe, administer, record and store medicines. Some clinic room temperatures and fridge temperatures were too high and appropriate action had not been taken by staff to mitigate this. There were missing checks of emergency bags on two wards.
  • The service did not comply with guidance relating to mixed sex accommodation in five of the eight mixed sex wards where there was an inadequate level of separation between the male and female sleeping areas. We observed male patients in female bedroom areas. Male patients were using designated female lounges.
  • Staff did not follow trust policy or best practice guidelines to ensure they were using and clearly recording the use of seclusion appropriately on Rowan Lea ward.
  • Not all staff had easy access to clinical information as agency staff could not access patient electronic records and on Rowan ward paper files did not contain the most up-to-date information.
  • Local audit schedules varied across teams and where staff did engage in local audit it was unclear whether staff always acted on findings or fed these up to management.

However:

  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • All patients had their physical health assessed and regularly reviewed during their time on the ward. The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and the wider service.

Wards for people with a learning disability or autism

Good

Updated 3 March 2020

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

  • The ward environments were safe and clean. The wards had enough nurses and doctors. Except for environmental risks, staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability (and/or autism) and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Although two wards did not meet the mixed sex accommodation requirements as specified in the Mental Health Act Code of Practice, staff understood and discharged their other roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason or lack of suitable placement for the patients.
  • The service worked to a recognised model of mental health rehabilitation.

However:

  • Staff had not assessed and managed all potential risks posed by the environment on Aysgarth ward.
  • Two wards did not meet the same-sex accommodation guidance specified in the Mental Health Act Code of Practice.
  • Staff did not always maintain the confidentiality or secure information held about patients.
  • Staff did not always identify incidents or record and report them appropriately.
  • Systems and processes were not fully established to support all wards with the transfer of patients to psychiatric intensive care units if a patient required more intensive care.
  • Governance processes did not always ensure that care delivered met national guidance.

Specialist community mental health services for children and young people

Requires improvement

Updated 3 March 2020

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

  • The service did not provide safe care. Clinical premises where patients were seen were not all safe or fit for purpose. The number of patients on the caseload of the teams, and of individual members of staff, were too high and staff could not give each patient the time they needed. There were not enough staff to manage the volume of patients. Staff did not manage waiting lists to ensure that patients who required urgent care were seen promptly.
  • The service was not easy to access. Staff were not always able to assess and treat patients promptly. Patients waited too long to start treatment.
  • Care plans were not always personalised, holistic or recovery-orientated.
  • Staff did not record decisions relating to consent well. There was no consistent approach to recording consent. Consent information was located within the electronic recording system and paper notes.

However:

  • Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Forensic inpatient or secure wards

Good

Updated 3 March 2020

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

  • All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Each ward was individualised and decorated by the patients.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s mental and physical health.
  • Staff provided a range of treatment and care for patients based on national guidance and best practice. This included access to psychological therapies, support for self-care and the development of everyday living skills and meaningful occupation. Staff supported patients with their physical health and encouraged them to live healthier lives.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Each patient had their own bedroom with an ensuite bathroom and could keep their personal belongings safe. There were quiet areas for privacy.
  • Staff supported patients with activities outside the service, such as work and education opportunities.
  • Staff had the skills, or access to people with the skills, to communicate in the way that suited the patient.
  • Teams had access to the information they needed to provide safe and effective care and used that information to good effect.
  • Staff collected analysed data about outcomes and performance and engaged actively in local and national quality improvement activities.

However:

  • Patient section 17 leave was regularly cancelled on Linnet and Mallard wards due to staffing issues.
  • Not all patients had access to personal alarms in the case of an emergency, in line with national guidance. Patients had been offered personal alarms, if they refused staff would review alarms with patients regularly.
  • Patients informed us that the hourly care rounds in the evening were impacting on their physical and mental health

Community-based mental health services for older people

Good

Updated 3 March 2020

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

  • The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude people who would have benefitted from care.
  • The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

Child and adolescent mental health wards

Updated 16 October 2019

Due to the concerns we found during this inspection, we used our powers under section 31 of the Health and Social Care Act to take immediate enforcement action and placed conditions on the trust’s registration. The conditions we placed upon the trust’s registration have closed the wards we inspected meaning that all the young people need to be moved to alternative services to ensure they receive safe, good quality care.

We rated the service as inadequate following the inspection in June 2019. We inspected this service again on 6 August 2019 and did not re-rate the service. This inspection on 20-21 August 2019 did not re-rate the service. We found the following issues of significant concern:

  • The service was not delivering safe care. Staff did not record young people’s observations in line with trust policy, so it was unclear whether staff were undertaking observation as they should. Many of the nursing staff, including both registered nurses and support workers did not have the knowledge or experience to provide safe care to young people with complex needs. The trust did not ensure that the wards were not staffed at all time with staff who had completed the required mandatory training. Staff at all levels told us that they were struggling to maintain the right balance between managing safety and implementing the principles of least restrictive practice. Staff did not consistently report incidents accurately, including whether physical interventions had been used to restrain young people.
  • The service was not delivering effective care. Staff did not deliver care in accordance with the young people’s intervention plans which detail the care that young people should be receiving. We saw examples of where care being delivered was not in line with intervention plans. One of the intervention plans contained contradictory information. There were limited therapeutic activity on the wards. Staff told us that they were spending most of their time trying to maintain safety and therefore did not have time to deliver therapies that would aid recovery.
  • The service was not well-led. Some staff described the service as ‘traumatised’ and told us that there was a divide between managers, the trust and staff working directly with young people. Audits were not effective and did not identify areas of concern in relation to observation records and incident reports. Managers had not ensured that all staff were familiar with young people’s intervention plans. There was limited oversight of the wards from senior managers who understood how quality care for young people should be delivered. In addition, the service did not have effective governance systems in place to ensure that the young people received high-quality care.

