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Provider: Cheshire and Wirral Partnership NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 4 December 2018

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

  • We rated well-led for the trust overall as good. The trust board and senior leadership team had the appropriate range of skills, knowledge and experience to perform its role and the non-executive directors provided robust and constructive challenge to the trust board. The trust board and leadership team demonstrated a high level of integrity. High priority was placed on doing the right thing for patients, staff and the organisation as a whole.
  • We rated effective and well led as good, safe as requires improvement and caring as outstanding. In rating the trust, we took into account the previous ratings of the services we did not inspect this time.
  • We rated 14 of the trust’s 15 services as good overall, and one as outstanding overall.
  • The rating for safe and well led for community health services for children, young people and families had improved from requires improvement to good. The rating for caring had improved from good to outstanding.
  • Leaders were visible in the service and approachable for patients and staff. Staff felt supported by their managers and felt they could raise concerns or approach managers for support.
  • The trust’s strategy, vision and values underpinned a culture that was person centred. There was a strong commitment to patient and carer involvement.
  • Staff completed thorough assessments of patients’ needs, including physical health and mental health assessments.
  • Care was provided that was in line with national guidance and staff were skilled to deliver care.

However:

  • We rated safe as requires improvement in four of the 15 services. Ratings in the safe domain for child and adolescent mental health wards and wards for older people with mental health problems went down from good to requires improvement.
  • Generally, staff felt well supported and many said they had clinical supervision. However, there was no trust target for clinical supervision and recorded rates were low.
  • In some services, compliance rates for mandatory training were below the trust target.
  • There had been no qualitative audits of staff practice in relation to seclusion and rapid tranquilisation. In one service, physical health checks following rapid tranquilisation had not been carried out in line with trust policy. In another service, there were gaps and shortfalls in seclusion records.

Inspection areas

Safe

Requires improvement

Updated 4 December 2018

  • We rated four of the 15 services as requires improvement for safe. We rated the three primary medical services as good for safe. We took into account the previous ratings of services that we did not inspect this time.
  • The rating for safe went down from good to requires improvement in child and adolescent mental health wards and wards for older people with mental health problems.
  • Staff on acute wards for adults of working age and psychiatric intensive care units did not always monitor patients following the use of rapid tranquilisation. On child and adolescent mental health wards there had been no qualitative audits of staff practice relating to rapid tranquilisation.
  • On child and adolescent mental health wards staff had not fully considered the threshold between seclusion and long-term segregation. There were gaps in seclusion records and nursing and medical reviews were not always occurring within required timescales.
  • Not all wards always complied with the Department of Health’s guidance to eliminate mixed sex accommodation. On wards for older people with mental health problems, this compromised patients’ privacy and dignity and could impact on their safety.
  • Staff compliance with mandatory training was below the trust target on acute and psychiatric intensive care units and wards for older people with mental health problems.
  • Patients on older people’s mental health wards did not have personal emergency evacuation plans in place.
  • Staff in community health services for children, young people and families were not aware of the trust procedure for effective cleaning of equipment, despite accessible policies and procedures.

However:

  • In community health services for children, young people and families, the rating for safe went up from requires improvement to good.
  • Managers used data effectively and made changes to services as a result.
  • Services had completed ligature risk assessments and staff were aware of these risks and how to manage them to keep patients safe.
  • Staff knew how to report incidents and there was a positive culture of incident reporting. Incidents were reviewed and there were effective mechanisms in place to ensure that learning was shared
  • Wards were clean and well maintained.

Effective

Good

Updated 4 December 2018

  • We rated all of the 15 services as good for effective. We rated the three primary medical services as good for effective. We took into account the previous ratings of services that we did not inspect this time.
  • There was good multi-disciplinary working taking place within services and care was provided in line with national guidance.
  • Staff undertook thorough assessments of patients’ needs. This included mental health and physical health assessments.
  • Staff received training on the Mental Health Act and its Code of Practice. Staff had access to advice and support on the implementation of the Mental Health Act.
  • Most patients were involved in decisions about their care.

However:

  • Generally, staff said they felt supported and that clinical supervision took place. However, there was no trust target and reported rates of clinical supervision were low.
  • In two services, care plans were not always person centred.

