Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

We carried out a responsive, unannounced inspection over three days. This was because of information we had received giving us concerns about the safety and quality of the services.

This was a focused inspection looking at safe effective and well led key questions. We did not rate key questions at this inspection. However, due to a regulatory breach in well led this domain has been limited to requires improvement.

Summary

• The use of restrictive practices had increased significantly since the last inspection, including the use of mechanical restraint.
• Governance systems had identified that limited formal debriefs were taking place. Managers had started to implement changes to address this. However, at the time of the inspection the level of formal debriefs taking place was not in line with trust policy.
• There was evidence of oversight and scrutiny of the use of restrictive practice within the trust management forums. However, the trust had not maintained a continued reduction in restrictive practices within services for children and young people.

However,

• The wards had enough nurses and doctors. Staff usually assessed and attempted to manage risks well.
• 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.
• 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 felt respected, supported and valued by local leaders.

How we carried out the inspection

We visited four wards at Ferndene and two wards at Alnwood. We spoke with 23 staff members including clinical managers, nurses, support workers and members of the multidisciplinary team, four young people, two carers and reviewed 15 care records and attended three meetings. We also spoke to the advocate and commissioners before the inspection.

What people who use the service say

We were able to speak to four young people who all said that they felt safe on the wards and that staff supported them. The young people said that staff had spoken to them after incidents of restraint, but one young person felt that they weren’t listened to about their experience of a restraint.

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

• Managers did not always ensure that staff had the range of skills needed to provide high quality care and did not always fully support staff with supervision or team meetings.
• Staff did not always assess and manage risks to patients and themselves well. Risk assessments were not always kept up to date and did not always reflect the current patient need. The management of long-term segregation and seclusion, and the use of mechanical restraint, did not always meet with best practice.
• Staff did not always develop holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff did not always follow physical healthcare plans in place for patients and were not always aware of the content of these.
• Staff did not always demonstrate clear understanding of their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and did not always act in line with the Mental Health Act Code of Practice.

However:

• Staff had received basic training to keep people safe from avoidable harm.
• The wards were generally safe and clean, with enough nursing and medical staff, who knew the patients. The ward staff participated in the provider’s restrictive interventions reduction programme and understood how to anticipate and de-escalate challenging behaviour.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staff undertook functional assessments when assessing the needs of patients and provided a range of treatment and care for patients based on national guidance and best practice.
• The ward team included the full range of specialists required to meet the needs of patients on the ward.

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

• We rated effective, caring, responsive and well-led as outstanding, and safe as good. We rated nine of the trust’s 15 services as outstanding overall and six as good. In rating the trust, we took into account the previous ratings of the services we did not inspect this time.
• We rated well-led for the trust overall as outstanding. The leadership, governance structures and culture within the trust were used to effectively drive and improve the delivery of high quality person-centred care. Leaders had a comprehensive understanding of the challenges faced by the trust and worked collaboratively to develop solutions.
• Leaders strived to continually review and improve services. The collective leadership model and operational locality delivery structures meant that staff were empowered to drive improvement at all levels of the organisation. Innovation and new initiatives were celebrated both within the trust and externally.
• The quality of performance data was outstanding. Staff at all levels had access to a wide range of real time data which was used to actively inform and shape how services were delivered and how care was provided. Staff on child and adolescent mental health wards used data to change practice. This had resulted in reduced use of restrictive physical interventions for patients.
• Staff maintained high compliance rates for mandatory training.
• There was an open incident reporting culture. Staff knew how to report incidents and there was evidence of learning from these. Staff received debriefing after serious incidents. There were comprehensive arrangements and procedures to safeguard children and young people. Staff in all services inspected demonstrated a good understanding of safeguarding and knew how to protect patients from abuse and report any concerns appropriately.
• Child and adolescent mental health wards and specialist community mental health services for children and young people had a truly holistic approach to assessing, planning and delivering care and treatment to patients. Patients had access to an extensive range of evidence based interventions. Staff worked consistently to ensure patients lived healthier lives and developed individualised approaches to meeting the physical and mental health needs of patients.
• The trust worked collaboratively with other organisations to ensure the highest provision of care for patients. This included facilitating training by specialists to enable staff on the wards to deliver the best care and treatment possible, particularly for patients with complex needs. Staff on inpatient mental health wards worked closely with community teams to facilitate effective discharge pathways for patients. The trust was working collaboratively with commissioners and staff to design specialist community based services for children and young people to prevent admission to hospital.
• Feedback from people who used the services, those who are close to them and stakeholders were continually positive about the way staff treat people. People said that staff go the extra mile and care exceeded expectations.
• There was a strong and visible person centred culture. Staff in all services we inspected were highly motivated to offer care that was kind and promoted people’s dignity. Relationships between staff and people who used services and their carers were supportive and caring.

However:

• The trust acknowledged there was more work to do to review restrictive practices including blanket restrictions across all inpatient services. The trust identified this was an area of development. Whilst there was evidence of significant reduction in the use of mechanical restraint and every use was based on individual risk assessment and subject to director level authorisation, this intervention in the management of violence and aggression was still being used.
• Staff appraisal rates were slightly below the trust target. Whilst there was no trust target for clinical supervision rates, some services had lower levels of clinical supervision. There were delays in staff receiving formal written outcomes following disciplinary and grievance procedures.
• In acute wards for adults of working age and psychiatric intensive care units, staff were not always monitoring the physical health of patients after rapid tranquilisation. Seven of these wards did not have nurse call alarms.
• Waiting times for treatment in community specialist mental health services for young people did not always meet the trust target of 18 weeks for certain specialist treatment pathways.

