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Provider: Kent and Medway NHS and Social Care Partnership Trust Good

Reports


Inspection carried out on 9 October to 29 November 2018

During a routine inspection

  • The team bases were safe for use by patients and staff.
  • Patients who were prescribed anti-psychotic medicine received regular monitoring of their physical health.
  • The service employed enough staff to meet the needs of the service. Staff felt supported by the trust, completed mandatory training, received supervision and had access to training opportunities.
  • Staff had manageable caseloads that were reviewed regularly. They completed detailed risk assessments and had support from the multidisciplinary team when their patients presented as high risk.
  • Staff had a good understanding of how to safeguard patients from abuse. They knew how to report incidents and were supported to gain learning from them.
  • Staff had access to a secure system where they could access and record information regarding patients’ care and treatment. Staff could to access this system remotely to record important updates and support their time management.
  • Staff carried out comprehensive assessments of patients’ needs and completed detailed care plans that addressed these identified needs.
  • The service employed clinical psychologists and occupational therapists who provided a range of interventions to improve treatment outcomes and promote independence.
  • The service had good links with internal and external agencies where patients, and their carers, could get support with social, dietary and physiological needs.
  • The service carried out a programme of audits around clinical documentation and physical health monitoring of patients on anti-psychotic medicine.
  • Patients, and their carers, were universally positive about the care and treatment they received. Staff knew their patients and treated them with compassion and respect.
  • Patients, and their carers were fully involved in decisions about their care and treatment. The service offered them exceptional support in the early stages of their diagnosis.
  • Admiral nurses supported families with all aspects of living with dementia. Healthcare assistants instilled hope in families by introducing them to emotional and practical support.
  • The service actively collected feedback, from patients and their carers, about their experiences of the service. Responses received were extremely positive.
  • The service was proactive in ensuring referrals were appropriately triaged and patients were seen and treated in a timely manner. All teams provided a duty service that could respond to emergencies.
  • The service responded to patients’ individual needs. Patients had a choice in what services they received support from. It was proactive in engaging patients and provided satellite sites to support patients from rural areas.
  • The service promoted dementia friendly communities and supported the concept of patients supporting each other. The service used feedback from complaints and compliments as learning opportunities.
  • The service had experienced senior managers and team leaders who staff felt were supportive and approachable. Staff enjoyed their jobs and felt supported by their colleagues.
  • The service maintained operational oversight through a well-structured schedule of meetings. Staff had access to an informative intranet site and the general public similarly had access to a user-friendly internet site.
  • All teams were accredited, or in the process of applying for accreditation, to the memory service national accreditation programme. The service involved themselves in many innovative projects to improve patient experience.

However:

  • Staff reported the current risk assessment template on the trust’s electronic care record system did not cover all risk areas common to older people with mental health issues. They also told us this same system could be hard to access, or respond slowly, during busy times.
  • The service did not have a consistent approach to some areas of clinical practice, such as recording supervision; measuring outcomes for patients who attended groups; and recording patients’ capacity or consent to treatment.
  • Due to commissioning arrangements, most areas of the trust were unable to provide a crisis service for patients with a diagnosis of dementia. Some teams were experiencing excessive waiting times for neuropsychology assessments.
  • Some interview rooms did not provide adequate soundproofing to maintain patients’ privacy and confidentiality. The service did not always have appropriate dementia friendly signage and features and some sites did not provide enough parking for people with disabilities.


