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Provider: Bradford District Care NHS Foundation Trust Requires improvement

On 15 September 2014, we published our inspection reports for Bradford District Care Trust.

Read the 2014 service reports

Inspection Summary


Overall summary & rating

Requires improvement

Updated 11 June 2019

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

  • We rated the trust as requires improvement overall in safe, effective and well led. We rated caring and responsive as good. Our rating for the trust took into account the current ratings of the services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.
  • Of the 14 core services, one is rated as inadequate and five as requires improvement, taking into account the current ratings of the services not inspected at this time. Of the eight core services inspected during this most recent inspection, one was rated as inadequate and three were rated as requires improvement.
  • Overall ratings went down for the acute inpatient mental health services for adults of working age and the psychiatric intensive care unit to inadequate, and for the community health services for children and young people to requires improvement. The forensic low secure services were rated as requires improvement. The rating stayed requires improvement for the wards for older people with a mental health problem.
  • Due to the concerns we found during our inspection of the trust’s acute inpatient mental health wards for adults of working age and psychiatric intensive care unit, we used our powers to take immediate enforcement action. We issued the trust with a Section 29A warning notice. This advised the trust that our findings indicated a need for significant improvement in the quality of healthcare. We will revisit these services to check that appropriate action has been taken and that quality of care has improved. However, by the time of the well-led review the trust had already taken significant action to address the issues identified in the warning notice.
  • The trust was not providing consistently safe care, particularly on the inpatient mental health wards. Issues identified included ligature and environmental risks not being identified and managed, the maintenance of premises and equipment, medicines management, blanket restrictions that were not individually risk assessed, no alarms for patients to call staff in an emergency.
  • The trust did not have effective systems in place to investigate incidents within appropriate timescales to identify learning from incidents and make improvements.
  • The trust was not consistently providing effective care. The trust had failed to address concerns identified in the 2017 inspection in relation to staff supervision and audit of the Mental Capacity Act. Staff understanding and adherence to the Act was inconsistent.
  • The arrangements for governance and performance management did not always operate effectively. Whilst there had been a recent review of governance arrangements the plans to change these were in the early stages and were not embedded at the time of the inspection.
  • The trust did not always deal with risk issues and poor performance appropriately. Senior leaders were not aware of all the concerns found during the inspection. Areas for improvement identified at the last inspection in 2017 had not been addressed at the time of this inspection.

However:

  • We rated community health services as outstanding overall for caring. We rated community end of life care services as outstanding overall. Three of the six mental health core services we inspected were rated as good. There were improvements in the overall ratings for the trust’s wards for people with a learning disability or autism and mental health crisis services and health-based places of safety. The community mental health services for older people with a mental health problem were also rated as good.
  • Two of the trust’s services were rated as outstanding for caring, and 11 were rated as good. (This took into account the current ratings of the six services not inspected this time.)
  • Staff interactions with patients we observed were kind, respectful and compassionate. Feedback from patients and those close to them was continually positive in almost all the services we inspected about the care provided. Feedback from patient and carer surveys was positive.
  • Staff found innovative ways to enable people to manage their own health and care, particularly in those services rated as outstanding.
  • Most of the trust’s core services were providing care in a way that was responsive to patients’ individual needs. The community end of life care services were rated as outstanding in the responsive key question.
  • The directors of the trust had completed all the checks needed to work at that level. They all had disclosure and barring service certificates and met the fit and proper person requirements.
  • The trust had implemented a new vision and strategy and had plans to improve services. Staff knew and understood the provider’s vision and values.
  • The trust actively engaged in collaborative work with regional and place-based external partners to agree joint health and care priorities to support the delivery of high-quality, sustainable care and treatment, and to meet the needs of the local population.
Inspection areas

Safe

Requires improvement

Updated 11 June 2019

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

  • We rated one of the trust’s 14 core services as inadequate in safe, eight as requires improvement and five as good. In rating the trust, we took into account the current ratings of the six services not inspected this time.
  • Staff were not assessing and managing the risks to patients. Ligature risk assessments in inpatient services were not fit for purpose and did not show how staff mitigated risk to patients who might try to harm themselves.
  • Staff did not consistently achieve the right balance between maintaining safety and providing the least restrictive environment possible to support patients’ recovery. Services had blanket restrictions in place that were not based on an individual assessment of risk and need.
  • Staff in two of the four inpatient core services we inspected did not record restrictive interventions such prone restraint, rapid tranquilisation, seclusion and long-term segregation appropriately. There was insufficient evidence that restrictive interventions were always appropriate, proportionate and the least restrictive response to an incident.
  • Clinical premises and equipment were not maintained appropriately in four of the eight services we inspected. Emergency equipment and drugs were not checked regularly and missing items were not replaced. Medicines were not managed, stored or administered safely in two core services.
  • Nurse call alarms were not in place in inpatient services for patients to use and there was no standard procedure for giving patients access to an alarm.
  • Staff could not access all the necessary information in order to provide care and treatment; staff were using different versions of documents and were recording information in different places or recording on separate paper records, which meant information was not easy to locate.
  • Effective systems were not in place to ensure that incidents were appropriately categorised and investigated within appropriate timescales to identify learning from incidents and make improvements. In some services, this meant that opportunities to prevent or minimise the risk of harm were missed.

