Cheshire and Wirral Partnership NHS Foundation Trust

Our overall rating for this service was Requires Improvement because:

Staff were familiar with how to report incidents and the relevant policy and procedure. However, the level of incident reporting was low, which could be indicative of staff not raising concerns appropriately. This was supported by examples of incidents that weren’t reported, which limited the opportunity for learning. When incidents were reported, lessons learned were not shared consistently with the teams.

The service did not maintain accurate, complete and contemporaneous records in respect of each service user. Records were not accessible to authorised people as necessary in order to deliver people’s care and treatment in a way that meets their needs and keeps them safe.

There was both a paper and electronic record for the majority of children in the service; however, there was no summary within the electronic record to identify historic concerns or issues. We also found that there was no reference in either paper or electronic records to alert professionals that there was another set of records for the child. In addition, it was identified that it would take a minimum of 24 four hours for staff to retrieve archived paper records. Managers were not able to give assurance that staff would be able to identify historic concerns written in paper records and share the information with the relevant services in a timely manner.

Safeguarding and other alerts could not be removed from the electronic record system, which meant the system did not provide an accurate reflection of which children had a child protection plan in place or where there were current child protection concerns.

The risk identified in relation to the management of records was not on the divisional risk register and no risk assessment had been completed in anticipation of the records being moved into deep storage with an external company. Managers were aware of the concerns relating to removal of alerts from the electronic record but this had not been raised on the risk register and no risk assessment had been completed for this.

However:

Care and treatment was delivered in line with national guidelines and evidence based practice. Maternal mental health assessments were completed appropriately and fully documented using a recognised assessment tool.

There was effective multidisciplinary working evident across the service. School nurses had developed good working relationships with the schools in their areas. There was a health visitor attached to each GP practice to ensure effective working relationships. There were systems in place to ensure breast feeding mothers received the required support from suitably trained staff.

The children and young people’s service was delivered by caring, committed and compassionate staff that treated people with dignity and respect. Staff actively involved young people and their parents and carers in all aspects or their care.

A range of services was provided by the division teams both in the community and in schools. The teams aimed to provide a flexible service where possible. The school nursing service was in the process of designing a website called ‘my wellbeing’. The work on this website was being undertaken with input from young people and the aim was for this to be launched in September 2015.

New initiatives had been established to meet the needs of people that use the services. Speech and language waiting times were being achieved with children waiting on average 11 weeks from referral to treatment which was better than the trust target of 13 weeks.

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.

We gave an overall rating for acute wards for working age adults and the psychiatric intensive care unit (PICU) as requires improvement because:

• Brackendale and Beech wards did not comply with the Department of Health required guidance on same sex accommodation.

• Acute wards were mixed gender. Not all bedrooms were en-suite and on some wards, female patients had to pass a male area to access toilet and bathroom facilities.

• Not all wards had designated female-only lounges.

• There were not clear lines of sight within the corridors housing patients of different genders.

• We observed a male and female patient going into a bedroom area, unobserved by staff.

Some of the seclusion records either did not record the time the doctor was informed and attended or did not explain the reasons why the doctor was delayed. This meant it was not always clear that the safeguards for seclusion or segregation were being met. Some of the restraint records did not record the time patients were restrained in the prone position.

Some patients’ risk assessments were lacking in detail and some identified a list of past risk incidents without detailing how current risks would be managed.

There was variable adherence to the MHA Code of Practice particularly around significant delays in recording of rights, capacity to consent for treatment for mental disorder and seclusion recording.

The trust’s governance arrangements relating to the oversight of the Mental Health Act was not effective. Our MHA reviewers had raised many of these concerns on previous MHA monitoring visits, but issues continued to be found.

Patients on Beech ward were not receiving regular input from the responsible clinician (RC), with some patients not seeing their RC for weeks.

However:

There were plans to improve the seclusion environment at the Jocelyn Solly (Millbrook) Unit as the current rooms used for seclusion did not meet the enhanced standards prescribed by the new Mental Health Act Code of Practice. There were significant efforts to reduce and review all episodes of prone restraint through various trust initiatives. Staff knew about potential risks to patients’ health and safety, and how to respond to and manage these. There were clear systems in place for reporting safeguarding concerns and staff understood what they had to do.