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

• There were good patient risk assessments on each ward. The service provided a safe environment and managed risks well. Patients told us they felt safe. Risk assessments included monitoring of existing and potential physical health risks.
• Staff understood that the use of restraint was a last resort. They used de-escalation and low levels of restraint to manage incidents of aggression wherever possible. Staff ensured they documented episodes of seclusion, restraint, and rapid tranquilisation in accordance with trust policy. The ward took part in the trust restrictive interventions reduction programme and reported incidents of restraint appropriately.
• Patients had detailed, personalised care plans, which included information about physical health needs. Patients and their carers felt involved in decisions about their care. Staff gathered information from families and carers to complete the Newcastle model of assessment record for patients with cognitive impairment. This reflected a patient’s history and preferences and contributed to their care plan. They used the five P’s assessment tool for patients with a functional mental health issue.
• There was effective multi-disciplinary team working with regular reviews of patients care and treatment needs. We saw the Mental Health Act, detention papers and associated records completed appropriately. Staff understood the application of the Mental Capacity Act. They recorded best interest decisions including when significant decisions were made for patients who lacked capacity.
• Patients, families, and carers appreciated and spoke highly about the quality of care and treatment the service provided. Staff involved patients in decisions about their care where possible. They engaged with and supported families and carers where appropriate. Staff contacted families and carers with updates on patient progress, held regular carers meetings, and invited them to reception meetings.
• The service accommodated patients in trust beds and sent them out of locality rather than out of area, they moved patients back to their local areas as soon as they were able, this meant carers could visit more easily. Staff worked towards discharges from the point of admission and where possible staff visited care homes and/or families to discuss the level of support the patient would need when they left hospital.
• On the functional disorder wards, activities were structured and planned whilst in the organic wards activities were ad-hoc and individualised. All of the wards had activity workers who worked shift patterns; this meant they were available to assist staff with activities on evenings and weekends.
• Internal changes within the service had led to a positive change in culture. Staff focused on the needs of the people using their service, providing high quality patient centred care, which reflected the trust’s vision and values. However:

However:

• On Castleside, there was an unpleasant smell and signage on the doors had been ripped off as well as flooring that had been damaged by a patient.
• We looked at 32 patient records and each patient had a risk assessment in place. However, some of the information was very brief, a question was answered with a tick and no explanation, and some of the information was not dated.
• Staff kept written records throughout the day of the patients’ dietary intake, their health checks and how their mood was. This information was added to the progress notes on the computer. However, we saw that these notes were not always added to the record in a timely way.

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

• Staff worked in creative and flexible ways to ensure that patient’s physical health was monitored effectively and that patients lived healthier lives. Physical health care was fully embedded into care and treatment. Where patients had complex needs, staff created graded exposure plans informed by formal assessments to work towards physical health monitoring. Staff worked with patients to enable them to take their own physical health measurements.
• The services worked in a truly holistic and individualised way to assess, plan and provide care and treatment to patients. This involved where appropriate seeking specialist treatments including input from experts, specialist training for staff and following best practice guidance and recommendations for meeting the needs of patients with eating disorders.
• Staff committed to an open culture and commitment to reflection following incidents. A dedicated trained responsive oncall debrief facilitator was present on Lennox and Ashby. They responded to incidents and led patient and staff debriefs following incidents. On all wards, debriefs from incidents fed into reflective practice sessions and into patients’ clinical team meetings.
• The trust had invested in, built and developed a model of care and an innovative bespoke system. Talk First focused on delivering safe and positive care and followed the principles of positive behavioural support, reducing the use of restrictive interventions and worked well with the initiatives Safe wards and Star wards. The system was not burdensome on staff as it generated an automated dashboard to analyse incidents live from incident reporting systems. The data could be reviewed by many different factors. Staff teams embedded individual patient dashboard reviews into patients’ clinical team meetings where they used the information to change practice. Trends and themes from incidents were integrated into ward environmental risk assessments. External lessons learnt were also incorporated into environmental risk assessment to assess dynamic risks.
• The services had clear leadership and governance structures following the recognised collective leadership model. The trust had invested in training to ensure leaders had the capacity and capability to deliver effective leadership in practice. Staff reported high levels of engagement, satisfaction and morale. They felt confident if they had any concerns to raise these. The services had clear frameworks of meetings with mechanisms to escalate and cascade information from ward to clinical business unit levels.
• Leaders and frontline staff were working with commissioners to deliver changes in service models in line with the Transforming Care Agenda. This had led to the closure of some beds and more beds were expected to close. The trust was developing specialist community based mental health services aimed at providing effective treatment and preventing hospital admission.
• Three wards had achieved Full Monty award from Star wards for implementing all 75 positive initiatives. They had also increased the duration of handover time to 30 minutes for all wards and reduced the use of bank and agency staff including the amount of shifts left unfilled.
• Patients and their carers were meaningfully involved as partners in care and treatment. Staff knew patients and their individual needs very well. Observations demonstrated that staff were calm, positive and responsive to patients’ needs. Patients were involved in local recruitment for some staff vacancies.
• The trust had invested in improving the environments to ensure these were more therapeutic, recovery focussed and comfortable. This had included work to overcome the environmental challenges of the historical build of Alnwood and the opening of a dedicated area at Ferndene for day service activities to take place.
• The services had 91% compliance rate for mandatory training.
• Staff understood and demonstrated their responsibilities in relation to safeguarding, Mental Health Act and the Mental Capacity Act.

However:

• Although the trust had invested in and made a significant commitment to reducing the use of restrictive interventions including reducing mechanical restraint by 68%, there were 84 uses of mechanical restraint between January to December 2017. All use of mechanical restraint was subject to individual risk assessment and subject to director level authorisation.
• We found some ligature points that the trust could remove on Fraser and Riding wards to further reduce risk.
• Care plans did not always reflect patient involvement and patient views that staff had sought. Although staff discussed discharge and made plans, care plans did not contain information on discharge planning.

