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Provider: Coventry and Warwickshire Partnership NHS Trust Good

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Good

Updated 21 December 2018

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

  • The trust had made a number of improvements since the previous inspection in June 2017. We rated effective, caring, responsive and well-led as good, and safe as requires improvement. Our rating of effective, responsive and well-led had improved from requires improvement to good from the previous inspection in June 2017.
  • We rated five of the trust’s seven core services as good and two services as requires improvement that we inspected on this occasion. In rating the trust, we took into account the previous ratings of the seven core services not inspected this time.
  • There was improved collective leadership and the trust had worked with and learnt from other NHS trusts to develop a culture of quality improvement. The trust had embedded a number of initiatives since the previous inspection of June 2017 that included; its vision and values, a workforce strategy, an electronic patient records system, and staff recognition and rewards.
  • The trust had worked with NHS Improvement and clinical commissioning groups specifically to reduce the waiting lists for some children and young people with mental health problems and plan the upgrade of wards to reduce risk in acute mental health wards for adults of working age.
  • The trust had identified three empty wards and had worked with NHS partners to design safer adult mental health wards for adults of working age. The work had started and there were clear plans in place for completion. To make patients safer, the trust and staff had robust risk assessments and care plans in place to reduce the risk of patients tying a ligature and in the use of seclusion.
  • For children and young people with mental health problems, the trust had significantly improved triage processes since the previous inspection in June 2017. This meant referrals were reviewed more quickly. The trust was working with partners across local the health and social care economy to reduce the impact on children and families who were waiting for treatment. Systems and processes were in place to monitor assessment and treatment times. However, there was further work to undertake to reduce waiting times for treatment, especially in neurodevelopment services.
  • The trust had good awareness of risk and was working collectively to monitor and address the main risks to the trust. Risks included the recruitment and retention of staff, financial sustainability whilst maintaining quality and safety to patients, and the upgrade of existing buildings and wards.
  • The trust had improved the way it worked with stakeholders across the health and social care economy of Coventry and Warwickshire. The trust continued to work with the public to design and improve services as part of its equal partners strategy. This had supported the Board’s awareness of local priorities to support care to local people. The trust continued to work with neighbouring mental health NHS trusts to develop new models of care to improve quality and safety.
  • The trust had further work to complete to support staff from minority or diverse groups. However, the experience of staff from these groups had shaped the development of specific support groups to black and minatory ethnic staff, LGBT staff and those staff who have a disability.
  • The trust had planned and was making effective use of technology to improve quality and safety to patients. There was outstanding use of medically certified technology in older people’s mental health wards and innovative approaches when working with stakeholders across Coventry. The IT department were leading the drive to make access to patient clinical records timely between the trust and GP services.

However:

  • There were still problems with medicines management across the trust. Not all areas across the trust stored and administered medicines safely. Although the trust had introduced new processes and equipment since the last inspection in June 2017, not all staff or teams adhered to safe medicines management.
  • Some wards did not have enough regular staff to meet the needs of patients. This meant that activities and leave were cancelled and it had an impact on the morale of permanent staff. However, the trust recognised this was a risk and had improved ways to recruit and retain staff.
  • We found that further improvements needed to be made to support managers to access information related to training, supervision, risk and audit.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RYG/reports.

Inspection areas

Safe

Requires improvement

Updated 21 December 2018

Our rating of safe stayed the same. We rated safe as requires improvement because:

  • We found a number of concerns related to the management of medicines across the trust. Across mental health wards for older people, acute wards for adults of working age and crisis teams, where medicines were stored, staff did not implement effective actions to keep room temperatures within the recommended range. This is what we also found at the previous inspection in June 2017.
  • We had concerns about the low numbers of permanent staff in core services and the reliance of bank and agency staff to cover shifts. This was most noticeable in acute mental wards for adults of working age, community health services for adults and wards for older people with mental health problems. There were a high number of staff vacancies in these services. This had an impact on staff morale in acute mental wards for adults of working age. However, the trust where possible, used regular bank staff to cover shifts. The trust, as part of the MERIT Vanguard, was working with three partner NHS trusts to recruit staff. This trust was employing innovative ways to recruit and retain staff.
  • In community health services for adults, safety checks on a number of items of equipment had not been undertaken by the trust. We told the trust and they were addressing the problem. In other core services managed by the trust, staff had undertaken the necessary checks.

However:

  • Since the last inspection in June 2017, the trust had improved the way it managed the risks to children and young people who accessed specialist community mental health services. The trust had a central safeguarding team in place that supported staff to report, manage and reduce risk consistently.
  • There were clear plans in place to reduce the risks to adults of working age who were admitted to acute mental health wards and psychiatric intensive care units. This included the re-design and refurbishment of wards to make them safer and robust risk assessments across clinical teams.
  • Staff undertook thorough risk assessments that considered all relevant factors. Risk assessments across the trust were up to date and met the needs of patients, families and staff. There was effective collaboration between multidisciplinary staff when risk was assessed. There were regular handovers between shifts and staff huddles to discuss risk regularly. Staff also used patient status at a glance boards to display important patient information that supported their role.
  • Staff knew how to identify and report risk to managers. We saw learning shared from incidents across teams and robust systems were in place to monitor and reduce risk. The trust had a dedicated quality and safety team that linked positively with clinical teams and supported staff to deliver safe care and treatment.

