South West Yorkshire Partnership NHS Foundation Trust

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

• Staff did not always assess or manage risk well. Staff did not follow up on all identified risks, create management plans or appropriate crisis plans. The service did not actively monitor children and young people on waiting lists to detect and respond to increases in level of risk.
• 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 offer this service. Children and young people on waitlists did not have a formal care plan until they received intensive treatment. For those admitted into the service care plan entries were written from a clinical perspective, more so than for the individual receiving treatment.
• Staff did not always record consent clearly for children or young people in their care records.
• Staff did not ensure that children and young people and their families and carers had access to all the information they should. This included information on complaints, carers assessments and LGBTI support.
• Issues relating to on-call provision were not yet fully resolved. There were staffing gaps in the rotas as there were not enough staff to cover all responsibilities.
• Staff did not always follow systems and processes for cleaning and checks of clinical equipment. The Barnsley service did not have CQC ratings from the previous inspection displayed in patient areas.

However;

• Clinical premises where children and young people were seen were safe and clean. The number of children and young people on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving people using the service the time they needed. Staff ensured that children and young people who required urgent care were seen promptly.
• The service had identified issues with long waiting lists for intensive treatment and gaps in commissioning and were working to resolve these. When appropriate, they provided low level interventions to those waiting for intensive treatment. They were implementing new service models to better meet the needs of people using the service and were working with commissioners to get additional funding and a clear service specification.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of children and young people. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of those using the service. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood the principles underpinning capacity and competence in line with the Mental Capacity Act and Gillick competence.
• Staff treated children and young people with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They actively involved children, young people and their families and carers in care decisions.
• The service was easy to access in terms of referrals and initial assessment. Staff assessed and were able to expedite treatment for children and young people who required urgent care promptly. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
• The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

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.

• The assessment of and management of patient risk was not consistent. The ward acuity was high and there was high rates of staff assaults. There were omissions in medicine management surrounding the review of ‘as required’ medication and physical health monitoring after rapid tranquilisation. Short shelf life medicine did not have a date of opening. Monitoring of emergency equipment was not consistently completed. Not all patients were able to summon assistance using a nurse call alarm if they needed to.
• Care assessments did not always consider the full range of patients’ diverse needs or evidence patient involvement.
• There were times when people did not feel well-supported or cared for. Nine patients we spoke to described staff as sometimes “rude” or “abrupt”. Staff did not consistently knock before entering patient bedrooms and patient confidentiality was not maintained on some wards.
• Bed occupancy was high and staff reported a pressure to admit patients despite voicing concerns about clinical risk. Patients were occasionally placed on an unsuitable ward or an air bed. Not all wards provided activities seven days a week.
• Clinical and internal audit processes were inconsistent in their impact and errors had been found in documentation of important clinical documents such as seclusion and Mental Capacity Act. Staff morale was mixed. Staff did not always raise concerns or suggestions as they did not feel they would be heard or that any action would come from it.

However:

• The environment was clean and well maintained. Some wards had implemented measures to reduce restrictive practice and staff used restraint and seclusion appropriately. Safeguarding was given sufficient priority and staff adhered to the duty of candour. There was evidence of investigations following serious events, lessons learnt were shared and duty of candour was well embedded. Staffing levels had been increased following work with NHSI. Staff could access specialist training to reflect the needs of the client group.

• Patients had a prompt physical health assessment on admission and monitoring though admission. The ward teams had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare. Some wards had AIMS accreditation. Staff had good understanding of their responsibilities under the Mental Health Act 1983.

• Interactions we observed were largely positive. Staff demonstrated a good knowledge of each patient. All carers we spoke with were involved in patient care. Patients and carers were able to feed back about the ward and have a say about their treatment options.

• The facilities allowed for a diverse activity programme, including tai chi and hydrotherapy. Patients enjoyed the food and accommodation. Patients had access to advocates, interpreters and pastoral care. Complaints and concerns were investigated and findings shared.

• Ward managers were knowledgeable and capable, committed to improve the quality of care for patients and involved in research projects. The modern matron post was giving wards the authority to implement change. There was good learning and support across and within the business delivery units. Staff had opportunities for development and career progression.

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

• The service had enough staff, who knew the patients and received basic training to keep patients safe from avoidable harm. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• Staff provided a range of treatment and care for the patients based on national guidance and best practice. They ensured that patients had good access to physical healthcare and supported patients to live healthier lives.
• Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
• Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
• The service was easy to access. Its referral criteria did not exclude patients who would have benefitted from care.
• The service had made significant progress towards reducing the waiting list times for access to psychological therapies. Although, continued to have some patients who had been waiting for an average of 174 weeks.
• Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed.
• Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution.

However:

• Following the migration to the new electronic patient records system we found information relating to patients’ risk assessment and care plans was not easily available and, in many cases, information had been transferred in to different areas of the new system.
• Resuscitation bags at Drury lane had not been checked for two weeks resulting in the airway aids been out of date.
• Staff in Barnsley and Kirklees told us they did not find senior managers to be visible within the service.

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

• The service had enough nursing and medical staff to deliver care and keep people safe from avoidable harm. Staff assessed patient and environmental risks and responded to changes in that risk. Staff reported adverse incidents and learnt from when things went wrong.
• Staff assessed the physical and mental health needs of patients on admission and worked collaboratively to meet patient need. Patients had access to a range of professionals as part of their care. Staff were supported with regular supervision and annual appraisal.
• Staff treated patients and carers with kindness and respect. Patients and carers were able to give feedback on the care and treatment they received. Patients and carers we spoke with were positive about staff and the service.
• There were clear admission criteria and processes. Staff managed beds well. Patients had access to a range of facilities and information. Staff were responsive to patient needs, including those with a protected characteristic.
• Staff considered managers to be supportive and described an open and honest culture. Governance systems and processes allowed staff to assure the quality of care and generate improvements. Managers were aware of the challenges the service faced and had plans to address them. Staff had been involved in an ongoing service transformation project.