Caring

Outstanding

Updated 4 December 2018

  • We rated three of the 15 services as outstanding for caring. We rated the remaining 12 services as good for caring. We rated the three primary medical services as good for caring. We took into account the previous ratings of services that we did not inspect this time.
  • In community health services from children, young people and families caring improved from good to outstanding. Staff were highly skilled at engaging with young people in a way that was person centred. Staff demonstrated excellent approaches to difficult and complex situations with compassion and understanding.
  • Staff cared for patients with compassion and respect. Feedback from patients was positive.
  • Staff engaged well with patients, families and carers, and people were able to feedback about the service. Changes had been made as a result.
  • Participation workers were employed by the trust to promote patient involvement.

Responsive

Good

Updated 4 December 2018

  • We rated two of the 15 services as outstanding for responsive. We rated the remaining 13 services as good for responsive. We rated one of the primary medical services as requires improvement and two as good for responsive. We took into account the previous ratings of services that we did not inspect this time.
  • Services were recovery focused and there were effective discharge planning processes.
  • The trust planned and provided services to meet the needs of local people.
  • Patients knew how to complain or raise concerns. Generally, complaints were handled in a timely manner, in line with trust policy.
  • Staff developed good working relationships with other services to ensure the needs of patients were met.

Well-led

Good

Updated 4 December 2018

We rated well-led at the trust as good because:

  • The trust board and senior leadership team had the appropriate skills, knowledge and experience to perform its role. Non-executive directors provided robust and constructive challenge to the trust board. The trust board and leadership team demonstrated a high level of integrity. High priority was placed on doing the right thing for patients, staff and the organisation as a whole.
  • Senior leaders were visible across the trust. Staff felt valued and were proud to work for the trust. The chief executive had made a personal commitment to staff engagement and had established opportunities to meet with staff regularly. There was a programme of board visits to front line services.
  • Leadership development opportunities were available and succession planning was in place throughout the trust.
  • The trust’s strategy, vision and values underpinned a culture which was person centred. The trust demonstrated a commitment to patient and carer involvement and had established a network of over 70 ‘lived experience connectors’. These were people with experience of accessing services. There was a lived experience, volunteering and engagement network in place.
  • There were effective systems in place to review incidents and share learning.
  • The trust had effective structures, systems and processes in place to support the delivery of its strategy. Operational delivery structures had changed in April 2018 and this process had been well managed.
  • There were robust processes and governance arrangements in place in relation to safeguarding. There was a comprehensive training programme in place across the trust.
  • The trust was actively engaged in collaborative work with external partners, including involvement with the local sustainability and transformation plans.
  • There were organisational systems in place to support improvement and innovation across the trust. Each care group had a designated service improvement lead and had quality improvement plans in place.

However:

  • The trust was not fully meeting the duty of candour requirements. Formal letters of apology were not routinely provided to patients and families.
  • Compliance rates for clinical supervision were variable between services. Although generally staff reported having regular supervision, there were not effective systems in place to record this. Senior leaders were aware of this issue, but steps had not been put in place to improve this across the trust.
  • Compliance rates for mandatory training were variable.
  • Despite the person-centred culture, not all services were engaging effectively with patients to encourage their involvement in the development of care plans.

Checks on specific services

Community health services for adults

Good

Updated 3 December 2015

Whilst staff were able to articulate the process for reporting incidents, staff did not always receive timely feedback about them or details of any lessons to be learned when things went wrong.

Staffing incidents were not reported via the electronic incident reporting system in line with trust policy. Instead, staff were encouraged to report staffing issues via the management escalation process which meant that not all staffing related incidents were recorded on the electronic system, potentially giving an inaccurate picture of staffing concerns.

The level of staffing and mix of skills in the integrated teams did not match patient needs. Although the trust had been monitoring staffing and capacity, it used its own tool to determine nursing caseloads, which did not take into account the acuity (the level of severity of illness or level of need) and complexity of patients. The trust acknowledged that further work was required to enhance the capacity tool to fully assess the acuity of patients. There were also a number of vacancies within the community nursing service. Following our visit, we were told of measures taken by the service to provide support for staffing levels and to ensure the appropriate skill mix to match the needs of patients more effectively.