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

• The service was providing effective care. All patients had a care plan which was regularly updated. Patients had access to a range of care and treatment options which were in line with national guidance. Staff were supervised effectively and had access to additional specialist training. Staff understood and implemented the Mental Health Act and Mental Capacity Act effectively.
• Staff were caring. Feedback from patients and carers was consistently positive about staff attitudes. The service was organised in a way that ensured staff focussed on interacting and engaging with patients as opposed to administrative tasks. Care records showed evidence of ongoing patient involvement and engagement through regular one to one sessions with nursing staff. Carers told us that they felt appropriately informed and involved in the care provided by the service.
• The service was providing care in a way that was responsive to people’s needs. Beds were managed appropriately to ensure that people could access the service when they needed it. Wards had a range of facilities to promote comfort, privacy and dignity. Most wards had good accessibility. The service could access interpreters, translators and other services designed to meet individual needs.
• The service was well-led. There was a stable management team with managers at all levels who had the skills, knowledge and experience to perform their roles. Ward managers and senior managers were highly visible on the wards and staff told us that managers at all levels were approachable. Almost all staff we spoke to told us that they felt respected, supported and valued. There were good systems and processes in place to assess and monitor quality and safety on the wards.

However;

• There were areas of improvement to maintain safety on the wards. Staff were not monitoring the physical health of patients after the administration of rapid tranquilisation. Several wards had implemented blanket restrictions. The service was not regularly reviewing blanket restrictions. Nurse call alarms were not available in patient bedrooms on seven of the eleven wards. Ligature risk assessments on two of the eleven wards had not identified all potential ligature points in patient accessible rooms.

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

• Care records contained up to date individual risk assessments and management plans. Staff could review complex cases in a multidisciplinary risk meeting and seek support and guidance to ensure risks were appropriately managed.
• Staff worked collaboratively with young people and their family/carers to efficiently deliver care in an outcomes based approach. Young people were actively involved in reviewing their progress towards their goals and outcomes.
• Staff were trained in an extensive range of therapeutic interventions in line with National Institute of Health and Care Excellence recommendations.
• Care plans captured the voice of the young person and placed them at the centre of their care.
• Managers and commissioners were working together to reduce waiting lists and ensure the service met the needs of children and young people locally.
• Key performance indicators were embedded within the service and effective governance processes were in place to monitor the quality of the service provided.

However:

• Assessment of Gillick competence was not easily accessible in young peoples care records.
• The service was not always meeting the trusts target of 18 weeks from referral to treatment for certain specialist treatment pathways. Whilst there was an effective process of triage, which enabled the trust to identify higher risk referrals, there was no system for routinely monitoring the risks of young people on the waiting list for treatment.

We did not rate acute wards for adults of working age and psychiatric intensive care units at this focused inspection.

We found the following issue that the trust needs to improve:

• Patients identified as being at risk of choking or swallowing on Beckfield ward did not have this documented in their risk assessment, although these issues were identified within care plans.

We also found the following areas of good practice:

• Patients’ risks were being assessed, monitored, and managed on a daily basis. Staff recognised changes in risk and responded appropriately.
• Staffing levels were adequate to keep people safe and effective handovers were taking place to ensure staff were able to manage risks.
• Staff were raising concerns and reporting incidents. These were investigated appropriately and lessons were communicated widely to support improvement.
• Patients were receiving a comprehensive assessment of their needs. Care and treatment was delivered through care plans, which reflected these needs.
• Staff had the skills required to deliver care and treatment. Learning needs were being identified and training was delivered to meet these needs.
• Staff were working together to assess, plan and deliver care and treatment.

We did not rate long stay/rehabilitation wards for working age adults at this focused inspection. All ratings shown in this report are from our previous inspection in June 2016.

We found the following issue that the trust needs to improve:

• Patients identified as being at risk of choking or swallowing on Bridgewell ward did not have this documented in their risk assessment, although these were reflected in care plans.

However, we also found the following areas of good practice:

• Patients’ risks were being assessed, monitored, and managed on a daily basis. Staff recognised changes in risk and responded appropriately.

• Staffing levels were adequate to keep people safe and effective handovers were taking place to ensure staff were able to manage risks.

• Staff were raising concerns and reporting incidents. These were investigated appropriately and lessons were communicated widely to support improvement.

• Patients were receiving a comprehensive assessment of their needs. Care and treatment was delivered through care plans, which reflected their needs.

• Staff had the skills required to deliver care and treatment. Learning needs were being identified and training was delivered to meet these needs.

• Staff were working together to assess, plan and deliver care and treatment.

We rated substance misuse services as good because;

All areas were clean, well maintained and offered good facilities for the service to be delivered. Staff carried personal alarms and adhered to the lone working policy. Clients and staff told us they felt safe using the service. Clients had risk assessments which were comprehensive and up to date. There was a system in place to ensure that incidents were recorded and investigations were undertaken whenever necessary.

Clients spoke positively of the service; they felt involved in their treatment options and told us the staff team treated them with dignity and respect. There was a helpful pack available to clients and carers which described how the service worked and information regarding support available through other agencies.

There were several treatment pathways available to clients depending on their individual needs. Teams took active steps to keep clients engaged in treatment including an initiative for clients new to the service and making contact with clients who did not attend appointments. Staff knew how to support clients in making a complaint and there was information available through the information packs and within all premises informing clients how to make a complaint.

We saw evidence of how the aims of the service were upheld by the staff team. Staff described good working relationships within the partnerships and the other agencies involved, Mandatory training, supervision and performance appraisal was undertaken within all teams.