However:

• Staff described challenges in managing a mix of organic and functional patients and signage on some wards was not dementia appropriate.
• Staff did not always review the use of as required and covert medication.
• Risk assessments were not always comprehensive or completed in a timely manner. Care plans were not always personalised and did not always evidence patient involvement.
• Wards did not have access to dedicated psychology input.

• There was not an effective approach to managing the premises. The service did not complete environmental risk assessments or infection control audits in line with best practice guidance. The premises at Barnsley were not always secured using the appropriate level of security that was needed in relation to the services being delivered. Staff were not always able to rebook appointments due to availability of rooms at the Barnsley and Wakefield West sites.
• Staff were not always following the trust’s procedures to keep them safe when on home visits or working out of hours. Some staff had no lone working device and staff that had, were not always using lone working devices in line with the guidance provided. There were not effective processes in place to monitor and improve compliance. This could place staff at risk.
• There were issues with connectivity to the trust network that affected staff. They struggled to access and remain in the trust’s network due to connectivity issues and limited licences. Staff were not always able to access information or update records as a result.
• People that used the service said that they were unclear how to feedback on the service. Families and carers shared concerns about the length of the waiting lists and told us they sometimes found it difficult communicating with the service. Carers told us that they were not provided with information about how to access a carer’s assessment.
• The out of hours on call service was not always fully staffed. We saw gaps in rotas and incidents recorded on the incident management system as a result. Four of the pathways were not meeting the 18 week referral to treatment standard. The autism spectrum disorder (ASD) pathway was the longest; it averaged 99 weeks.
• The senior leadership team had not successfully communicated the provider’s vision and values to the frontline staff and none of the staff we spoke with knew who their organisation’s Speak Up Guardians were, although they were aware of the whistleblowing procedures.

However:

• All areas were clean, had good furnishings and were well-maintained. The service had a range of rooms and equipment to support treatment and care. Therapy and clinic rooms had alarms and staff responded when they were used.
• Staff provided a wide range of care and treatment interventions suitable for the children, young people, families and carers that used the service. Staff completed a comprehensive mental health assessment that included a risk assessment for children or young person receiving treatment from the service. Care plans were personalised, holistic and recognised physical health needs. Age appropriate consent was recorded and reviewed.
• Safeguarding was embedded in the service and there were mechanisms in place to provide feedback and support staff following incidents. There were systems and processes in place monitor the effectiveness of the service.
• Staff in the service arranged appointments flexibly and provided choices on location and timings. Staff interaction with children and young people was friendly, informative, compassionate and respectful. Children and young people told us that they liked going to the service as they felt listened to and were not judged. Staff spoke directly to the child or young person and checked if they and their families or carers understood what was being asked. Carers and families spoke positively about the service once they had received an appointment.
• The service had introduced a number of initiatives across the sites that had improved waiting times and reduced risk. The service had clear criteria for accepting referrals had a process to expedite urgent cases.
• Leaders understood the services they managed. Staff understood arrangements for working with other teams, both within the provider and external, to best meet the needs of the people using the service. Staff made suggestions about developing the service and implemented new groups to support the strategy. Leaders were proud of their staff and the care they provided. The provider recognised staff successes within the service via Trust Excellence Awards.

• Staff did not always review and update people’s risk assessments and management plans at necessary intervals and following serious incidents. We found some shortfalls in relation to information in care plans not being personalised and lacking clear objectives.

• There were still long waiting times for people accessing specific individual therapies which was an issue we found at our previous inspection. Staff did not routinely monitor people waiting for therapies where they had long waits. There were differences in how and when people were able to access services through the single point of access teams within the different localities.

• There was low compliance with some areas of mandatory training for staff, including personal safety training. Staff found the availability of some of the courses was lacking which meant it was difficult to book on courses.

• Some people and their carers were not aware of how to provide feedback about the service and had not the opportunity to give any. Most carers we spoke with had not been offered, and were not aware of carers assessments.

• Although environments were well maintained, some environmental assessments were not completed at the necessary frequencies. The site at Lundwood did not have accessible toilet facilities.

However:

• We observed staff to be kind, caring and compassionate during their interactions with patients. Patients and carers spoke positively about the staff and reported staff were caring and listened to them.
• The transformation work undertaken at the service meant staff now worked in integrated teams on the same site. We saw good evidence of multidisciplinary working and staff said this improved how they worked together to better meet the needs of people.
• Most premises had accessible facilities and staff could provide information for people in format to meet their needs.
• Staff felt supported in their roles and had access to further training and development opportunities. Staff spoke positively about their managers and felt able to speak about any concerns.
• We saw some good evidence in care records of comprehensive care planning and risk assessment. There were good levels of information within progress notes to show what support people were receiving.

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

• The trust had acted upon our feedback from the previous inspection of this service. People’s risk assessments were available and easily accessible in all the electronic care records we reviewed. They were up to date and demonstrated staff assessed, managed, and monitored people to protect them from avoidable harm and abuse.
• The teams we visited included a full range of staff disciplines. Staff worked in a collaborative manner and were flexible in their approach across the different functions provided in each location.
• People received effective care and treatment. Staff planned and provided care and treatment that was in line with current evidence based standards and best practice. Staff completed care plans that were holistic, personalised, and involved people in decisions about their care and treatment.
• There were sufficient numbers of skilled and experienced staff in the community teams. Staff felt their caseloads were manageable. All staff met the trust’s compliance target for appraisals, supervision and mandatory training. Staff we spoke with felt valued and well supported by their clinical leads.
• Staff provided compassionate care and clearly understood people’s feelings, preferences and their social needs People were involved in decisions about their care and treatment. Communication with people was clear and individualised. Staff used open questions and simple language. They gave people time to respond and provided appropriate levels of verbal prompting if necessary.
• The trust had acted upon our feedback from the previous inspection of this service. They had restructured the service to include multi-disciplinary teams providing a more joined up approach. This led to a significant reduction in waiting times with improved access to a range of specialist assessments. The community teams had a clear pathway that provided flexibility for staff to provide care that met the needs of individual patients. The intensive support teams responded to urgent and crisis referrals within the recommended referral wait times.
• The service had a clear and effective leadership structure. Senior staff were knowledgeable about the service and committed to making continuous improvements. Staff morale was positive overall and the culture of the service was consistent with the trust values.