Care and treatment was evidence-based and was provided in line with best practice guidance. The implementation of the integrated therapy service promoted multidisciplinary and multiprofessional approach to therapies, which enabled patients and families to avoid duplication of services and receive therapy support nearer to their homes.

Patients and their families were cared for by staff who were kind and compassionate. Patients were involved in the assessment, planning and delivery of their care, and were kept informed of changes and developments by members of the multidisciplinary team.

Data provided by the trust indicated that the services were provided within the national 18 week target but staff told us they were struggling to maintain that. There was also a delay of five months in the non-urgent review of venous flow conditions clinic due to long-term sickness.

Referrals to the district nursing service were being managed and records showed that in the month prior to our visit, patient assessments and visits had been deferred to help manage the delays. We found that this could have an adverse effect on patients’ care and treatment.

There were examples of good local leadership across the individual services. However, there were a lot of staff in temporary and ‘acting’ roles across the integrated community teams and a lack of professional nursing and therapy leadership was commented on by staff. The lack of nursing leadership had been acknowledged by the trust as part of an incident investigation and the trust had plans to provide more robust clinical leadership.

Child and adolescent mental health wards

Good

Updated 4 December 2018

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

  • There were sufficient numbers of skilled staff to provide direct care and treatment. Most staff had completed ongoing mandatory training. Managers carried out detailed reviews of restraint and prone restraint episodes. Following a review of incidents, managers had increased staffing levels to try and prevent incidents from occurring at these times.
  • Staff completed detailed goal based care plans and risk management plans for each patient. Staff followed national guidance in the routine prescribing of medication for children and young people and the care and treatment of patients with eating disorders. There was good multidisciplinary working with clinical psychologists, family therapists and occupational therapists. Staff had improved their recording of patient rights and competence and capacity decisions following our Mental Health Act monitoring visits.
  • Patients were mostly happy with the quality of care and support. Staff made great efforts to involve patients and carers in the building of Ancora House, their own care and treatment and the running of the wards, including patients coproducing a dedicated website. There was a high response and satisfaction rate from surveys of patients and carers.
  • The building at Ancora House provided an exemplary environment for the care of children and young people. The assessment and outreach team completed detailed admission assessments and managed patient admissions well. Staff had paid attention to meeting the needs of all patients with disabled access and leaflets translated into different languages. Patients spoke highly of the school attached to Ancora House which had very well-equipped classrooms to meet young people’s educational needs.
  • There was good morale among the staff team. The trust produced locality data pack, which provided detailed information to managers on key indicators. Staff completed regular audits which promoted good practice. Managers took immediate action on the gaps in auditing around seclusion and rapid tranquilisation which we identified. The wards had been assessed through the Royal College of Psychiatrists’ peer accreditation scheme and were awaiting the results.

However:

  • Staff had not always ensured that they were recording their responsibilities under the Mental Health Act Code of Practice relating to seclusion as we found gaps and shortfalls in the records. Staff had not always fully recorded whether they had considered the threshold between seclusion and long-term segregation in cases where patients were in seclusion for long periods due to sustained risk.
  • There had been no audits of staff practice relating to seclusion or rapid tranquilisation to benchmark practice against national guidance with the aim of improving safe practice and recording of responsibilities.
  • Although there were only a small number of complaints, we saw one complaints response which did not clearly state what stage the complaint was, the patient had not been given a full decision to enable them to understand the outcome and the patient was not signposted where to go if they were unhappy with the latest response.
  • While there was a commitment to quality improvement, ward staff did not articulate the ward’s future objectives, improvements following audit or a clear clinical governance framework to drive quality.

Wards for older people with mental health problems

Good

Updated 4 December 2018

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

  • The service provided a range of care and treatment suitable for patients in line with best practice and national guidelines. Staff involved patients, families and carers in patients’ care and treatment. Staff used therapeutic drug and physical health monitoring, nutritional screening, podiatry services, speech and language and occupational therapies.
  • Each ward had enough staff to provide care and treatment for patients.
  • Clinical areas were clean and stocks and equipment were maintained.
  • Staff assessed risks, including the risk of ligature points (places to which those intent on self-harm could attach something to strangle themselves) and took action to remove or reduce risks.
  • Recent patient-led assessments of the care environment (PLACE) (2017) showed that the service had scored higher than other similar trusts for cleanliness, condition, appearance and maintenance of the wards and for the food provided on the wards.
  • There was good teamwork among staff and staff were happy to work in the service. Staff felt able to raise concerns. They said managers supported and encouraged them to access further training to develop their skills.
  • Families and carers were involved in the patients’ treatment from the admission stage through to discharge.