Effective

Good

Updated 21 December 2018

Our rating of effective improved. We rated services as good because:

  • Following the previous CQC inspection in June 2017, the trust had improved the monitoring of physical healthcare on wards for older people with mental health problems. The trust had improved the access to, and the quality of training, in dementia and physical healthcare across the trust. Staff monitored patients’ physical healthcare across the trust.
  • Following the previous CQC inspection in June 2017, the trust had improved access to clinical supervision for staff. Staff reported in most services that they had received clinical supervision. The trust did not have an effective mechanism to capture this data but were introducing a new IT system that would support managers’ monitoring this data. Staff working in acute wards for adults of working age and psychiatric intensive care units did not always receive clinical supervision because of staff shortages.
  • The trust had improved access to Mental Health Act and Mental Capacity Act training across the trust since the last inspection in June 2017. The trust trajectory for training in these areas was 95% by December 2018 and completion by the end of March 2019. The trust average for training the Mental Health Act in June 2018 was 66% however, the average for staff working in clinical areas was above 75%. Training figures in community health services for adults in the Mental Capacity Act were low. There was good staff awareness and knowledge of the Mental Health Act and Mental Capacity Act cross the trust. We found evidence of discussions related to these Acts in patient records. Staff working in community mental health services for children and young people had a good understanding of Gillick competence.
  • Most staff had the necessary skills to provide care that was safe. Staff were able to deliver treatment and therapy to meet the needs of patients. Staff used a range of recognised rating scales to assess and record severity and outcomes for patients. Most core services undertook audits to monitor the effectiveness of clinical outcomes and shared the learning within their teams. However, the trust needed to strengthen the use of audits in end of life services and community health services for adults.

However:

  • We could not find recorded evidence of capacity assessments in wards for older people with mental health problems and acute wards for adults of working age and psychiatric intensive care units, in line with trust policy and national guidance. Although we could not find evidence of any impact to patient care or welfare, staff should have recorded the decisions they made on an individual’s mental capacity.

Caring

Good

Updated 21 December 2018

Our rating of caring stayed the same. We rated services as good because:

  • Staff were compassionate, kind, caring and worked hard in their roles. Staff were discreet when they needed to be and placed the patient at the centre of their care pathway. Some staff went above and beyond in the work they did with patients and this was observed in community based mental health services for older people.
  • Staff met the emotional, physical, social and mental health needs of patients. Staff recognised the importance of diversity in planning care, including, cultural, religious and gender. Where there was a gap, staff acted quickly to ensure the needs were highlighted. For example, to meet the needs of older people of the LGBT community, a poster from a national charity was prominent on the ward highlighting what could be expected from services. Staff in community based services for older people showed exceptional skills when communicating with patients, involving families, especially when distressing information was relayed.
  • Staff supported patients and carers to participate in the planning of their care. Patients regularly told us about the detail within care plans and what their discharge arrangements were. Patients and carers knew who to contact in an emergency. Care plans for children and young people using mental health services were specific to this age group and placed them at the centre of their care.
  • The trust worked with partners across the health and social care economy to involve patients and carers. The equal partners strategy was embedded and this led to greater collaboration when designing services specifically for patients and carers. The local branch of a national charity had been involved in redesigning and running services for children and young people with mental health problems.

However:

  • Not all patients and carers were given a copy of their care plan, including mental health crisis teams and older people’s mental health wards.
  • Some patients in end of life care services who required equipment to support them had delays in the delivery of equipment. This was because specialist palliative care staff had to refer patients to the community nursing teams solely to order equipment rather than ordering themselves.

Responsive

Good

Updated 21 December 2018

Our rating of responsive improved. We rated services as good because:

  • Patients had access to assessment and treatment in line with national guidelines. Patients and families knew who to contact in an emergency and systems were in place to contact patients who did not attend appointments.
  • Following the previous CQC inspection in June 2017, the trust had reduced the number of patients having to move wards, called sleepovers, whilst treated on acute wards for adults of working age. Patients were consulted about any transfers and these discussions were recorded. At the last inspection, sleepovers had an impact on long stay rehabilitation wards for adults of working age because patients moved from acute mental health beds to these wards. We did not inspect long stay rehabilitation wards at this inspection but the reduction in sleepovers of patients from acute mental health wards meant there was less pressure on this core service. As part of the MERIT Vanguard, the trust had worked with three neighbouring NHS mental health trusts to develop a system where bed availability was monitored across all acute inpatient beds. This meant patients could access an acute mental health bed in their region even if there was not one in their local area. This meant patients were not always placed a long way from their home and community.
  • We saw many improvements in the care pathways for children and young people, including triage and assessment. Post assessment, the trust had introduced workshops for parents in the neurodevelopment pathway to access learning about key issues, including how to manage relationships and access family support. Local and operational managers, and the trust board, were aware of the waiting lists and were actively working with local partners to reduce these lists. This included weekly meetings with local commissioners to monitor waiting lists and partnership working with the local authority and education services. However, there was further work to undertake to reduce waiting times for treatment, especially in neurodevelopment services.
  • The trust provided services that reflected the needs of the local population. Staff adapted their approach depending on the needs of patients and families. Facilities were appropriate for patients. Wards for older people with mental health problems had been adapted to make them more dementia friendly. Information was available for patients in various formats that was easy to read and accessible. Information packs for patients and carers were detailed and included how to access services, how to make a complaint, how to access advocacy and other important details. The trust was proud of their engagement with diverse groups across Coventry and Warwickshire.
  • The trust recorded, highlighted and shared information with others when required, and gained consent when they did so. Staff had access to IT systems that enabled quick access to path results following routine investigations. The trust was leading the work with partners across Coventry to share information in a digital format that would improve the timeliness of clinicians receiving essential clinical information.