Staff knew how to report incidents, complaints and safeguarding concerns and the service had developed an APP (software designed to run on a computer) to support staff in getting feedback on incidents, the outcomes and any shared learning or changes to practice. There was a risk register which listed risks, actions, dates and those responsible for taking any action.

However;

In one location services were provided on the first floor of the building and there were no facilities for anyone with physical disabilities to access these areas. Staff told us this could be problematic but this was mitigated by using alternative rooms for clinical interventions or clients manoeuvred the stairs as best they could.

A system for checking medical equipment in one location had recently been introduced but had not been undertaken in the week of our inspection.

The system for checking stocks of prescriptions in one location did not allow for regular reconciliation of unused prescriptions.

We rated Northumberland, Tyne and Wear NHS Foundation Trust Forensic Inpatient/Secure wards as good because :

The service was built around a principle of person centred practice, which was representative of the trusts values, this was demonstrated through the interactions we observed between staff and patients. Staff were seen to demonstrate dignity, respect and an understanding of individual needs within their interactions with patients.

There was an open culture in the service and patients were able to approach staff or managers for support at any time. Patients’ views were sought through regular 1:1 time, weekly multidisciplinary meetings and clinical case reviews; these were reflected in patients care planning, individual therapeutic programme and outcome measures. Patients were also encouraged to provide feedback on the service through the use of comments cards and regular community meetings.

The service held a weekly multidisciplinary single point of referral meeting which included representation from NHS England. All new referrals were discussed to decide if the service could meet the needs of the patient and which ward would provide the most appropriate care pathway. Patients received a multidisciplinary pre-admission assessment, which included an assessment of patients’ physical health and any on-going support which may be required following admission.

Patients had the support of a full multidisciplinary team who worked with patients to provide an individualised support package specific to the patients needs including a range of psychological and occupational therapies. Facilities within the service supported this through the provision of therapy rooms, therapeutic kitchen, activity rooms, a gym and an all-weather outdoor sports arena. The service also had links within the community to provide patients access to activities including an allotment and walking groups.

Patient completed both a Functional Analysis of Care Environments and Historical Clinical Risk assessment with staff. These were live documents which were updated as needs changed or a minimum of every three months. Oswin ward had also developed a formulation pathway for patients which included input from the patients and all relevant professionals to ensure the service had a full risk profile of the patients.

The principles of relational security were embedded within the service and all staff we spoke to were able to describe the importance of this. The use of restraint and seclusion was low, this was seen as a last resort and staff used their knowledge of and relationship with patients to identify potential trigger points and de-escalate behaviours before issues arose

The seclusion room on Aidan did not meet the recommended standards for seclusion facilities, the service was aware of this and work had begun on building new ‘Gold standard’ seclusion facilities.

When incidents did occur there was a process of providing a debrief for both the staff and patients involved. Incidents were monitored and reviewed; lessons learned were shared across the service and discussed within team meetings. The staff we spoke to were able to articulate their responsibility under the Duty of Candour and provide examples of when they would need to fulfil this responsibility. The trusts electronic incident recording system provided prompts for staff to consider the need for the Duty of Candour.

Staff morale was seen to be high across the service; staff were aware of the trusts visions and values and could describe how these were embedded from the point of recruitment in to supervision and appraisals.

We found that the provider was performing at a level which led to a judgement of Outstanding because:

• The trust had a clear vision and values which were incorporated into all aspects of the trust’s business and supported by a set of strategic objectives which were developed with the involvement of patients, carers and staff. Staff felt involved in most changes and empowered to contribute to the development of services. Staff were given the autonomy to provide services based upon the needs of their service users and to develop innovative practice. Staff we spoke to told us that the trust leadership was approachable, accessible and encouraging.
• Feedback from patients and carers regarding their care and treatment was consistently positive. Staff were professional, thoughtful and caring when supporting patients and their carers throughout all the services we visited. Staff supported each other, many staff told us of the strength of teamwork and the support they received from their colleagues. Staff recognised the contribution of families and carers in supporting patients and sought and valued their views.
• Assessment of patients’ needs was holistic and identified potential risks. Care plans were developed with patients and carers to meet the identified needs. Multi-disciplinary teams with a range of professionals worked together to support patients in their recovery and achievement of goals through evidence based care and treatment.
• The trust was open and transparent about safety and staff were encouraged to report incidents. Processes were in place to keep adults and children safe and safeguarded from abuse. Staff were able to describe what action they would take to safeguard a patient if they had a concern. Data provided by the trust showed each pressure ulcer, fall, catheter associated urinary tract infection and venous thromboembolism reported was fully investigated and identified the cause.
• The trust supported the physical healthcare of patients and mental health nurses were trained in tissue viability to meet the needs of patients on the ward. A physical healthcare practitioner provided expert advice, guidance and support to mental health nurses and acted as a liaison with acute hospitals, to ensure that patients’ physical healthcare needs could be fully met before being transferred to a mental health hospital.
• Where services provided care and treatment to patients detained under the Mental Health Act, this was found to meet the requirements of the Code of Practice in most areas. The Mental Health Act office in the trust provided support to clinical areas to ensure relevant documentation was completed correctly, reviewed and appropriately stored.
• Discharge planning started from the point of admission. Outcome measures were used to inform the assessment process and measure the success of interventions and treatment outcomes. Staff worked flexibly to adapt care and stretch existing boundaries to meet the needs of individual patients and their carers.
• Staff were enthusiastic and generally very positive about working in the trust. Staff had pride in the care and treatment they provided and looked for opportunities to improve the experience of patients receiving services. The trust encouraged personal and professional development in all roles within the organisation and the inspection team saw many examples of staff who were continuing to develop their career with the trust.
• External stakeholders found the leadership within the trust to be proactive. The senior leadership could clearly articulate the strategy and the key issues and challenges they faced, and how they were responding to these. Working in triumvirates, clinical leads worked with senior managers to ensure clinical engagement and involvement in operational management.
• Governance within the trust was robust with clear ward to board structures and process in place. An electronic dashboard accessible to all staff within the organisation supported this. The board assurance framework included principal risks linked to the trust’s strategic objectives.
• The trust use values based recruitment to ensure that it recruited staff that shared its values and vision of delivering services and held the required knowledge and skills. Staff at service level confirmed this process resulted in people with the right attitudes and values joining the trust.
• The trust exceeded the majority of its internal targets. Medical revalidation rates were 100% for the trust as a whole. The overall mandatory training rate was 92%, exceeding the trust target of 85%. The average rate for clinical supervision across all 155 teams was 90% in the period 1 May 2015 – 30 April 2016.
• The trust had systems in place to monitor its services against national guidance. Staff in core services participated in clinical audit which led to improvements in services. The trust participated in research and had a director of research, innovation and clinical effectiveness who led in this area.
• The trust looks to work collaboratively in the delivery of all services. The trust worked with a neighbouring trust to provide considerable improvement to a region-wide eating disorders service, with two key, senior staff members seconded to the other trust. The trust participates in external peer review and accreditation schemes and services from around the trust had gained accreditation in these schemes.
• The trust’s ‘Positive and Safe Strategy’ led by the executive director of nursing and operations, aims to reduce the use of restrictive practices in response to managing challenging behaviour, aggression and violence.
• All wards and community team bases were found to be clean and mostly well maintained. The patient led assessments of the care environment score in relation to cleanliness in 2015 was 99%. Environmental risk assessments were completed in all areas and where risks were identified action was taken to remove or reduce these risks. The trust has an estates strategy in place to improve the environment for patients, visitors and staff. A number of projects were due to start or complete around the inspection period.
• However, the environment at Alnwood did not support children and young people’s recovery and linked to high levels of mechanical restraint.