However:

  • Meadowbank and Croft wards were not compliant with the Department of Health guidance on eliminating mixed sex accommodation. The service reported 29 breaches in the year to 30 April 2018 on Croft and Cherry wards, mainly due to urgent admissions of male patients onto female areas of the wards.
  • Patients did not have personal emergency evacuation plans in place to assure safety in the event of an emergency evacuation. The wards admitted frail older people, some of whom had significant mobility issues. There were no plans in place for patients to set out how they would be evacuated in an emergency.
  • Patients were not able to close the observation windows from inside their bedroom doors. This could compromise their privacy and dignity.
  • The accessible bathroom did not have a shower curtain around the bath to protect patient’s dignity and privacy and laundry was being stored in there which could present an infection control risk.
  • Care plans on Meadowbank ward were not personalised.
  • There were low compliance rates with mandatory training, including fire evacuation.

Community health services for children, young people and families

Good

Updated 4 December 2018

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

  • The trust had addressed the recommendations identified by the CQC at the last inspection and made significant improvements across the service.
  • The trust electronic patient record system was shared across all services and anyone with access to the system could see the full patient history.
  • Staff were aware of the importance of raising incidents and there was a positive culture of incident reporting.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service made sure staff were competent for their roles and there were excellent professional relationships across all services.
  • There was an exceptional family focused approach to care delivery and staff had extensive knowledge about their patients.
  • Caseloads across all services we visited were very well managed and care was tailored to meet individual needs.
  • The trust planned and provided services in a way that met the needs of local people and worked well with external organisations.
  • There was a diverse knowledge base among managers that was utilised across the services.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • There was an improvement in the way services were delivered and staff felt this was due to the new ways in which the teams worked.

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

Good

Updated 4 December 2018

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

  • Ligature risk assessments for patients and the wards had been carried out and had been updated. Staff members had personal alarms and patients had access to nurse call buttons in each room. Clinic rooms were clean and had equipment that had been recently calibrated and maintained, and drug cupboards were in order. Fridge temperatures were monitored, and emergency equipment was checked daily and all equipment in date. Seclusion rooms met specifications of guidance, and recording of seclusion events followed policy. Staff knew safeguarding policies and applied them when required, keeping patients from harm or neglect. Staffing levels were sufficient for the service, with use of bank nurses familiar to the wards. Risk assessments were completed on each patient on arrival on the wards.
  • Care plans were created within 72 hours of admission, and were comprehensive, holistic and considered the views of the patients. Physical health monitoring was being recorded regularly, with specific health problems monitored and treated accordingly. Clinical audit was being undertaken by staff on wards and reflected in practice. The Mental Health Act was being adhered to and the Code of Practice was available to all staff on each ward. Mental Health Act paperwork was regularly audited, patients were being read their rights, and there was a dedicated team who monitored all aspects of the Mental Health Act. Capacity was being assessed for each patient, and best interest meetings were taking place on the wards.
  • Staff interacted positively with patients across the service. Patients described staff in positive terms, with no complaints made about staff. Carers and patients were given opportunities to feed back into the service through several channels. Patient led assessment of the care environment results put the service at above the national average. Patient meeting minutes showed consideration and actions by the service in respect of patient suggestions. Patients could get involved in decisions about the service, with the trust running an expert patient programmed designed to involve patients in aspects of the service.
  • The wards were clean and well furnished with appropriate furniture for the service. There were enough rooms for therapies and social activities to take place. Patients were happy with the quality of the food and choice available. There was information across the service regarding medication and treatment that was available to patients. Patient complaints were being acted upon when received, with feedback taking place. There was reasonable adjustment of rooms across the service for patients with physical disabilities.
  • The multi-disciplinary teams across the service worked well together, and the relationship with ward staff and management was good. Ward managers were experienced and knew the role and purpose of their wards, as well as relevant policies and protocols. Trust values were integrated into ward philosophies, and all staff knew the trust values when discussed. The trust used locality data packs to keep the service informed of performance within the service, and to guide staff to areas of improvement or good practice. The service had acted on feedback from the last inspection, and had made improvements based on that feedback.