Well-led

Good

Updated 21 December 2018

Our rating of well-led improved. We rated the trust as good because:

  • Since the previous inspection in June 2017, the trust board had strengthened the governance of the trust. The trust had worked towards collective leadership and we saw cohesive working across the board and senior leadership team.
  • Following the last inspection in June 2017, the trust worked quickly to address the concerns in the warning notice we issued to wards for older people with mental health problems. We undertook a focussed inspection in November 2017 and found improvements had been made that meant we changed our rating to requires improvement. At this inspection, we found that the trust had continued to improve physical health care and monitoring of patients.
  • The trust board and senior leaders had the skills, knowledge, experience and integrity to fulfil their roles. They understood the challenges to quality and safety within the trust and were key partners across the local health and social care economy in the sustainability and transformation programme. Board members and senior leaders were visible across the trust.
  • There was a clear vision and a set of values that the board, senior leaders and staff believed in that focussed on being a “great place to care”. The strategy for the trust was aligned to the wider health and social care system and services were planned to meet the local population. The board monitored progress against the delivery of the strategy.
  • There was a strong culture of supporting staff and promotion of their well-being that was reflected in their workforce strategy. However, the trust was disappointed by the outcomes of their last staff survey, in particular how staff from a black and minority ethnic (BAME) background felt they were treated. As a result, the trust had undertaken a lot of co-production work with diverse groups and we saw innovative ways that the trust supported BAME and LGBT staff, and those staff who had a disability.
  • There were assurance systems in place to monitor risk and performance and these were regularly reviewed and revised. For example, the responsibility for financial governance moved this year from one sub-committee of the trust board to the financial planning and infrastructure committee. There was detailed discussion at board meetings that ensured executives and non-executives understood the financial plan and risks. The safety and quality operational group provided oversight of risk and reported directly to the board. Sixteen sub-groups provided detail to the safety and quality operation group that included information governance, mortality, serious incidents, complaints, and research and innovation. The trust board and senior leaders were aware of the main risks to the trust that included staff recruitment and retention, delivering cost improvements programmes whilst maintaining quality and safety, and maintaining building and IT infrastructures.
  • There was a comprehensive and detailed medicines optimisation strategy, which drew on issues raised by the CQC and incorporated external engagement opportunities. This was presented to the trust board by the Chief Pharmacist as part of the annual medicines report. The trust had a programme of clinical audits around medicines’ safe storage, medicine administration-missed doses and controlled drugs to identify areas of good practice and concern. Some of these concerns had been actioned, though others were still outstanding at the time of the inspection.
  • The board met every two months and had access to the information they required to make decisions. There was discussion in points in the board meeting that were not made public however we questioned whether they should be in the public eye. The trust said they were reviewing aspects of their board meetings and what would be relevant to discuss in public. The board had a plan of visits to clinical services that they undertook bi-monthly. Appropriate governance arrangements were in place in relation to Mental Health Act administration and compliance.

  • The trust had completed the roll out of a new electronic patient record system. It was embedded in those services who were first to receive the electronic system.

However:

  • Although there were processes in place for the board to have oversight of the quality and safety of care delivery but we found a number of concerns across core services that required improvement and further scrutiny at a local level would support identification of risk issues. For instance, the trust had introduced equipment to improve medicines management but we found mistakes occurring across a number of core services. Also, not all local managers could describe local risk within their services.
  • We found concerns about the levels of morale of staff on some acute mental health wards due to low levels of permanent staff and the uncertainty of staff moves when refurbished wards are opened at the Caludon Centre. However, we recognised the work the trust had undertaken to increase staffing levels and engagement with staff to discuss future moves.
  • The trust had not addressed environmental risks such as ligature risks and the layout of a seclusion room since the last inspection in June 2017. This meant there was still a risk of patients tying a ligature and patients and staff being harmed whilst moving a patient into seclusion. However, the trust had clear plans in place, alongside NHSI and clinical commissioning groups, to renovate three empty wards, with the work having already started. We found that the trust and ward staff had reduced risk through assessment and care planning.
  • Although the trust had introduced improved access to training in the Mental Health Act and the Mental Capacity Act, the levels of compliance had not reached the level expected for staff working across its services.

Checks on specific services

Mental health crisis services and health-based places of safety

Good

Updated 21 December 2018

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

  • We rated effective, caring, responsive and well-led as good and safe as requires improvement.
  • The service kept people safe from avoidable harm by ensuring sufficient staff with the right training, supervision, knowledge and skills. Risk assessments were thorough and staff planned patient care around their needs. Staff had good awareness of safeguarding issues, followed the trust lone working policy, incidents were reported, and lessons learnt were cascaded to staff.
  • Staff used best practice and national guidance to complete comprehensive assessments of their patients, and communicated their needs within the multidisciplinary team, the wider trust and with their external partners to ensure patients received effective and consistent care and treatment.
  • Patients told us staff treated them respectfully and they were involved in their own care. They felt they were listened to and both patients and carers were provided with relevant information and support to manage their condition.
  • The teams responded to patients quickly and managed their caseload effectively to ensure they could provide care when the patient required it. Teams were meeting their targets and dealt with complaints effectively.
  • There were good governance arrangements in place and experienced managers and staff monitored the quality of the service they provided through the use of audits, patient feedback, incidents and complaints and key performance indicators. Staff were positive about the trust and their managers.

However:

  • We found that processes and procedures for medicines management were not in place to adequately safeguard against abuse, ensure they were safe to use so patients were protected against harm.
  • Staff could not easily identify when patients had been involved within their care plan and had received a copy, however patients and carers we spoke with felt they had sufficient information about their plan of care and treatment.

