Coventry and Warwickshire Partnership NHS Trust

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

• Ligature risk assessments across the service did not explain how staff managed these risks. When staff identified ligature risks, there were no clear action plans of how staff mitigate these.

• Hawkesbury Lodge did not comply with the Mental Health Act code of practice on eliminating mixed sex accommodation.

• There was no resuscitation and emergency equipment at Hawkesbury Lodge or Highfield House.

• We found no records of the monitoring of the temperature in the clinic rooms or identified room where medications were stored.

• Staff compliance with the management and prevention of aggression training was low across the service, as was the compliance with MHA training.

• Risk assessments were variable across the service. Staff did not update these or review on a regular basis. Care plans were brief, not person centred, holistic and not recovery focused on two of the three wards. Staff did not review care plans regularly and there was minimal evidence of patient involvement.

• Two of the three wards had a clinical supervision rate of 49%. This was below the trust target. There had been a reported lack of psychology input across the service due to vacancies.

• Patients were transferred from the acute ward to the rehabilitation services for the purpose of a “sleep-over”. This was due to pressure on bed availability as opposed to assessed clinical need.

• There was a low morale among the staff interviewed. The staff felt uncertain regarding the future of the rehabilitation services.

However,

• The wards were visibly clean.

• Ward managers were able to adjust the staffing on a day-to-day basis to ensure that patients’ needs were met.

• Staff regularly met with patients on a one to one basis.

• Patients had risk assessments completed upon admission to the service. Staff carried out regular and thorough physical health assessments for patients.

• Staff understood what constituted an incident and knew how to report them.

• New staff underwent a formal induction, which prepared them for their new role and enabled them to familiarise themselves with designated ward. Most staff had completed their annual appraisal.

• There were effective links with outside agencies, which enabled staff to support patient care on an individual basis.

• Most staff had received awareness training around the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards.

• Patients had the opportunity to attend regular community meetings.

• The service maintained contact with carers, and invited them to review meetings if patients wanted them present.

• Managers carried out audits to monitor the quality of the service.

•    Staff felt supported by their immediate line managers.

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

• The service had not identified ligature risks and blind spots areas on the adolescent wards, particularly in unsupervised areas.
• The adolescent wards at Tuxford Avenue and Jade ward had high levels of staff vacancies and, whilst regular staff filled vacant shifts, this increased the workload for regular staff.
• Staff did not always ensure that medications were stored and administered safely. Staff were using four bottles of medication that were out of date and left medication on the side that was not secured. Staff could not account for this.
• Staff restrained patients frequently between June and November 2015, this included restraint in the prone position (face down). Patients positive behaviour support plans did not state patients preferred to be restrained face down. Doctors did not attend medical reviews following restraint as required by trust policy and the Mental Health Act code of practice.
• Mandatory training compliance was low at 58%. 78% of staff had received safeguarding vulnerable adults and children training.
• Mental Health Act, Deprivation of Liberty (DOLS), and Mental Capacity Act training was mandatory for qualified staff; however, unqualified staff could request to attend training. The attendance at this training was significantly lower than the trusts target of 95%. 88% of staff on Amber ward had received training, 52% of staff on Jade ward and 63% of staff at Tuxford Avenue wards.
• Staff we spoke with on the adolescent wards did not understand Gillick competence and consequently did not have the knowledge and skills to assess capacity of children under the age of 16. For children under the age of 16, the young person’s decision-making ability is governed by Gillick competence. The concept of Gillick competence recognises that some children may have sufficient maturity to make some decisions for themselves.
• Staff did not receive regular supervision in line with trust policy, so were not receiving the appropriate support and management review of performance to carry out their role.
• Staff told us morale was particularly low on Jade Ward.

However:

• Staff completed comprehensive risk assessments, which indicated how patients wanted to be treated when in distress and how any aggressive or challenging behaviour should be managed. This demonstrated that patients could be involved in their care, even at times of acute distress.
• A review of prescribing concluded that medical staff prescribed medications in line with NICE guidance and regularly reviewed their practices and adapted to changes in the guidance.
• Psychological therapies such as behavioural therapy, was offered to patients in line with the National Institute for Health and Care Excellence (NICE) guidance.
• Easy read material was accessible and available. This included posters informing patients how to complain, care plans, positive behaviour plans, weekly menus, therapy programmes, and pictorial emotional boards to support patients unable to verbally express their feelings.
• Staff supported all patients to have Section 17 leave to local community activities, with appropriate support. This enhanced patients’ lives and promoted recovery.
• Staff could request additional training to support patients with different communication needs.
• Admission and discharge planning was innovative, creative and gradual. This recognised the needs of the patient group to support smooth discharge to further placements, whether that was at home, another hospital or community.

