During a routine inspection

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

• We rated effective, caring, responsive and well-led as good, and safe as requires improvement. We rated 12 of the trust’s 14 services as good and two as requires improvement. In rating the trust, we took into account the previous ratings of the 10 services not inspected this time.
• Although we still rated the acute wards for adults of working age and psychiatric intensive care units core service as requires improvement we could see areas of improvement. We improved the overall ratings for two of the four core services inspected. We rated the community-based mental health service for adults of working age as good for all five key questions.
• The trust board and senior leaders had the appropriate range of skills, knowledge and experience to perform their role. The trust had a clear vision and set of values which were embedded and respected across the organisation.
• Leadership development opportunities were available, including opportunities for staff below team manager level. The leadership and management development offer to staff took an inclusive approach, the pathway was open to both registered clinicians and non-registered support staff.
• The trust’s target rate for appraisal compliance was 95%. At the time of inspection, the overall appraisal compliance rate was 97%. The appraisal process was aligned to the trust values and staff spoke positively regarding this process. On the whole staff felt respected, supported and valued within their teams.
• The trust had a policy on restrictive practices which had recently been introduced. Each ward now had a reducing restrictive practice log/risk assessment which recorded the local restrictions in place, and what the risk assessment was with and without each restriction in place, what the decision was, and the plan for review of any restrictive practice. This had helped services identify and reduce restrictive practices across the inpatient wards.
• On the whole, across the core services, we observed staff to be kind and caring towards patients. We observed positive relationships and could see staff knew the patients well.

However:

• We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement overall. Although we could see areas of improvement since our last inspection the core service still rated requires improvement for the safe, effective, caring and well led key question.
• Children and young people were waiting over 18 weeks to receive treatment in some areas. Across the service four team’s referral to treatment times exceeded 18 weeks. There were significant delays in accessing assessment for children and young people with autism spectrum disorder in all locations that offered this service.
• Although staff reported feeing respected, supported and valued amongst their local team and most by the senior managers. Two groups of staff felt they were not valued by senior leadership.

During a routine inspection

• We rated acute wards for adults of working age and psychiatric intensive care units, community-based mental health services for adults of working age and specialist community mental health services for children and young people as requires improvement.
• We rated the key questions of safe and responsive as requires improvement.
• The trust did not have a trust wide approach to reducing restrictive practices across inpatient wards.
• At our last inspection in 2017 we identified that the trust should ensure that they continue to work to meet the strategic aims for pharmacy and medicines optimisation. At this inspection we found that this had not happened. There was no strategy, or future plan, for the development of medicines optimisation within the trust and there was no formal workforce plan and limited workforce mapping to establish the workforce needs of the organisation.
• Although the trust had completed a recent review of the freedom to speak up guardian and had increased resources within this role, with a clear plan moving forward, we found that not all staff were aware of this role.
• The trust had not fully embedded the equality, diversity and inclusion agenda into the culture of the organisation. We could see progress had been made and the benefit of this for staff and patients however further work was needed to secure this across all of the organisation.
• The trust did not have a clear process in place to risk assess complaints when they were received.
• Not all of the human resource files contained all the required paperwork needed to satisfy the fit and proper person requirement.
• There was no process in place to identify whether a mental capacity assessment for treatment was completed at the time of a patient admission.

However:

• We rated the key questions of effective, caring and well led as good overall. Our rating took into account the previous rating of the four services not inspected this time.
• We rated forensic inpatient services, wards for people with a learning disability or autism and community mental health services for people with a learning disability or autism as good.
• The trust had an established, experienced board with strong leadership, all staff we spoke with described leaders as approachable and visible. The trust had a clear vision, set of values and strategy which were person centred and focused on sustainability. Staff felt supported, valued and were proud of the work they did.
• There was an open culture with good reporting of incidents and learning from when things went wrong. Although our inspection team identified some lapses in procedures, we could see there was a good governance structure in place with systems and processes to support board oversight. We saw evidence that the trust were aware of the issues we had identified as a concern and had given these issues consideration.
• The trust had a good learning from deaths process in place; incident reporting was good with thorough investigations. Learning from incidents and complaints was made available trust wide and the trust held learning events following the completion of all death investigations, this was an opportunity to explore recommendations and share learning across the organisation.
• The trust had strong relationships with partners investing in these relationships to ensure sustainable care.

During an inspection to make sure that the improvements required had been made

After the inspection in January 2017, we have changed the overall rating for the trust from requires improvement to good because:

• In March 2016, we rated 8 of the 14 mental health and community health core services as good. Since that inspection we have received no information that would cause us to re-inspect a core service or change the rating.