CQC inspections of services

Service reports published 1 March 2019
Inspection carried out on 9 October to 29 November 2018 During an inspection of Community-based mental health services for older people Download report PDF | 678.34 KB (opens in a new tab)
Inspection carried out on 9 October to 29 November 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 678.34 KB (opens in a new tab)
Inspection carried out on 9 October to 29 November 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF | 678.34 KB (opens in a new tab)
Inspection carried out on 9 October to 29 November 2018 During an inspection of Reference: not found Download report PDF | 678.34 KB (opens in a new tab)
Inspection carried out on 9 October to 29 November 2018 During an inspection of Forensic inpatient or secure wards Download report PDF | 678.34 KB (opens in a new tab)
See more service reports published 1 March 2019
Service reports published 18 July 2018
Inspection carried out on 15 - 16 May 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF | 292.12 KB (opens in a new tab)
Service reports published 12 July 2018
Inspection carried out on 17 April 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 276.81 KB (opens in a new tab)
Service reports published 21 June 2018
Inspection carried out on 18 April 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 283.29 KB (opens in a new tab)
Service reports published 9 May 2018
Inspection carried out on 22 - 24 January 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF | 284.69 KB (opens in a new tab)
Service reports published 12 April 2017
Inspection carried out on 16-20 January 2017 During an inspection of Wards for people with a learning disability or autism Download report PDF | 426.15 KB (opens in a new tab)
Inspection carried out on 17 - 19 January 2017 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 301.23 KB (opens in a new tab)
Inspection carried out on 17th -19th January 2017 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 379.74 KB (opens in a new tab)
Inspection carried out on 16-20 January 2017 During an inspection of Community-based mental health services for older people Download report PDF | 354 KB (opens in a new tab)
Inspection carried out on 17 to 19 January 2017 During an inspection of Forensic inpatient or secure wards Download report PDF | 395.77 KB (opens in a new tab)
Inspection carried out on 16th-19th January 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF | 331.74 KB (opens in a new tab)
Inspection carried out on 17 - 20 January 2017 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 334.24 KB (opens in a new tab)
Inspection carried out on 16 - 20 January 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 468.4 KB (opens in a new tab)
Inspection carried out on 17-20 January 2017 During an inspection of Wards for older people with mental health problems Download report PDF | 317.47 KB (opens in a new tab)
Inspection carried out on 27 January 2017 During an inspection of Substance misuse services Download report PDF | 319.76 KB (opens in a new tab)
See more service reports published 12 April 2017
Service reports published 30 July 2015
Inspection carried out on 21 May 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 247.98 KB (opens in a new tab)
Inspection carried out on 16-20 March 2015 During an inspection of Forensic inpatient or secure wards Download report PDF | 351.38 KB (opens in a new tab)
Inspection carried out on 16 - 20 March 2015 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 282.99 KB (opens in a new tab)
Inspection carried out on 17 March 2015 During an inspection of Substance misuse services Download report PDF | 242.06 KB (opens in a new tab)
Inspection carried out on 17 – 20 March 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 267.01 KB (opens in a new tab)
Inspection carried out on 17 to 20 March 2015 During an inspection of Community-based mental health services for older people Download report PDF | 315.69 KB (opens in a new tab)
Inspection carried out on 17 - 20 March 2015 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 331.98 KB (opens in a new tab)
Inspection carried out on 17 to 20 March 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 371.85 KB (opens in a new tab)
Inspection carried out on 16 - 20 March 2015 During an inspection of Wards for people with a learning disability or autism Download report PDF | 325.63 KB (opens in a new tab)
Inspection carried out on 17 - 20 March 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 375.56 KB (opens in a new tab)
Inspection carried out on 17/03/2015 During an inspection of Services for people with acquired brain injury Download report PDF | 312.59 KB (opens in a new tab)
See more service reports published 30 July 2015
Inspection carried out on 17 – 19, 25, 27 January 2017

During a routine inspection

We rated Kent and Medway NHS and Social Care Partnership Trust as good because:

  • Following this most recent inspection, we rated five of the ten mental health core services as good and three as outstanding. This was a significant improvement on three that were rated good following the March 2015 inspection. Two core services had now moved from requires improvement ratings to good ratings. These were the wards for older people with mental health problems and community based mental health services for older people. Wards for people with a learning disability had moved from a good rating to an outstanding rating. The long stay rehabilitation mental health wards for working age adults had moved from a requires improvement rating to an outstanding rating. We also rated the substance misuse services as outstanding. This service had not been rated during the last inspection.