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

• National guidance was followed by teams and embedded into the services provided.
• The service delivered an extensive range of psychological interventions recommended by National Institute for Health and Care Excellence to meet the needs of children and young people who used the service
• There was an embedded culture of continuous professional development through training in evidence based interventions
• The service had clear criteria for categorising risk and was able to respond quickly to referrals of young people presenting with high risks.
• Feedback from people who use services and their carers was universally positive about the care they received.
• Staff were passionate, enthusiastic and dedicated to their work with children and young people
• The service was responsive to feedback and we saw examples where the service had used service user feedback to improve the service

We rated community based services for people with learning disabilities or autism as outstanding because:

• A proactive approach to anticipating and managing risks to people who use services was embedded and was recognised as being the responsibility of all staff. This was reflected in the risk assessments and plans.

• Staffing levels were sufficient to meet the needs of the service. Staffing levels had been estimated by obtaining the advice of staff, carers and other agencies. This model had been implemented in the Sunderland team and was in the process of being rolled out to other teams.

• Staff knew how to report incidents. All staff were open and transparent, and fully committed to reporting incidents and near misses.

• There was a team approach to the prescribing of medication. The approach ensured that psychological and social factors were given full consideration before medication was prescribed. This meant that service users were less likely to be prescribed medication unnecessarily.

• There was a truly holistic team approach to assessing, planning and delivering care and treatment to people who use services. The safe use of innovative and pioneering approaches to care and how it was delivered were actively encouraged. New evidence based techniques were used to support the delivery of high quality care.

• We found the continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice. This was reflected in the specialist training provided and the effectiveness of multidisciplinary meetings.

• Staff had close links with external agencies, including them in multi-disciplinary team meetings where appropriate. The systems to manage and share the information that was needed to deliver effective care were fully integrated and provided information across teams and services. This was reflected in the training provided to external care providers and families.

• Feedback from people who use the service, those who are close to them and stakeholders was continually positive about the way staff treat people. People that staff went the extra mile and the care they received exceeded their expectations.

• The involvement of other organisations and the local community was integral to how services were planned and ensured that services met people’s needs. There were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs.

• There were high levels of staff satisfaction across all teams. Staff were proud of the organisation as a place to work and spoke highly of the culture. There were consistently high levels of constructive engagement with staff across all teams. Staff at all levels were actively encouraged to raise concerns.

• The leadership drove continuous improvement and staff were accountable for delivering change.

• Safe innovation was celebrated. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. This included working with other agencies to reduce the number of people with learning disability or autism living away from their local communities or in long stay hospitals.

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

• There was a truly holistic approach to assessing, planning and delivering care and treatment to patients. Staff were responsive to individual patient’s needs and actively engaged in assessing and managing risk. Staff worked effectively together to share knowledge and deliver evidence-based treatment to patients.

• Staff empowered patients and carers to have an active role in their care and treatment. Staff developed positive relationships with patients and carers to ensure their needs and individual preferences were reflected in the planning of their care. Patients and carers reported staff went the extra mile and exceeded their expectations.

• The services were flexible, provided choice and ensured continuity of care for patients. Patients could access services in a way and at a time which suited them. Staff worked collaboratively with other services, within integrated person-centered pathways to ensure they met patients’ needs.

• Staff were committed to continually developing their skills and competencies to ensure they delivered high quality care. Staff attended additional specialist training to enable them to acquire new skills and share best practice. Staff were encouraged to take an active role in research and innovative practices.

• Leaders had an inspiring shared purpose which succeeded in developing a strong, visible person-centered culture. Staff were highly motivated to offer high quality care and were proud of the service they delivered.

