All inspections: North West Boroughs Healthcare NHS Foundation Trust

North West Boroughs Healthcare NHS Foundation Trust has one ward for people with learning disabilities or autism. Byron ward at Hollins Park Hospital in Warrington provides an assessment and treatment service for adults with a learning disability or autism. It provides inpatient services for adults with a learning disability or autism from the boroughs of Halton, Knowsley, St Helens and Warrington. Byron ward has 12 beds for men and women.

This core service was last inspected in October 2019. The service was rated as requires improvement overall. It was rated inadequate for the effective key question, requires improvement for caring and well-led key questions and good for safe and responsive.

Following the inspection in October 2019, we issued two requirement notices against the effective key question. These were for Regulation 9 (person centred care), and Regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. On that inspection, we told the trust that they must:

ensure patients have access to a full multidisciplinary team to enable patients to receive interventions in line with best practice. (Regulation 9)
ensure that staff follow good practice in relation to assessing and supporting patients with epilepsy and communication needs. (Regulation 9) and
ensure that training is provided to staff in the specific needs of the patients including learning disability, autism and epilepsy. (Regulation 18).

As a result of these requirement notices, the effective key question was rated as inadequate. This inspection focused on whether improvements had been made in these areas relating to the effective key question.

On the October 2019 inspection, we also told the trust they must ensure they involve carers in the care of their relative by sharing information and inviting them to meetings if consent allows (Regulation 9). We did not look at this aspect of the regulation 9 requirement notice on this inspection as this related to the caring key question.

Our inspection took place on 18 August 2020. It was a short-notice announced, focused inspection (staff knew we were coming approximately an hour before we arrived) to enable us to observe routine activity. On the day of the inspection, there were four patients on the ward and managers told us that five was the maximum number of patients they would have on the ward. As well as looking at the effective key question, we also checked that staff were following patients’ positive behavioural support plans and looked at the seclusion arrangements to check that vulnerable patients were not placed in seclusion unnecessarily.

On this inspection we found that the provider had made significant changes and had made improvements to provide effective care and treatment. On this inspection, we found that the provider had met the requirements notices for regulation 9 relating to the effective key question - multidisciplinary working and following good practice. The trust had also made good progress to make sure that training was provided to staff in the specific needs of the patients by December 2020 in order to meet the requirement notice relating to staffing (regulation 18). We did not review the ratings for the effective key question on this inspection as there were other aspects of checking whether the service is effective that we did not look at (such as working within the Mental Health Act and Mental Capacity Act).

We therefore continued to rate North West Boroughs Healthcare NHS Foundation Trust wards for people with learning disabilities or autism as requires improvement.

Before the inspection visit, we reviewed information that we held about the service and asked a range of other organisations for information.

During the inspection visit, the inspection team:

visited the ward, looked at the quality of the ward environment and the seclusion room;
observed how staff were caring for patients;
spoke with four patients who were using the service;
spoke with two carers;
spoke with the ward manager and seven other ward staff members; including a doctor, the occupational therapist, nurses, healthcare assistants, a pharmacist and the activity coordinator;
spoke with a speech and language therapist and a consultant psychologist from the community learning disability teams;
attended and observed one handover;
looked at four care and treatment records of patients; and
looked at a range of policies, procedures and other documents relating to the running of the service.

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

We did not review the ratings for the effective key question on this inspection as this was a focused inspection to check whether improvements had been made. There were other aspects of the effective key question that we did not look at.
In a small number of cases, there were delays in doctors attending seclusion to carry out medical reviews when patients were secluded and staff did not provide fuller or cogent reasons for not meeting this important safeguard as required by the Mental Health Act Code of Practice.