However,

  • Staff did not follow trust policy or national guidance in relation to rapid tranquilisation, several care records did not show monitoring of physical health after intra-muscular administration of medication.
  • Work to eliminate mixed sex accommodation had been undertaken since the last inspection, but more action was required. On Adelphi and Bollin wards, some rooms contained beds for two people, separated only by a curtain in the middle of the room.

  • Bed management was taking place, although the wards were admitting over the 85% trust target for occupancy. This meant that when patients returned from episodes of leave they could not always return to the same ward.
  • Risk assessments were taking place but not always being updated to reflect changes in patient risk.
  • Mandatory training was taking place, but staff were not all completing the required training.
  • Supervision was not happening regularly for clinical staff, and the trust did not have a target level.

Forensic inpatient or secure wards

Good

Updated 4 December 2018

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

  • Staff knew about any risks to each patient and acted to prevent or reduce risks. Staff and managers worked to keep the use of restrictive interventions to a minimum. The service had low levels of the use of restraint, rapid tranquilisation and seclusion.
  • The service had enough staff with the right skills, qualifications and experience for each shift. Patients had regular one to one sessions with their named nurse. Patients rarely had their escorted leave cancelled, even when the wards were short staffed. The service had enough daytime and night time medical cover and a doctor was available to come to the ward in an emergency.
  • Staff completed a comprehensive mental health assessment of each patient either on admission or soon after. All patients had their physical health assessed soon after admission and regularly reviewed during their time on the ward. Staff developed a comprehensive care plan for each patient that met their mental and physical health needs.
  • Staff delivered care in line with best practice and national guidance. Staff used recognised rating scales to assess and record the severity of patient conditions and care and treatment outcomes.
  • The Mental Health Act was implemented effectively. Staff received training about the Mental Health Act and knew how to access advice.
  • Staff were aware of the Mental Capacity Act, and knew how it worked in relation to best interest decision making.
  • Care plans were holistic and recovery orientated. There was a programme of activities for patients, which were based on their individual needs and preferences.
  • Staff were respectful and responsive when caring for patients. The patients we spoke with were generally positive about the staff. Patients knew how to raise concerns. Patients gave feedback about the service through a weekly meeting called ‘my service, my say’. Patients had personalised bedrooms, which they could access with an electronic key. There were facilities on the wards such as an activities of daily living kitchen and a gym.
  • The trust had clinical governance structures that the secure wards fed into. Information packs were generated for each of the services in the trust, which contained key information such as staffing and incidents.

However:

  • Not all care plans were person centred, and some described what the patient would do (“you will”) rather than involving the patient (“I will”).
  • Capacity decisions were recorded, but they were not always easy to find in the care record.
  • Most patients we spoke with thought the food was of poor quality.

Substance misuse services

Good

Updated 3 February 2017

We rated substance misuse services as good because:

  • There was good risk management. Clients had their risks assessed on admission and on an ongoing basis. There were appropriate risk assessments around prescribing substitute medication including home condition assessments. Building and health and safety risk assessments were in place. Lone working protocols were followed.

  • Staff were knowledgeable around safeguarding and understood trust policies and procedures in this regard. Staff with active safeguarding cases received specialist supervision. There were good links with local safeguarding bodies.

  • Clients had care plans in place. Care plans were up to date and comprehensive. Clients were involved in decisions about their care and treatment. Care plans included client views and objectives.

  • The team monitored the quality of the service and client outcomes. Care record audits were in place and the team completed treatment outcome profiles as part of the national drug treatment monitoring service.

  • Staff treated clients with respect and compassion. Feedback from clients about the staff and the treatment they provided was positive. Clients were able to give feedback about the care they received and get involved in decisions about the service.

  • There were clear referral pathways into the team. There was a dedicated team to review and prioritise referrals. Staff followed up with clients post discharge.

  • Staff morale was positive. There was good team working and mutual support. Senior management were a visible presence and staff felt comfortable raising concerns.