Community end of life care

Good

Updated 21 December 2018

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

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service provided mandatory training in key skills to staff and most staff had completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service-controlled infection risk well. The service prescribed, gave, and recorded medicines well. Staff kept appropriate records of patients’ care and treatment.
  • The service managed and reported patient safety incidents well most of the time. Staff recognised most incidents and reported them appropriately.
  • The service provided care and treatment based on national guidance and evidenced some areas of its effectiveness. Staff assessed nutrition and hydration and provided advice to meet patients’ needs and improve their health. Pain was assessed appropriately.
  • The service made sure staff were competent for their roles. Staff worked together as a team to benefit patients.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff involved patients and those close to them in decisions about their care and treatment.
  • Services were planned and delivered to meet the needs of patients and their relatives. The service took account of patients’ individual needs. People could access the service when they needed it.
  • The service treated concerns and complaints seriously. Complaints were investigated when received. Lessons learned were shared with all staff.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • There was an effective governance structure in place. Processes and systems of accountability supported the delivery of the end of life care strategy.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There was a strong sense of culture that was centred on the needs of patients at the end of their life.

However,

  • The service had suitable equipment but did not always use the equipment in line with national guidance. For example, syringe drivers were not routinely stored in the plastic lockable cases when in use. The service took action to resolve this when we raised it. Not all incidents identified in relation to syringe drivers had been reported as an incident.
  • The quality of records had not been routinely audited.
  • The service did not have a clear audit plan in place. The service did not have any mechanisms in place to monitor their results and benchmark against other similar services.
  • Post-bereavement services feedback data was slightly worse than the previous year. Some patients’ equipment was delayed due to the specialist palliative care team referring patients to the community nursing teams solely for the ordering of equipment.
  • Systems to review risks, planning to eliminate or reduce them, and coping with both the expected and unexpected were in place but risks were not always identified and there was no evidence of risks being discussed.

Specialist community mental health services for children and young people

Good

Updated 21 December 2018

  • For children and young people with mental health problems, the trust had significantly improved triage processes since the previous inspection in June 2017 that meant referrals were reviewed quickly. The trust was working with partners across local the health and social care economy to reduce the impact on children and families who were waiting for treatment. Systems and processes were in place to monitor assessment and treatment times. However, there was further work to undertake to reduce waiting times for treatment, especially in neurodevelopment and child and adolescent mental health services.
  • Staff received training on an extensive range of therapeutic interventions and provided care in line with National Institute for Health and Care Excellence guidelines.
  • Care plans captured the voice of the young person and placed them at the centre of their care. Young people were actively involved in reviewing their progress towards their goals and outcomes.
  • Staff reviewed complex cases using a multidisciplinary approach, were able seek support and guidance to ensure risks were appropriately managed. Care records contained up to date individual risk assessments and management plans.
  • Staff morale was good and staff felt positive about their teams. The managers promoted a positive culture that supported and valued staff, creating a sense of mutual purpose based on shared values.
  • Staff knew how to identify abuse and safeguard young people in line with current recognised guidance and trust policy. Staff followed safeguarding processes and ensured that they highlighted any safeguarding information on the electronic recording system.
  • Young people felt that staff listened to them and provided them with appropriate emotional and practical support. Young people described the staff as caring, supportive and non-judgemental.
  • Staff reported incidents appropriately and shared lessons learnt from the investigations. The teams had regular and effective multidisciplinary team meetings and worked well with other external organisations.
  • The trust demonstrated how it was working to meet the recommendations of the previous inspection and how it was addressing the issues identified. Managers and commissioners were working together to reduce waiting lists and ensure that the service met the needs of children and young people locally.

However:

  • Although we found that staff received regular supervision, the trust did not have a consistent and effective system for collating and monitoring supervision data.

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

Requires improvement

Updated 21 December 2018

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

  • The trust had not made changes to the entrance to the seclusion room which they had been required to do following the inspection in June 2017. We also found the door locking mechanism was not substantial and could be forced open. This meant there was still a risk to patient and staff safety when the room was in use.
  • Wards did not have enough permanent staff and relied heavily on bank and agency staff. This meant that at times staff reported the wards felt unsafe and they could not always give patients one to one time or escorted leave.
  • Staff training figures in the Mental Health Act and Mental Capacity Act were low and staff required this training to support them in their roles.
  • Staff did not always store medication safely. Room temperatures on some wards were above the recommended levels and on one ward the fridge temperatures had not been checked daily. This meant it was not possible for staff to know when medication was no longer safe to use.
  • Staff did not always complete physical health monitoring for patients after medication had been administered and this was required. One patient had an additional antipsychotic medication prescribed other than the one agreed on their consent to treatment form. The box indicating patients had a known allergy had not always been ticked and staff had used abbreviations instead which could be confusing for new staff or those from agencies.
  • The Mental Health Act paperwork had not always been completed correctly. We found consent to treatment forms were missing and in one case the writing was illegible so staff could not follow the instructions on it. Section 17 leave paperwork was completed but stated leave was at nurses’ discretion which is not in line with guidance from the Mental Health Act code of practice.
  • Governance on the wards was not robust. Managers had to continually manage issues relating to staff shortages and at times they had to be part of the clinical team supporting the patients. Supervision levels and training was not always at a consistently good level and managers did not always have oversight of routines such as the checks in the clinic room.
  • Due to staff shortages supervision rates were low on some wards. Staff stated they felt supported by managers but supervision did not take regularly due to the demands of the wards and the needs of the patients.
  • Although staff wrote about a patient’s mental capacity in the daily notes we could not find any paperwork which indicated formal mental capacity assessments and best interests decisions had taken place for individual patients.
  • On Willowvale Ward we observed informal patients being told they could only leave the ward at certain times. This meant staff were restricting their rights as informal patients to leave the ward when they wanted to.
  • Staff did not always adhere to infection control principles when removing protective clothing which they did in an area used by staff for storing their belongings while on shift. This increased the risk of cross contamination.