  • Since we last visited in March 2015, the trust had developed and implemented a quality improvement plan. We found during this inspection the majority of actions had been implemented and services had improved along with people’s experience. For example, this was evident in the wards for people with a learning disability where improvements had been made in relation to safeguarding service users from abuse and improper treatment and premises and equipment. We also found significant improvements in the wards for older people with mental health problems.

  • We observed staff to be caring, kind, compassionate and respectful towards patients, people who use services and their relatives/carers. Staff were dedicated and committed to their roles. We rated four of the ten core services as outstanding for the caring domain. The remaining six core services were rated as good for caring. We found patients were involved in decisions about their care and the involvement of their relatives/carers was encouraged. We found care planning to generally be good.

  • Improvements had been made to protect patients from the unsafe management of medicines across the trust.

  • The management and monitoring of the physical health care of patients had improved since our last inspection. We found on the acute wards for adults of working age and psychiatric intensive care units registered general nurses were employed to monitor physical health on a daily basis.

  • All inpatient wards had weekly activity programmes. The acute and PICU wards had access to therapies seven days a week. The introduction of the therapeutic staffing model had helped increase the number of activities available.

  • The trust had a patient advice and liaison service that offered advice and support to people wanting to make a complaint.

  • The trust were proactive in their responses to concerns identified and raised during the inspection. The trust were open and transparent and provided prompt updates.

  • We received very positive feedback about the leadership of the trust from staff and stakeholders. The chief executive had had a positive impact on the culture of the organisation and staff morale and engagement had improved.Directors and managers demonstrated commitment and enthusiasm about the trust and were passionate about their work. The trust had met the fit and proper persons test.

However:

  • At this inspection, of ten core services visited (services for substance misuse were not rated on our last inspection); we rated two as requires improvement. These were acute wards for adults of working age and psychiatric intensive care units and Community-based mental health services for adults of working age. We still had concerns about the acute wards for adults of working age and psychiatric intensive care units. We found one ward was not complying with the guidance on same-sex accommodation. We also found a number of ligature risks that had not been identified in risk assessments on one ward. A ligature risk is an anchor point which may be used to self harm. We found there were still issues with staffing and some wards had excessive vacancies and relied on bank and agency staffing. Patient risk assessments were not always reviewed or updated following incidents and care plans were not always recovery focussed. Within the community based mental health services for adults of working age staff still had high caseloads. This was an issue we found in March 2015. Across the teams visited there were large numbers of patients waiting to be allocated to a named worker and have their care co-ordinated. The trust was missing the target of 28 days to provide an initial assessment for patients who had been referred to the service.

  • We have changed the rating of the forensic inpatient /secure wards from outstanding to a good rating. This is because we found ligature risks on the wards. There were beds on a ward that were not fixed to the floor and posed potential ligature risks. Staff were not sighted on these risks.

  • Staff working on the wards for older people with mental health problems were inconsistent in their application of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS).

  • We found the governance systems in place did not always provide the board with sufficient assurance. For example, there were inconsistent rates of staff supervision and appraisal taking place.

  • We found there was no direct sub-committee of the board that related to the Mental Health Act. We were concerned about where governance for the Mental Health Act sat within the trust.

Inspection carried out on 17 - 20 March 2015

During a routine inspection

Overall we rated the trust as requires improvement because:

  • We had serious concerns about the quality of care at Littlestone Lodge. We identified poor practice including, staff not meeting the needs of patients and observed unsafe care. For example, we found patient’s pain was not being managed; all patients were wearing incontinence pads without their needs being assessed and medicines were being administered covertly without rationale. There was also a lack of senior clinical staff presence on this ward.
  • KMPT had failed to respond appropriately to the risks it identified on Littlestone Lodge. In December 2014 an acting ward manager was appointed to help improve the quality of care. In February 2015 one of the trust’s senior managers had visited the ward and although had addressed some issues had failed to rectify all of the key risks, including the need to provide additional experienced nurses to support the day to day delivery of care. This left the acting ward manager to address a large range of serious issues with limited support. However, the senior manager did ensure advice from specialist nurses was made available, such as advice from the physical health nurse and also provided opportunities for the acting ward manager to discuss the improvements required with the service manager. We were also concerned about the culture on Littlestone Lodge, the lack of care by some staff, the lack of recording and lack of responsiveness by staff to the acting manager’s attempts to improve the service along with the lack of detailed and appropriate recording in patient notes, care plans and prescription charts
  • We asked the trust to take immediate action to address concerns and also took enforcement action, serving two warning notices. The two warning notices served notified the trust that CQC had judged the quality of care being provided as requiring significant improvement. The first warning notice was to ensure the safety, care and welfare of the patients. The second notice highlighted the trust’s failure to monitor the quality of care it provided adequately. The warning notices expiry dates were 15 May 2015 (for further information see below)
  • We also had concerns about the care and welfare of patients on other wards across the older persons’ inpatient service. In particular, we were concerned about a number of issues related to poor care delivery and lack of care planning for patients’ needs on Cranmer ward
  • We identified clear gaps in the governance processes. For example, an overreliance on quantitative data and a lack of robust qualitative monitoring. In addition, the trust failed to act on some risks it has identified in a timely manner. There was some disconnect between the boards awareness of the quality of care in some area and this was evident in the trust's response to the concerns identified at Littlestone Lodge. Another key example of gaps in the governance was related to medicines practice; the processes in place were failing to highlight the pockets of poor medicines practice that we observed and identified to the trust. The systems for managing risk had also failed to highlight some key risks issues at ward/service delivery level, failed to identify the lack of action at ward level to rectify problems identified and also failed to identify the lack of reporting risks in some areas.

  • The use of the Mental Health Act (MHA), Mental Capacity Act (MCA) and Depravation of Liberty safeguards (DoLs) was inconsistent across the trust with poor practice identified in several areas
  • The quality of care planning was inconsistent across the trust and at times it was not evident how or whether people were involved in their care. However, we also found some outstanding examples of people being involved in their care.  
  • The trust has a vacancy rate of 17.4% in October 2014 and although had reduced this to 9.7% across the trust by March 2015 some wards and teams still had high vacancy rates. This meant there was a high usage of agency staff in the majority of areas, including large case loads in the community teams
  • Risks to patients were not regularly reviewed in a number of services following a change in behaviour or an incident
  • There was evidence of poor reporting of incidents both within the trust and to other agencies such as the local authorities and CQC

  • The environment in the health based places of safety (section 136 suites) and seclusion rooms across the trust did not meet establish national standards

However, care was delivered by kind, sensitive and caring staff that were passionate about their work and committed to delivering high quality services. Patients and their families told us that the majority of staff treated them with respect and dignity.

There was evidence of good leadership and commitment from the board, the executive team and senior managers. The majority of KMPT's board (executives and non-executives) had been in post for less than four years; the chief executive had been appointed in April 2012. We concluded that they were a cohesive team who shared a common purpose.

It was evident that there was a clear vision, set of values and cohesive strategy based around driving improvements in clinical practice and we saw evidence of this in some areas of the trust. However, there were several areas were practice was poor, inconsistent or not embedded. We heard of many new initiatives and the trust was continually looking for ways to improve, including through an ambitious transformation programme. However, it was clear that time was needed to fully realise the scale and complexity of the changes.

The trust was actively addressing staff morale and its below national average levels in the friends and family' test. We saw attempts to address these issues with innovative communication methods such as the 'big white wall' and 'green button'.

The trust was currently maintaining a financial surplus and a comprehensive programme to improve facilities and infrastructure was underway. For example, a new modular ward was being built at the trust's Maidstone site.

The dignity and privacy of the patients were not always protected due to failure to meet same sex accommodation guidance in a number of areas. However, the trust acknowledged that it did not always meet guidance but felt there was a clear clinical and safety rationale for this and was working to ensure guidance was met in all areas. In some areas we were shown clear plans or observed building work on the environment to rectify these issues.