  • There was a governance structure in place to support the delivery of care. Performance monitoring was in place. The service met quarterly with partner agencies to review performance.

Community-based mental health services for adults of working age

Good

Updated 3 February 2017

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

  • Following our inspection in June 2015, we rated the services as ‘good’ for safe, caring, responsive and well led. Since that inspection, we have received no information that would cause us to re-inspect these key questions or change the ratings.
  • We re-rated the effective question from requires improvement to good following this inspection. This was because the provider had taken action to make improvements. We found that staff read patients their rights under the Mental Health Act 1983 routinely throughout treatment. We also found that staff assessed patients’ capacity when there was a reason to do so and involved family members in making decisions when patients lacked capacity.

However:

  • Copies of capacity to consent to treatment forms were not kept with medication charts at both of the teams we visited.

  • It was not clear whether all patients had been offered a copy of their care plan.

Specialist community mental health services for children and young people

Good

Updated 3 February 2017

We have rated specialist community mental health services for children and young people as good overall because:

  • Following our inspection in June 2015, we rated the service as ‘good’ for effective, caring, responsive and well-led. Since that inspection, we have received no information that would cause us to re-inspect these key questions or change the ratings.

  • We re-rated the safe question from requires improvement to good following this inspection. This was because the provider had taken action to make improvements. We found that staff followed the trust and local lone working procedures, that the environment at the team bases were safe and that team managers monitored waiting lists.

  • We also found that patients' risk assessment and management plans were up to date and completed to a high standard. Safeguarding procedures were followed. Serious incidents were reported and investigated.

Community-based mental health services for older people

Good

Updated 3 February 2017

We rated

community-based mental health services for older people as good because:

  • Following our inspection in June 2015, we rated the services as ‘good’ for safe, caring, responsive and well led. Since that inspection, we have received no information that would cause us to re-inspect these key questions or change the ratings.
  • Following this focused inspection, we amended the rating for effective from “requires improvement” to “good”. We found that the provider had taken action with regards to the findings of the previous inspection.

Wards for people with a learning disability or autism

Outstanding

Updated 3 December 2015

We rated Cheshire and Wirral Partnership NHS Foundation Trust, wards for people with learning disabilities as outstanding because:

  • Staffing levels on the units ensured patients did not miss out on social leave and outings, and was sufficient to provide consistent care. Staff worked long days, and could adjust their routine during the day. This meant that staff were able to respond to the needs of the patients rather than impose a routine on them. The managers were extra to the staffing compliment so they could provide support if they were unable to get staff to cover short notice sickness.
  • Patients admitted to the units had an assessment within 72 hours of their admission. The assessment was then developed in to a care plan which was reviewed and re-written when necessary. Patients were fully involved in the development of their care plans.
  • The use of restraint was closely monitored, recorded and risk assessed after every incident. Staff had on several occasions used prone restraint and the trust should ensure it is only used in line with the MHA Code of Practice.
  • Incidents on the units were reported and reviewed on a daily basis and learning from these incidents was shared across the trust.

  • Staff had a good understanding of safeguarding and worked closely with the local safeguarding boards to ensure people’s right were protected.

  • Medicines were managed appropriately and the units received support from the trust pharmacist on a weekly basis to ensure the medicines were administered and stored in a way that protected people.

  • Unit managers supported staff in their roles. Staff received monthly supervision and had completed the majority of their mandatory training. Staff could also access external training to enhance their skills. Staff also received support when they needed it to ensure they were able to continue at work.

  • Staff had a good understanding of the Mental Health Act (MHA), the MHA Code of Practice and the Mental Capacity act (MCA) 2005. They applied the principles of the MCA in their daily practice.

  • There was a clear collaborative approach between patients and staff with patients treated as equal partners in decisions about their care. Interactions were positive and patient-centred, and staff responded to patients with patience and warmth.