However

• The base at Wakefield was in the city centre and also used by several mental health services. The location and multi-discipline use of the base presented staff with challenges regarding retention of health support workers and agile working. The waiting area was large and impersonal, with no easy read information displayed.

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

• Staff did not adhere to the trust policies and best practice in the management of patients in seclusion and the monitoring of patients’ physical health following rapid tranquilisation. Staff did not document de-brief with patients following incidents of restraint. Staff did not always reflect incidents involving patients on risk assessment documents or grade them accurately.
• Staff did not fully complete medication administration records for 17 patients. Staff did not monitor clinic room temperatures, fridge temperatures and equipment in line with the trust policies.
• Staff did not assess the risk of patients in line with trust policy. Staff did not fully complete Section 17 leave documentation to ensure that patients and carers were informed of the requirements and responsibilities of Section 17 leave.
• Staff did not ensure that plans for patients’ care, treatment and discharge involved patients and their families and carers. Care plans were not personalised and did not reflect the patient’s voice.
• Not all patients had access to nurse call systems in their bedrooms to enable them to summon assistance if required.
• Seven of the wards had over 100% bed occupancy and the service had high numbers of out of area placements. Patients did not always have a bed available to them on return from leave.
• Governance systems and process were not effective in ensuring that change was implemented. Managers were aware of some of the key areas for improvement within the service; but these issues were still a concern at the time of inspection.

However:

• Patients reported staff treated them in a kind and caring manner. Staff involved patients in weekly multi-disciplinary review meetings and held regular community meetings to enable patients to provide feedback on the care and treatment they received.
• Staff used observation levels to maintain the safety of patients on the ward. Staff understood the needs of patients and adapted their practice to take into account their personal and social needs.
• Staff felt supported by their immediate managers and reported they worked well together within their teams. Staff had annual appraisals and were supported to access specialist training. Staff knew the vision and values of the trust.
• The service provided facilities to meet the needs of patients. All wards were clean and furnishings were well maintained.

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

• The trust had acted upon our feedback from our previous inspection of this service and there had been overall improvements in the safety of patient care.
• Following our previous inspection, the ward had taken action to reduce blanket restrictions. However, there was no system or process that supported how staff identified and reviewed blanket restrictions and some blanket restrictions remained.
• Staff had a culture of openness and honesty and safety was a high priority for all staff. Managers monitored the safety and quality of the service and took action to improve safety. Staff regularly assessed and monitored risks to patients, to protect them from avoidable harm and abuse.
• Patients received effective care and treatment. Staff planned and delivered care and treatment that was in line with current evidence based standards and best practice. Training for the Mental Health Act and Mental Capacity Act was now mandatory for all staff. Staff completed care plans that were holistic, personalised, and involved patients in decisions about their care and treatment.
• Staff provided person-centred care that patients’ needs and treated patients with dignity and respect. Feedback we received from people who used the service was overall positive and we observed staff who were kind, caring, and respectful. However, we had concerns about the limited opportunities for patient feedback and carer support on the ward.
• The ward had a clear pathway that provided flexibility for staff to deliver care that met the needs of individual patients. Staff planned and managed admissions and discharges to the ward so that patients had timely access and successful discharges from the ward. The facilities promoted the comfort, dignity and privacy of patients and the ward planned to make further improvements to the environment.
• The ward needed to make further improvements in the arrangements for reviewing blanket restrictions and obtaining the views of people who used the service. However, staff morale was overall positive about managers who were highly visible and supportive. Senior staff were knowledgeable about the ward and committed to making continuous improvements.

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

• The services had a clear leadership and governance structure. Systems and processes enabled senior leaders to have oversight of performance and areas that required improvement. The services had clear embedded pathways for care and treatment across the medium and low secure services. When serious incidents occurred, the trust ensured that these were investigated and frontline staff received information on lessons learnt.
• Newhaven ward had a specialist forensic outreach nurse to facilitate discharge and provide short-term support after discharge. The services had no delayed discharges and no readmissions within 28 days.
• The service had made improvements in the training compliance rates of Mental Health Act and the Mental Capacity Act. Most staff now had a reasonable understanding of their responsibilities.
• Physical health care was easily accessible and embedded into patients’ care and treatment well.
• Staff ensured patients had access to therapies and activities to promote their care and treatment on the wards, within the services and at the recovery college. The services had sufficient space to facilitate sessions and activities. The service ran a number of events for patients and carers.
• Staff involved patients in their care and treatment. They treated patients with respect and provided support. Care plans were written in easy read format and alternative languages.

However:

• Patients did not routinely have access to a nurse call system but staff ensured on an individual basis that alarms were in place when required.
• Thornhill and Johnson wards had some issues with safe medicines management in relation to equipment, temperatures, secure storage and administration recording. Ryburn and Newhaven wards could not raise an external staff response quickly if required.
• The trust had a timescale to replace door handles that could be used as a ligature anchor point.
• Feedback from staff reported difficulties in gaining input from speech and language therapists. Staff and patients reported issues with staffing, leading to section 17 leave being cancelled. Patients provided mixed feedback about the food provided.
• Observation windows with an external curtain and staff administering medication through the hatch of the clinic room did not promote privacy and dignity. Six patients also told us staff did not always knock before entering their bedrooms or looking through observation windows.
• Feedback from patients and staff included some challenges in facilitating section 17 leave. It was unclear from the patient feedback whether this was due to patient expectations or because of agreed leave cancelation. However, records showed that only 14% of leave was cancelled due to staff shortages.

• 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.

All patients were protected from potential harm and abuse. Patients individual needs were met through timely risk assessments, that were reviewed and updated regularly. The service had enough staff with the right training and support to deliver safe care and treatment.

Regular assessment of environmental risk ensured facilities and equipment were safe for patients and staff.

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.

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

• The trust had not ensured that staff undertook training necessary to enable them to deliver safe and effective care.On average, 64% of staff had undertaken training in cardiopulmonary resuscitation. On one ward less than one-quarter, and on a further two wards less than one-half of staff had completed the training. The low compliance meant that not all staff would know how to respond to patients in a physical health emergency. Fewer than one-half of all eligible staff had undertaken recent training in the Mental Capacity Act and Mental Health Act.As a result, staff did not have a clear understanding of the Mental Capacity Act, and most staff struggled to describe the circumstances where it should be used.