However:

  • Staff ensured that patients had good access to other services such as spiritual support and advocacy. Activity programmes were in place and occupational therapists took an active role on the wards to ensure patients were supported to build skills ready for being discharged.
  • Staff supported patients in a way that was kind and caring. All wards provided support for carers and staff understood why this was important for helping to maintain the wellbeing of their patients.
  • Staff stated they were supported by managers locally and found they were approachable and helpful. Staff knew how to raise concerns if they needed to and understood the role of the Freedom to Speak Up Guardian within the trust.

Wards for older people with mental health problems

Good

Updated 21 December 2018

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

  • Patients had thorough assessments covering both their mental and physical health. Staff reviewed and updated risk assessments and care plans in a timely manner. Patients and relatives were positive about the quality of care and treatment that staff delivered. Vacancies remained high in the nursing teams across the service but managers filled most posts with regular temporary staff who were known to the service. There were sufficient staff of the right grades and professions to assess, treat and support patients.
  • Patient care was delivered by a multi-disciplinary team involving a wide range of professionals who worked well together. Patients had access to good support to identify and manage physical health problems. Patients could access the right care at the right time.
  • Patients and relatives told us that staff were kind, treating them with dignity and respect. Staff encouraged patients to give feedback about the service they delivered. They tailored these opportunities to meet patients’ communication abilities.
  • Patients did not experience delays in their discharge. Any delays were outside of the control this service. Most patients who experienced delays were waiting for a community support package or new housing.
  • Ward managers led their service well. They carried out regular audits to provide assurance about the quality of care provided by the service. Middle managers involved staff in service development. Staff received regular supervision and appraisals. They had opportunities for career development and good access to specialist training. Senior managers made visits to the wards so they were visible to staff. Staff knew how to contact senior managers if they wanted to raise concerns. The service was working toward accreditation with the Royal College of Psychiatrists’ Quality Network for Older Adults Mental Health Services and the Triangle of Care.

However:

  • Room temperatures where medicines were stored regularly exceed the recommended range on three out of the four wards. The trust had supplied some wards with air-conditioning units and these were being used correctly. Staff had to wait six weeks for a faulty medicines fridge to be replaced on Pembleton ward. Not all wards had personal emergency evacuations plans for patients who needed them. Staff on Pembleton ward had not followed trust policy or best practice when covertly administering medicines for a patient.
  • Staff routinely completed mental capacity assessments when they needed to, but did not always use trust documents to evidence the assessments. Patients on Pembleton and Stanley wards had limited access to psychological assessment and formulation because the trust had struggled to recruit a psychologist.
  • There was nowhere other than the daily records for staff to record that they had offered patients a copy of their care plan.
  • Morale amongst some of the nursing teams was poor due to rumours about the future of the service and the number of vacant posts within the service.

Community health services for adults

Requires improvement

Updated 21 December 2018

Our rating of this service went down. We rated it as requires improvement because:

  • The service did not have always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. There were high vacancy levels for nursing staff and a dependence on bank and agency staff to cover shifts. However, the trust was aware of the issues and had put strategies in place to try and address this problem
  • The service generally had suitable premises but did not always have equipment that was regularly maintained. There were large amounts of equipment used in the community nursing service that were out of date for annual testing. We raised this with the trust who took action to address this.
  • Staff understood how to protect patients from abuse and they were aware of the requirement to work well with other agencies to do so. However, not all staff were up to date with training on how to recognise and report abuse.
  • The service did not use safety monitoring results well. Although staff collected safety information and shared it with staff, there was limited evidence of how the service used information to improve the service.
  • The service did not routinely monitor the effectiveness of care and treatment and generally did not use audit findings or analyse outcomes to improve services. There was not a systematic approach to reviewing patient outcomes. There was some comparison of national audit results with those of other similar services. Audit outcomes were not routinely used to drive improvements.
  • Staff generally understood their roles and responsibilities under the Mental Capacity Act 2005. However, there was poor compliance with MCA training within the service.
  • There were some services which were unable to meet targets for waiting times due to capacity issues within services.
  • There was not a consistent approach to improving the quality of services and safeguarding high standards of care through use of clinical audit systems and clinical outcomes.

However:

  • The service provided mandatory training in key skills to all staff and made sure most people completed it and remained up to date.
  • The service controlled infection risk well most of the time. Staff generally kept themselves, equipment and the premises clean. They usually used control measures to prevent the spread of infection.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • The service made sure staff were competent for their roles. Managers appraised most staff’s work performance and held supervision meetings with them to provide support and monitor staff progress with personal objectives set at annual performance and development reviews.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment
  • The trust planned and provided services in a way that met the needs of local people.
  • The service took account of patients’ individual needs.
  • People could usually access services when they needed to. Waiting times from assessment to treatment, were generally in line with good practice.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • The service generally had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service generally engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.

Community-based mental health services for older people

Good

Updated 21 December 2018

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

  • There were sufficient staff to meet the needs of patients; to assess, diagnose, treat and support them in a timely manner. Monitoring and reviews took place in a timely manner, and changes and concerns were responded to promptly. Patient and carer feedback about the approach and support of staff was consistently positive.
  • Staff showed a good understanding of how to support people in making decisions, when support was needed, and the appropriate steps to take when decisions were made for people.
  • Patients and carers were fully involved in comprehensive assessments which were patient focused and took account of physical health, mental well-being, their environment and all other relevant factors. Patients were well supported through assessment and diagnosis by skilled and sensitive staff, who re-assured patients and conveyed information effectively. Information and advice was made available to help patients and carers live with dementia and assist patients to access opportunities in the wider community.
  • Teams had a wide range of skills, qualifications and experience, and worked together well to ensure any delays or deficits were minimal. Teams worked well with other agencies to ensure good support was available when needed.
  • The service addressed the wide range of needs in the diverse communities they served.
  • Staff and managers all worked together well and positively and flexibly to ensure that the service worked effectively under pressure to meet patient need. Staff were confident and were positive about their experience within the teams.