However:

  • All but two of the core services inspected had enough staff, who knew the patients and received basic training to keep them safe from avoidable harm.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • When things went wrong, staff apologised and gave patients honest information and suitable support. Most staff had a good understanding of the Duty of Candour. The trust had effective systems in place to review consider the requirements of the Duty of Candour following an incident.

Effective

Requires improvement

Updated 11 June 2019

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

  • We rated four of the trust’s 14 core services requires improvement in effective and ten as good. In rating the trust, we took into account the current ratings of the six services not inspected this time.
  • The trust had failed to address concerns identified in the 2017 inspection in relation to staff supervision. Staff were still not supported with supervision in line with the trust’s policy. Systems to record and monitor staff supervision were still ineffective.
  • The trust did not have in place effective systems to mitigate the negative consequences of deploying psychiatrists to work across both the acute mental health wards for working age adults and the community mental health services for working age adults. There was a model of multi-disciplinary care in place offered to patients with the exception of the psychiatric intensive care unit. The consultant psychiatrists were not ward based, and worked from a continuing care model. Multi-disciplinary meetings were not always planned in advance which reduced the opportunity for the attendance of the patient, their carers and relatives, community mental health teams and advocates.
  • In two core services staff understanding of the trust policy on the Mental Capacity Act was varied and we found assessment and recording of capacity and best interest decision making missing in some patients’ records.
  • The trust did not effectively audit the use of the Mental Capacity Act at the time of the inspection.

However:

  • Staff in most services assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected patients’ assessed needs, and were personalised, holistic and recovery-oriented.
  • Staff provided a range of treatment and care for patients based on national guidance and best practice. They ensured that patients had good access to physical healthcare and supported them to live healthier lives. Staff used recognised rating scales to assess and record severity and outcomes.
  • Staff in most services understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice. Managers made sure that staff could explain patients’ rights to them.
  • Managers made sure that staff had the range of skills needed to provide high quality care. They supported staff with appraisals and opportunities to update and further develop their skills. Managers provided an induction programme for new staff.

Caring

Good

Updated 11 June 2019

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

  • We rated two of the trust’s 14 core services as outstanding for caring; these were both community health services. Eleven of the core services were rated as good. We took into account the current ratings of the six services not inspected this time.
  • Feedback from patients and those close to them was continually positive in almost all the services we inspected about the care provided; they thought staff went above and beyond their expectations in a number of these services. Feedback from patient and carer surveys was positive.
  • Most patients described staff as professional, approachable, helpful, polite, discreet, approachable and understanding. Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity and understood the individual needs of patients and supported them to understand and manage their care, treatment or condition.
  • In the community end of life service, people were truly respected and valued as individuals. They were empowered as a partner in their care practically and emotionally by an exceptional distinctive service.
  • Staff informed and involved families and carers in assessments and in the design of treatment interventions. Carers were active partners in peoples' care in those community health services rated as outstanding, where staff were fully committed to working in partnership with people and making this a reality for each person.
  • Staff understood and respected the personal, cultural, social and religious needs of patients and their families and took these into account in the way they delivered services.

However:

  • The trust’s acute mental health wards for working age adults and psychiatric intensive care units did not consistently provide dignified care. Patients and their carers did not feel involved in care and treatment. Carers were critical of the service’s communication.
  • Patients were not routinely given a copy of their care plan.

Responsive

Good

Updated 11 June 2019

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

  • We rated one of the trust’s 14 core services as outstanding, 11 as good and two as requires improvement. In rating the trust, we took into account the current ratings of the six services not inspected this time.
  • Staff in most services planned and managed discharge well. They liaised well with services that would provide aftercare and were assertive in managing care pathways for patients who were making the transition to another inpatient service, community services or to prison. As a result, discharge was rarely delayed for other than clinical reasons.
  • Services were easy to access. Referral criteria did not exclude patients who would have benefitted from care. Staff assessed and treated patients who required urgent care promptly and patients who did not require urgent care did not wait too long to start treatment. Staff followed up patients who missed appointments.
  • The design, layout, and furnishings of most inpatient services and community services supported patients’ treatment, privacy and dignity. Each patient had their own bedroom and could keep their personal belongings safe. There were quiet areas for privacy. The food was of good quality and patients could make hot drinks and snacks at any time.
  • The trust met the needs of all patients, including those with protected characteristics. Staff helped patients with communication, advocacy and cultural and spiritual support. Staff had the skills, or access to people with the skills, to communicate in the way that suited patients.
  • The trust treated concerns and complaints seriously and investigated them appropriately. There was an effective system in place to learned lessons from the results and monitor actions taken to prevent recurrence.