• On average, only 18% of staff received regular supervision. Some staff told us they received regular supervision whereas others told us it had been months since they had last received supervision.

However:

• The trust had addressed the areas of concern from the previous inspection around poor lines of sight on the wards, risk assessments and the safe monitoring of high dose medication.

• Patient and carer feedback from most wards was positive about the ward environment and the ward staff.

• Most care records were personalised, holistic and recovery focused with evidence of patient participation and ongoing physical health monitoring. Staff were positive about the trust’s electronic patient record system and told us it had improved since the last inspection.

• Staff morale was high on most wards. Ward staff and managers were positive about their teams and their work. The wards had effective systems and processes to monitor and assess performance. Ward managers recognised the areas where the wards needed to improve and were able to clearly describe how they planned to achieve improvements.

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

• Following our inspection in March 2016, we rated the services as good for effective and caring.

• During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe and well led as requires improvement following the March 2016 inspection.As a result, the service was now meeting the requirements of Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

• The service had introduced a process to help manage risks of young people on the waiting list. This had also helped to reduce waiting times within some teams. Staff had reviewed, and started to implement, new ways of working in order to try to make the service more appropriate for young people requiring support and treatment.

• Improvements had been made to the quality of information in records by way of additional and bespoke training for staff. Records ‘champions’ were in place at each team and staff reported that quality of data recording had improved.

• The service had taken action to improve and strengthen lone working practices by way of extra training. Staff had also taken action to review and improve the storage of prescription charts and to improve staff training compliance in basic life support.

However

• Although waiting times for treatment for young people had improved in Calderdale and Kirklees, and Wakefield, there were still significant delays within the Barnsley team with some young people waiting over 22 months. There were long waits across all teams for young people waiting to be assessed for autistic spectrum disorder and related conditions.

We rated forensic inpatient secure wards as good overall because:

• Following our inspection in March 2016, we rated the services as good for caring and responsive. Since that inspection we have received no information that would cause us to re-inspect these key questions or change the ratings.

• During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe and well-led as requires improvement following the March 2016 inspection.

• Forensic inpatient secure wards were now meeting Regulations 12, 17 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

• We reviewed the actions we said the trust should take to improve, all of which had been addressed.

• However, whilst we found that the trust had met the breach of Regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014 at the inspection in March 2016 in relation to the trust ensuring that positive behaviour support plans or equivalent are implemented for all patients with learning disability or autism, we found the trust were not adhering to the best interests checklists as defined by the Mental Capacity Act. Mental capacity assessments were not recorded in patients notes and best interest decisions were not documented. Staff did not understand the processes necessary to clearly document capacity issues. This was a breach of Regulation 11 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We rated community-based mental health services for people with learning disabilities or autism as requires improvement overall because:

• Staff could not quickly access risk assessments in 17 of the 26 care records we reviewed. They were either stored in different formats and/or different locations, or had not migrated to the new electronic system.

• Waiting times to see members of the multidisciplinary team and for specialist clinics were long in Barnsley and Kirklees. Therefore, the community-based mental health services for people with a learning disability or autism were still not meeting Regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

However:

• The community based mental health services for people with a learning disability or autism had improved speed of access to psychology, meaning that nobody was waiting for longer than 18 weeks for psychological assessment or therapy.

• The trust had ensured systems and processes were in place to monitor the quality and safety of services integrated with local authority services. The trust had worked with commissioners to develop key performance indicators that were meaningful to staff and people who used the service. They had restructured their learning disability teams and all staff were now accountable to trust managers. The community based mental health services for people with learning disabilities or autism were now meeting Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014. Therefore we found at this inspection that the services had addressed the issues that had caused us to rate the well-led domain as requires improvement following the inspection in March 2016.

• The trust had also completed actions in response to recommendations CQC stated they should take following the inspection in March 2016. At this inspection, almost all care records documented consideration of consent and capacity, and some included detailed accounts of decision-making when people lacked capacity to decide for themselves. Also, all staff could access the trust electronic care record system to access and input information about people who were using the service. There was a policy in place governing information sharing with other organisations, including the local authority.

• Following our inspection in March 2016, we rated the services as good for effective and caring. Since that inspection we have received no information that would cause us to re-inspect these key questions or change the ratings.

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

• Following our inspection in March 2016, we rated the services as good for effective, caring, responsive and well led.

• During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe as requires improvement following the March 2016 inspection.

• The wards for older people with mental health problems were now meeting Regulations 12 and 15 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We rated South West Yorkshire Partnership NHS Foundation Trust as good because:

• The service had effective governance process in place which demonstrated a clear link between senior management and front line staff.

• Weekly multidisciplinary review meetings and risk review meetings were held and patients care plans and risk assessments were updated as required.

• Patients had the opportunity to speak to a consultant at least once a month or more regularly if requested.

• Patients’ physical health was monitored regularly through weekly physical health and wellbeing clinics led by a band 6 nurse and the junior doctor.

• Staff had received training in the Mental Health Act and completed regular audits of patients consent to treatment records, all of which were correct and in date at the time of the inspection.

We rated South West Yorkshire Partnership NHS Foundation Trust as good because:

• All the teams were using electronic patient records to store patient information. This meant staff had better access to records, the documentation and records were consistent, and there was less chance that work was duplicated or missed. Care documentation was completed in a timely manner.

• Staff carried out routine assessments within the nationally recognised targets of 14 days, and urgent assessments within four hours. Teams were able to offer treatment to patients in a timely manner from assessment. All the teamsallocated a care coordinator within a week of the patient having their assessment. Some specialised treatments took longer than others, however, the trust data demonstrated they were able to meet all treatments within 18 weeks.Patients had access to crisis support 24 hours a day seven days a week.

• At this inspection all the actions we told the provider it should take had been completed. Staff were learning from incidents at a local level, trust level and national level. Senior staff held monthly meetings open to all staff looking at serious incidents and what learning would take place. This included learning events where the trust reviewed incidents that took place in other services where the lessons learnt could also be applicable to them. Learning from incidents was also embedded into team meetings and supervision.