Community-based mental health services for adults of working age

Good

Updated 8 November 2017

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

:

  • During the most recent inspection, we found that the service had addressed the issues that led us to rate community-based mental health services for adults of working age as requires improvement following the April 2016 inspection.
  • At our last inspection, we had found that clinical areas did not contain emergency equipment. The trust confirmed that its emergency response for community mental health teams was limited to the administration of basic life support, the use of automated external defibrillators, and a call to emergency services. Each community mental health team base had adrenalin pens, automated emergency defibrillators and additional safety equipment such as spill kits and resuscitation masks to support the administration of basic life support.
  • At our last inspection, we were unable to locate legal documents associated with Ministry of Justice orders and community treatment orders. We also found that staff had not incorporated the conditions into risk assessments and care plans. At this inspection, we found that staff stored scanned copies of legal documentation in patients’ electronic records, and that they incorporated the conditions into risk assessments and care plans.
  • Since our last inspection, we found that staff received and were up-to-date with mandatory training that included safeguarding, infection prevention, personal safety, and basic life support. Care plans were holistic, person-centred and recovery-oriented. Records showed that staff offered patients copies of their care plans. Staff in all teams considered patients’ physical healthcare needs and offered them support.
  • At this inspection, we found that teams had sufficient staffing levels to cover shifts, and good duty arrangements to respond promptly to patients when they contacted by telephone.
  • Staff received regular supervision and had access to weekly team meetings, monthly business meetings, peer group meetings and reflective practice sessions.
  • Staff had good, collaborative working relationships with their patients. They showed dignity and respect towards patients and their carers/relatives in their interactions with them.
  • All community teams took active steps to prevent non-attendance at appointments and work with patients who found it difficult to engage with services.
  • Staff showed compassion and respect, and demonstrated genuine commitment to working together and achieving excellence.
  • Staff morale was high across all teams we inspected. Staff experienced a strong sense of job satisfaction and empowerment in their roles, and benefited from good team working and mutual support.
  • Community teams participated in a range of quality improvement and research projects.

However:

  • The wellbeing teams had waiting times of between four to 12 weeks for a team assessment and long waiting lists for allocation of a care coordinator. Most teams had waiting times of up to five months for psychology services.
  • Coventry wellbeing team staff found it difficult to access their team’s psychiatrists urgently, and at times had to request medical support from crisis services.
  • Clinic room temperatures at the Nuneaton base used by the North Warwickshire teams exceeded the maximum level on 11 occasions in the month to 28 June 2017.
  • Some teams did not have enough suitable, lockable bags for the safe and secure transport of medicines.
  • Four medication charts at the Coventry wellbeing team did not have consent to treatment forms attached to them.
  • Staff had not yet migrated all patients’ records onto the trust’s new electronic care records system. Not all information was stored consistently on the new system.
  • Not all staff had received their annual appraisals.
  • Staff in the Coventry wellbeing team found it difficult to find available interview rooms onsite or in other premises, which meant that occasionally, they changed face-to-face appointments to telephone calls.
  • Staff did not always inform the trust’s complaints departments of the complaints they had dealt with, for the trust’s records.
  • Few staff knew about the duty of candour and the trust’s policy.
  • Some teams did not have administrative support in their teams and the trust’s administrative hub did not meet their teams’ needs effectively.

Community dental services

Good

Updated 8 November 2017

Overall, we rated the service as good because:

  • Staff reported incidents appropriately. Incidents were investigated, shared, and there was evidence of lessons learned.

  • Staff understood their safeguarding responsibilities and were aware of the safeguarding policies and procedures. Staff had up to date safeguarding training at the appropriate level.

  • Medicines were stored, handled and administered safely.

  • Equipment was well maintained and fit for purpose.

  • Staffing levels were appropriate and met patients’ needs at the time of inspection.

  • Patients’ individual care records were comprehensively written in a way that kept patients safe. Relevant information was recorded appropriately and staff had access to relevant details before providing care.

  • Standards of cleanliness and hygiene were generally well maintained.

  • Mandatory training was provided for staff and compliance was 100% for most topics. There was an action plan for the one topic, which did not meet the trust target of 95% compliance.

  • Staff had the necessary qualifications and skills they needed to carry out their roles effectively. Further training and development opportunities were available for staff.

  • Appropriate systems were in place to respond to medical emergencies.

  • Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.

  • The service followed effective evidence based care and treatment policies that were based on national guidance.
  • There was evidence of good multidisciplinary working with staff. Teams and services worked together to deliver effective care and treatment.
  • During the inspection, we saw and were told by patients, that all staff working in the service were kind, caring and compassionate at every stage of their treatment.

  • Patients were treated respectfully and their privacy was maintained in person and through the actions of staff to maintain confidentiality and dignity.

  • Staff were sensitive to the needs of all patients and were skilled in supporting patients and young people with a disability and complex needs. We saw there were systems to ensure that services were able to meet the individual needs, for example, for people living with dementia and a learning disability.

  • Staff involved patients and those close to them in aspects of their care and treatment. Information about treatment plans was provided to meet the needs of patients.

  • There was an effective system to record concerns and complaints about the service. Complaints were reviewed and actioned appropriately with a view to improving patient care.

  • Staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.

  • There was a very positive and forward looking attitude and culture apparent among the staff we spoke with.

However, we found that:

  • Not all staff followed standard infection control precautions at all times.

  • Some medical records were not locked away securely, although there was limited public access to this area.

  • The service was unable to provide evidence of water quality monitoring and the results of water quality checks.