• Leaders consistently engaged with staff and actively encouraged them to raise concerns. Staff were open and transparent in reviewing incidents and learning lessons when things went wrong. Staff shared this learning across the trust and this was used to inform service development.

However:

• Staff caseloads were high in some services and some services felt they did not have sufficient administrative support. Managers were aware of this and were continually reviewing ways to develop systems and processes to address these issues. Managers had sufficient authority to increase staffing levels as required.

We rated community-based mental health services for adults of working age as outstanding because:

There was a truly holistic approach to assessment, care planning and delivery of care to patients:

• Assessment and treatment of patients was a multi-disciplinary approach and considered the holistic needs of the patient which was incorporated into their care and treatment.
• Where appropriate patient’s religious and spiritual identity was incorporated in to their recovery journey, care and treatment through access to spiritual therapy which was delivered by the chaplaincy team.
• Creative care planning was used to meet patient’s needs. A pictorial care plan was created for a person with a learning disability written in basic language with easy read pictures.
• There was good access to a range of psychological therapies in both group and individual sessions recognised by National Institute for Health and Care Excellence.
• Patient’s physical health was seen as an integral part of their mental health care and treatment. Robust systems were in place to identify and monitor people’s physical health. Physical health checks and monitoring of medication levels such as, high dose anti-psychotic medication therapies, clozapine and lithium were completed and recorded.
• Teams used recognised outcome measuring tools to measure patient rated outcome and experiences, clinical rated outcome measures were used, such as perspective on side effects of medication.

• Patients and staff participated in research. Hexham community mental health team participated in NHS research in a focussed study into the effectiveness of cognitive behavioural therapy in people with a diagnosis of schizophrenia.

There was a commitment to the continual development of staff and their professional development. Professional development of staff was maximised through team training stars developed using evidence based information, considered patient need and team feedback about staff learning needs.

Teleport house was equipped with a private treatment recovery room which was furnished with comfortable furniture and entertainment facilities.

The feedback from patients and their carers was universally positive. Patients and their carers felt that they were an active partner in their care and told us that staff went the extra mile. Patient’s felt that staff understood the totality of their needs from mental health, physical health to spiritual and religious identity.

• Teams made reasonable adjustments for patients with additional needs.
• Risks to people were assessed and monitored.
• Staff reviewed risk assessments regularly to reflect any changes in risk to people. Teams identified and responded to changes in people’s health. Teams were flexible and saw people urgently when needed.

• Teams used lone worker procedures and equipment was in place to support and protect safety of staff.
• Feedback from investigations was shared with staff in team meetings and in email communications from the trust.
• Gateshead community treatment team (non-psychosis) held weekend assessment clinics when needed.
• The trust’s vision and values were embedded into teams. Staff knew the trust’s values and explained how these applied to their everyday work.
• There was an open and transparent culture to raising concerns or issues to management and there was good staff knowledge of the trust’s whistleblowing policy.
• Services were well managed with good governance structures. Staff knew who senior managers were. Staff felt supported by their managers and managers had the authority to make decisions about their service.

We rated mental health crisis services and health-based places of safety as good because :

• The service had effective systems to assess, monitor, and manage risks to people who used services. There was a clear pathway for people to access services including those people who referred themselves to the crisis teams.
• People who used services received care which focused on their needs and was based on recovery. Care records were of a high standard and most people who used services felt fully involved in their care planning.
• There was good inter-agency working with Northumbria police. The introduction of the street triage service had led to a significant reduction in the number of people detained under section 136 of the Mental Health Act.
• Staff provided kind and compassionate care and treated people who used services with dignity and respect.
• Staff provided support to carers and with consent included them in their relatives care.
• Staff received feedback from incidents and complaints. There were systems in place for learning and sharing from incidents and complaints to be cascaded.
• Overall compliance with mandatory training was good. Where areas were low managers had actions in place to improve.
• Staff were receiving supervision and had had an annual appraisal. Managers had taken steps to improve compliance with supervision. The steps taken had made a difference.

However:

• The service had an action plan with environmental improvements needed for two of the health based places of safety. There was not a date for completion of some of these required actions.
• There were conflicting reports from staff regarding how many staff should be available for police to hand over a detained person in the health based places of safety.
• There was not access to a full range of disciplines in the crisis teams. Staff told us they would like more access to psychology, occupational therapy and social work support.
• Some professionals reported delays in accessing services via the telephone response service.
• Staff removed medication from their original containers for people to use in their own homes which constituted secondary dispensing.

We rated long stay rehabilitation mental health wards for working age adults at Northumberland, Tyne and Wear NHS Foundation Trust as outstanding because:

• Governance arrangements allowed ward managers to coordinate and manage performance using an electronic performance dashboard system. In addition, some wards were piloting additional electronic trackers that identified uncompleted tasks and improved discharge planning.

• The service inspired and motivated staff to succeed, encouraging professional development and a culture of staff self-belief and dedication. There were high levels of staff satisfaction. Staff were proud to work for the organisation and felt valued and supported. Staff provided feedback and ideas to improve the quality of care and treatment.

• There was a commitment to continuous improvement implementing safe innovative rehabilitation and recovery focused care across the wards. New working practices reflected best practice and wards reviewed these proactively. Each ward was either involved in a pilot, research or had introduced staff initiatives to improve the quality of the service.

• Patient’s individual needs and preference were central to the planning and delivery of the rehabilitation and recovery pathway. Planning for discharge commenced on admission with patients actively involved in choosing their preferred discharge location. Wards maintained strong links with community mental health teams and local third sector organisations to ensure continuity of care. Elm House was unique in having close links with Gateshead local authority, providing a seamless transition back into the community.