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

• We reviewed 24 care records and found that staff were not updating these on a regular basis. We found 13 care records that did not have a risk assessment. We also found 10 that staff had not completed records or there was information missing.
• Of the care records we reviewed, four did not have an initial assessment in place identifying patients’ initial needs. Care records were not accessible to other team members because individual staff kept their own word files. This meant that if a named worker was not available during a patient crisis, staff covering might not have the appropriate information to manage the patient’s needs safely. Staff were not completing crisis plans with patients.
• Staff were non-compliant with mandatory training and managers did not audit training compliance. This meant that staff might not have the knowledge needed care for patients in line with the trust’s policies and procedures and best practice guidelines. Staff had not received supervision in line with the trust’s guidelines of six weekly for the first six months and then every two months.
• Staff had a poor understanding of capacity, best interests and Deprivation of Liberty Safeguards. Patients consent to care and treatment was not recorded and decisions about mental capacity were not always assessed and recorded in accordance with the Mental Capacity Act (2005). Training compliance was below the trust’s target.
• Interview rooms did not have alarms fitted and if a risk of aggression was identified a second member of staff would either accompany the assessing staff, or wait outside the room. Staff told us they struggled to find appropriate rooms for assessing patients. They told us that there were not enough spaces and it took considerate time to organise.
• Community teams did not have effective governance systems in place to assess, monitor, and improve service performance. Managers did not undertake clinical audits that would have identified service short falls. Such as care plans and risk assessment’s being incomplete.

However

• The service had robust systems in place for triaging referrals. Patients waiting for psychology support would be allocated a care coordinator in the interim, without delay.
• The acute liaison team supported individualised care for patients in general hospitals and prevented lengthy admissions.
• Patients and relatives told us that staff were kind and caring.
• Staff treated patients with respect and dignity. They always contacted patients if they were running late for appointments.
• The trust shared lessons learnt with staff in a variety of formats.
• Staff had access to development and professional training to enhance their roles. 

We rated specialist community mental health services for child and young people as good because:

• All care records reviewed contained up to date, personalised, holistic, recovery-oriented care plans. The majority of care plans evidenced that young people and their families were involved in planning their care.
• Most staff completed a risk assessment for every young person during the initial assessment. The assessments were comprehensive, and staff updated them regularly. Although we could not find three risk assessments out of 21 case records reviewed.
• Staff completed a variety of assessments to monitor, record severity and outcomes for young people.
• Young people had rapid access to a psychiatrist when required, including an out of hours service.
• Managers assessed and managed caseloads and the waiting list at a weekly multidisciplinary meeting and staff meetings.
• There was effective working across different pathways within the children’s service in order to meet the individual needs of the young people.
• All staff knew what incidents needed reporting, and how to report them using an electronic incident reporting system. The service had no serious incidents in the last 12 months.
• Staff evidenced consent to treatment in case notes and the views of both the young person and their family were recorded.
• We observed staff interactions with service users and their families in clinic appointments and found that they were responsive, respectful, and provided appropriate practical and emotional support.
• Families told us that staff were responsive to the needs of the young people and used a variety of techniques to help support the young people with their treatment.
• Staff supported young people to be involved in the recruitment of new staff to the service and in designing the CAMHS link on the trust website.
• The provider used team board reports to gauge the performance of the team. The reports were presented in an accessible format.
• Staff reported that they enjoyed their roles and that morale within the team was good. They were committed to improving the service by participating in Quality Network for Community CAMHS and research.

However:

• The service had 11% vacancies, this included two team managers and seven qualified nurses.

• 265 young people had not been allocated a care coordinator.

• Waiting times could be up to 49 weeks for young people to access treatment.

• Staff had not followed the safeguarding policy correctly for two safeguarding concerns.

• Managers did not ensure that the 95% compliance rate for mandatory training across the service had been achieved.

• Interview rooms were booked for adult community teams to use. This meant young people could be placed at risk when waiting for an appointment.

• Two services did not have alarms fitted in interview rooms and did not provide personal alarms for staff to summon help if required.

• Compliance with Mental Health Act and Mental Capacity Act was low at 53%. This training was mandatory for staff within the service. Staff had not evidenced that they had considered that capacity to consent covered all areas of treatment.