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

• The ward environment was autism friendly and supportive of the sensory integration needs of people with autism. There was a sensory room and other quiet, uncluttered areas for patients to use. Bedroom doors had tactile door surrounds to assist with room recognition.

• Staffing levels were appropriate to meet patients’ needs. Staff were able to spend 1:1 time with patients.
• There was a person-centred culture in which individual patients' needs were prioritised. We saw that staff identified and met patients' emotional and social needs. There was a range of activities available to patients.
• Care records were holistic, recovery-focussed and up to date. Care plans were very detailed and clearly described interventions, enabling a consistent approach from all staff.
• Patients had comprehensive physical assessments on admission and physical health care needs were being met.
• All patients had a positive behaviour support plan which aimed to improve their quality of life. Plans included details of behaviours of concern, triggers to these behaviours and early warning signs.
• Staff received mandatory training and annual appraisals. There was clear learning from incidents.

However:

• Not all information for patients was accessible. The ward team were aware of this and we saw an action plan for improvements to be made.
• Centrally collated data regarding the use of restraint and seclusion was not accurate.
• Mental Health Act and Mental Capacity Act training was not mandatory but was classed as core training for staff on the ward. The recording and monitoring of what staff had had training at ward level was not effective.
• The ward did not have junior doctor cover and some staff felt access to the medical cover which was provided was a concern.
• Missing medication doses were not always being recorded as incidents.

We rated community health services for children, young people and families as good because:

• Services were safe and people were protected from harm. Staff knew how to manage and report incidents. We saw there had been learning following serious case reviews. Risks were actively monitored and acted upon. We found that there were good safeguarding processes in place.
• We found that there was enough staff with the right qualifications to meet families’ needs.
• The clinics and health centres we visited were clean.
• Services were effective. We found good evidence that the service reviewed and implemented national good practice guidelines. The trust had also successfully implemented evidence based programmes, such as the family nurse partnership programme.
• We also saw that patient outcomes and performance were monitored regularly, and that all staff received regular training, supervision and an annual appraisal. There was good evidence of multidisciplinary and multi-agency working across the services.
• Services were caring. Children, young people and parents told us that they received compassionate care with excellent emotional support.
• Services were responsive. We found the service planned and delivered services to meet the need of local families. Parents, children and young people were able to quickly access care at home or in a location that was appropriate to them.

• Services were well led. Staff we spoke with told us the patient was at the centre of what they do, they were positive and proud about working for the organisation. There was an open culture in the service, and staff were engaged in the process of service improvement. Staff reported being supported by their line managers and teams within the organisation.
• Staff worked with national and regional partners to share good practice. The service had been recognised by the Department of Health for their information sharing procedures and also received recognition from the Institute of Health Visiting and NHS England following the development of the health visitor caseload weighting tool. All managers were very proud of their teams.

Overall we rated the trust as good for community end of life care services because:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons were learned and communicated widely to support improvements.

• High performance within the service was recognised by credible external bodies.

• Staff in the community and on the wards of the community hospitals demonstrated a consistently good level of knowledge of end of life care issues.

• The palliative care team was multi-disciplinary with medical, nursing, social work, occupational therapy, physiotherapy and dietetic membership.

• The end of life care lead for the trust was also the end of life care lead for the locality and the trust had a significant role in contributing to the shaping of end of life care services.

• We saw that staff would find ways of making the experience of care as easy as possible for people and that there was a commitment to end of life care at all levels ofthe community service.

• 84% of patients known to the Specialist Palliative Care Team achieved their preferred place of care at the end of life.

• The integrated multidisciplinary model adopted by the palliative care service supported the development of responsive care packages in the community, including the management of a supportive care at home service.

• There was a clear vision, strategy and values for end of life care with well-defined objectives that were reviewed as part of a district end of life care steering group.

• We observed strong leadership from the Specialist Palliative Care Team (SPCT) and senior staff in the community.

• There was a commitment and culture for providing high quality end of life care that was patient focused.

• Innovation was apparent across the SPCT as a whole.

• The service proactively engaged staff and patients to ensure their views were heard and acted upon, including the use of volunteers to obtain patient and family feedback.

We rated community inpatient services as good because:

• The service prioritised patient protection and there were defined systems, processes and standard operating procedures to keep people safe and safeguarded from abuse. We saw evidence of open and transparent culture in relation to incident reporting. Opportunities were available to learn from investigations and staff were comfortable reporting their concerns or any near misses. The duty of candour process and practice was in place across all community inpatient locations. Complaint and concern responses were provided in a timely way with improvements made to the quality of care as a result.

• The department was clean and there were infection control and prevention audits, which showed high scoring outcomes. We found that medicine management and recording of information was to a good standard and well maintained.

• Training levels were in line with trust targets as a whole and staff competence was apparent during inspection. All safeguarding training took place as part of the trust’s mandatory training programme and nursing staff demonstrated a good level of knowledge in relation to safeguarding triggers, forms of abuse and processes.

• Risks to people who use services were assessed, monitored and managed on a day-to-day basis. Risk assessments were person-centred, proportionate and reviewed regularly. The service applied national early warning scores to identify when the escalation of care needs was appropriate.

• Feedback from numerous patients across both of the community locations was very positive. We heard that staff responded compassionately to patients’ needs and were skilled in dealing with vulnerable individuals with complex physical and mental health needs. Relatives said they felt involved and had the opportunity to speak with medical and nursing staff when required.

• We observed the treatment of patients to be compassionate, dignified, and respectful throughout our inspection. Ward managers were available on the wards so that relatives and patients could speak with them as necessary. Staff were hard working, caring and committed to delivering a good quality service. They spoke with passion about their work and were proud of what they did.
• We found that the trust’s contribution to local and national audit was in line with the national average, and evidence of changes made by specialities in response to their outcomes was available and had been actioned.
• Planning and delivery processes were in a place to enable services to meet the needs of the local population. The importance of flexibility, choice and continuity of care was evident within each service. The needs of different people were taken into account when planning and delivering services and reasonable adjustments were made to remove barriers when people found it hard to use or access services.