However:

  • The trust’s acute mental health wards for working age adults and psychiatric intensive care units were not responsive to patients’ needs. The admission process was not led by ward teams. Bed occupancy rates and readmission rates were high. This meant that patients could not always return to the ward and the wards for older people were used to ‘guest’ patients. Staff did not find effective ways to communicate and care plan for patients with communication difficulties and did not have care plans in place to ensure they could communicate their wishes.
  • Key performance indicators focussing on the responsiveness of the service, including data around waiting times for assessments and length of stay, were not regularly monitored in the trust’s mental health crisis services and health-based places of safety.
  • Access to specific assessments within the trust’s community mental health services for older people with mental health problems was delayed in certain localities due to long waiting lists. The trust had plans in place to address this.

Well-led

Requires improvement

Updated 11 June 2019

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • We rated one of the trust’s 14 core services as inadequate, three as requires improvement and ten as good. In rating the trust, we took into account the current ratings of the six services not inspected this time.
  • The action taken by the trust to address many of the areas for improvement identified from the last inspection had not been effective in all areas. Whilst actions have been implemented they have not yet become embedded and their full impact has not been realised at this stage.

  • The trust had still not put effective systems in place to ensure that serious incidents were reviewed and thoroughly investigated within appropriate timescales, and monitored to make sure that action was taken to remedy the situation, prevent further occurrences and make sure that improvements were made as a result. This was an area for improvement identified in the previous inspection in 2017.
  • The trust had still not put effective governance processes in place to ensure that there was oversight of the use of restrictive interventions in inpatient services. This was an area for improvement identified in the previous inspection in 2017.
  • The trust had introduced a system to monitor compliance rates for staff supervision, but this had not been effective. Effective oversight of supervision compliance was an area for improvement identified in the previous inspection in 2017.

  • The trust had failed to update all active policies to reflect the changes to the Mental Health Act Code of Practice introduced in 2015. This was an area for improvement identified in the previous inspection in 2017.
  • The trust did not have a clear and effective approach to local ward audits within services. There was limited evidence of audits being used effectively to improve quality or identify areas of poor performance within services. This was an area for improvement identified in the previous inspection in 2017.
  • Internal governance processes had not identified most concerns found during the inspection of the trust’s core services. The trust did not have systematic approach to continually improving the quality of its services and safeguarding high standards of care.
  • The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust did not have a clear structure for overseeing performance, quality and risk, with board members represented across the divisions. Senior leaders did not have oversight of all issues facing services.

However:

  • The newly developed trust strategy was directly linked to the vision and values of the trust. The trust involved clinicians, patients and groups from the local community in the development of the strategy.
  • The trust had recently implemented a new management structure which included changes to the structure and composition of the board of executive and non-executive directors. The changes to the board of directors both strengthened and clarified the board level accountability for quality and operational management in the trust.
  • Senior leaders made sure they visited all parts of the trust and fed back to the board to discuss challenges staff and the services faced. The trust’s board of governors was proactive and provided constructive challenge to the trust’s senior leadership team. The board of governors was moderately reflective of the local community.
  • The trust welcomed and proactively sought external scrutiny of its services and its internal processes. The trust had commissioned an external provider review of the trust’s leadership team and another to undertake thematic analysis of serious incidents involving the deaths of patients in both inpatient and community settings. The recommendations of these reviews were accepted by the trust board.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. The trust had a number of effective processes in place for staff to raise concerns and staff told us that they felt able to raise concerns without fear of retribution.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The trust had addressed areas for improvement from the 2017 inspection relation ensuring checks were completed for all its executive and non-executive directors, and that accurate records of these checks were maintained in line with the Fit and Proper Person Requirement regulation and the trust’s policy. The trust had ensured that all staff were checked by the Disclosure and Barring Service in line with trust policy.
Checks on specific services

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

Updated 8 November 2019

We did not re-rate the service following this inspection:

  • Whilst there had been significant improvements in ensuring that patients were safe, systems and processes were still embedding and there remained some areas of concern including staff not always completing environmental checks, ligature risk assessments not always identifying all the ligature risks or being updated, risk management plans were not always personalised or specific to the risks identified in the risk assessment, controlled drugs were not always managed appropriately, and patient leave documentation and the allocation of a risk rating for incidents was not always completed in line with the trust’s policies.