• In response to the inspection findings from the follow-up inspection visits, we have changed the ratings of four core services from requires improvement to good: community mental health services for older people, specialist community mental health services for young people, the forensic secure inpatient wards, and the long stay rehabilitation mental health wards for adults of working age.

• Also after the January 2017 inspection, we have changed ratings of the following key questions from requires improvement to good:

- responsive and well-led key for the acute inpatient mental health wards for adults of working age and psychiatric intensive care unit

- safe for wards for older people with mental health problems

- safe and well-led for the forensic inpatient secure wards

- safe, effective and well-led for the long stay rehabilitation mental health wards for adults of working age

- effective and responsive for the community mental health services for older people

- safe and well-led in the specialist community mental health services for young people

- well-led for the community mental health services for people with a learning disability and autism

• The trust had acted to meet the three trust-wide breaches of regulation identified at our inspection in March 2016. The trust had resolved almost all the technical issues with its electronic systems, and addressed staff performance issues on the system via staff training and revised user guidance. Mental Health Act and Mental Capacity Act training was mandatory. The trust was on a trajectory to meet the trust 80% compliance target by the end of March 2017 and training sessions had been planned for staff in to meet this trajectory within the timescale. They had an action plan to implement the revised code of practice across the trust, and almost all its policies, procedures and other documentation were in line with the revised Code of Practice. The trust ensured that all its executive directors and non-executive directors met the fit and proper person requirement and all personnel files had the relevant documentation to demonstrate the checks had been completed.

• Since the last inspection, the trust had appointed a new chief executive officer, which had a significant and positive impact on the organisation. The non-executive and executive directors described examples demonstrating an increased presence in the services across the organisation.The trio management structure, which included a general manager, a clinical lead and a practice governance coach, in the service lines in each business delivery unit was further embedded in the trust governance structures which had a positive influence on staff and service delivery. The trust had improved its approach to performance, governance and risk. Improvement had been made around communication and engagement with staff, and staff articulated a change in culture across the organisation and demonstrated a clear understanding of the organisation’s vision and values, and the trust’s direction of travel. The trust had revised and its governance structures to improve operational visibility at board level and improve communication vertically and horizontally board to wards and across business delivery units. The trust’s business delivery units were responsible for delivering safe and effective services within geographical or specialist service areas,

• At these follow-up inspection visits between November 2016 and January 2017 the trust had taken action to meet 15 of the 17 requirement notices issued at core service level following our previous inspection, in addition to the three trust-wide requirement notices. These included improvements in relation to ligature risks and blind spots, completion and review of risk assessments and risk management plans, access to electronic patient record systems and record keeping, wait times to access psychology, training in the Mental Health Act, application of the Mental Health Act, staffing levels on the ward to ensure safe treatment and care, physical health monitoring for high dose antipsychotic medication, regular multidisciplinary reviews, and performance indicators and audit.

However:

• We have again rated the acute wards for adults of working age and psychiatric units and the community mental health services for people with a learning disability or autism as requires improvement overall . We rated the acute inpatient mental health services as rated requires improvement in the safe and effective domains due to staff training compliance for immediate life support, staff supervision, and the understanding and application of the Mental Capacity Act. The community mental health services for people with a learning disability or autism was rated requires improvement for safe and responsive due to risk assessments and risk management plans not being accessible at the time of the inspection and wait times to access specialist services and other professionals.

• The forensic secure inpatient wards remained rated as requires improvement in the effective domain due to staff’s lack of understanding and application of the Mental Capacity Act and the specialist community mental health services for young people remained rated as requires improvement in the responsive key question due to waiting times to access treatment.

• Whilst the trust had completed work in relation to its strategic aims for pharmacy and medicines optimisation, due to the size of this large-scale project some of these actions were behind target. Three policies were not compliant with the revised Mental Health Act Code of Practice (2015), one policy was yet to be implemented, and four policies had their review dates extended. Supervision systems, the trust’s work on equality and diversity and inclusion for service users and staff, the development of the freedom to speak up guardian role, and the systems to identify and review incidents of mortality, were all still in their infancy and required further embedding across the trust.

• Following the March 2016 inspection, we rated community based mental health services for adults of working age as requires improvement in the responsive domain due to waiting time for access to psychological therapies. The trust has provided clear action plans explaining the changes taking place over a longer timescale due for completion in March 2017. The Care Quality Commission will return at a later date to re-inspect this service.

The full report of the inspection carried out in March 2016 can be found here at http://www.cqc.org.uk/provider/RXG.

During a routine inspection

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

We found that the provider was performing at a level which led to a rating of requires improvement. We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

We rated the trust as requires improvement overall because:

• Staffing levels in some of the inpatient areas did not always meet the safer staffing levels set by the trust. This adversely impacted on activities, escorted leave and potentially patient and staff safety. We also found some patients were waiting a long time for a service, this was especially so in specialist community mental health services for children and young people and psychology therapy services. The waiting lists were also not being appropriately managed which could lead to escalation in patient risk not being recognised.