• There was evidence of competent, responsive, multidisciplinary working between all professionals. They worked closely with the local authority when planning discharge of complex patients and when raising safeguarding alerts.

• The behaviours and actions of staff working in the division mirrored the trust values of ‘patients’ first, safe and high quality care, and responsibility and accountability’ of which we saw multiple examples of during our inspection.

We rated this core service as good because:

• Systems to manage and report incidents were in place, safeguarding procedures were robust and records were up to date.
• Medicines were stored and administered appropriately. Equipment was readily available and cleanliness and infection control procedures were followed.
• Risks to the delivery of care for patients were managed and action taken to mitigate them.
• Services were mainly fully staffed, mandatory training was up to date and staff development was supported.
• Care and treatment followed evidence based guidance.
• Care pathways were coordinated, multidisciplinary working was effective and outcomes for patients were evidenced and audited.
• Patient’s consent to care and treatment was documented.
• Care was delivered with compassion and staff treated patients with dignity and respect. Patients were involved in decisions about their care and treatment and received emotional support.
• Community services had a clear vision focussed on the patient at the centre and the needs of patients influenced the planning and delivery of services, including care for patients with diverse cultural needs.
• Patients had timely access to services, with minimal waits for most services. Few complaints were received by the service.
• Governance arrangements supported the delivery of care for patients. Performance measures were used which were monitored and action was taken when issues were identified.
• The service demonstrated a positive, focussed culture.
• Community services operated in an environment that encouraged improvement and innovation.

We rated community mental health services for people with learning disabilities or autism as requires improvement because

• Some of the community nursing teams were co-located and managed within local authority community learning disability services. These teams utilised the local authority electronic recording systems to create and maintain patient records. Although these staff could access Rio, the trusts electronic recording system, they were not all able to update the records and could not easily share the information held on the local authority system. Staff that used Rio told us the system did not enable them to input and upload some assessments which they had to store on a network drive. This resulted in staff from other teams being unable to directly access all the relevant information on a patient’s record.

• We saw evidence that patients risk was assessed as part of their initial assessment however risk assessments were not always reviewed routinely, unless there was a known change in a patient’s needs.

• The teams integrated within local authority services were not governed by any key performance indicators and were not required to provide performance data to enable the trust to monitor the quality and safety of service provision.

• Psychology teams were not always meeting the services target of 18 week treatment pathway and some people had been waiting 13 months to access the treatment.

However,

• Patients had holistic care plans based on individual need, including care plans in easy read formats. Staff demonstrated a strong person centred culture through their knowledge of the patients they supported.

• Teams held weekly meetings to review new referrals and waiting lists, where patients presented to be in crisis the service would prioritise their need for support.

• Staff were supported to make suggestions for innovative ideas. The service had supported the development of the ‘cook and eat’ books, a range of easy read cook books designed for use by people themselves and within therapy sessions.

• The service had a robust process in place to record incidents, learn from incidents was reviewed at management level and disseminated through to teams. Staff were all aware of their responsibility under the duty of candour and this had been incorporated in to the incident reporting system.

We rated Community Mental Health service for older adults as requires improvement because:

• There were long waiting times from referral to treatment. Access to psychological therapies was limited causing long waiting times in some areas.

• Not all services had a full multidisciplinary team complement.

• It was difficult for staff within teams to ensure records all held the same information as some services used paper and others used computerised systems. in addition, the use of different systems meant there was duplication of work when recording information.

• Some patients’ care records did not reflect the involvement of the person and their wishes for care and treatment.

• Trust wide learning events were carried out following incidents however attendance at these was not mandatory.

• There was no crisis service for older people.

However:

• Managers were able to asses required staffing levels and ensure enough staff were available to provide care. Staff knew what their responsibilities were in relation to safeguarding and what they needed to do to keep themselves and patients safe.

• Staff we spoke with understood the Mental Capacity Act and we saw evidence of this put into practice. Best interest meetings were carried out when required and documented in care records. Regular multi-disciplinary team (MDT) meetings were carried out and were used to discuss patients’ care and any concerns that may have arisen since the last meeting.

• Staff treated patients and carers with dignity and respect. Appointments were rarely cancelled and patients told us that staff were very accessible. Staff made time to speak with patients and their carers. Patients were encouraged to ask questions and participate in their care and treatment decisions.

• Staff knew about the duty of candour and were aware of the types of incidents that should be reported. Learning events were carried out following incidents and staff were given debriefs and support.

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

• the service was using a combination of electronic and paper records and some information was being stored in the clinical records and some on restricted access shared drives

• waiting lists for treatment were long and unless someone contacted the service for assistance it was not possible to monitor any changes in risk. The trust were not able to provide accurate information about how long children and young people were waiting for treatment after they had been assessed

• a procedure was in place for safe visiting, which included staff carrying a personal safety device, but staff were not fully following this which put staff at increased risk of harm from others.

• the trust required clinical staff to have basic life support training but the compliance with this was significantly below trust target, this meant hat staff who were not trained were unable to provide basic life support in an emergency situation.

• the trust could not provide accurate up to date information on waiting times and average caseloads of the teams.

• Clinical audits were not being regularly undertaken to ensure quality standards were in place.

We rated South West Yorkshire NHS Partnership Foundation Trust as good because :

• The environment of the health based places of safety (136 Suites) were adequate and in line with Mental Health Act guidance. It optimised patient dignity, safety and comfort.
• The crisis teams had robust monitoring of medication and had rapid access to psychiatry; patients could be seen within the day. We saw examples of the crisis team learning from incidents and implementing changes within their practice. Staff across all the teams were up to date in their adult and child safeguarding training.
• All the teams worked alongside external stakeholders to respond to people in crisis effectively. This was in line with the trust’s responsibilities under the crisis concordat.
• All initial assessments are carried out by a band 5 or band 6 nurse. If a band 5 nurse carries out the initial assessment, this is always discussed with a band 6 nurse. We saw initial assessments were comprehensive and detailed. Staff across all the teams had a good understanding of the Mental Health Act and Mental Capacity Act. They understood the guiding principles and were able to give examples of how they could apply it in practice.
• We observed meaningful, compassionate and person centred care delivered by dedicated staff. Patients were positive about their experiences with the crisis teams.
• Staff within the crisis teams met their targets to complete initial assessments within four hours of referral. We observed flexible working around patients’ needs. Staff adjusted their schedules so that patients could attend their appointments. Crisis teams utilised a range of resources which increased the quality of the service they delivered, for example, self-help leaflets and interpreting services.
• We saw effective use of auditing which provided oversight of team performance. These enabled team leaders to plan work and identify gaps. We saw teams shared good practice across the different regions, learning from each other’s experiences. Staff had good morale and were happy about how they were managed. Staff felt valued and that their thoughts mattered.