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

• The wards did not provide a safe environment. There were ligature risks in all wards. A ligature point is a fixed item to which a person could tie something for the purpose of self-strangulation. The trust had completed ligature risk assessments. However, there was no clear plan to help staff manage these risks. There had been a recent serious incident on one of the in-patient wards, which involved the use of a plastic bag, which was still under investigation. Wards had multiple blind spots where staff could not easily observe patients. In Larches, there was a plastic bag by the patient telephone, which was not in a part of the ward that staff can easily observe. This caused a risk to patient safety. Staff were unable to open the anti-barricade doors on one ward.

• The trust did not conform to standards for accommodating young people admitted to adult wards. Department of Health guidance says, ‘A young person’s sleeping area should be in a securely separated area of the ward away from the opposite sex. All young people should bathe and wash in privacy and in areas separate from the opposite sex.’ The environment on Rowans ward did not meet this guidance for the young person on the ward. However, the inpatient wards only admit young people as an exception. The environment was based on commissioned services for adults.

• The trust was non-compliant with the Mental Health Act code of practice guidelines on single sex accommodation in their psychiatric intensive care units (PICU). Sherbourne ward had a mixed corridor. Rowans ward did not meet the mixed sex accommodation regulations. There were no separate bathrooms for women. There was no separate female lounge.

• There was one seclusion room available based on Sherbourne ward which required improvement.

• There were nurse call bells in the bedrooms and bathrooms on the wards. However, the bells were silenced. This meant that patients expecting a response from a call bell would not receive one. During the unannounced phase of the inspection, we returned to the wards. Call bells were activated. However, there remained confusion due to there being two systems. One had been deactivated. It was not clear which bell was working and which had been deactivated. However, the call bell in the bathroom in Larches was not working.

• Staff did not always print risk assessments, date them and place them in care records. Not all staff had access to the electronic risk assessment. Staff could not verify the risk assessments in the records were up to date.

• On Sherbourne and Westwood wards a second member of staff had not signed records for controlled drugs on five occasions. Controlled drugs are drugs that require additional controls because of their potential for abuse. The Standards for Medicines Management by the Nursing and Midwifery Council states ‘It is recommended that for the administration of Controlled Drugs a secondary signatory is required within secondary care’.

• Some staff did not allow patients to access hot drinks on some wards after 9pm until the next morning. However, the trust advised there was a trolley with hot drinks available between 10pm and 11pm each night.

• Patients were unable to charge their mobile phones during the day on two wards.

• Patients on Larches and Willowvale wards were unable to access the garden freely at the time of inspection. Larches ward is upstairs. The trust advised the garden was closed for safety reasons due to its location. Informal patients also required a staff escort to the garden.

  However:

• Staff were actively involved in clinical audit.

• Staff told us that the ward managers were known on the wards, approachable and supportive. Teams were cohesive and enthusiastic.

• There were good systems for reporting, recording and reviewing complaints.
• Staff were passionate and enthusiastic about providing care to patients. We observed positive and meaningful interactions between staff and patients.

Overall rating for this core service                                             

Overall, we rated the service as requiring improvement because:

• There was an excessive waiting list for children who had been referred to the service and were waiting for their first assessment appointment. Some patients had been waiting for nine to ten months.

• The service was taking steps to identify inappropriate referrals and to review the patients the waiting list but there was not a clearly defined process surrounding this to effectively manage the waiting list.

• There was not a clearly defined strategy for the service in place to drive improvement and innovation.

• There was not a robust oversight and management of risks within the service.

• For the mobile dental unit, risk assessments had not been undertaken to ensure it was a suitable environment to undertake clinical care.

• Policies and risk assessments were not in place for treatment delivered in the local acute hospital.

• Records were not kept in a secure storage area.

• Not all risks in the environment and in the service had been recognized and addressed.

• Risk assessments regarding community visits were not in place.

• A lack of suitable storage space meant that one of the surgery rooms was being used for purposes it had not been designed for. The service took immediate actions to address this.

• Not all chemicals hazardous to health were appropriately stored. The service took immediate actions to address this.

However, we found that:

• Staff reported incidents appropriately, incidents were investigated, shared, and lessons learned.

• Staff understood their responsibilities and were aware of safeguarding policies and procedures.

• Generally, there were effective systems in place regarding the handling of medicines.

• Equipment was generally well maintained and fit for purpose.

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

• Patients’ individual care records were written and managed in a way that kept people safe

• Standards of cleanliness and hygiene were generally well maintained. Reliable systems were in place to prevent and protect people from a healthcare associated infection.

• Robust decontamination procedures were in place.

• Mandatory training was provided for staff and compliance was 97%.