• The service recognised that social inclusion was integral to the recovery process and was proactive in establishing links with third sector organisations to facilitate this. There were examples of innovative approaches to provide an integrated person centred pathway of care for people with complex needs. Clearbrook ward had developed links with local parishioners leading to jointly organised events taking place in the community. Staff recorded these events in a yearbook to remind patients of their progress. At St George’s Park, two wards had established patient led mutual help meetings and developed their own local community.

• Staff were skilled in providing patients with evidence based psychosocial interventions. They used interventions based on The Royal College of Psychiatrist’s model for inpatient rehabilitation to care for patients with complex needs. The multidisciplinary team considered all relevant factors and risk management at patient meetings and reviews to provide a framework to develop the most suitable treatment for a patient. This meant patients received care and treatment that suited their individual needs.

• Records showed and managers, staff and patients confirmed staffing levels were sufficient to meet the service needs. One to one interaction, activities, patient leave, and staff training went as planned. Vacancies were mostly due to progression or retirement, which meant there was high staff retention. Patients were familiar with staff covering shifts due to absences, as agency use was low.

• The service recognised that ongoing development of staff skills, competence, and knowledge led to high quality care. Staff were encouraged to undertake specialist recovery focused training.

• There was a commitment to involving carers and families in the treatment and care of the patient. Staff ensured carers and families were kept informed and had access to support throughout the duration of a patient’s stay on the ward.

However,

• Entrance and exit to the wards at Hopewood Park was via a double door airlock controlled by staff. The level of control and security felt restrictive and was more appropriate to secure facilities than long stay rehabilitation wards.

• Staff had not monitored a patient receiving a high dose antipsychotic treatment in line with best practice guidance. We saw other patient records where monitoring had taken place.

• At Hopewood Park, care plans did not always reflect the involvement of patients or include detailed and personalised information about the management of long-term physical health conditions. The service had introduced an ongoing initiative to improve the quality of care plans. The care plans on the short-term wards were detailed, holistic and recovery focused.

We rated wards for people with learning disabilities or autism as outstanding because:

• There was a truly holistic approach to assessing, planning and delivering care and treatment to patients. Staff from different disciplines worked in collaboration and a mutual respect amongst professionals was evident. There was a multi-disciplinary approach to the delivery of treatment at all stages, including the review of referrals prior to admission onto the wards.
• Patients and carers were active partners in the planning and delivery of care. Patients were generally very positive about their level of involvement in the development of care plans.
• There were excellent arrangements in place to assess, monitor and review physical health needs of patients.
• The range of therapeutic activities was excellent. Patients had individualised activity plans that took account of patient preferences, likes and dislikes.
• Staff knew how to report incidents and used analysis of incident data to inform practice. Learning was based on thorough analysis and investigation. Staff undertook a dynamic approach to using data, including in the reformulation of treatment plans. There was evidence of effective debriefing processes for staff and patients following incidents. The trust had robust mechanisms to disseminate learning following reviews of incidents. All staff were encouraged to participate in learning to improve safety.
• Staff demonstrated a proactive approach to anticipating and managing risks. Patients and their carers were actively involved in managing their own risks through the use of collaborative risk assessment tools.
• There were excellent performance management systems in place at service, ward and staff level. Staff were committed to contributing to the achievement of personal and service level targets.
• Staff delivered treatment in a respectful and caring way and demonstrated an advanced understanding of patient needs. Patient and carers spoke very highly of staff and the quality of care received.
• Staff were passionate about their work and spoke with pride about the wards they worked on. Staff were proud to work for the trust.
• Staff were actively encouraged to review practice and identify ways to improve service delivery and patient outcomes.
• There were sufficient staff working on the wards, providing safe and effective care to patients. Managers could bring in additional staff to meet the needs of patients. Mandatory training rates for staff on learning disability and autism wards were above trust targets. Staff had access to a range of specialist training, that was directly linked to the needs of patients. This included additional training for nursing staff in physical health care and monitoring. Staff received regular supervision and appraisal.

However:

Clinic facilities for the wards on Kenneth Day Unit were limited. Medication was stored and administered from the nursing office. This meant there was limited privacy for patients when accessing medication. Staff acknowledged this and hoped to develop one bedroom on each of the wards as a dedicated clinic room. Seclusion rooms on the Kenneth Day Unit had low ceilings with CCTV monitors, which patients could reach. This presented a potential hazard to patients.

We rated wards for older people at Northumberland, Tyne and Wear NHS Foundation Trust as good because:

• Staffing levels were good throughout and managers had the ability to increase these dependent on need. Additional staff were familiar with the environments they worked in.

• Mandatory training compliance was high across all wards.

• Patients had good access to physical healthcare on admission and ongoing monitoring; this included access to specialists when needed.

• A full range of disciplines provided input into the care of patients.

• Staff showed a caring attitude when interacting with patients and their carers.

• Staff ensured carers and families were kept informed and involved throughout the duration of a patient’s stay.

• Staff worked with on-going care providers to minimise a patient’s trauma when transferred to new care facilities and therefore reduce re-admissions.

• Managers were able to input into decisions relating to bed management.

• Activity co-ordinators were included in the ward’s staff mix enabling access to activities seven days a week.

• Staff knew the trust’s values and talked about them in a manner that reflected their working practice.

• There was high morale among all staff.

• Staff were able to contribute ideas for quality improvement and innovation.

However:

• We observed staff delivering and discussing person-centred care. This however, was not reflected in the care plans which had limited personalisation and did not reflect the involvement of patients or their carers.

• Staff did not always use the electronic care plans as their first point of reference. This meant that staff did not always deliver patient care as planned.

