North Cumbria Integrated Care NHS Foundation Trust

Updated 20 November 2023

We plan our next inspections based on everything we know about services, including whether they appear to be getting better or worse.

This report describes our judgement of the quality of care provided by this trust. We base it on a combination of what we found when we inspected and other information available to us. It includes information given to us from staff at the trust, people who use the service, the public and other organisations.

We rated well-led (leadership) from our inspection of trust management, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement.

Overall summary

North Cumbria Integrated Care NHS Foundation Trust (NCIC) was created in October 2019 following an acquisition of North Cumbria University Hospitals NHS Trust (NCUH) by Cumbria Partnership Foundation Trust (CPFT). During the acquisition the mental health and learning disability services were transferred out to another NHS trust.

When a trust acquires another trust in order to improve the quality and safety of care, we do not aggregate ratings from the previously separate trust at trust level for up to two years.

Our normal practice following an acquisition would be to inspect all services run by the enlarged trust. However, our usual inspection work has been curtailed by the COVID-19 pandemic and since that time we have maintained a risk based approach.

In our ratings tables we show all ratings for services run by the trust, including those from earlier inspections and from those hospitals we did not inspect at this time. The ratings shown are an aggregation of ratings from the original trust and those acquired by the trust which have been inspected since the acquisition as well as new ratings from this inspection.

The trust provides a range of acute hospital services based at the Cumberland Infirmary in Carlisle (CIC) and the West Cumberland Hospital (WCH) in Whitehaven. It also provides a midwifery-led maternity service at Penrith Community Hospital and community services covering the Cumbria region (adult and children's community services in north Cumbria and some which are whole county based). The trust has 536 inpatient beds across the acute hospital sites and 133 beds across six community hospitals. The trust employs over 5,400 members of staff.

The trust serves a population of approximately 320,000 in the west, north and east of Cumbria, in the districts of Allerdale, Carlisle, Copeland, Eden Valley and South lakes and Furness for some community services. It also provides services to parts of Northumberland and Dumfries & Galloway. The community is spread over a large geographical area, with 51% of residents living in rural settings. Over 65s make up a larger proportion of the population than the national average. Deprivation is similar to the England average and about 11,700 children (14.5%) live in poverty.

We carried out this unannounced inspection of North Cumbria Integrated Care NHS Foundation Trust as part of our continual checks on the safety and quality of healthcare services.

We inspected Emergency and Urgent Care and Medical care. We also inspected the well-led key question for the trust overall. We did not inspect maternity services, surgery, critical care, services for young people and children, end of life care, out-patients, or diagnostics at this inspection.

At our last inspection in 2020 we rated the trust overall as requires improvement. At that inspection we issued the trust with a section 29A warning notice in regard to the standards of care provided. At this inspection the trust rating has stayed the same. We did see improvements made as a result of our warning notice.

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

• We rated safe, effective, responsive and well-led as requires improvement, and caring as good
• We rated 4 of the trust’s 17 services as requires improvement. In rating the trust, we took into account the current ratings of the 13 services not inspected this time
• The service did not always have enough staff to care for patients and keep them safe. Not all staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service did not always control infection risk well. Staff did not always assess risks to patients, act on them and keep good care records. Pain relief was not always given timely when they needed it
• The service did not always manage the safe storage of medicines and hazardous cleaning materials
• The service did not always manage safety incidents well and although there was evidence of learning following safety incidents, there was further work required to manage environmental hazards and associated risks
• Leaders did not always run services using reliable information systems. The trust’s vision and values were developed but did not have clear underpinning strategies

However:

• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers
• The service planned care to meet the needs of local people, took account of patients’ individual needs and made it easy for people to give feedback

How we carried out the inspection

The team that carried out the inspection included two inspection managers, 10 inspectors, 5 specialist advisors, one assistant inspector and an inspection planner. In addition, there was an executive reviewer plus three specialist advisors experienced in executive leadership of NHS trusts. The inspection team was overseen by Sarah Dronsfield, Deputy Director of Operations.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 23 March 2016

Overall rating for this core service was good:

Staff were encouraged to report incidents and systems were in place following investigation to help rapidly disseminate learning.

The delivery of care and treatment was based on guidance issued by professional and expert bodies such as the National Institute for Health and Care Excellence (NICE) guidelines in the treatment of head injury.

Patients had self-management plans to help them to stay well and manage long-lasting respiratory conditions; therefore they avoided hospital admission. The response times to treatment in relation to restorative dentistry, physiotherapy, diabetes, and neuroscience were good.