• 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 had effective evidence based care and treatment policies based on national guidance.

• We saw evidence of robust multidisciplinary working with staff, teams and services working together to deliver effective care and treatment.
• Staff had the necessary qualifications and skills they needed to carry out their roles effectively.
• Staff were supported to maintain and further develop their professional skills and experience.

• Staff generally had the necessary information they needed before providing care and treatment.

• Consent to care and treatment was obtained in line with legislation and guidance.

• Performance in national audits was better than the national average.

• 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.

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

• 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.

• Patients we spoke with during our inspection were very positive about the way they were treated.

• All staff were sensitive to the needs of all patients and were skilled in supporting patients and young people with disabilities and complex needs.

• The service provided flexibility to provide community services closer to patients’ own homes.

• There were systems to ensure that services were able to meet the individual needs, for example, for people living with dementia and learning disabilities.

• Effective systems to record concerns and complaints raised within the service, to review these and take action to improve patients’ experience were in place.

• Generally, the service planned to take account of the needs of different people reflecting the diversity of the local community.

• Staff were familiar with the trust wide vision and values and felt part of the trust as a whole.

• 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 strong culture of team working across the areas we visited.

Overall rating for this core service

Overall, we rated community health services for adults to be good because:

• All patients were seen within the 18 week referral to treatment time with the exception of podiatry. The trust confirmed they were in consultation with the commissioners to resolve the situation for these services.

• Staff across the service understood the importance of reporting incidents and did so appropriately. Lessons learnt from incidents were shared amongst teams.

• Whilst there were vacancies across the majority of teams, staff felt the current workload was manageable and teams supported each other when demand increased. Training levels on subjects such as manual handling and health and safety were consistent across the community services.

• Multi-disciplinary team working was apparent with services using referral pathways as required and there were good links with the local GP practices.

• Appraisals and peer to peer learning provided staff with time to develop and share knowledge. Staff felt well supported in their continuing professional development and were provided with clinical and caseload supervision at regular intervals.

• Patients said that staff were “absolutely fabulous” and showed compassionate and considerate care during their visits. Patients said that they could call staff with any problems and they would visit within a few hours. They said they felt that staff often went above and beyond the requirements of their role to ensure patients received high quality care.

• Staff were extremely passionate about their role in improving patient conditions not only clinically but also emotionally. Well-being was a strong focus in all contacts with patients and consistent positive feedback was given about services provided.

• The services provided a range of interventions to prevent admission to hospital and to facilitate discharges from acute settings.

• Therapy and nursing teams had good knowledge of how to improve care for those living with dementia/complex needs. The patient’s needs were detailed in care plans and were person centred.

• There was a clear vision and strategy for the future of the service. Senior staff attended governance meetings and staff felt supported by their team, immediate managers and the trust.

However, we found that:

• Equipment was not always stored appropriately. For example, in the storage room which was shared by the podiatry and acupuncture clinic and wheelchair services, we found rooms being left unlocked and unattended with access to hazardous material and acupuncture needles. Staff within the wheelchair services did not use protective glasses when working in the workshop.

• Records within the clinical assessment service (CAS) and podiatry service had incomplete information. This meant that staff may not have the appropriate information to support the patient with their care and well-being. This was brought to the attention of senior staff who confirmed they would review all records based on our findings.

• There was poor understanding of the Mental Capacity Act 2005 (MCA) which was reflected in staff training records. Senior management confirmed they had an MCA lead coming to work alongside the teams to improve their knowledge and training.
• During our visits to the clinics and community services, we observed that most staff did not comply with best practice regarding infection prevention and control policies. Staff were seen not washing their hands or using hand sanitising gel between patients. Staff did not always wear personal protective clothing whilst providing care to patients. 

We rated mental health crisis services and health based places of safety as good because:

• Services were able to respond to people’s needs promptly and effectively, helping to minimise distress and risk to individual patients. Teams contained sufficient staff of a suitable quality, skills mix and experience to enable this to happen. Staff shared knowledge and skills to the benefit of patient well-being and recovery. Teams worked well together with a good mix of professional disciplines, ensuring expert advice was readily available. Where specific professionals were not present in a team, teams could contact them for advice and support promptly as required.

• Teams had good links with other statutory or and voluntary agencies and organisations, helping to ensure patients moved from one service to another to meet their needs as effectively as possible.

• Staff were caring, dedicated and showed understanding of people in crisis. Feedback we had from patients and carers showed they valued the caring, compassionate and understanding approaches displayed by staff.

• Staff ensured patients and carers were informed and involved in their care and treatment.