  • Dental staff did not always ensure they followed their own policy on obtaining and recording informed consent.

  • There were frequent inappropriate referrals into the service, which led to delays in the provision of treatment for some patients. However, the service had taken steps to reduce these and there was evidence that the number of inappropriate referrals had reduced.

  • The newly developed dental strategy covered the period from 2016 to 2020. It was not fully operational as it relied on a dental plan that was incomplete at the time of our inspection. However, staff told us the plan was a work in progress and that it would be completed. The plan did not contain dates when the actions should be allocated, reviewed or completed by.

Forensic inpatient or secure wards

Good

Updated 8 November 2017

We rated forensic inpatient/secure wards as good because:

  • Environments were clean and well presented. Where there were risks, these had been mitigated. Staff were experienced and fully trained for their roles. Specialist training was also available. Management were also aware of the needs of the staff group and were able to support them through their personal development.

  • Documentation relating to the care of the patients were complete and of a high standard. Staff were aware of these and had good knowledge of the information care records contained. There was a full range of staff to ensure that care was developed and delivered to a high standard.

  • Patients and carers were very complimentary about the staff and the service that was provided. Staff were seen to be engaging patients and carers in a positive way and there was a good deal of patient involvement in ward developments. This included patient involvement in recruiting staff.

  • There was a range of rooms available and “the retreat” had been developed to enhance sessions and provide patients from Snowdon Ward with an area that they could go to undertake sessions that was away from the ward areas.

  • Staff we spoke top were happy in their roles. They stated that they were happy working in the trust and felt that the senior managers were a visible presence that re-enforced the trusts core values.

However:

  • There were errors found in the safe storage of medication. Room temperatures exceeded those laid out in best practice guidelines on Janet Shaw and Malvern wards. There were also out of date clinical equipment in some of the clinics we checked.

  • Some staff had been unable to access training in the Mental Health Act. We were shown evidence that all staff had been booked onto training but, due to the limited number of places, some staff had to wait to complete this.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 8 November 2017

  • We rated acute wards for adults of working age and psychiatric intensive care units as good because: During this inspection we found that the trust had addressed four of the five the issues that caused us to rate them as requires improvement at our last inspection in April 2016.

  • During our last inspection in April 2016, we found risk assessments were not comprehensive and had not been regularly updated. During this inspection, we found staff had improved the way they worked to keep patients safe. We saw that risk assessments were detailed and comprehensive and that staff regularly updated them.

  • During our last inspection in April 2016, we found wards had ligature points that had not been managed or mitigated. During this inspection, we saw that existing ligature points had been risk assessed and that there was a management plan present.

  • During our last inspection in April 2016, we found care plans were not always personalised, did not include patients view and were not recovery orientated. During this inspection, we found care planning was more effective. Care plans had improved and we saw specific, personalised care plans that covered a range of issues and were recovery focused.

  • During our last inspection in April 2016, we found that staff were not receiving regular clinical supervision. During this inspection, we found that staff were receiving regular management and clinical supervision and some staff disciplines were receiving profession specific supervision.

However:

  • Patients were being moved between services for non-clinical reasons for “sleep overs.” This was because of pressure on beds in acute services. This created disruption for some patients on the ward who had their possessions moved whilst they were on leave to create space for “sleep overs.”

  • During our last inspection, we asked the trust to ensure that staff completed mandatory training and Mental Health Act training. During this inspection, we found that a number of staff had not yet completed their Mental Health Act training and that a significant number of staff had not completed manual handling of people training.

  • There had been progress made regarding the reduction of ligature points, but the trust had this not yet completed this work, the date set for completion was not until December 2017.

Wards for people with a learning disability or autism

Good

Updated 8 November 2017

We rated the inpatient wards for people with a learning disability or autism as good because:

  • During this most recent inspection, we found that the services had made improvements and addressed most issues that had caused us to rate the inpatient wards for people with a learning disability or autism as requires improvement following the April 2016 inspection.

  • Staffing levels on all wards were sufficient and ensured safe clinical practice. Ward managers ensured a balance of staff skills and gender mix across all wards. Wards had enough staff to meet needs of patients and provide therapeutic time for patients. All patients had up-to-date risk assessments that informed risk management plans.

  • We saw many improvements to the awareness of environmental risks. Staff undertook assessments of ligature points and, where these were identified, took adequate action to mitigate the risk. Staff were made aware of both the ligature risk assessment and the mitigation plan for each ward.

  • There were low rates of restraints and prone restraints. The trust had adopted robust effective systems to review and learn from incidents.

  • Staff demonstrated good knowledge of the Mental Health Act, Mental Capacity Act and Gillick competency.

  • Staff were receiving regular clinical supervision and were appraised in line with the trust policy and procedures. Staff had access to a range of specialist training that was directly linked to the needs of patients. This included additional training for nursing staff in physical health care and monitoring.

  • Staff delivered treatment in a respectful and caring way and demonstrated an advanced understanding of patient needs. Patient and carers spoke very highly of staff and the quality of care received.

  • Staff were passionate about their work and spoke with pride about the wards they worked on.

  • Patients had easy access to information on advocacy, complaints, treatments, and legal rights. Patients had access to community (patients) meetings where they could raise issues and concerns. Patients knew how to make complaints, and received outcomes from their complaints.

However:

  • The wards did not adhere to all safeguards relating to long-term segregation, in accordance with the Mental Health Act Code of Practice, for the patients nursed in long-term segregation. There was no evidence of external three monthly reviews taking place.

  • Medical reviews in seclusion records were not consistent. One of those seclusions lasted five hours with no medical reviews taking place and no clear justification why the doctor did not attend.

  • Patients and visitors could see confidential patient information on the patient information boards in the staff offices.