Patients and their relatives were treated with kindness, dignity and respect, and we saw compassionate care being delivered.

The service was planned and delivered to meet patient needs. People with urgent care needs were prioritised for treatment and their needs were met in a timely way. Patients waited less than 18 weeks for a first appointment relating to physiotherapy, diabetes, and neuroscience. This was similar or better than the national target of 95% for a first appointment to attend these specialist services within 18 weeks.

Complaints were taken seriously, discussed with staff in their team meetings and included lessons learnt.

The service had a vision, mission and strategy which they clearly published for people and staff to see. Their values were known by staff. The chief executive and their team encouraged people and staff to have a voice and contribute to the way the service developed.

There was good local management and leadership. However, due to the recently restructure of the service some staff did not have confidence in the changes and told us they did not feel supported by middle management. They felt the changes in working practices relating to staffing, had not been fully discussed and they had not felt listened to.

The trust produced a ‘Trust Talk’ newsletter for patients, the public and members of staff. The newsletter kept people up to date with information about the services and included patient stories and challenges the trust needed to address.

We also found:

Work had commenced to review staffing levels in relation to caseloads and service provision. However, not all actions had been fully implemented or embedded in practice. In some areas there were shortfalls in staffing and although due to the goodwill of staff they continued to provide a service, they were not able to fully meet the needs of the patients.

Data showed mandatory training compliance across the teams was 75% with a trust target of 80%.

Training had been added to the risk register for the community teams in the north and south of Cumbria and the physiotherapy team in Furness. The service had an action plan, with a review date to address the concern and for staff to access training.

Information provided by the trust showed not all non-medical staff had an appraisal in the last 12 months. However, records held locally showed staff had received a 12 months appraisal, or they had a date booked when their appraisal would take place.

Record keeping was generally of a good standard. However, not all staff had been consistently recording in both electronic and paper care documentation when the information related to the same patient. Managers were aware of these issues and were implementing through a pilot, the use of mobile laptops in the community. Staff also reported they were in the process and being supported to use the electronic form of record keeping. This meant paper records would not be used which would address the inconsistencies in record keeping.

Several policies were past their review date. This could have meant staff did not always follow up to date guidance.

Updated 21 April 2017

Overall rating for this core service

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

• The leadership, governance, and culture promoted the delivery of high quality person-centred care. Senior managers and staff had made significant improvements since CQC’s previous inspection, in November 2015. A strong, cohesive senior leadership team, supported by a proactive team of managers, had good oversight of risks and incidents, which they monitored and reviewed regularly.
• Staff protected children and young people from avoidable harm and abuse, and they followed appropriate processes and procedures to keep them safe. The named nurse for safeguarding children had been instrumental in the establishment of a robust safeguarding supervision model, to ensure staff shared best practice and lessons learnt from serious incidents and serious case reviews involving children and young people.
• Managers and staff managed caseloads well and there were effective handovers between health visitors and school nurses to keep children safe at all times. On a day-to-day basis, staff assessed, monitored, and managed risks to children and young people. This included risks to children who were subject to a child protection plan or who had complex health needs.
• Children, young people, and families felt staff communicated with them effectively, kept them involved and informed about care and treatment, promoted the values of dignity and respect, and were kind and compassionate.
• Services for children and young people were organised to meet the needs of children and young people. Managers and healthcare professionals from the team worked collaboratively with partner organisations and other agencies to ensure services provided choice, flexibility, and continuity of care.
• Since the previous CQC inspection, in 2015, managers and staff had improved waiting times to ensure children and young people received the right care at the right time in community paediatrics, audiology, learning disability nursing, and physiotherapy. Although occupational therapy and speech and language therapy services waiting times were still outside of the required target, managers had taken appropriate action to reduce the time families had to wait.
• Senior managers had developed a strategy that planned to introduce a new service delivery model, which included changes to the structure of the Care Group. Senior managers and staff had worked collaboratively with the local authority and commissioners and had proactively engaged with staff. The planned changes included the introduction of a dedicated team caring for the most vulnerable children and families across the county.

However:

• Staff did not consistently complete care records within the required timescales recommended by the Nursing and Midwifery Council. Although staff had their own laptops, most did not use them to update patient records whilst away from their office base.
• The trust did not provide a qualified specialist community public health nurse (SCPHN) for each secondary school in the county, which was in breach of Royal College of Nursing guidelines. Also, the school nursing service did not provide health promotion initiatives in local schools.
• Morale was low amongst some staff due to the planned service changes. Although staff acknowledged senior leaders had shared information and provided regular updates, staff were unclear if their views had been included.