However:

  • The safety of the service had improved.
  • Wards were safer, clean, well equipped, well furnished, mostly well-maintained and fit for purpose.
  • Most staff had completed and kept up to date with their mandatory training, which was comprehensive and met the needs of patients and staff.
  • Staff assessed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.
  • Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
  • The governance framework and processes had improved and ensured that ward procedures ran more smoothly and ensured that senior leaders within the service had better oversight.
  • Staff spoke of a change in the culture of the organisation and that there was a collective responsibility. Senior leaders within the organisation were accessible and managers and staff felt supported.
  • Most patients reported they had a positive experience and that most staff were nice. They told us staff kept them safe and they rarely used physical restraint.

Community end of life care

Outstanding

Updated 11 June 2019

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

  • The service used innovative approaches to provide integrated person-centred pathways of care that involved other service providers.
  • The service was responsive to the needs of the local population and engaged well with hard to reach groups and ethnic minorities to provide individualised care. There was a proactive approach to understanding the needs and preferences of different groups of people.
  • The service used technology innovatively to ensure people had timely access to treatment, support and care. The Gold Line gave round-the-clock telephone support to patients and carers who needed help, reassurance or advice.
  • People were truly respected and valued as individuals. They were empowered as a partner in their care practically and emotionally by an exceptional distinctive service.
  • Carers were seen as active partners in peoples’ care. Staff were fully committed to working in partnership with people and making this a reality for each person.
  • Staff found innovative ways to enable people to manage their own health and care and delivered holistic patient centred care.
  • We found that without exception staff were passionate about the care they delivered and were determined to give the best care they could to patients and their relatives. Staff understood and respected the personal, cultural, social and religious needs of patients and their families and took these into account in the way they delivered services. We saw staff delivering holistic patient centred care.
  • There was a positive culture with good relationships between staff who worked well together. They worked with partner organisations effectively to provide seamless patients care.
  • The service was well led. Staff spoke highly of the clinical lead and their line managers and said they felt supported. Staff were proud to work for the service and were focused on the needs and experience of patients and families who used the service.
  • We found the service was continually striving to improve. There was a positive culture of learning, continuous improvement and innovation.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service made sure staff were competent for their roles and provided training and development to other staff providing care for patients at their end of life.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff followed best practice when prescribing, giving, recording and storing medicines.

However:

  • Although the service managed patient safety incidents well, not all staff were familiar with how to locate and complete an incident report.
  • Staff did not complete the ‘Comfort and Dignity Care Plan’ for all patients who were identified as entering their last days of life.
  • We had some concerns around staff who updated patients’ records on return to the office. This meant the records were not completed contemporaneously and this may impact on the patients shared care. Staff confirmed there had been no incidents because of this.

Forensic inpatient or secure wards

Requires improvement

Updated 11 June 2019

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

  • The service did not always deliver safe care. Risk assessments of the environment did not include all potential risks, had not been reviewed as required and the trust had not taken action to mitigate all those risks. There were no nurse call alarms on any of the wards for patients to use and no standard procedure for giving patients access to an alarm. The service had blanket restrictions in place that were not based on an individual assessment of risk and need. Staff did not adhere to trust policy in searching patients and monitoring their mail. Staff did not clearly evidence that they had used long term segregation appropriately or that they had followed best practice and trust policy in doing so. The seclusion room contained a safety hazard.
  • The service was not always well led. Senior managers did not have sufficient oversight of the issues in their service and ensure staff were adhering to trust policy in relation to searching, mail monitoring and long-term segregation. Systems and processes in place to enable good governance of the wards were not always effective. The trust did not have robust systems in place to monitor and safeguard patients in long term segregation. Staff supervision was not effectively monitored and the electronic record system did not enable staff to effectively document seclusion episodes or the monitoring of rapid tranquilisation.