• Staff knew how to report safeguarding concerns and incidents.

• Medicines were managed safely and effectively.

• Staff were well supported, well-motivated, experienced, confident and proud of their work in helping people in crisis. Sickness, absence and turnover rates were low.

However,

• The service did not always effectively show in records the work it was doing, particularly with regards informing and involving patients and carers in care and treatment.

• Not all non-medical staff were receiving appraisals.

• The planned imposition of car parking charges for staff, including essential car users, had an adverse impact on staff morale.

• Not all staff were effectively utilising lone working safety systems to enable them to work safely.

The trust needs to take steps to improve the quality of their services and we find that they were in breach of five regulations. We have issued one warning notice and three requirement notices which outline the breaches and require the trust to take action to address. We will be working with them to agree an action plan to assist them in improving the standards of care and treatment.

We found that the trust was performing at a level which led to a rating of requires improvement because:

• Some of the wards did not provide a safe environment.

• The Department of Health guidance and Mental Health Act 1983 Code of Practice in relation to the arrangements for eliminating mixed sex accommodation were not met on six wards, Stanley, Pembleton, Ferndale, Sherbourne, Rowans and Hawkesbury Lodge. On Rowans ward, women were sleeping in the male area of the ward and a young person was not provided with a separate lounge due to the limited space on the ward.

• Some wards had many potential ligature anchor points with unclear management plans in place. On Larches ward there were multiple ligatures, for example bathroom taps, shower fittings and bedroom windows and handles. Ligature cutters were kept in clinic rooms which were locked. The problem with ligature points was compounded on some wards because of blind spots where staff could not observe patients easily.

• Anti-barricade doors on Spencer ward could not be opened because staff could not locate the correct key.

• On Larches ward there were two call bell systems in place. One system was de-activated but buttons still visible. Call bells were ‘disabled’ during original inspection. On a follow-up visit the bells were working, with the exception of one bathroom which remained broken.

• Medicines were not always stored safely nor disposed of correctly in the learning disabilities service.

• Record keeping was poor particularly in relation to the Mental Health Act documentation. Patients were not being told of their right to support from an Independent Mental Health Act Advocate (IMHA). Those patients lacking capacity were not referred to advocacy automatically in line with MHA code of practice. Section 17 leave forms did not always record who else had been given a copy other than the patient. Some care records showed no evidence of assessment of mental capacity. No records of Mental Health Act (MHA) paperwork or Ministry of Justice (MoJ) warrants or orders were available in paper or electronic forms at IPU 10-17, Swanswell Point. Ministry of Justice records were not available at the MHA office at the Caludon centre. Medical staff had made errors on consent to treatment documents (T2 and T3 forms) on two wards, relating to three patients. Prescribing did not adhere to the agreed plan, which made the treatment invalid for the detained patients in question. Community treatment order conditions were not included in the care plan for one patient. In the community health service overall, not all services had undertaken robust risk assessments to manage risks in the delivery of care and treatment. Not all records were kept in a secure storage area and some were not maintained in accordance with trust procedures.

• The trust had identified high levels of restraint and prone restraint used in 2014 and had completed an action plan to reduce this. A review of the action plan in 2015 identified that some recommendations had not been actioned, and some only partially actioned. This included doctors reviewing patients who had been restrained within two hours and for staff to explore alternative restraint methods. However, at the time of inspection we noted that doctor reviews were still not taking place and there had still been a high level of use of prone restraint, in particular on Amber ward.

• Not all teams achieved the compliance rate for MHA and Mental Capacity Act (MCA) training, the trust’s target was 95%. Staff on adolescent units did not understand the Gillick competence and consequently did not have the knowledge and skills to assess capacity. In the community adult nursing service, we found that there was a poor understanding of the Mental Capacity Act 2005 (MCA) and some teams had poor staff training compliance in this area.

• There were long waiting times in some of the community services.Data showed 138 young people in the children and adolescent mental health services had waited up to 24 weeks and 117 had waited from 25 to over 49 weeks to access treatment. In the community dental service, we found there was an excessive waiting list for children who had been referred to the service and were waiting for their first assessment appointment. Some patients had been waiting nine to ten months. We saw evidence of increasing demand and acuity in the community health therapy services leading to pressures on staff, which sometimes had an impact on waiting times.

• In the community dental service, there was no clearly defined strategy for the service in place to drive improvement and innovation. There was not a robust oversight and management of risks within the service.