• Risk assessment and management were inconsistent across the trust. Staff did not always assess patient risk in line with the trust’s policy. Staff did not always update the assessment in a timely manner when patient condition and presentation changed and risks were identified. Staff did not always share information regarding risk with other parts of the service. There were also environmental risks in some inpatient areas that had not been adequately managed by the trust.

• Physical health monitoring across the services was inconsistent. This was especially so where physical health monitoring was necessary in relation to specific medication and its use in long stay and rehabilitation and acute and psychiatric intensive care wards.

• Mental Health Act (MHA) and Mental Capacity Act (MCA) training was not mandatory for the trust staff and there was no overall board knowledge or overview of what training was being delivered or to which staff. Training was arranged and delivered locally and we found some areas where staff knowledge of the legislation in practice was very good. Unfortunately, we also found some areas where the staff knowledge of legislation in practice was very poor.

• Alongside the training for the MHA, we found that the trust had not implemented the changes to the 2015 MHA code of practice in the organisation. There were policies and procedures that had not been updated to meet the requirement of the 2015 code and the changes had not been actioned in practice. This meant that there was no assurance that patients and their carer’s rights were protected.

• Whilst there was overview of staff appraisal in the trust there was no overview of managerial or clinical supervision for staff. We saw examples of supervision at a local level on an individual and group basis. However, this was not consistent across the trust and there were areas where supervision was not being held for a considerable period.

• The trust’s electronic recording system, RIO, had been recently upgraded and different services across the trust were at various levels of implementation. Most services were finding it difficult to use the system effectively with areas needing to find their own solutions to the problems they were encountering. The difficulties were due to the system being slow to load and use information, a mixture of paper based and electronic records at various levels of development and different groups and disciplines or staff using different systems. Whilst some areas had developed their own solutions to problems with health records the inconsistency across the trust left risks to patient care and service delivery.

• There was a lack of assurance that the governance structures in place were effective across the organisation. Senior staff presented information to the board through governance meetings. We found that policies and procedures agreed at the board were not always consistent at a local level. Practice such as medication management, management of environmental risks across services and wards, monitoring and management of waiting lists, data quality to inform performance and the use of electronic and paper based health records were all found to be inconsistent. Some of the practice we saw in these areas was effective and staff had worked hard to provide a good service. However, there was potential for the board not to be aware of the quality of practice delivered by frontline staff due to the governance structure. This was especially evident in Enfield Down, one of the long stay rehabilitation wards, where the governance system had not identified failings in the service.

• The board approved the fit and proper person’s policy on 31 March 2015; this details the trust’s responsibilities and states that the trust will ensure that it has procedures in place to assess an individual against the fit and proper person’s requirements for all the new directors, prior to their appointment. Three of the new non-executive directors had not had Disclosure and Barring Service checks in line with the fit and proper person requirement, which came into force for NHS bodies on the 1 October 2014. This meant the trust was not complying with its policy or this requirement.

However:

• Consistently across the service, we found good communication between staff and patients and staff treating patients with kindness, dignity, compassion and respect. This was supported by comments from patients who were positive about the care and treatment they received from services. There were also good examples of patient and carer involvement in their care.

• Staff uptake of mandatory training was above the trust standard of 80% in the majority of inpatient areas.

• We saw examples of good practice across the organisation and areas where staff had developed aspects of their service. There was proactive management across the trust, often in a challenging environment. We saw some areas of notable practice across areas of the trust, which are detailed within the report. These include; navigation / tele health service; adult epilepsy service; commitment to working collaboratively; ADHD service and prison in-reach; production of easy read cook books; community eating disorder pathway; falls audit and change to practice.

• The trust had a clear structure and governance in place for the reporting of safeguarding incidents from the ward to the board via a number of different groups. Staff followed the incident reporting, complaints and safeguarding procedures, across the services, including duty of candour. Staff described instances where they had received feedback following learning from incidents and we observed evidence of lessons learnt from board to ward in the almost all services. There were named safeguarding nurses and mandatory safeguarding training. Staff were able to explain their responsibilities and local referral procedures for safeguarding.

• The trust had a clear strategy, which established its long-term vision and strategic goals, underpinned by the values of the organisation. The trust had worked closely with its stakeholders to develop these values. The values were embedded in the business delivery units and reflected in the staff behaviours we observed during our inspection. The introduction of the trio of managers, comprising a general manager, a clinical lead and a practice governance coach, in the service lines in each business delivery unit had improved the service delivery, the staff understanding of the transformation programme, and staff morale.