• Ward managers were working towards ensuring that restrictions were not imposed on all patients due to the risks of some. However, there were still some blanket restrictions on wards and staff did not always individually assess a patient and consider the least restrictive option.

• Staff did not commence discharge planning at the point of a patient’s admission.

• Staff did not always ensure a patient’s rights were clearly explained to them on admission and routinely thereafter.

• Staff did not always carry a personal alarm.

We rated Acute and PICU services as good because:

• Staff knew and understood the vision and values of the trust and the recruitment of new staff was based on the vision and values. Ward managers and clinical leads on all the wards were identified as being supportive and effective leaders.

• Staff knew who the senior managers for the acute and psychiatric intensive care unit services were and told us they also visited the wards on a regular basis. Ward managers received positive support from their line managers and were able to manage their ward.

• Mandatory training was above the trust compliance target on all wards and staff received regular supervision and appraisals.

• Mental Health Act documentation for detained patients was in good order. Patients were regularly read their rights under the Mental Health Act. All detained patients received an automatic referral to an independent mental health advocate.

• Any member of staff, via a web form, could report incidents.

• Following incidents, we saw evidence that lessons were shared and learned. Staff understood the whistleblowing policy and knew whom to contact.

• Staff on all wards reviewed their practise when using restraint or seclusion to see if they could have managed anything differently

• There was a bed management team in place and wards had access to a discharge facilitator. Beds for patients who were on leave from the ward were rated either red, green or amber. New patients would not be admitted to a bed rated as red so that the patient on leave could come back at short notice.

• There was a wide range of activities available from the occupation therapy department, the exercise therapy team and activity organisers on each ward.

• Patients had keys to bedrooms. The trust was trialling a sensory room as a new approach with patients who could display challenging behaviour.

• Information and support was available to patients from minority groups. Patients had a good choice of hot and cold food, including healthy options. All of the wards provided access to spiritual support.

• Patients told us they knew how to make a complaint. Staff knew how to handle complaints in line with the trust policy. Patients told us that staff were kind, caring and respectful

• Training in the Mental Health Act and the Mental Capacity Act was mandatory and 94% of staff had completed the training. Staff received management and clinical supervision in line with trust policy.

• There was a good range of staff working within a multi-disciplinary team.

• Staff had a clear understanding of the definition of rapid tranquilisation and carried out the required physical checks and observations of patients. Seclusion rooms were being used in line with principles within the Mental Health Act code of practice.

However:

• The trust were using mechanical restraint as an intervention in the management of violence and aggression in Acute and psychiatric intensive care unit services.

• The trust uses prone restraint during episodes where patients’ behaviour is challenging and to withdraw from the seclusion room, this is not in line with the Mental Health Act Code of Practice. The trust should review their use of prone restraint and look at how they can bring their practise in to line with the Mental Health Act Code of Practice.

• Care plans were not person centred the trust should ensure that all care plans are person centred.

We rated child and adolescent mental health ward services as good because:

• The service provided patients with a weekly timetable encompassing a range of care via an individualised structured day programme.

• Information leaflets, ‘at a glance’ records and post incident debrief documentation provided to patients were in easy read, pictorial and written formats. Riding ward used social stories to orientate patients to the service.

• Staff from different disciplines demonstrated a clear mutual respect and the views of all professionals were valued; the multidisciplinary team worked well together. Patients and carers told us that the staff were respectful, kind and understanding. Staff understood the individual needs of patients. Staff were positive about local and senior managers in the trust and advised that senior managers were visible on the wards.

• Local and senior managers were present on the ward, offering support and leadership to staff. There were clear systems and processes to monitor risk, incidents, appraisals and training that underpinned the Trust’s values.

• The education provision had been rated as outstanding by Ofsted and was tailored to the patients’ needs. Staff at Ferndene helped patients to set up a healthy snack tuckshop where patients planned what to eat, budgeted and chose what to buy before preparing the snacks for sale as a group.

However:

• Mechanical restraint in the form of emergency response belts and soft handcuffs were used. Use of restraint and seclusion was high on all three wards at Alnwood and on Redburn ward at Ferndene.

• There were high levels of bank and agency staff used and staff were moved to cover staffing levels across wards. Patients and families spoke of their discomfort with agency staff on the wards and a lack of understanding of their needs. Patients, families and staff said activities and section 17 ground leave were cancelled regularly due to a lack of staff and managers reported that releasing staff to supervision and training was difficult for some wards.

• We attended one handover meeting where there was little discussion of the patient or interest by the team; Ferndene wards had short 10 minute handovers however this was the trust standard for Ferndene wards.

We found the following areas of good practice:

• The ward was clean and well maintained. The trust had taken appropriate action to repair damage to the building by a patient. A risk register was in place for the ward which was reviewed regularly and appropriate controls had been put in place for all risks.

• There were appropriate numbers of skilled and competent staff on the ward, with a strong multi-disciplinary team (MDT) providing specialist input into patient care. This included weekly MDT meetings, core group meetings and reviews as part of the care programme approach.

• Risk assessments were comprehensive and regularly updated for patients. Care plans reflected the areas identified within risk assessments.

• All staff understood how to report incidents appropriately and there were effective processes in place to monitor and review incidents. Staff and patients were involved in de-briefing sessions after incidents took place.

However; we also found some areas that could be improved:

• Staff on the wardfrequently used physical restraint to manage disturbed behaviour and a high proportion of incidents of restraint were in the prone (face-down) position.

• Although staff used positive behaviour support (PBS) approaches to support patients, they had not implemented the PBS pathway fully.

• There were occasions when patients over the age of 18 were accommodated on the ward.

• The walls in the seclusion room needed to be repaired.