Updated 26 January 2018

This was the first time we had inspected this service. We rated it as requires improvement because:

• At the time of our inspection, there were 743 patients on the treatment waiting list for more than the 18 weeks notional target. Of this total figure, 278 patients were waiting for treatment under General Anaesthesia (GA), including 172 children, some of whom were likely to be in pain. Some of the patients had been on the GA waiting list for nine to twelve months.
• The service completed risk assessments and audits and some of the results were stored centrally. The service did not have oversight of some of these documents and we observed action plans were not always completed.
• The service did not have an effective system to ensure that all dentists in the emergency dental service and University of Central Lancashire, with honorary contracts, were up to date with continuing professional development and registration requirements issued by the General Dental Council.
• The service and commissioners had developed a set of acceptance and discharge criteria so that only the most appropriate patients were seen by the service. The service had not taken steps in the last 12 months to work with referring dentists to identify inappropriate referrals and to review processes surrounding this to effectively manage the waiting list.

However:

• Staff reported incidents appropriately. Incidents were investigated, the results of the investigation shared, and there was evidence of lessons learned.
• Staff understood their safeguarding responsibilities and could describe the safeguarding policies and procedures. Staff had up to date safeguarding training at the appropriate level.
• Staff stored, handled and administered medicines safely.
• Staff maintained equipment well and it was fit for purpose.
• Staffing levels were appropriate and met patients’ needs at the time of inspection.
• Patients’ care records were comprehensive and included the information required to keep people safe. Relevant information was recorded appropriately and staff had access to the information they needed before providing care.
• Standards of cleanliness and hygiene were generally well maintained. Systems were effective in preventing and protecting people from healthcare associated infection.
• Mandatory training was provided for staff and compliance met or exceeded the trust targets in most topics.
• Staff had the necessary qualifications and skills they needed to carry out their roles effectively. Further training and development opportunities were available for staff.
• Appropriate systems were used to respond to medical emergencies.
• Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
• The service followed effective evidence based care and treatment policies which were based on national guidance.
• There was evidence of good multidisciplinary working with staff. Teams and services worked together to deliver effective care and treatment.
• During the inspection, we saw and were told by patients, that all staff working in the service were kind, caring and compassionate at every stage of their treatment.
• People were treated respectfully and their privacy was maintained in person and through the actions of staff to maintain confidentiality and dignity.
• Staffs were sensitive to the needs of all patients and were skilled in supporting patients and young people with disabilities and complex needs. We saw there were systems to ensure that services were able to meet individual needs, for example, for people living with dementia and learning disabilities.
• Staff involved patients and those close to them in aspects of their care and treatment. Information about treatment plans was provided to meet the needs of patients.
• There was an effective system to record concerns and complaints about the service. Complaints were reviewed and actioned appropriately with a view to improving patient care.
• Staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.
• There was a very positive and forward looking attitude and culture apparent among the staff we spoke with.

Updated 26 January 2018

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

• We rated safe, effective and well led as requires improvement. We rated caring and responsive as good.
• Although staff had Mental Capacity Act and Deprivation of Liberty Safeguards training, not all staff had an understanding.
• Patient care documentation was a mixture of electronic and paper. Records were not all up to date or contained completed risk assessment and reviews. The records were not individualised and updated to reflect patient’s needs.
• Managers used a dependency and acuity tool to determine safe staffing levels and had a staffing escalation plan in place. However, on some wards they used additional health care support workers to maintain safe staffing levels. This meant that on some occasions registered nurses were not able to take a break away from the ward in line with the national working time directive.

However:

• Mental Capacity Act and Deprivation of Liberty Safeguard training was now compulsory for all staff. Compliance for the inpatient services in May 2017 was 100%, which exceeded the trust target of 80%.
• All staff received mandatory training and had an appraisal.
• Staff checked and ensured resuscitation and emergency equipment was ready for use.
• Medicines management had improved since the last inspection.
• Staff assessed patients who were at risk of falls are assessed and the occupational therapy staff used TOMS outcome measures.
• Managers had introduced quality safety checks in inpatient services to assure themselves that quality was being monitored.
• Managers shared learning from incidents and investigation was shared with staff.
• The end of life document reflected national best practice guidance and contained a pathway for patients with mental health conditions.
• There were strong multi-disciplinary team working relationships between therapists and nursing staff.