However,

• We saw that the staff on the 136 suites did not always review their ligature risk assessments in a timely manner.
• Monitoring for Mental Health Act and Mental Capacity Act training were not always present.
• Appraisals for staff had not been completed equally across the four crisis teams.
• Not all teams provided crisis team leaflets describing their crisis service other than in English.
• Not all teams were commissioned to have police liaison officers.
• The crisis team in Barnsley had high levels of sickness. The sickness levels year to date was 12%.
• Teams felt less confident with the management structure above the team leaders.

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

• patients had risk assessments in place which were reviewed regularly. Risk management was practised in daily and weekly multi-disciplinary meetings

• there were good safeguarding practices in place. Staff knew how to identify abuse and raise concerns

• there were lone worker protocols in place that staff understood and adhered to

• services were engaged in clinical audit. Systems were in place to monitor adherence to National Institute for Health and Care Excellence (NICE) guidance. Action plans were in place to achieve compliance where required

• patients were involved in decisions about their care. Care plans were personalised, holistic and recovery focused

• feedback from patients was positive. We observed patients being treated in a respectful manner and with a caring and empathic approach

• there were processes in place to prioritise referrals and respond to urgent referrals. Teams were able to engage with individuals who found it difficult or were reluctant to engage with services

• there was strong leadership at team and business delivery unit levels.

However;

• there were long waiting times for access to psychological therapies in parts of the service. In Barnsley North community mental health team this was an average of 54 weeks. Provision of psychological therapies to the South Kirklees assertive outreach team was also insufficient

• the ADHD and autism team had a referral to first contact time of 44 weeks. The time from first contact to second contact was 14 weeks. Commissioners were introducing increased funding for the service to help address this

• training on the Mental Health Act and Mental Capacity Act was not mandatory training and not all staff had received training

• electronic systems used to store patient records were unreliable. Contingency plans to use paper records were in place. The issue of electronic records systems was on the trust risk register

• staff expressed concerns about caseload and capacity. They were concerned that teams were reaching, or at their maximum workloads and this would limit the amount of time they could spend with each person who used the service.

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

• All wards were clean, tidy, and well maintained. The clinic rooms were fully equipped and emergency equipment was checked regularly. Staff were aware of how to report incidents and did so via the online incident reporting system. The ward complied with guidance on same sex accommodation by having single en-suite bedrooms and a designated female lounge area. There were good medicines management procedures for recording, dispensing and storing of medication. Staff were aware of the duty of candour and their responsibilities surrounding this.

• All patients had a physical health check on admission and there was evidence of ongoing physical health monitoring. There was evidence that National Institute for Health and Care Excellence guidance was being followed in relation to prescribing of medication and there was a range of psychological therapies on offer to patients. Clinical staff participated in a wide range of clinical audit, including medications, mental health act and care records. Eighty seven percent of staff had received an appraisal in the last twelve months. Mandatory training was at 89% for the core service. This was above both the national average and the trust target of 80%.
• We saw positive interactions between staff and patients. All patients we spoke with told us they were treated in a dignified, respectful and caring manner. The staff we spoke with knew the patients well and this was reflected in the care plans of the patients. Patients all had a copy of their care plan if they wanted one and they were fully involved in developing them. There were weekly community meetings where patients were given the opportunity to give feedback on the ward. Patients told us they were encouraged to join in with activities that were available.

• Discharge was always well planned and happened at an appropriate time for that person. There was a full range of rooms to support care and treatment of the patients. Patients had the facilities to make a phone call in private. There was a lot of emphasis on patients accessing local groups for activities. However, there was also a wide range of activities available on the ward seven days a week, including evenings. Staff and patients were able to discuss any issues in community meetings and staff meetings. Information leaflets were available in a range of languages if required. Patients had access to an independent mental health advocate who visited the ward on a weekly basis. Staff were aware of the organisation’s vision and values and used them as a basis for their work with patients’. These were displayed in the communal areas.

• The clinical leadership on the ward was clear and all staff said that they felt supported and listened to. Staff were aware of the trust vision and values and were committed to providing good care in line with this.

However:

• On The Poplars, Ward 19 and Chantry Unit the ward layout did not allow staff to observe all parts of the ward. This was not mitigated by the use of mirrors on Chantry Unit or Ward 19. The use of observations did not include staff being present in those areas on a routine basis and on the day of our inspection staff were not present in those areas. Risk assessments of patients did not refer to the blind spots within the wards when considering the risks to and from that patient. This meant that the ward was not doing all that was practicably possible to reduce the risk of harm to patient s and staff.
• The bedrooms door handles at Ward 19 were a ligature risk. Although this was identified on the annual ligature risk assessment to be managed locally there were no bedrooms without these door handles. This meant that if patients were a high risk of self harm they would need to be nursed on close observations which was not the least restrictive option.

We rated forensic inpatient secure wards as requires improvement because:

• The nursing staff levels on each ward did not match the number of nurses required to facilitate adequate nursing care. This meant that patient’s leave, physical health appointments and ward based activities were cancelled due to the lack of staff.
• The temperature in the clinic room was too high and exceeded the recommended level for the safe storage of medicines. This meant that the stability of medicines was unsafe and that medicines were at risk of being less effective.
• Not all patients with a learning disability or autism had positive behaviour support plans or equivelants in place. This meant that staff would not be providing a consistent approach towards patient exhibiting behaviour which was challenging. This is not in keeping with guidance from NHS England, (Transforming care for people with learning disabilities, 2015).

