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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.

Reports


Inspection carried out on 24 Sep to 6 Nov 2019

During a routine inspection

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.


CQC inspections of services

Service reports published 3 March 2020
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Specialist eating disorders service Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 Sep to 6 Nov 2019 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 3 March 2020
Service reports published 16 October 2019
Inspection carried out on 20-21 August 2019 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Inspection carried out on 6 August 2019 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Service reports published 21 August 2019
Inspection carried out on 20, 21, 24 June 2019 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Service reports published 23 October 2018
Inspection carried out on 12 June to 25 July 2018 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 June to 25 July 2018 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 June to 25 July 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 June to 25 July 2018 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 June to 25 July 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 June to 25 July 2018 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 23 October 2018
Service reports published 2 October 2018
Inspection carried out on 21 June 2018 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)
Service reports published 11 May 2017
Inspection carried out on 23 - 27 January 2017 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)
Inspection carried out on 23 - 30 January 2017 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
Service reports published 23 February 2017
Inspection carried out on 1 November 2016 to 4 November 2016 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 1 November 2016 to 7 November 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 12 June to 25 July 2018

During a routine inspection

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

  • We rated, effective, caring, responsive and well-led as good, with safe as requires improvement. We rated three of the trust’s 11 services as good and three as requires improvement. In rating the trust, we took into account the current ratings of the five services not inspected this time.
  • We rated well-led for the trust overall as good.
  • The trust had an effective leadership and governance structure. There were groups and committees at all levels and across the specialities to facilitate this. The trust board and senior leadership team had the appropriate range of skills, knowledge and experience to perform their respective roles. There was appropriate challenge at board meetings which was accepted and responded to in a positive way by the executive team.
  • The trust had a strong quality improvement culture which was well developed and embedded across all services and localities. There were examples of where the trust had developed its services by applying this methodology.
  • The trust had an effective incident reporting system that analysed trends, captured learning and shared this learning across the services and localities.
  • Staff were skilled and supported. Compliance with mandatory training was high. Staff had access to other training suitable for their role and the trust had leadership and development training which targeted specific groups of staff.
  • In wards for older people and child and adolescent services there was good patient risk assessment practice for both formulation and review of risk.
  • Report out meetings were effective and used across the services. They provided an effective system for ensuring care was patient focused, therapeutic, informed by risk and formulated with a discharge focus. They also provided an effective means of information flow through the organisation.
  • Morale was high across the trust. Staff felt motivated, supported, valued and displayed a positive attitude about their role and the trust as an organisation.
  • There was good engagement with patients and carers and the trust sought feedback to inform the performance and development of the service.
  • The trust engaged well with its stakeholders. Stakeholders spoke positively about the trust performance and interactions they had with them.

However:

  • We rated safe as requires improvement in four of the 11 core services and responsive as requires improvement in two of the 11 core services.
  • There were some privacy and dignity issues on some wards with dormitory style accommodation and only a curtain between beds. Although the majority of bedrooms had ensuite facilities not all rooms were ensuite.
  • Some wards were short staffed which had an impact on patients accessing leave from the ward, staff observation of patients and access to meaningful activities.
  • Staff supervision records did not reflect what staff described. Despite some compliance records being low we found that staff were well supported by their managers and received regular supervision. The trust also had a plan in place to address this.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RX3/reports.

Inspection carried out on 23 January to 27 January 2017

During an inspection looking at part of the service

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.

After the inspection in January 2017 the overall rating for the trust has not changed from good because:

  • All ratings in the provider report and core service report key questions remained the same except; long stay/ rehabilitation mental health wards where there was a change of rating from requires improvement to good in safe;  community services for people with learning disabilities or autism was not previously rated and following this inspection has a rating of good; wards for older people with mental health problems ratings have changed from good to requires improvement; the provider quality report ratings have changed in well led from outstanding to good.

  • Staff engaged with patients in a caring, compassionate and respectful manner throughout our visits to the wards. Feedback received from patients and carers was positive in relation to the care and treatment they received and they felt involved in care planning. Patients had access to advocacy services. The trust actively sought the views and experiences of patients across all the services we visited.

  • Staff had a good understanding of the Mental Health Act and applied this in practice. The trust had a system for monitoring and reducing restrictive physical interventions with a ‘force reduction programme’, this was trust wide. The trust was making a positive effort to reduce blanket restrictions on wards and had started to share effective findings with other parts of the trust. Patient’s capacity and consent to treatment was recorded and staff regularly explained patient’s rights to them.

  • Staff managed medicines well on acute wards, psychiatric intensive care units and long stay rehabilitation wards. Staff completed the correct documentation when they administered covert medication to patients on older people’s wards. Staff carried out a comprehensive assessments of patient’s needs and  reviewed patient’s risks regularly.

  • The trust worked actively to promote the wellbeing of staff.  As a result, the overall sickness rate was low and staff morale was generally high.  The trust was undertaking a ‘staff engagement pilot’ with the aim of increasing the engagement of staff working in the trust. It had also set up a residential retreat programme for staff which aided participant’s wellbeing and helped staff to make the most of their lives.

However:

  • The trust did not take all necessary action to ensure the safety of patients under its care.  Staff on the wards did not always undertake annual environmental audits to reduce the risk of suicide nor were all staff aware of the risks in the ward environment. The Orchards had no nurse on call system for patients to summon staff in an emergency. Rowan ward and Wingfield ward did not comply with Department of Health guidance on eliminating mixed sex accommodation because they did not provide a seprate lounge-space for women.  Few staff on the wards for older people with mental health problems had completed the training that the trust considered essential and only one-half of staff across the trust had completed training in resuscitation.