Some staff were concerned about the outcome of the service reviews and how that would affect the community wards and the forward strategy. However most staff we spoke with said that staff engagement and communication about proposals was positive.

Updated 23 March 2016

Overall we rated the end of life care services by Cumbria Partnership NHS Foundation Trust hospital as requires improvement. We rated safety, caring and responsive as good and effectiveness and being well-led as requires improvement. We identified areas where there was potential for improvement and these had been acknowledged by the trust. We saw evidence that work was in progress to address the shortfalls and improve the services. We have rated well-led as requiring improvement. This is due to the lack of monitoring of quality, lack of evidence of patient choice in treatment arrangements and the lack of measurement of the organisational performance against other similar services.

We saw good evidence that incidents were reported, investigated and outcomes were shared with staff and action taken to avoid it happening again.

Staff had a good understanding of the procedures for making safeguarding referrals. Patients and family members told us that they were satisfied that staff members respected their wishes and that they did not feel threatened or worried by them.

We observed staff adhering to the infection prevention and control policies when attending to patients. When visiting patients, staff carried with them hand gel and personal protective equipment and used them appropriately.

District nurses said that their jobs were challenging as they had high caseloads and also hadg to travel long distances when visiting patients in their homes. They said they prioritised and ensured patients with end of life care and palliative care needs were attended to. Community nurse specialists also got involved and worked alongside by delivering advice and treatment in the community.

Patients and families told us that staff continuously assessed the level of pain and administered appropriate pain relief. Although pain killers were in use, staff also introduced patients to other ways of relaxing and easing pain, such as aromatherapy and massage. Anticipatory medication prescriptions for pain relief were in use for people requiring end of life care and it was managed by district nurses or the community nurse specialists.

We attended two multidisciplinary meetings and found them patient focused, discussions were open, transparent and all attendees’ views were considered when decisions were made about the management of patients. At each meeting in-patients and community patients were discussed.

We observed examples where staff sought valid consent from patients and gave patients time to understand what was discussed. Staff did not hesitate to revisit discussions when they found the patient was having difficulty concentrating.

Patients and their family members told us that staff were sensitive to their feelings and able to support when they were distressed. They said nothing was too small for staff and ‘went that extra mile’ to help them resolve problems.

Part of planning and offering care for palliative and end of life care patients meant that patients after treatment had to travel long distances between treatment centres and their homes/ community hospitals. Although this could not be helped, patients and carers said this was distressing for them. They said a lack of choice and the lack of treatment centres near them made it difficult for everybody.

People who used the services told us that they knew how to make a formal complaint and said that they were confident to speak up if they were unsatisfied.

We received positive comments from patients and relatives which confirmed that end of life and palliative care patients received a seamless service between the hospital and the community. We saw that the trust governance arrangements included the local GPs; where agreement had been reached to work to Gold standard frame work.

Medical, nursing staff and managers were fully aware of the required improvements in the service and also the need for up-skilling staff to sustain good quality care. Further work identified were: end of life care Pathway was not established and this remained on their risk register, Care of the Dying Patient programme had not been implemented and a meeting with the acute trust was held to take this forward and there were plans to fund Care of the Dying facilitators and provide education for staff.       

Updated 26 January 2018

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

• Risk assessments were not present or incomplete in nine of the 19 records reviewed.
• Care plans were not present in the records we reviewed, young people were copied into letters to GP’s which were described not being in an accessible format by patients and their carers.
• Consultant psychiatrist posts had been filled by locums which had impacted on the continuity of care for people who use the service. The service was not meeting its target times from referral to initial assessment and then to appointing care coordination and intervention for routine referrals. Under the NHS constitution, no patient should wait more than 18 weeks for any treatment. The service did not monitor waiting times for specific conditions such as first episode psychosis or eating disorder waiting times in line with the national guidance.
• The service did not have a methodology or tool to assess the services staffing requirements and it was unclear how staffing levels and skills mix were calculated.
• The service did not have the staff with the necessary skills to provide the full range of evidence based interventions recommended by the National Institute for Health and Care Excellence and were unable to offer evidence based interventions to all.
• Mandatory training and appraisal figures were not compliant with trust targets.
• At the time of the inspection there was no comprehensive out of hours service provision for young people as the trust had not been commissioned to provide this service.
• The waiting area for patients at Workington CAMHS service was shared with a GP surgery and did not promote the privacy and dignity of the young people who attended the service.
• Staff morale was low with staff telling us they did not feel supported by senior members of the trust.