However:

  • There were sufficient staff to meet the care and treatment needs of patients. Staff and patients reported they felt safe on the ward. The wards were clean and the environment was well maintained.
  • Staff undertook comprehensive assessments of patients’ physical and mental health needs and used these to develop care plans in collaboration with patients. Staff provided a range of treatment interventions suitable for the patient group and used recognised rating scales to monitor outcomes. Staff across all disciplines worked well together and teams had effective working relationships with external agencies.
  • Staff treated patients with kindness and respect. Staff understood the individual needs of patients and supported them to manage their condition and treatment. Staff involved patients in their care and treatment and won awards for their innovative practice in patient care. The service provided carers with the opportunity to be involved in their relative’s treatment and to provide feedback on the care they were receiving.
  • The service was responsive to patients' needs. Staff planned for discharge from admission and discharge only occurred when a patient was ready to move on. A transition team supported patients from pre-admission to post-discharge. Patients had access to facilities to meet their needs and reported the food was of good quality. The trust ensured patients had access to spiritual support and interpreters where required. Patients knew how to complain and staff handled complaints appropriately.
  • Staff spoke positively about managers within the service and most staff felt respected and supported. Staff reported morale was generally good and that all members of the multi-disciplinary team felt their voice was heard and opinion respected. Staff were not afraid to speak up and felt able to raise concerns if needed.

Mental health crisis services and health-based places of safety

Good

Updated 11 June 2019

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

  • People in the area were receiving an effective 24/7 crisis response. Those in immediate risk could be seen and responded to immediately. Peoples’ risks were consistently managed and any changing risks were considered and addressed through effective handover meetings.
  • People had access to a full pathway of care from the first call or referral, including identification of risks, completion of a comprehensive assessment and interventions delivered all in a timely manner.
  • Staff were skilled and able to deliver best practice interventions to people accessing the service. Staff were using innovative approaches of working with patients using technology. The needs of the families were consistently considered and the teams were looking at ways in which family members could be further supported.
  • Patients were supported to access resources in the community and to look at ways in which they could keep themselves well. The service worked well with other teams within the trust and with external partners such as the police, local authority and the ambulance service to ensure that new ways of helping people were always being explored.
  • All teams had effective leadership who understood the needs of staff and patients. Staff felt supported and staffing levels were managed. Systems and processes were generally well established and operated effectively to assess and manage risk and improve the quality of the service.

However:

  • Staff were not up to date with ten of the role specific training courses, which included safeguarding children, basic life support and immediate life support.
  • Staff did not feel informed about several serious incidents which had occurred in the previous 12 months. Investigations from serious incidents were not effectively communicated to staff and staff were unclear as to the actions and learning from these incidents. Incidents were not always categorised by staff appropriately which meant they were not investigated as they should have been in line with the trust’s policy.
  • The trust was not collecting data to monitor the effectiveness of the service. The local managers understood the running of the service on a day to day basis, but this did not form any key performance indicator monitoring.
  • There were some issues with the patient record system which meant that information was not always stored in the correct place. The trust was aware of the issues and were working on ways to improve this for staff and patients.

Wards for people with a learning disability or autism

Good

Updated 11 June 2019

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

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.

  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability (and/or autism) and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.

  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.

  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

  • The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.

However:

  • Staff did not review the blanket restriction mandated by the trust in relation to bathrooms and shower rooms.
  • The trust did not have an effective system to record and monitor supervision. The service did not have local arrangements to support that staff received regular supervision in line with trust policy.

Community-based mental health services for older people

Good

Updated 11 June 2019

  • The service provided safe and effective care, there were sufficient numbers of staff who were adequately supported through supervision and appraisal and staff were very knowledgeable about their areas of work.
  • Managers provided extensive support to staff and were approachable, visible and always helpful. Staff and managers clearly had a lot of respect for each other and worked well together.
  • Staff used best practice in treatment and care offered.
  • Staff treated patients with compassion and kindness. They showed a good understanding of patients’ needs and they made efforts to involve families and carers wherever they could.
  • The service work closely with the community to ensure they were able to reach individuals that might need the service. They offered a wide range of appropriate interventions and activities which met the needs of patients.
  • The service had implemented an effective incident reporting system and they ensured that they shared information gathered using this process. They used lessons learnt from incidents and complaints and patient and carer feedback to make changes to services where appropriate.

However:

  • We had some concerns about the way information was recorded and stored on the new electronic patients recording system and it was not clear if patients were routinely offered a copy of their care plan.
  • Whilst the sites that we visited were clean and well maintained, some clinics and storage areas were cluttered and untidy.
  • Waiting time for a memory assessment in some areas were high.

Community health services for children, young people and families

Requires improvement

Updated 11 June 2019

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

  • The service did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Best practice staffing guidance was not followed following a reduction in the children’s community staffing budget as the service was in transition and part way through a service transformation process. The service had a number of vacancies due to the recent procurement of 0-19 services in Bradford and the transition of skill mix changes. The trust's skill mix information confirmed shortfalls in health visiting, school nursing and looked after children staffing groups.
  • Caseloads for school nursing and health visiting nursing staff were high. Caseloads for looked after children were high and fell outside of recommended guidance of 100 children per whole time equivalent nurse.
  • Staff said work related stress had increased and described poor technology connectivity and the increase in safeguarding work as having contributed to this stress.
  • Performance against children’s health needs assessments was poor.
  • The service provided annual mandatory training in key skills to all staff which not all staff had completed. The trust did not meet fire safety year one, information governance attendance and Mental Capacity Act level 1 training sessions. Monthly reporting of compliance levels were reported at senior leadership meetings.
  • The trust target of 80% attendance for Mental Capacity Act level one training was not achieved, figures submitted by the trust confirmed completion of 76% as of 30 November 2018.