Services were evidence-based and focused on the needs of patients. However, there was a lack of psychology input on the wards. Staffing levels were generally safe.

The trust provided a caring service for patients across the acute wards and the PICU. We saw examples of staff treating patients with kindness, dignity and compassion. The feedback received from patients was generally positive about their experiences of the care and treatment provided by the staff on the acute wards and the PICU.

Wards employed peer support workers so patients were supported by a staff team that included suitable people who had direct experience of mental illness. Ward managers were supported in the day-to-day management by a resource manager who managed the non-clinical aspects of running the ward. This enabled ward managers to focus on ensuring the wards provided good quality clinical care.

Patients were able to access beds in their local acute psychiatric service within reasonable timescales. Whilst there was some pressure on beds, this did not significantly affect patient care.

Patients told us they knew how to make a complaint should they need to.

The wards and PICU were committed to provide high-quality care and continuous improvement in line with the trust’s stated values and strategy. Staff reported they felt well supported by their managers.

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).

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.

The child and adolescent mental health wards had a good track record of safety. Staff were aware of the process of reporting and acting upon incidents. There was a clear understanding of the safeguarding process within the team. Staff took a proactive approach to safeguarding and this was explored with patients early into their hospital admission. Effective work took place with the local authority in relation to child protection and safeguarding concerns.

Staffing levels have been reviewed by the trust and increased to reflect the needs of the service. Thorough handovers took place with the multidisciplinary team to ensure relevant information was shared to support patients effectively.

The environment was clean, welcoming, and young person friendly. Patients were fully involved in the décor of the wards with their art work on display.

Patients’ care and treatment was planned and delivered in line with best practice as recommended by National Institute for Health and Care Excellence. A number of psychological therapies were offered as well as family therapy. Patients were fully involved in their care. Young person friendly documentation was in use including “my anxiety plan”. Comprehensive assessments were completed which included “my moving on plan” to focus on the future and discharge.

Patients completed self assessments upon admission and reviewed these during their stay.

The service was involved with the Quality Network for Inpatient CAMHS, which accredited them as excellent. Internal peer review took place with other wards.

Feedback from patients, their parents and carers was excellent about the care they received.

We observed young people were treated with dignity and respect. Staff interactions with patients were positive, nurturing and encouraging. Staff genuinely cared about the patients and respond appropriately to their needs.

Information about medication and treatment was freely available in a format that was meaningful to young people.

Education was an important and embedded part of the service. The education sessions were tailored to the needs of the patients. Ofsted rated the education provision as outstanding.

The trust had a clear vision and values which the staff and patients were aware of. Information from the executive board was disseminated to the staff team via team meetings. Regular email updates were used for all staff.

The ward managers were approachable. Staff reported, and we saw, an open door policy. Staff were confident at seeking guidance from the ward managers.

Regular supervision took place both individually and group supervision.

The facilities for delivering care and treatment were clean and safe.

Managers planned and reviewed the staffing skill mix to ensure patients received safe care and treatment. They allocated referrals among staff based on caseload, complexity of cases and expertise of staff and they monitored caseloads during supervision. Staff understood their roles and responsibilities to raise concerns and report incidents and near misses.

Staff talked about their work in terms of the recovery model. Their focus on supporting people to remain in the community was clear. However, some care plans, while containing elements of a recovery based approach, were mainly generic. There was inconsistency in care pathways and structure for care. We found little evidence of processes and systems being embedded into practice. Some staff were unclear about whether systems were in place or not. Systems to ensure care plans were reviewed regularly were not robust or effective.

We did not find evidence to show how patient’s views and experiences were gathered locally so that they could be used to drive improvement or influence service development.

Best practice guidance was not embedded consistently. Outcomes were not being measured and at Vale House, physical health needs were not being assessed routinely.

People who were subject to the Mental Health Act (MHA) 1983 were assessed, cared for and treated in line with the Act and the MHA Code of Practice.

Capacity assessments carried out under the Mental Capacity Act 2005 were not always specific to the decision needing to be made.