However:

• We observed good interactions between staff and young people who used the service.
• Staff had a clear understanding of safeguarding policy and procedures
• Risk for young people on the waiting list was discussed and priority given to young people in crisis, the service met their target times for young people highlighted as a priority.

Updated 23 March 2016

We rated Cumbria Community Learning Disability Team as good because :

• staff were caring and treated patients with dignity and respect

• people had mostly been involved in the development of their care plans

• staff responded quickly to changes in people’s health or level of risk and there were no waiting lists for initial assessment

• complaints were listened and responded to appropriately

• all staff had received safeguarding training and had a good understanding of how to raise and report safeguarding concerns or alerts

• there were effective processes for managing staff caseloads

• staff worked effectively to lone working practices and adhered to the trust policies and procedures

However:

• Care records had inconsistencies and gaps that meant some people had incomplete risk assessment plans, reviews and recording of risks.

• Care plans did not always demonstrate holistic, person-centred or treatment focused care in line with best practice guidance, such as positive behavioural support plans. Care records did not contain any evidence of advance decisions.

• People did not receive care in accordance with their assessed needs. The service did not follow best practice and guidance in relation to supporting patients with communication difficulties and complex behaviours.

• care records were difficult to navigate, this meant that important patient documents and information was not always easily found within the care records

• the service had experienced continuing difficulties with staffing, including recruitment, retention and sickness, which meant that staffing, was not adequate to meet the needs of the people who use the service

• some of the community teams did not have a full complement of professionals within their multi-disciplinary team which meant that people could not always access these professionals in a timely and effective way

• staff appraisal figures were low with an average percentage of staff in the service that had received an appraisal in the last 12 months at 39% and non-medical staff appraisals averaging 30%

• there was a lack of consistency across the service for people accessing treatment following assessment

Updated 26 January 2018

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

• The environment in Whitehaven was poor and did not meet service users’ needs. There was a lack of space and no disabled access facilities. Furniture was old and worn.
• Care plans and risk assessments were missing or not completed well. Risk assessments and care plans were often out of date and did not correspond to current information.
• Staff supervision was not recorded or poorly recorded. Information about staff supervision was not shared with senior managers. It was not possible for senior managers to be assured that supervision was taking place.
• Staff training and appraisal rates for non-medical staff were below the trust target.
• There was a delayed response to items placed on the trusts risk register. There had been limited action regarding the poor environment in Whitehaven. This was affecting staff morale.

However:

• Positive initiatives were encouraged and shared within the service. These included the virtual memory clinic and the delirium outreach support service. There were effective strategies to save time and costs.
• Assessments were comprehensive and completed in a timely way. Service users were seen quickly from being referred.
• Staff were kind and caring towards service users and carers. Staff were highly praised by service users and they were observed to be empathic and sensitive.
• There were strong links with external services such as care homes and GP’s. Staff met regularly to discuss service users with complex needs.

Updated 25 September 2019

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

• The systems and processes established were not operating effectively to assess, monitor and improve the safety and quality of the service or assess monitor and mitigate the risks relating to the health safety and welfare of patients.
• The physical environment of the health-based place of safety at Kendal did not meet the requirements of the Mental Health Act Code of Practice.
• There was not always a dedicated member of staff to observe patients in the health-based places of safety.
• Some facilities in the health-based places of safety did not promote the privacy and dignity of patients.
• Not all staff supporting patients in the health-based places of safety were trained in the prevention and management of violence and aggression.
• There was not always a record on the electronic patient record system that patients had their section 136 rights explained when accessing the health-based places of safety.
• Care plans were not always completed on the right documentation and a record of whether all patients received a copy of their care plan was not evident.
• Staff managing patient care were not receiving supervision and appraisal in line with trust policy.
• Staff did not feel supported by senior management.
• Most staff did not feel respected, supported and valued. They did not feel able to raise concerns without fear of retribution. Not all staff were aware of the Freedom to Speak Up Guardian.

However:

• The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The mental health crisis service and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately.

Updated 16 February 2017

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

• There was no clear process to review and learn from incidents. Staff did not feel they received constructive feedback following incidents.This had not improved since the previous inspection in November 2015.

• Patients did not have access to occupational therapy support on the ward.

• Compliance rates with some elements of mandatory training were below the trust target of 80% including training in Mental Health legislation.

• Staff did not demonstrate a good understanding of duty of candour.