However:

  • We spoke with 15 mothers, four fathers, one child and one young person. about their experiences. They said they were involved in their care and decision-making and were happy with the care and treatment received.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • The service-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had suitable premises and equipment and looked after them well.
  • Staff completed detailed records of patients’ care and treatment and updated risk assessments for each patient. Records were clear, up to-date and easily available to all staff providing care.

  • The service managed patient safety incidents well. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. The trust had made good progress in the implementation of the Healthy Child Programme and had evidenced based initiatives in place.
  • The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

Wards for older people with mental health problems

Requires improvement

Updated 11 June 2019

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

  • Staff did not always follow their processes for maintaining and checking emergency equipment and drugs. Also, staff did not always follow best practice when dispensing and recording medication to reduce the risk of error and patient harm.
  • Staff had implemented blanket restrictions on both wards including the use of plastic cups, locked bedroom doors and outdoor spaces on the Dementia Assessment Unit and daily room searches on Bracken Ward with no audit or review.
  • Not all staff understood the Mental Capacity Act. Staff did not record capacity and best interest decisions in some patients’ records. Staff did not make deprivation of liberty safeguards applications when needed. Staff did not monitor the progress of applications to supervisory bodies.
  • Staff reported issues with the entering and accessing of information on the new electronic patient record system.
  • Trust governance processes were not always effective in ensuring staff applied policy and practice consistently across the services. There was lack of evidence of mental capacity compliance audits and there was no overarching policy for the management of ‘guest’ patients on Bracken Ward.

However:

  • Patients assessments were comprehensive, evidence based and contained detailed physical health assessments. Care plans and risk assessments were holistic and reflected individual patient need.
  • Ward environments were accessible to all patients including patients who had difficulties with mobility or a disability. There was a range of facilities available to patients and a range of inclusive activities.
  • Both wards were clean, well equipped, well furnished, well maintained and fit for purpose.
  • Staff involved patients and their carers and families in all aspects of their care. Patients and carers told us they were treated with kindness, dignity and respect and staff demonstrated a knowledge and awareness of the individual needs of patients.
  • Managers made sure staff teams incorporated a range of skills needed to provide high quality care. Staff were supported with regular appraisals, supervision, team meetings and opportunities to develop and innovate.
  • Concerns and complaints were taken seriously. Staff had a good understanding of the duty of candour. Complaints would be investigated, lessons learnt and shared.
  • Managers had processes and procedures in place to monitor and meet key performance indicators in relation to training, supervision, appraisals and bed management.

Community health services for adults

Good

Updated 12 February 2018

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

  • The service provided safe care and treatment to patients. Staff were competent in reporting and learning from incidents and safeguarding concerns. Staff were also supported to develop competencies and their professional practice.
  • Multidisciplinary teams delivered evidence based care and treatment across the service. Services were planned and delivered to meet the needs of patients, including tailored services for patients with specific needs.
  • Staff delivered outstanding care to patients. This was supported by comments and feedback received from patients, observations of caring interactions, and examples of where staff were able to go ‘over and above’ to deliver person centred care.
  • There was a positive, patient centred culture within the service where staff felt supported by leaders to deliver good quality patient care.

However:

  • Governance processes did not always provide assurance about performance or practice within the service. Examples of this included management and clinical supervision not being consistently practiced or documented. Other examples of this included incomplete data being provided around role specific training for staff.