However:

• Staff had a good understanding of how to protect patients from abuse. Staff could identify what would constitute a safeguarding referral, how to report, and who to report too. Staff regularly completed safety and security audits of the ward areas. Appropriate arrangements were in place for children visiting. Patients told us that they felt safe on the wards. 100% of staff who required safeguarding children level 3 were trained.

• For the community health services, we rated two services as being outstanding for caring - end of life care and children and young people and families services.

• Ward equipment was well maintained and the wards were clean, bright and airy. Interview and waiting areas used by patients were clean, well-maintained and safe.

• Staffing levels in community health services were appropriate and met patients’ needs at the time of inspection, despite some areas having staffing pressures. Staffing shortages were acted upon appropriately with the use of temporary staff and an effective induction process was in place.

• Patients’ physical health needs were identified in most services. Medical staff documented physical health examinations and assessments following the patient’s admission to the wards. Ongoing monitoring of physical health care problems was taking place. Patients accessed a range of physical healthcare services including podiatrists, district nurses, tissue viability nurses and opticians. Outcomes for patients using the services were monitored and audited. This included the monitoring of key performance indicators such as length of stay and readmissions within 30 days of discharge. Sherbourne ward had robust system to review physical healthcare needs weekly via implementation of a wellbeing clinic.

• In the community health services, we found that patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice. These services had effective evidence based care and treatment policies based on national guidance and had introduced an individualised plan for care for the dying person for patients with end of life needs.

• Nursing staff treated patients with care and respect and communicated in ways patients understood. Staff knew of individual needs and concerns, and spoke respectfully about patients. Staff were positive, experienced, confident, well-motivated and worked together well. They frequently expressed satisfaction in doing a good job in helping people in crisis.

• Staff helped patients with their personal care, this was done in private and patient dignity was maintained. We observed positive and meaningful interactions between staff and patients. Staff listened to patients and used appropriate forms of communication to ascertain people’s thoughts and feelings when these were not easily expressed.

• Community health services were planned and delivered to meet the needs of individual patients and of the local community. Effective relationships with key stakeholders and commissioners led to a coordinated approach to service design and delivery.

• In community health services, most staff and service leads were clear about their priorities and vision and felt involved with the development of services. Staff showed an awareness of the trust strategy for the service. There was good feedback from patient surveys. Leadership within community health services was effective. Most staff felt supported by their immediate managers and senior managers within the community.

• Staff told us they were aware of the trust vision and values. Ward managers said they had sufficient authority and felt able to carry out their role effectively. Staff knew who the most senior managers in the trust were.

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

• Three patients with a criminal history, under supervision of the Ministry of Justice (MOJ), did not have their conditions included in their risk or care plans. The Ministry of Justice (MOJ) monitors and set conditions for the care, treatment, and whereabouts of mental health patients with a criminal history. Community Treatment Order (CTO) conditions were not included in the care plan for one patient. Two patients’ MOJ records were not available at the MHA office at the Caludon centre. One patient’s MOJ reports were kept on a clinician’s own computer rather than on the electronic or paper records available for all staff to view. Mental Health Act (MHA) and Ministry of Justice (MOJ) records were not available in paper or electronic forms at Swanswell Point.

• Emergency equipment was not available on any site except at Avenue House day service. Some services administered depot medication on site. In case of an emergency, the services would be required to call emergency services. Clinic rooms were small and did not include a couch for physical examinations.

• Staff overall training rates for community teams were 85%, which did not meet the trusts 95% target for all mandatory training. Staff achieved 65% of training for mental Health Act and Mental Capacity Act training.

• We reviewed 42 patient care records and found that staff had not consistently completed care plans at Avenue House and Swanswell Point. Some care plans were not holistic and did not include the goals of patients.

• Some teams had a waiting list of up to six months for patients to access psychological therapies.

• Staff from a range of disciplines raised concerns about the integrated practice unit (IPU) model of patient care. The model uses a care clustering approach to determine which teams’ patients are treated by. Clusters 3 to 8 are for patients with a non-psychotic diagnosis and clusters 10 to 17 are for patients with a psychotic diagnosis. Staff spoke with us about their concerns for patients who do not fit in to this model. However, this did not impact on patient care.

• Managers at most of the services did not maintain a system to monitor the frequency of supervision and supervision target rates varied between sites. We therefore had to look through individual supervision notes to gauge how frequently supervision occurred. Supervision was mostly completed on a four to six weekly basis but there was a lack of consistency in recording supervision. IPU 3-8 at the Tile Hill centre had the lowest supervision rates of 68% which did not meet their target supervision rate of 83%. All other teams completed supervision exceeding their individual team target rates.