• Patients were not always receiving 25 hours a week of meaningful activities as recommended by NHS England. This meant that patients were not reaching their potential for recovery and rehabilitation in a timely way.

• Patient care records did not always contain evidence of the patients’ involvement in their care. MHA, Mental Capacity Act (MCA) and immediate life support training was available but was not mandatory training for staff. The training being delivered was variable, inconsistent and accurate attendance figures were not kept by the service. The trust had no oversight regarding staff knowledge and understanding of the MHA, MCA or levels of competency for life support.

• Patients’ rights, the recording of patients’ capacity to consent to treatment and advance decision statements were not consistently recorded in patients care records.

• The care and treatment of one patient in long-term segregation did not meet the standards set out in the MHA code of practice.

• Not all staff had timely access to patients’ electronic care records which could compromise the care delivered.

• Food choice availability was inconsistent.

• There was no system in place to ensure that staff were receiving regular supervision as described in the trust supervision policy. Information was collected at ward level but this was not accessible at trust level. This meant that the trust had no data to provide assurance that supervision was being delivered.

• On two wards, compliance with appraisals was 50% and 46% which was not in line with trust policy.

However:

• Staff showed a good understanding of safeguarding issues and there were good links with the local safeguarding authority.

• The facilities provided by the service were clean, spacious and focussed on promoting patients recovery whilst maintaining appropriate levels of security.

• Family and carers were kept informed of patient’s care when patients had consented to this. Family and carers were invited to review meetings and felt involved in patient care and decisions.

• We found effective multidisciplinary team (MDT) working. Teams were cohesive with good communication between different professionals and agencies.

• There was a range of professionals involved in patient care which ensured a holistic approach was taken towards patient care.

• There was effective psychology provision available to patients with a range of psychological approaches offered. The psychologist was part of the MDT and contributed to the care planning process. This meant that patients needing psychology could access this service directly and that a psychological approach was embedded in the ward philosophy.

• Staff followed the trust’s complaints policy and lessons were learnt from adverse events. This meant that patients’ views were listened to and acted upon.

• Staff were kind and caring and treated patients with respect. This meant that patients felt supported and had a good relationship with their care team.

• There was an effective discharge planning process in place that involved the MDT. This meant that patients ready to move on from the service were not unnecessarily delayed.

• Staff understood and agreed with the mission and values of the trust and felt they were applicable to their role and reflected in the service objectives.

• The senior management team were a visible presence on each ward.

• Each ward was involved in the safer wards programme to help improve the safety and comfort for patients and staff.

• Staff reported that morale was good.

• Staff had the opportunity to give feedback on services and input into service development.

We rated long stay/rehabilitation mental health wards for working age adults as requires improvement because:

• Staff at Enfield Down did not review the risk assessments that they had undertaken and did not update these to reflect changes in risks associated with changes in patient presentation. This placed patients at risk of harm from incorrect information being held about them, and their current risks not being managed effectively.

• Staff at Enfield Down did not always follow national guidelines and best practice with regards to medicines management. They did not review PRN medication (medication when required) regularly.

• Staff at Enfield Down had prescribed high dose antipsychotic medication for two patients but had not undertaken regular electrocardiograms; despite one patient being at high risk of cardiac problems. This meant patients on high dose antipsychotics where at risk of physical health complications because they were not being monitored appropriately.

• Staff st Enfield Down, did not hold regular multidisciplinary meetings to discuss the care of patients. The service held Care Programme Approach meetings on a three to six monthly basis and this would be when patients would be fully reviewed. This meant that staff might not meet the needs of patients in a timely and efficient manner.

• The services within the trust were led by a team of three senior clinicians.Within the rehab service the governance lead post was vacant and was out to advertisement. At Enfield Down, governance processes had failed to identify that there were insufficient monitoring of patients on high dose antipsychotic medication, that patients were not being reviewed in a timely manner, and that risk assessments were not being reviewed or updated as required.

However

• The average mandatory training rate for the whole service was 93% with both units achieving above the trust standard of 85%.

• Care plans were developed in collaboration with the patients, were holistic and covered a range of areas such as mental health, physical health, drug and alcohol issues and social issues. The occupational therapist also contributed to the care plans demonstrating a multidisciplinary approach.

• We saw interaction between staff and patients that was respectful, thoughtful, considerate, timely, and professional. Patients we spoke to told us that staff members were professional at all times. Staff members were praised by patients for being approachable, caring and always making time to talk.

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

• Some wards had poor lines of sight, which put patients at risk where the trust had not mitigated ligature risks or in some cases identified them.
• Bathroom facilities were not adequate on Beamshaw and Clarke wards.
• Patients on Beamshaw and Clarke wards could not take a bath without staff present. This was a blanket restriction.
• Staff did not routinely carry out monitoring of high doses of medication.
• Managers did not ensure staffing levels were always sufficient to keep patients safe. Escorted section 17 leave was either cancelled or cut short due to staffing levels.
• Staff on ward 18 had either not completed patients’ risk assessment or had not completed them on time.
• Line managers did not provide regular supervision to staff on all of the wards.
• It was not always clear in records whether people had capacity and therefore whether there was any requirement for capacity assessments to be undertaken where necessary. Staff did not always follow the best interest process.
• There was not always a bed available on patients’ return from leave and in some cases beds were put in communal rooms.
• Access to activities was limited at weekends.
• Information on how to complain was not displayed on Trinity 1.
• We observed one example of a patient’s privacy and dignity being compromised.

However:

• We observed staff interacting with patients in a respectful manner and in ways that were appropriate to the needs of the person.
• The provider had introduced a co-production care plan. However, this had not been adopted in all areas.
• Ward rounds involved the patient and patients were very positive about the care they received.
• Patients had good access to advocacy services.
• Patients were given a pack of information on admission to the wards.
• Staff reported good support within the teams and there was a good team spirit on most wards.
• Staff followed duty of candour by being open and transparent and verbally apologising when something went wrong.
• My physical health and my mental health documents had been introduced on some wards.

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.