Community mental health services with learning disabilities or autism

Good

Updated 12 February 2018

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

  • The service building was clean and tidy and all necessary testing in relation to health and safety such as fire, electrical wiring and gas safety had been completed.
  • There were contingency plans in place in the event of the service building or electronic systems being unavailable.
  • The people who used the service that spoke with us told us staff were kind, caring and were aware of their needs and that they were involved in decisions about their care and treatment.
  • The people who used the service were able to given feedback via surveys and user groups.
  • Two patients worked as volunteers at the service.
  • Staff made efforts to engage with patients who had not attended appointments or were reluctant to engage with mental health services.
  • The trust had policies and procedures in place to protect people from discrimination, unfair treatment, harassment and bullying.
  • Staff assessed and monitored patients’ physical health and encouraged them to attend appointments with other services such as GP appointments.
  • Staff encouraged patients to live healthier lifestyles by taking exercise, eating healthily and smoking cessation and there were posters and leaflets in the waiting area giving advice on a wide range of health conditions such as cancer and diabetes. The service provided breast screening in conjunction with another external organisation.
  • Staff were knowledgeable about safeguarding, knew how to report incidents and received information about learned lessons from incidents, complaints and patient feedback to improve practice within the service.
  • The trust reported there were no serious incidents in the 12 months prior to our inspection.
  • Staff knew what their responsibilities were under the duty of candour in relation to being open, honest and transparent with people when things go wrong.
  • Staff received training in equality and diversity and the trust had policies to protect people from discrimination, unfair treatment, bullying and harassment
  • There were sufficient numbers of staff to meet the needs of the patients, there was no freeze on staff recruitment, and sickness absence figures were at 2.12% which was better than the trust’s target of keeping levels down to 4%.
  • The multidisciplinary team comprised a wide range of professionals and there were effective meetings and handover arrangements within the team.
  • Staff were experienced and qualified to do their job.
  • Staff had access to specialist training for their role and managers identified their training and development needs.
  • The service’s medicines management arrangements were effective and were in line with the National Institute for Care and Health Excellence, Royal College of Psychiatrists, Faculty of Intellectual Disabilities and Stopping the Over-Medication of People with Learning Disability and Autism guidance.
  • The service had an effective lone working process to ensure staff were safe when they were working in the community.
  • Pathways used by the service included mental health, behaviour, maternity, ophthalmology, respiratory and dementia.
  • Patient care records were holistic, person-centred and recovery orientated.
  • The service used positive behaviour support plans for patients, which were tailored to meet patients’ individual needs and centred around reducing their behaviours that challenged.
  • Staff received mandatory training in the Mental Capacity Act and had a good knowledge of the Act.
  • The service made effective and appropriate use of best interests decisions and capacity assessments and supported patients to make their own decisions.
  • Staff were appraised and agreed with the trust’s visions and values.
  • The numbers, experience and role mix of staff meant the service could meet patients’ needs.
  • Staff morale and job satisfaction were positive, there was a good level of support from peers and managers, staff felt proud to work for the trust.
  • The trust recognised staff’s success and staff within the team had won awards from the trust and a member of staff had won a national learning disability award.
  • Staff could add items to the service and trust risk registers and knew where to access the trust’s whistleblowing policy.
  • The service worked with the local police to raise awareness of issues associated with learning disabilities, a health care support worker supported the service and trust with the delivery of learning disabilities awareness training for first year student nurses and a speech and language therapist led a quarterly communications champions' network forum and ran consultancy clinics during which staff could discuss patient cases.
  • The service worked with external care providers and services to promote the use of information technology to older people to enable them access to various forms of online support. It also delivered learning disability awareness sessions to acute hospitals.
  • The service had run training sessions to local support providers around active support and behavioural monitoring and had positive and proactive champions and communication champions networks that shared best practice around the use of positive behaviour support and communication methods for people with a learning disability.
  • The service participated in one of the Commissioning for Quality and Innovation’s national audits in relation to ensuring patients were able to access national physical health checks.

However

  • Staff compliance rates for required training in level three safeguarding children and adults, managing violence and aggression – breakaway and basic life support were below 75%.
  • The garden area that was situated at the top of a grassy bank with a steep incline with insufficient protection to prevent people falling.
  • Mental Health Act training was not a mandatory training requirement for staff at the service.
  • The service were unable to provide accurate data in relation to the number of cancelled appointments, numbers of patients subject to community treatment orders and numbers of complaints.
  • The service had insufficient monitoring arrangements in place to ensure mandatory training was within the trust’s 80% compliance target, clinical supervision was taking place, all care plans and risk assessments were reviewed at least every six months in line with the service’s policy and all initial risk assessments were included in care records. The trust did not monitor compliance with staff supervision.

Community-based mental health services for adults of working age

Requires improvement

Updated 12 February 2018

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

  • The service could not evidence they had carried out fire risk assessments or health and safety assessments at two of the locations we inspected where they saw patients.
  • Half of the patients’ records we looked at did not contain up-to-date risk assessments and some did not have a crisis plan documented for patients. Staff did not monitor physical health needs for all the patients in their care.
  • The service did not carry out medication audits so could not ensure medicines were always managed appropriately. Some medication records had not been reviewed in line with trust policy.
  • Some patients did not have up-to-date assessments of their needs and some did not have a personalised care plan. The service did not monitor outcomes for patients and none of the records we looked at had discharge plans in place for patients.
  • Managers could not provide assurance that all staff had access to regular supervision in line with trust policy.
  • Not all staff knew about the application of the Mental Capacity Act or about the trust’s responsibilities regarding duty of candour. Not all staff were up-to-date with their required training and managers did not provide training for staff in the Mental Health Act.
  • The service did not monitor waiting times for patients in the community mental health service and did not always respond effectively when audits highlighted gaps in care records.