However:

• Clinical practice had improved since the last inspection in November 2015, with the implementation of a positive behaviour support model.

• There had been improvements in the quality of care plans, communication plans and discharge plans since the previous inspection in November 2015.

• Staff used appropriate tools to assess risk and the needs of patients. Risk assessments were regularly reviewed.

• Staff had a good understanding of safeguarding procedures and all staff had completed safeguarding adults training.

• Patients felt well supported by staff and staff demonstrated a good understanding of the needs of patients, including their communication needs.

Updated 23 March 2016

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

• There were enough staff for people to receive the care and treatment they required

• staff identified ligature points (places where someone intent on self-harm might tie something to strangle themselves) and took action to remove or minimise risks

• the ward was clean and tidy and was maintained to a high standard

• the staff were caring and treated patients in a respectful and dignified manner

• there was good multidisciplinary team working and staff engaged well with community teams as well as outside organisations

• there were no complaints about this service in the last twelve months

• the clinical leadership on the ward was clear and all staff said that they felt supported and listened to

• staff were aware of the trust vision and values and were committed to providing good care in line with this.

However:  

Patients’ bedrooms were on the first floor of the building except two bedrooms on the ground floor. There was no nurse call system or alarm system in patients’ bedrooms. There were blind spots on the first floor, these were mitigated by the use of parabolic mirrors. However, staff did not routinely work on the first floor, the only staff presence was during hourly observations. This meant there patients had no means of summoning staff help or support in an emergency. This is a breach of regulation 12 of the Health and Social Care Act 2008.

Updated 25 September 2019

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

• There were notable variations between the ward environments. Oakwood ward had not improved since the last inspection and dormitory accommodation was still in place. The ward was not fit for purpose and it was unclear when the relocation of the ward would take place.
• There were vacant nursing posts on Ramsey ward which could not be filled. This meant that the ward relied on bank and agency. Feedback from carers was mixed about the care and treatment on the ward.
• There had been a number of serious incidents on Ramsey unit. The trust had carried out investigations, but these continued to be areas of concern.
• Section 17 leave forms on Ruskin and Oakwood were generic and not patient specific.

However:

• There had been improvements since the last inspection in relation to the mental capacity act, the introduction of psychology onto Ramsey ward and staff supervision.
• Ruskin ward provided a dementia friendly environment with a good balance between patient safety and ensuring patients were comfortable.
• Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented wellbeing diaries which were informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients 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, supervision and appraisal. The ward staff worked well together as a multidisciplinary team.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
• The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
• The service was well led, and governance processes were in place to monitor the service.

Updated 25 September 2019

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

• The governance systems and processes in place were not always adequate. Bed management did not ensure beds were always available locally. Staff on Rowanwood were not assured of the effectiveness of the serious incidents reviewed. Staffing and recruitment was an increasing issue, despite measures already in place to eradicate this.
• Staff did not do all that was reasonably practicable to mitigate risks to the health and safety of patients. Blanket restrictions were in place without being individually assessed. Staff did not always monitor patients’ physical health needs following use of rapid tranquilisation and repairs to Dova Unit were ineffective to ensure a patient room was suitable for use.

However:

• 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.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary 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.

Updated 26 January 2018

A summary of our findings about this service appears in the overall summary.

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

• Services were well managed with good governance structures in place to ensure a good flow of information up and down the structure through the relevant forums.
• The trust had acted upon our feedback from our last comprehensive inspection and made some improvements.
• The trust’s vision and values were well embedded into teams. Staff knew and applied the trust’s values in their daily work.
• Staff morale was good and team cultures were described as supportive, open and honest so staff were confident about raising concerns.
• Feedback from patients and carers was universally positive. Patients said that staff had a good understanding of their individual needs and treated them with dignity and respect.
• Patients were assessed quickly and comprehensively and prioritised according to needs and risks. If patients were placed on a waiting list they were regularly monitored by clinical leads.
• Care records were up to date, personalised, recovery orientated and included evidence of ongoing physical care, informed consent and appropriate consideration of mental capacity.

However:

• Not all premises had disabled facilities and so were not accessible for all patients.
• There were inconsistencies in the storage and management of medicines at the three locations inspected.
• Although mandatory training for the core service was just below the trusts target rate, some classroom based training courses were significantly below this target.
• Supervision was taking place but not always 4-6 weekly and the templates used varied. There was also no central monitoring of supervision for senior management oversight.
• The trust measures referral to assessment times but does not record or monitor referral to treatment for patients.