     

  • The trust was not fully complying with the requirements of duty of candour. There were some omissions in the records showing when medication had been administered and recording physical observations when rapid tranquilisation had been used.

  • The trust had not fully updated all of the policies and procedures listed in annex b of the Mental Health Act code of practice 2015. The mental health legislation committee, who was responsible for assuring the Mental Health Act code of practice was implemented, had not adequately monitored annex b of the code. Seclusion recording in some parts of the trust was not fully available in the electronic record.

  • The trust had not included external feedback in its equality delivery system 2 report as part of the workforce race equality system.

  • The trust had not made significant progress in a number of patient safety areas detailed in the action plan for the York and Selby locality.

The full report of the inspection carried out in January 2015 can be found here at

http://www.cqc.org.uk/provider/RX3?lk

Inspection carried out on January 2015

During a routine inspection

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

We found that the provider was performing at a level which led to a rating of Good.

Mostly patients were protected from avoidable harm or abuse, but we found some patient safety issues that need to be addressed:

  • There were breaches of same sex accommodation guidance on Earlston Ward, a 15 bed rehabilitation ward.
  • There were some environmental and ligature risks identified on Ward 15, Cedar ward, Abdale House and Primrose Lodge. On the acute wards not all risks had an associated intervention plan.
  • On Ceddesfeld and Hamsterley wards, medicines were being administered covertly, but the information about this was not recorded in line with the trust policy.

The trust strongly encouraged openness and transparency. The trust carried out a thorough investigation following serious untoward incidents. We did note that relatives and carers were not as engaged in the process as they should be. Other healthcare professionals and staff were engaged in the process of the review. Lessons were learned and improvements to safety were made and then monitored.

There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse. There was executive team leadership in safeguarding. The trust actively worked with other organisations and were engaged in local safeguarding boards and procedures.

Staffing levels were planned, reviewed and implemented to keep people safe. The trust published their staffing levels on their website.

Staff recognised and responded appropriately to changes in risks to people who use services. The trust had developed a physical restraint reduction plan and were using positive behaviour support to manage behaviours that challenge.

The trust had developed a strategy to minimise restrictive practices. We did however see some restrictive practices taking place in the trust although they were working towards improving this problem. We saw this in the acute wards and on Fulmar and Kirkdale rehabilitation wards.

Patients had good outcomes because their care and treatment was effective at meeting their needs. Patients had comprehensive assessments of their needs carried out at the point of admission. Care and treatment was planned and delivered in line with current evidence based practice. Information about patient care and treatment, and their outcomes, was routinely collected and monitored. This information was used to improve care. However in the learning disabilities wards patients did not have a comprehensive person-centred, holistic discharge plan in place to support commissioners and other authorities to find accommodation that will meet individual needs and preferences on discharge.

Patients that were detained had their rights protected. With the exception of the recording of seclusion on Ward 15, staff complied with the Code of Practice.

With the exception of 367 Thornaby Road, staff were in receipt of clinical and management supervision and appraisals. Learning needs were identified and training set up to meet those needs.

Issues about capacity and consent were mostly understood. However staff on Earlston House, the CAMHS community teams and the older peoples’ wards did not fully understand how the Mental Capacity Act and Deprivation of Liberty Safeguards applied to their work.

Patients were respected and were partners in their care and treatment. We observed and saw records that demonstrated active patient engagement in all aspects of their care. Patients also contributed to the running of the wards and changes to services. The trust participated in the ‘triangle of care’. Carers’ were seen as an integral partner, alongside the patient and staff in the care and treatment delivered to the patient. Patients’ privacy and dignity was maintained with the exception of Ward 15 and Cedar ward which were both located in acute general hospitals.

With the exception of 367 Thornaby Road, there was information available about advocacy services and Independent Mental Health Advocacy for detained patients.

Patients’ needs were met through the organisation and delivery of services. Services were planned in collaboration and consultation with health and social care partners or commissioners. We heard that the trust was willing to engage in future strategy planning and delivery of services. However we noted that patients in the learning disability wards had been in the service between 2-14 years. The service struggled to discharge patients because external authorities did not identify suitable places for patients to move to. There were delays in funding from external authorities which meant patients remained in hospital longer than necessary.

There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that met those needs and promotes equality. There were interpreting services that could be accessed easily if needed. Reasonable adjustments were made and action taken to remove barriers when patients found it difficult to access services. Lessons from complaints were discussed at ‘daily report out’ meetings, team meetings or clinical supervision. Feedback was shared with patients via the ‘you said, we did’ boards.

The leadership, governance and culture were used to drive and improve the delivery of high quality patient-centred care. Leaders had an inspiring shared purpose, were determined to deliver and motivated staff to succeed. There was ownership of the vision, values and quality improvement system throughout the organisation. There were high levels of staff satisfaction. Staff were proud of the organisation as a place to work and spoke highly of the culture. Staff felt engaged in the delivery and continuous improvement of services. The trust quality improvement system was embedded at every level across the organisation. The trust participated in external peer review and accreditation.

Intelligent Monitoring

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

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


Joint inspection reports with Ofsted

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


Reports under our old system of regulation (including those from before CQC was created)


Mental Health Act Commissioner reports

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

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


Other types of report

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.