• Staff did not consistently monitor physical health across all teams. Patients at Avenue House and Swanswell Point were not consistently monitored for physical health or checks on an annual basis. However, for patients prescribed high dose anti psychotics or lithium there were systems in place.

• Teams across the trust used different recording systems. Staff at the community teams used the electronic system whereas doctors and inpatient ward staff used paper recording. This meant professionals between teams were unable to see entries from each other when patients moved between teams.

However:

• Staff used an approved risk assessment tool to assess and monitor risk.

• Patients had crisis and relapse plans in place.

• Patients waiting for care co-ordinator allocation were contacted regularly to give them an update. Care co-ordinator allocation took up to two weeks but there was scope for this to be done sooner if there was a risk or urgency.

• Staff were aware of and followed lone working policies.

• Comprehensive assessments were completed in a timely manner.

• Staff followed National Institute for Health and Care Excellence (NICE) guidelines when prescribing antipsychotic medication.

• Staff explained patients their rights.

• Patients spoke positively about staff. They told us staff were kind, listened to them and supported them with their individual needs.

• Staff at two sites reviewed referrals and had set up a clinic to reduce waiting times for patients to have an assessment.

• We saw high levels of team working and positive interactions between staff members within all services visited.

We gave an overall rating for forensic inpatient / secure wards of good because:

• Care and treatment was delivered in a person-centred, kind and respectful way. Staff worked well together to assess and plan for the needs of patients. Treatment plans focused on recovery and rehabilitation and there was active discharge planning.

• Patients had care plans and risk assessments in easy read format. Staff updated and reviewed these regularly.

• Patients and their relatives told us that staff treated them with kindness and respect.

• Patients and relatives were involved in the planning and reviewing of care.

• Staff regularly held patient review meetings and care programme approach meetings.

• Staff managed complex behaviours effectively, using verbal de-escalation and a low stimulus environment as a first approach, and using medications or physical restraint as a last resort.

• Mental Health Act records were completed correctly and stored appropriately.

• Staff told us that they felt supported by the trust and could confidently report any concerns to senior staff without the fear of reprisal.

However,

• The seclusion room on the Janet Shaw clinic was not fit for purpose. In the en-suite area, there were bolts that had not been fitted properly so could pose a self-harm risk to patients. Staff had identified that the panels could be pulled off and used as a weapon. There was no clock, no mattress and no two-way communication system, which meant that patients had to call out to staff for assistance.

• One ward’s ligature risk assessment lacked clear action plans of how risks were being managed safely.

• Patients did not have call bells in their bedrooms to alert staff for assistance.

• There was a blanket restriction on mobile telephones across the wards. This meant that patients could not always phone relatives and friends at the times they wanted. Hot drinks were limited to set times and so patients could not always access a hot drink.

• Forty-three percent of the care records examined on Eden ward had gaps in the recording of observation documentation.

• There were no daily clinic room temperature checks to ensure that medicines were stored appropriately.

• None of the four wards had achieved the trust wide supervision target.

• Staff said that they had not received training on the updated Mental Health Act 1983 code of practice.

Overall we rated wards for older people with mental health problems as requires improvement because:

• The ward environments were not safe or conducive to dignified care. They did not comply with the requirement to eliminate mixed sex accommodation in accordance with the Department of Health guidance and Mental Health Act 1983 Code of Practice. Female patients were sleeping in male areas of the ward. On all wards there were multiple ligature points (places to which patients intent on self-harm might tie something to harm themselves), these included window latches, taps and doors. Staff had completed annual ligature risk assessments. However they had not assessed the risk to individual patients. This meant that patients with a known risk of self-harm had not been adequately assessed. Staff kept ligature cutters in the clinic room which was locked. This meant that they were not easily accessible to staff. There were blind spots on all wards which meant staff could not observe all areas to maintain patient and staff safety. Some mirrors were in place on one ward. All bedroom doors were solid wood and did not have privacy panels to observe patients. None of the wards had a couch in the clinic room. Staff used a link corridor for de-escalation and the management of aggression. This meant that agitated and aggressive patients were cared for in an area that was not designed for seclusion.
• Some care plans were not personalised or holistic. Patients views recorded in the ‘this is me’ document were not included in the care plan. Not all patients had a copy of their care plan.
• Staff did not always comply with the requirements of the Mental Health Act. They did not always inform patients of their right to support from an Independent Mental Health Advocate in line with Mental Health Act code of practice. Some section 17 leave forms did not indicate to whom they had been given in addition to the patient. When staff confined patients in the link corridor they used seclusion policy documentation.
• There was a high bed occupancy rate and a high length of stay on all wards. When patients went on leave their bed was used for another admission. If the patient needed to come back to hospital a bed would be found on another ward. There were two delayed discharges, one patient was awaiting funding and another was awaiting a suitable community placement. Patients’ full names were displayed on bedroom doors.