  • On Jade and Amber wards, there was no unified approach to records consolidation. Patient notes were stored in four different files. This meant records were not easily accessible to staff and there was a risk that records could be misfiled.

Community mental health services with learning disabilities or autism

Good

Updated 8 November 2017

We rated community mental health services for people with learning disabilities or autism as good because:

  • Staffing levels were appropriate across the teams and caseloads were well managed to ensure patient safety.

  • Initial triage assessments were completed within 24 hours of a referral being received by the service.

  • Teams completed comprehensive risk assessments for all patients who received care and support from the service.

  • Staff had completed mandatory training and had the knowledge and skills to meet the patients’ needs.

  • Staff reported incidents appropriately and there were systems in place to learn from incidents to improve practice.

  • Patient records were stored on an electronic care record system that all staff used to access and update patient records.

  • Care plans and reviews were person centred, holistic and in a format, the patient could understand.

  • The acute liaison team provided support to local acute hospital staff to help them understand the patient’s needs, like and dislikes during their stay and the intensive support team supported patients to remain in the community to prevent admission to learning disability inpatient wards.

  • Staff had a good understanding and knowledge of the Mental Health Act and the Mental Capacity Act and applied the knowledge to practice.

  • Staff treated patients, family members and carers with dignity and respect and fully involved them in all aspects of the patient’s care.

  • Patients and family members spoke highly of the care and treatment they received and said staff were always available for support between arranged appointments.

  • Staff worked in partnership with external statutory and non-statutory agencies including local GPs, acute hospitals, police, local authorities, colleges, care providers, housing providers, and support networks to ensure the patient was supported to live in the community.

  • The service had good governance systems in place to assess, monitor and improve service performance. Clinical audits were undertaken and practice was benchmarked against national guidance.

  • Managers provided good leadership of the teams and were knowledgeable about the service. Staff reported feeling valued by the management team and supported in their roles.

However:

  • There were long waiting lists for patients to access assessments. Patients had to wait up to 118 weeks for an occupational therapy assessment and up to 52 weeks for a psychology assessment. This was outside the 18 week national target.
  • There was no emergency equipment at the respite units.

Community health services for children, young people and families

Good

Updated 12 July 2016

Overall rating for this core service                                                              GOOD 

Overall, we rated the service as good with the service being outstanding for caring and good in the other four areas.

  • A caring and effective multidisciplinary and multiagency service was provided for children, young people and their families (CYPF) who required assessment, support and intervention to ensure their wellbeing and development.

  • A highly skilled and empathetic workforce using an integrated “one stop” holistic approach across community settings provided services in a confidential and supportive environment.

  • Evidenced based practice was evident and there was a strong ethos of audit and research to support the “best practice” of children young people and patients.

  • The service had achieved accreditation for the UNICEF Baby Friendly Initiative Stage 3.

  • Staff had appropriate skills, knowledge and experience to deliver effective care and treatment, with appraisal rates exceeding 90%.

  • Children were truly respected and valued as individuals, encouraged to care for themselves self-care, and were supported to achieve their full potential within the limitations of their clinical condition.

  • Children were active partners with the planning of their care whenever possible. Parents were closely involved throughout the assessment, planning and delivery of their child’s care and were kept informed of changes and developments by members of the multidisciplinary team.

  • Feedback from parents who used the service and stakeholders were continually positive about the way staff treated people. Parents said “staff went the extra mile” and the care they received exceeded their expectations.

  • The service was generally meeting most national performance measures regarding timely access to care and treatment.

  • Services were well-led and staff were aware of the wider vision of the trust and service strategy and felt supported in their roles.

  • The Integrated Sexual Health Service (ISHS) provided caring and effective multidisciplinary and multiagency sexual health service-to-service users who required a full range of sexual health services.

  • Feedback from service users was very positive about the way ISHS staff treated people. Services were well-led at local level.

However, we found that:

  • In the integrated sexual health service levels of staff requiring Level 3 safeguarding training were lower than expected in light of the CQC safeguarding review (2015).

  • The clinical procedure for the insertion of contraceptive devices did not include inserting the devices in a patient’s home. This was raised with the service lead at the time of the inspection. The relevant patient group directives and risk assessments were in place to mitigate the level of risk.

  • The policy for ordering, storing and handling of vaccines (NHS England 2015) was observed but there was no policy for the administration of the vaccine. Information was recorded on the PGD about administration of the vaccine but did not cover the entire process.

  • CYPF had a mixture of paper and electronic care records. Copies of each were kept in the child or young person’s home and a copy was stored at the Paybody Building, the organisational hub for children, young people and family services. We noted there were delays with updating some care records in CYPF, which could affect the continuity of care for children and young people. Plans were in place to address this.

  • There were difficulties with connectivity in relation to the use of laptops in some areas of the CYPF service.

  • There was a high level of demand for the CYPF service, which was affecting waiting times in therapy and autism services.

  • Staff raised concerns about the staffing levels in the children’s continuing care service, the learning disabilities respite service for children and young people, and the looked-after children service. There were difficulties recruiting specialist children’s nurses and there were 28 vacancies across the service. The service had taken action to mitigate the risks to children and young people.

  • There was a shortage of consultants in ISHS due to retirements and staff sickness. The service had taken actions to mitigate the risks to patients. For example, the use of locum medical staff and the reconfiguration of clinical and support roles in sexual health teams.

  • Withdrawal of the trainee doctor’s deanery contract occurred in July 2015. ISHS and Health Education England (HEE) were addressing the issues with plans to reintroduce trainee doctors in August 2016.

  • There were clear governance frameworks in place and the outcomes of audits and governance meetings were shared with staff. However, not all risks in the service had been addressed in a timely manner.