  • Patients and their carers knew how to make a complaint. Staff ensured that information was available to them regarding their rights and the complaints process in various
  • Both units were clean and benefitted from a maintenance programme. Eastway was waiting for its décor to be upgraded and we were shown a selection of styles they had opted for.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 3 December 2015

We rated long stay rehabilitation mental health wards for working age adults good because:

The wards had systems in place to manage patient safety. The ligature risk management plan identified ligature points and how they might be used by patients who were suicidal. This made sure that staff were fully aware of the risk presented. The suicide prevention environmental risk assessment clearly documented where the risks were, the level of risk and how they were to be mitigated

The service generally had sufficient numbers and the appropriate skill mix of staff on duty to meet patients’ needs. Ward managers could increase staffing levels when appropriate. There was access to a regular cohort of bank staff.

There were clear processes in place for reporting safeguarding concerns. Staff had a good understanding of procedures and were confident in applying trust policy. Safeguarding was a standing item on the team meeting agenda.

Staff delivered care and treatment that was underpinned by best practice and a recovery focused theme was evident across the service.

Supervision and appraisals took place in line with trust policy. This meant that staff were supported by managers and colleagues and received the professional development needed to carry out their duties effectively. Managers were able to assess the quality of staff performance.

Peer support workers helped support patients, carers and staff. A peer support worker is a person with direct experience of mental illness.

The admission process informed and oriented patients to the wards. Each patient received an information pack before admission. Staff organised a series of pre-admission visits that gradually introduced the patient to the ward environment. Both patient and carer were included in these visits. On the day of admission patients were met by a member of staff who was familiar to them.

There was effective management of complaints. Patients discussed informal concerns during community meetings and nursing staff discussed any actions arising from these discussions during hand over. The ward manager investigated formal complaints in line with trust policy.

The service captured the ethos of the trust’s vision and values and this was evident in the care and treatment provided by the staff. Senior management had a visible presence on the wards and supported ward managers and staff.

There were good governance systems at a local level. Ward managers routinely monitored key performance information. Team meetings included governance issues as standing items on the agenda.

However, the service was struggling to enforce the nicotine management policy relating to the restriction of tobacco related products. Staff were aware that patients were bringing tobacco and lighters on to the ward and had been reminded about the trust’s search policy. In spite of this, we found little documented evidence relating to the searching of patients or their rooms for contraband items.

We were concerned about the confidentiality of patient and carers information due to the location of the office whiteboard on Rosewood. Information contained on the board, which included home contact numbers for patients and their relatives/carers was visible to anyone who passed by the office on their way to the dining area.

There was not enough emphasis on adhering to the Mental Health code of practice in respect of section 132 rights and access to an independent mental health advocate (IMHA).

Community mental health services with learning disabilities or autism

Good

Updated 3 December 2015

We rated the community mental health services for people with learning disabilities and autism as good.

Patient care and treatment was planned and delivered in line with current best practice and evidence based guidance. We saw evidence that risk assessments were completed when patients were accepted into the service. Risk assessments were also updated regularly to reflect the changing needs of the patients.

Patient problems were picked up quickly and dealt with as soon as possible to prevent hospital admission.

The caseloads varied between staff because of patient needs and hours worked. All staff spoken to felt their caseload was manageable and all had regular supervision where caseload management was discussed.

Staff understood the lone working policy and followed it. Electronic diaries were used to help keep track of staff whereabouts.

Staff were appropriately experienced and skilled to deliver care to their patients. The overall compliance rates for mandatory training were 90%, which was above the trust target of 85%.

Patients and carers were positive in their comments about the service.

Staff that we interviewed shared the values and vision of the trust and spoke positively about how they put these into practice in their work.

All working areas were clean and well-maintained.