However:

  • The overall appearance of the patient areas in both the locations we inspected were clean, well maintained and had furnishings which were in good order.
  • Staff were good at responding when patients became mentally unwell. Generally patients had good access to a psychiatrist when needed. Staff met regularly and frequently to discuss patients and share information with the wider care team. They knew how to identify potential signs of abuse and neglect and how to report these.
  • Patients had access to a skilled multidisciplinary staff team with access to healthier lifestyle advice, employment support and activities aimed at promoting recovery.
  • Feedback from patients and observations of interactions showed that staff demonstrated a caring and compassionate approach. Staff treated them with respect, listened to their concerns, and showed genuine empathy. Staff had good links with carer’s support and signposted patients’ families and carers.
  • Staff provided assertive outreach visits for patients and referred them to a rapid response service when they needed support out-of-hours.
  • The service had an accessible complaints procedure and patients found staff approachable and willing to resolve concerns.
  • Senior leaders understood the services they managed and communicated the trust vision and values to staff. Staff felt valued by their immediate managers and could raise concerns when needed.
  • Staff met to discuss learning from incidents and where needed, they made changes to systems and procedures.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 12 February 2018

We rated long-stay or rehabilitation wards for working age adults as requires improvement because:

  • The service did not always have enough staff. The trust reported that 80 shifts were not filled in the 12 month period between 01 July 2016 and 30 June 2017. Between 01 January 2017 and 31 July 2017 56 shifts fell below the safe minimum staffing levels and three shifts did not have a registered nurse on duty. Staff told us that registered nurses could not always have dedicated time with patients.
  • Half of the patients’ care plans reviewed did not contain information about interventions and support required to meet patients’ needs. None of the records reviewed contained care plans with evidence of patient involvement or completed outcome measures. Staff had not ensured that they informed two patients of their rights under the Mental Health Act regularly. Training rates for Mental Health Act were low at 41%. Training in the Mental Capacity Act had not been consistent and although this was at 94% at the time of inspection, it had been 65% prior to our inspection.
  • The clinic room was cluttered and this could impact on how quickly emergency equipment could be accessed when needed. A bottle of alcohol was stored with controlled drugs in the clinic room.
  • The service did not have an allocated member of staff to complete patient observations each shift. When patients were on leave and missed physical health monitoring, staff did not always record whether they offered these checks again when patients’ returned.
  • The therapy kitchen was not fully accessible for disabled people because no areas of the kitchen had lowered worktops. Staff did not always respect patients’ privacy; two patients told us they did not knock on their bedroom doors before opening and entering.

However:

  • The ward was open access and had the appropriate restrictions expected for a rehabilitation ward. Patients had open access to a therapy kitchen and could make their own meals and drinks at any time. The service had facilities, activities and encouraged access to work to promote mental health rehabilitation and recovery. The service was clean, had good furnishings and was well maintained.
  • Feedback from patients and observations showed that staff knew patients and their needs well. Staff were polite, respectful and supportive. They involved patients and their families, carers, advocates and care co-ordinators in multi-disciplinary meetings well.
  • Staff managed and mitigated risks well. Patients risk assessments contained detailed information on risks and staff understood regular risk assessments of the care environment. Staff used de-escalation techniques and the service reported only three incidents of physical restraint in a 12-month period.
  • The service reported no delayed discharges, serious incidents or safeguarding referrals and complaints in a 12-month period.
  • Senior leaders were visible in the service and understood the services. Staff had opportunities for leadership development and they felt supported and valued.
  • The trust provided opportunities for staff to participate in seminars on research, conferences and specialised learning events.

Community dental services

Good

Updated 12 February 2018

We rated community dental services as good because:

  • The service provided a welcoming and clean community dental service that was well regarded by the patients we spoke with.
  • A range of clinics were offered including: clinics for emergency dental care, clinics for those patients who were unable to leave the house, dental care for patients who, because of their particular needs, could not be seen by a general dental practitioner, and mobile care for hard to reach groups, such as the homeless.
  • Staff appeared motivated and had systems and processes in place to support them, including access to equipment they needed, and enough time, to enable them to see and treat patients safely.
  • The service was well-led by a team of senior leaders who ensured there were adequate governance, risk and quality management systems in place to ensure safe care of patients and that the service continually strived to meet the needs of its local population.