However:

• Wards were visibly clean and well maintained. Cleaning records were up to date and there were practices in place to ensure infection control. Clinic rooms were well equipped. There were wheelchairs and bathing facilities specific to the needs of older frail people with reduced physical ability.

• There were sufficient numbers of staff on all wards. Ward managers were able to adjust staffing levels daily to take into account increased clinical needs such as levels of observation or patient escort. Regular bank and agency staff were used to ensure that the correct number of staff were on duty.

• Staff identified patients physical health needs. Medical staff documented physical health examinations and assessments following admission to the wards. Physical health examinations and assessments were documented by medical staff following the patient’s admission to the wards. They also undertook ongoing monitoring of physical care problems. Ongoing monitoring of physical health care problems was taking place.

• All wards used paper care records. These were stored securely and available to staff when they needed them.

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.

We rated the memory assessment and dementia services as requires improvement because:

• There were five whole time equivalent vacancies in the Coventry team that managers had not been filled at the time of the inspection.

• Staff in the Coventry team had not completed care plans or updated risk assessments following incidents. In North Warwickshire and Coventry teams, there was a high number of health reviews outstanding for people with diagnosed dementia and who were taking anti-dementia medications. Across all teams, the care pathway following diagnosis was not complete. Skills training groups were in short supply and there was on average a four-month waiting list for psychology intervention.

• Care plans were not person centred, and not routinely given to patients or carers. Fifteen out the 26 care records we looked at did not have any completed consent to treatment forms attached.

• Records showed that 47% of staff did not have up to date recorded supervision. Managers did not monitor supervision and so could not be sure about the quality of the supervision their staff were receiving or monitoring their staff’s clinical competencies. Eighty-eight per cent of staff had in date annual appraisal.

• Communication between the two managers in the Coventry team was poor and they were unfamiliar with each other’s roles. Each manager had different standards and points of focus, this had led to inconsistent practice within the team, and cover for manager absences was not effective.

However:

• Staff told us their caseloads for routine assessment and initial treatments were manageable. We saw evidence showing, that routine caseloads were between 20 – 25 cases per qualified clinician. All the staff we spoke with appeared knowledgeable about how the Mental Health Act and the Mental Capacity Act related to their work. Data showed that 98% of staff had completed Mental Health Act training and 100% had completed mental capacity act training.

• In the North and South Warwickshire teams, staffing levels were good with a high proportion of qualified staff in the teams. Multidisciplinary team working was in evidence, and staff morale was high. Staff told us their managers were approachable.

• Staff saw patients in their homes at times that were convenient to patients and their carers. Staff had facilities to make confidential telephone calls to patients and all care records were stored safely.

Overall rating for this core service Good ●

Overall, we rated community end of life care as good because:

• The feedback from people who used the service and those who were close to them was extremely positive about the care received by patients nearing the end of life. We saw that staff were motivated to go the ‘extra mile’ to meet patient’s needs and the care patients received exceeded their expectations.
• Staff had received appropriate training and were managed in a way which ensured they understood how to keep people safe from abuse and how to report or escalate concerns.
• There was an open culture in reporting incidents and there were systems in place to learn from incidents and reduce the chances of them happening again.
• Community end of life services enabled rapid discharge of patients from the acute hospital, providing support to meet patient’s individual needs and wishes.
• Clear records were maintained in relation to all aspects of the service including patient health records.
• There was evidence of multidisciplinary working across the community teams who provided end of life care and there were good links with the local GP practices.
• There was a good provision of equipment, including syringe drivers and mattresses for patient use in the community. We saw pre-emptive prescribing of anticipatory medicines and availability of the ‘just in case’ medicines.
• End of life care was delivered through evidence based research and guidance. Education programmes had been developed and delivered; new documentation had been successfully introduced to the trust improving the care for patients.
• Policies and guidelines were all evidence based and we saw excellent examples of multi-disciplinary and multi-agency working and collaboration.
• There was a clear vision that focused on the early identification of patients at the end of life, patients being cared for in their preferred place of care and the use of partnership working to develop services.
• We saw strong leadership, commitment and support from the senior team within the specialist palliative care team.

However, we found that:

The specialist palliative care team did not have a clear strategy in place for delivering end of life care services.