Mental health crisis services and health-based places of safety

Good

Updated 3 December 2015

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

  • Teams were fully staffed and carried a caseload which was monitored and assessed daily with input from the consultant psychiatrist or junior doctor. Risks were considered from the point of referral to discharge and clearly documented within service users records. Workflow was discussed in handover. Work was prioritised by the teams and co-ordinated through a dedicated member of the team responsible for triage and shift co-ordination. This helped to ensure the teams worked efficiently to meet the daily demands of the service each day.
  • We saw good working relationships between teams: crisis care, street triage, liaison psychiatry, community teams, accident and emergency staff. The hospital inpatient wards and a dedicated member of the crisis team communicated on a daily basis to offer a structured approach to support people who use services. Care plans and crisis intervention plans were present and up to date. Staff understood the guiding principles of the Mental Health Act. We saw evidence of this in practice where staff always looked to provide the least restrictive care options, in collaboration with the person and their family/carer.
  • Teams received mostly positive feedback from people who use the service with regard to their care and treatment. The Care Quality Commission carry out an annual survey of community mental health service users, sending a questionnaire to service users who are in receipt of care from community teams. The survey carried out in 2014 showed the trust scored better than average overall in comparison with other trusts.
  • We observed a collaborative approach between teams to support people being referred to crisis services. This helped to prevent inappropriate admissions to inpatient services and supported timely discharge from hospital with home treatment packages. Staff had a good awareness of the timeframes for urgent admissions and recorded times from referral throughout the process in individual service user records. Trust data showed a low number of complaints received into the service. Staff made us aware that any issues were often dealt with at a local level and did not get escalated through the complaints process. In support of the crisis care concordat, street triage teams were introduced to East and West Cheshire in November 2014 on a one year pilot scheme. This had resulted in a 92% reduction in the number of people detained under the Mental Health Act under section 136 and a subsequent reduction in the use of the health base place of safety.
  • Staff we spoke with were aware of the organisations vision and values. The trust was working to embed aspects of the Crisis Care Concordat through improvements in service design and delivery. All staff reported enjoying their work but in teams where there had been lots of change, morale varied. Staff training was mostly up to date.

However:

  • The Crisis Care Concordat and Royal College of Psychiatrists recommend that teams are multi-disciplinary in composition but the teams at Cheshire and Wirral Partnership NHS Foundation Trust were mainly composed of registered nursing staff.
  • The health based place of safety at the Countess of Chester Hospital was basic. The toilet facility was not easily accessible or assessed as safe for people in an acute phase of a mental health crisis.
  • Staff did not always understand their role with regard to assessing mental
  • capacity and consent to treatment. This was not always clearly documented within patient records.
  • Service users did not always feel involved in their care planning. We observed that some plans lacked detail and evidence of patient involvement. Staff did not routinely offer copies to service users.
  • Management information was not available to support the monitoring, analysis and evaluation of referral, or triage and treatment times. This meant teams could not effectively review their performance levels or ensure adherence to trust policy and recommendations included within the Crisis Care Concordat.
  • Staff supervision and appraisal was low in some areas where there had been changes within the teams. This was also highlighted as an issue at trust level. Enhancing the skills of appraisers, supervisors and line manager’s formed part of the overall trust strategy.
  • Team managers acknowledged that teams had different strengths and different ways of working. Previously team managers held meetings on a quarterly basis but there was no current link to unite the teams and share best practice.

End of life care

Good

Updated 3 December 2015

Staffing levels were well managed by the team leader, with low levels of sickness and no current vacancies due to recent recruitment. However, trust managers had not taken a systematic approach to establishing the required staffing levels and acuity (level of patient need) of caseloads.

Appropriate equipment was available to patients. Medicines were managed appropriately. Information in relation to patient care and treatment was available to staff and records were adequately completed. There was a sufficient number of staff who had received appropriate high level training.

Patients received care and treatment according to national guidelines. Staff were patient focused on achieving the best outcomes possible for the people they cared for. Multi-disciplinary care was being provided and links were well established with good communication between disciplines.

Patient records were of a good standard and stored correctly in the patient’s home. There were no serious incidents reported relating to end of life care in the community within the 12 months prior to the inspection. Patients told us they felt safe.

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

Staff showed an awareness of people in vulnerable circumstances and gave examples of how to make care more accessible to them. People had the opportunity to comment on the service they received. Complaints were dealt with primarily at local level.

The diverse needs of people were met and there were appropriate provisions of care for patients and their families in line with their personal or religious wishes.

There was no overarching performance quality dashboard for end of life care. Staff measured quality locally which helped staff steer the direction of the service. However, staff felt that some of the changes put in place across the trust had been rapid and on occasion had been difficult to deal with.

Audits results for ‘do not attempt cardio-pulmonary resuscitation’ forms go to the end of life steering group and then to the overarching safety and quality group. However, we found no evidence of action plans and learning as a result of these audits.

Whilst some staff had seen members of the board once or twice, some had never come into contact with any of them which supported the feeling that teams and services were locally driven.