We observed outstanding care planning and outstanding care interactions within the trust's forensic service line which included the learning disability and forensic inpatient wards. Despite both services being rated as requiring improvement in the safety domain, the overall patient and staff involvement and engagement impressed the teams who visited all these wards. The two teams visiting these wards were overwhelmed with the volume of evidence of innovative practice to support and include patients in their care. They observed early intervention and engagement which led to reductions in the levels of restraint and seclusion.  

The trust was open and clear about the risks it faced regarding the level of vacancies, use of agency and bank and the number of unfilled/incorrect skills mix shifts it currently had. There had been attempts made to address the vacancies and to mitigate the risks such as longer term/contract agency staff.

Overall, we gave a rating of good for caring, with forensic and learning disability inpatient areas rated outstanding. This was because staff were found to be compassionate, kind, motivated to involve patients in their care and went above and beyond expectations in the manner in which they cared for patients.

High bed occupancy levels were having an impact on patient care, in particular in the wards for adults of working age and psychiatric intensive care unit (PICU).  88% of the wards had a average bed occupancy of 85% or more. In some areas the bed occupancy was over a 100% and PICU 107%. We found a handful of examples where a patient was sleeping on a bean bag, patients slept in other patients rooms that were spending time at home and section 136 suites being used to nurse patients that did not require section136 care.

Several of KMPT services participated in national service accreditation and peer review programmes. These included, the accreditation for inpatient mental health services (AIMS) on two wards, the home treatment accreditation scheme in one CMHT, the quality network for forensic mental health services, the community of communities – a quality improvement network for therapeutic communities and the memory services national accreditation programme. We also saw that the patient engagement programme had won external awards for engaging and seeking feedback in the community.

It was our view that the provider had made significant progress in developing services and bringing about improvements and that, given time, the provider would realise its vision. However, some significant work was still required to improve the quality and consistency of its services across the trust.

We found that the trust was in breach of a number of regulations. We will require the trust to meet the requirements of the regulations within a specified time period and will return to check that it has done so.

Additional information relating to Littlestone Lodge

In March 2015 we inspected Littestone Lodge (now known as Littlestone continuing care unit (CCU) as part of a comprehensive inspection of Kent and Medway NHS and Social Care Partnership Trust. During our inspection we found that the trust was not meeting the standards expected in meeting the care and welfare needs of patients, and how it assessed and monitored the quality of the service at Littlestone CCU.

We found the trust was in breach of regulations 9(1) (2) and 10(1) ((2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We issued two warning notices under each of these regulations on 30 March 2015. We told the trust that it must comply with the requirements of the regulations by 15 May 2015. The trust sent us an action plan, and later confirmed that it believed it was compliant with the requirements (as of 15 May 2015).

We carried out an unannounced, focussed inspection on 21 May 2015 to assess if the trust had addressed the concerns identified at our inspection in March 2015, and to determine if it was now compliant with the requirements of the regulations. We found that the trust had taken action, that improvements had been made to the services delivered at Littlestone CCU since our visit in March, and that staff were positive about the changes to the unit. A number of new or revised processes had been implemented for ensuring that patient care and welfare needs were met. However, we found that these were not always carried out or recorded consistently.

Our inspection in March 2015 assessed compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These regulations were replaced with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 on the 1 April 2015. As such, the inspection carried out on 21 May 2015 looked at the trust’s compliance with the 2014 regulations (namely the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).

Due to the improvements made we were able to withdraw the warning notices. However, we found that the trust had not met all the requirements of the regulations and as such have issued a requirement notice in respect of Regulation 17(1)(2)(b)(c) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Good Governance.

A separate report of the unannounced, focussed inspection of 21 May 2015 has been produced. This report describes our specific findings at Littlestone CCU (March 2015) and the related finding from our focussed inspection (May 2015). This report also provides details of the requirement notice that the trust must take action to address.

This can be found on our website.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Organisation Review of Compliance


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.