We gathered information from a range of sources to gain feedback from patients and their carers. Their feedback was positive, particularly about the way staff treated them. Patients and their family members were treated with kindness and respect. They felt they were involved in decisions about their care. They told us they were listened to and supported during their care and treatment. Staff were sensitive and respectful of patients’ wishes and were committed to providing personalised care based upon their needs.

The teams focused on assisting people to remain within the community and avoid admission to hospital where possible. They facilitated early discharge by offering people intensive support during the move from hospital to the community. Patients were enabled to participate in the activities of the local community so that they could exercise their right to be a citizen as independently as they were able to. The teams made efforts to meet people’s diverse needs.

Staff felt respected, valued and supported. There was a meeting structure to escalate and cascade information through all levels of staff. This included governance and incidents. We found some good examples of practice designed to improve services. However, there was little evidence of local audits being carried out which could be used to ensure that systems were working and drive improvement, and the strength of local leadership differed significantly in the teams.

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

• Cherry ward, Meadowbank ward and Croft ward were all located in different areas and had completely different layouts. However, all three wards were clean, tidy and were free from odours. We found that staff were delivering care that was safe, effective, caring, responsive and well led. Staff were passionate about caring for older adult patients and they ensured the privacy and dignity of them.
• Action was taken to mitigate all ligature points on the wards following environmental ligature risk assessments.
• All three ward managers had sufficient authority to increase staffing levels if they required extra nursing care and there were always enough staff to carry out interventions safely.
• All of the clinic rooms were clean and tidy.The wards had good medicine management practices. There was good storage, dispensing, reconciliation and destruction of medication.
• The wards followed many national guidelines related to the care and treatment of the older adult. The advancing quality dementia measures were in place. This quality standard covered care provided by health and social care staff in direct contact with people with dementia in hospital, the community, home-based, group care, residential or specialist care settings. This standard was recommended by national institute for health and care excellence. There was also a dementia specific e-learning package in place that staff working in older adults services had to undertake.
• Staff knew and agreed with the organisation’s values. Ward managers were engaged in the organisational values and staff felt supported by their immediate line manager. There was a sense of teamwork in the wards and staff reported close teams that supported each other while on shift, recognising that they were working with a challenging patient group.
• Resuscitation equipment including automated external defibrillators was available and checked regularly. All equipment was in date and had clearly identified expiry dates on them.
• There were ligature points on windows and some doors. However, over the door alarms had been fitted in bedroom areas that would be activated if pressure was put on the door. Action was taken to mitigate all ligature points on the wards following environmental ligature risk assessments.
• All patient notes had up to date risk assessments in place and care plans generally showed the involvement of patients and carers.

However:

• The trust’s target for bed occupancy was 85%. All three wards exceeded this target. Leave beds were sometimes used but usually following consultation with the multi-disciplinary team.
• Cherry ward had two delayed discharges in the last six months, Croft and Meadowbank had none.
•  We did find inconsistencies in practices around reading detained patients their rights.
• Overall compliance rates for all mandatory training were 65% for Cherry ward 80% for Meadowbank ward and 85% for Croft ward. Both Cherry ward and Meadowbank wards rates were below the trust’s target of 85%.
• Appraisal data supplied by the trust for the three wards showed varying rates of compliance with the trust’s target of 85%. Cherry ward was 84% compliant, Meadowbank ward was 17% compliant and Croft was 60% compliant. Ward managers informed us that these rates had now increased significantly since the submission of this data and Meadowbank had now appraised all staff who were currently at work. Croft and Cherry ward had also significantly increased their compliance.

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.

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

• Risks to people using the service were assessed, monitored and managed on a daily basis and staff recognised and responded appropriately to changes in risks to people.

• Staff understood their responsibilities to report on incidents and near misses and were supported when they do so.

• Adults and children were appropriately protected and staff took steps to report any incidents of safeguarding to the local authorities.

• All three teams reported low staffing vacancies, mainly due to maternity leave, secondment and advanced practitioner training; however, systems were in place to address the vacancies with staff being offered temporary contracts and vacant posts being filled to keep people safe.

• Staff received feedback from investigations and incidents. Actions from incidents and patient alerts were regularly discussed in team meetings to ensure lessons were learnt.