However:

  • During the inspection we saw a number of interactions between staff and young people that were kind, caring and compassionate.

Community-based mental health services for adults of working age

Good

Updated 23 October 2018

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

  • The services ensured their community environments were clean, well maintained and appropriately risk assessed. The service used a staffing tool to ensure caseloads were manageable and all patients’ records we reviewed had appropriate risk assessments and crisis plans. Staff understood their responsibilities under safeguarding, and there were appropriate processes to support them doing so. We saw staff were regularly reporting and learning from incidents.
  • The service used a range of biopsychosocial interventions recognised by best practice, with good access to different types of psychology, occupational therapies, education, and medication. There was robust physical health monitoring for patients who required this and staff had access to specialist information systems which meant they could access blood results. There was a wide range of skilled staff who worked closely in a multidisciplinary setting. Staff received regular supervisions and annual appraisals, they felt well supported through these processes.
  • Staff had a good working knowledge of the Mental Capacity Act and Mental Health Act. We found the Community Treatment Order documentation was up to date and appropriately documented within care plans. Staff were regularly discussing issues around patient capacity and least restrictive practices.
  • We spoke to 40 patients and 18 carers, all of whom were positive about the care and treatment received by staff. We observed kind and compassionate care through interactions between staff and patients within their homes and community bases. The service offered a holistic service which ensured patients and carers were at the centre of their treatment. Patients and carers were involved in the delivery and improvement of services through various platforms.
  • The community mental health services for adults had a clear referral criteria and care pathway into the service. Services were meeting their 28 day referral to assessment target, and there was no wait times to access support once the patient met the criteria. Access to psychology was excellent across the community teams with a maximum wait time of three weeks. The service was learning from complaints and improving their services as a result. The teams were able to meet patients’ disability, accessibility, learning disabilities, cultural and religious needs.
  • The service was well led. Staff, managers and senior managers told us how supported they felt within the organisation. Staff were able to demonstrate the values and understood the direction in which services were going. Teams had good oversight of risk and there was an escalation process. The trust had a clear governance structure which demonstrated how information flowed up the organisation to the executive team and back down to operational staff.

However:

  • The service was in the process of reviewing its use of emergency equipment during clinics therefore most of the clinics within the community mental health teams did not have emergency equipment in place. The trusts senior leadership team and oversight of the risks and had a process in place to mitigate them.
  • Teams within Durham and Darlington did not always accurately document information on patients’ paper medical records in line with their electronic records.
  • The trust had recently introduced Mental Capacity Act and Mental Health Act training in April 2018 as mandatory. Although staff had a good working knowledge in both areas, the community mental health teams had not yet achieved the trusts target of 90%. The trust projected this would be complete in May 2019.
  • Although staff received regular annual appraisals and regular annual supervision, recording of clinical supervision was not always accurate, the trust figures did not reflect what staff told us in some teams.
  • The trust did not use a recognised risk assessment tool in line with best practice.

Community mental health services with learning disabilities or autism

Good

Updated 23 October 2018

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

  • There were sufficient numbers of trained, supervised and appraised staff to meet the needs of patients within the service.
  • Staff made safeguarding alerts, reported incidents where appropriate and received relevant lessons learned. Staff understood the duty of candour and were open and transparent with patients. Staff and patients knew how to complain and received feedback following complaints made. Staff knew how to contact the trust Freedom to Speak Up Guardian and could access the trust whistleblowing policy.
  • Staff interacted with patients in a kind and caring manner. Staff involved patients in decisions about their care and treatment and communicated with patients using their preferred communication methods. Carers were positive about the service and told us they felt involved in patients’ care. Teams had effective working relationships with both internal and external providers in order to enhance patient care.
  • Consultant psychiatrists did not prescribe or recommend antipsychotic medication for behaviour as a first response and would only prescribe if other non-medical interventions were insufficient. When medicines were administered on site staff followed good practice in medicines management.
  • Staff understood and applied the trust vision and values in their work and engaged in quality improvement work to improve the service for patients. Effective systems ensured good governance.

However:

  • At The Orchard capacity assessments were not always completed or documented and staff did not regularly or consistently use the National Early Warning Scores tool to monitor patients’ physical health. Also risk assessments were not always updated following a change in risk presentation or reviewed within the required timescales. At Lancaster House adult autism service patients were waiting an average of 13 weeks for an appointment, with the longest wait being 58 weeks, which is not in line with the National Institute for Health and Care Excellence guidance.