• People who used the service had comprehensive assessments of their needs which included consideration of their clinical needs, mental health, physical health and their well-being.

• Information about peoples’ care and treatment and their outcomes were collected and monitored.

• The teams participated in local and national audits and front line staff were involved.

• Staff were qualified and skilled to deliver care and treatment to their people but there were some gaps in their mandatory training.

• Peoples’ care and treatment was planned and delivered in line with current best practice and evidenced based guidance.

• Feedback from people who used the services was positive about the way staff treated them. People reported and we directly observed they were treated with respect, kindness and were involved in making decisions about their care and treatment

• People’ social needs were understood and people were assisted to maintain and develop their social networks and community support where needed.

• Information about patient and carer experience was reported back to teams from information collated in relation to the friends and family test.

• There was an effective process in place to identify, monitor and address risk issues.

• Staff were open, transparent and were aware of their ‘duty of candour’ in relation to the NHS organisation they worked in.

• There was a strong focus on continued learning and improvements for staff within the teams they worked in.

• The number of staff who had completed mandatory training was below expected levels in some areas. This had the potential to put people who use the service and staff members at risk.

• Systems existed to monitor and manage risk. Escalation procedures for urgent referrals were in place. Assessments were carried out in a timely manner, reviewed and reflected in care plans. Safeguarding was embedded within the service. Staff displayed a good understanding of their roles and responsibilities in this regard.

• Feedback from people who use the service was positive. We observed people who use the service being treated in a respectful manner and with care and empathy. We saw evidence of involvement in their care and decisions over treatment. Where families and / or carers were involved their opinions and views were also reflected. People who use the service were routinely offered a copy of their care plan.

• The trust had a clear vision and a set of values and staff were aware of these.

• The trust had a quality strategy, processes and systems were in place around governance.

• The teams had processes in place to manage team performance and the quality of care and treatment provided.

• Processes were in place to monitor performance. Regular governance meetings were held and performance data was on display in teams. There were key performance indicators (KPIs) in place for monitoring quality initiatives.

• Teams informed us they were positively supported and well managed locally and the service manager and general manager were visible and approachable.

However:

• Where people were subject to a community treatment order (CTO) under the Mental Health Act there was no evidence in the paper or electronic system care notes that people were being read their rights. Records reviewed informed us people did not have their rights explained to them routinely and there was no documented evidence from the care coordinator.

• Staff were not routinely assessing people’s capacity to understand the risks and benefits of treatment offered to them.

• Complaints and concerns information was displayed in the waiting rooms used by people that used the service. However, the information about complaints was only displayed in English.

We rated low-secure forensic inpatient services for working age adults as requires improvement because:

• Staff failed to follow the Mental Health Act code of practice or the Cheshire and Wirral NHS Partnership Foundation Trust policy in relation to seclusion and segregation. One patient had been cared for in seclusion for eight days. Records did not demonstrate the need for the patient to be nursed in seclusion for this extended period of time.
• Staff working on the units were not aware of the high-risk ligature points identified in the trust annual ligature audit undertaken in July 2014.
• There were additional ligature risks and a number of multiple blind spots throughout both units, which could have compromised the safety of patients, visitors and staff.
• There were blanket restrictions in place and patients told us that rules changed day to day, depending upon which staff were on duty.
• Patients told us that activities and planned leave had been cancelled due to staff shortages.
• The vision and values of the trust were not demonstrated by all members of the staff. This could be seen in complaints about staff attitudes and behaviour.
• Managers had failed to identify concerns regarding the use of seclusion, the standard of recording in the clinical records when seclusion had been implemented and the recording of incidents.

We rated Specialist community mental health services for children and young people as good because:

• Staff had a thorough understanding of the safeguarding procedures and were confident in making safeguarding referrals. Lessons were learnt from the serious incidents within the service.
• Progress that young people were making was measured and recorded. This was also gathered in an innovative way of an iPad remotely, and in real time, to avoid delays and ensure information was current.
• Goal based care plans were in place for young people with individual aims. The care plans were co-produced by the young person and their practitioner from the CAMHS team.
• Staff received supervision every four to six weeks.
• Job mapping was completed with their managers to ensure equity of allocations of new referrals for the choice and partnership allocations.
• We observed good multi-disciplinary working within the teams that were young person focussed.
• Staff treated young people using the service, and their family, with dignity and respect. We observed several sessions with practitioners and young people, all of them showed supportive, nurturing and encouraging approaches from staff. Young people we spoke to said they felt supported, listened to and were pleased that someone showed an interest in them.
• The young people who used the specialist community mental health services created the Mymind website and twitter account. The resources provided information for young people and professionals including self-help resources on addressing their mental health needs, the services that were provided by the trust and what to expect from the service in an accessible format.
• Young people who used the service help to run training for professionals on topics including self-harm. Evaluation of the training was extremely positive and the most helpful part of the feedback was young people’s involvement.
• There was a clear statement of vision and values. Staff were aware of this and embedded it into their daily practice. Staff felt valued and had job satisfaction and appreciated the innovative approaches and projects they had been involved in.
• Senior managers had highlighted the risk of an increase in demand for the service. They introduced an innovative way of limiting the intervention in tier two services and submitted a business case to commissioners for increased funding for four new posts, which was successful.

However:

• Individual risk assessments for young people using the service were not comprehensive or completed in a timely manner after the needs of a young person changed.
• There was limited understanding of the lone worker policy within the service. Staff did not follow the trusts’ lone worker policy consistently.
• Team mangers did not have the information they needed available to them in a centralised system. This meant they could not monitor the waiting list for the service or take into account risks to young people waiting for the service.

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.

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

We found that the provider was performing at a level that led to a rating of ‘Good’ because;

• The trust was committed to and working towards reducing restrictive practices in line with their trust-wide campaign ‘zero harm’, which started in July 2014. The campaign focusses on encouraging staff to ‘Stop, Think and Listen’ and to continually reflect and review their everyday working life to identify possible practices that could result in unwarranted harm to patients. However, in the low secure forensic services, there were a number of restrictive practices not based on clinical risk.

• The trust had worked hard to improve staffing levels significantly over the six months to June 2015 although it continued to face staffing challenges on some wards. Overall, we found staffing levels were safe. Caseloads across the community teams were in line with current guidance.

• The trust was committed to improving the quality of services and had governance structures to support that aim Morale was good across services, and staff teams were motivated and committed to providing good care and treatment to patients in line with the trust’s vision and values. This was shown through a number of initiatives staff had implemented to improve outcomes for patients and carers. We noted several examples of good practice where staff teams had ‘gone the extra mile’ to ensure patients’ needs were being met.

• The trust board and senior managers we spoke with were open and transparent. They recognised areas that needed to be improved in addition to areas that were working well. There was a positive culture of learning and continuous improvement. When we raised concerns to the trust board about care in Saddlebridge Recovery centre during the inspection, they were very open in their responses and provided assurance that the issues we raised would be managed effectively.

• The trust acknowledged that there were some difficulties with their current information technology (IT) system, which had been escalated onto the board assurance framework risk register with actions to deal with them.

• We identified a number of issues regarding the way the trust dealt with complaints but the trust was aware of them and already had plans to manage complaints more effectively.

However;

• Some of the seclusion rooms did not comply with the Mental Health Act Code of Practice and some staff were not following trust policy and national guidance in relation to the use of seclusion rooms.

• Some of the acute mental health wards did not fully comply with the Department of Health required guidance on same-sex accommodation.

• In some services, individual patient risks were not always reviewed and updated in a timely manner and environmental risks were not always identified and mitigated.

• Within community (physical health) services for children and young people, the service did not maintain accurate, complete and contemporaneous records in respect of each service user. Records were not accessible to authorised people as necessary in order to deliver care and treatment in a way that meets their needs and keeps them safe.

• Compliance with mandatory training and appraisal of work performance was variable across services.

• Issues that had previously been raised through Mental Health Act monitoring visits in relation to patients detained under the Act had not been fully dealt with by the trust.

• Compliance with the Mental Capacity Act 2005 (MCA) was variable across the trust. Although we found good practices in relation to the MCA in some services, in others staff lacked confidence in assessing patients’ capacity to make decisions about their care and did not feel that the current e-learning training sufficiently enabled them to develop their skills and confidence in this area.