However:

The provider had taken action to address the shortfalls we found on the last inspection relating to the effective key question.
Care plans had improved and reflected the assessed needs of patients, including when patients had epilepsy or communication needs.
The ward now employed an occupational therapist to assess and support patients with self-care, the development of everyday living skills, and to access meaningful activities. Patients now had better access to improved meaningful and rehabilitation activities.
Although the ward had not managed to employ a designated psychologist, staff and patients were supported by clinical and consultant psychologists from the community learning disability teams.
Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care.
Staff continued to develop and implement good positive behaviour support plans and followed best practice in anticipating, de-escalating and managing challenging behaviour. As a result, they used seclusion only after attempts at de-escalation had failed.

We did not rate the hospital at this inspection as it was a focused inspection of the safe key question for one ward. The previous inspection rating of good from October 2018 still applies.

The service did not provide safe care and environmental risks were not mitigated through existing control measures. Staff assessed patient risk, however did not carry out patient observations in line with trust policy to keep them safe. A ward ligature risk assessment was completed and reviewed; however, this did not identify all the ligature risks in the environment.
On the tour of the ward we found that when en-suite doors were closed there was a gap between the door and door frame which was a potential ligature point. These doors were of a solid construction and potentially weight bearing, and this risk was not identified individually on the environmental ligature point risk assessment.
Staff did not record the times and intervals of observations in accordance with the trust’s observation, safety and engagement policy. The policy specifies:
at section 2.5 ‘they avoid predictability when undertaking intermittent observations; for example, ritualistic practices i.e.’15 min checks’ are not likely to reduce risk of harm to self.
at section 6.16 ‘all records specifically utilised in services in support of this policy must be fully completed with timed observations being captured accurately and contemporaneously’.
These sections confirm observations should be irregular but within the prescribed window. This is to avoid patients being able to predict when they will next be observed and therefore reduce the opportunity for a patient to harm themselves or others during this timeframe.

However

The ward environment was clean. The ward had enough nurses and doctors. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by an assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
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 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.
The service had experienced a high bed occupancy and had experienced admissions to the ward by people from outside Halton, though had managed beds 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. At the time of the inspection the ward had suspended admissions following a serious incident on the ward.
Weaver ward had experienced changes to the leadership team with a new temporary ward manager and at the time of inspection there were no deputy ward managers in place. The ward manager had introduced an action plan to address shortfalls in the monitoring of patient observations prior to the inspection.

We carried out this urgent focused inspection of Weaver ward at the Brooker Centre, Runcorn, due to concerns about the safety of patients on this ward. This was following a serious incident and complaints from patients and their families.

Prior to the inspection we requested the following information:

staffing levels, including the expected, actual and fill rate numbers for staff on shift, a breakdown of agency/ bank and permanent staff, details of how many shifts that agency/bank staff covered on these two weeks and details of how many agency/bank staff completed a ward induction and when they completed it.
information on bed occupancy for the weeks commencing 07 and 13 July 2020.
the numbers of patients on varying levels of observations for the weeks commencing 07 and 13 July 2020.
information on risk assessment/security checks of the ward environment.
incident numbers and type of incident from 01 July onwards.
details of complaints made by patients 01 July onwards.

During the inspection we:

looked at the quality of the environment and observed how staff were caring for patients.
spoke with two people who were using the service.
spoke with the ward manager and operations manager.
spoke with six other staff members including the clinical lead, registered nurse, health care assistant, psychologist, ward administrator and ward pharmacist.
looked at seven care and treatment records and five prescription charts.
carried out a specific check of the medication management, checked the clinic and treatment rooms.
looked at a range of policies, procedures and other documents relating to the care and treatment of patients.
requested additional individual patient records to review off site.

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

The trust did not have a specific observation policy for the use of the health-based places of safety. Staff described how they would manage observations whilst patients were in the places of safety, but this was not consistent across the three locations visited. This meant the trust could not be assured that staff were completing observations and managing the places of safety safely.
The trust did not have a policy or process that staff managing the health-based places of safety should follow when medication had been administered to patients within the places of safety, in terms of observing and monitoring the effects on patients. Staff managing the places of safety did not receive specific training to safely support patients when medication had been used or restraint was required.
The trust stated that the health-based place of safety at Atherleigh Park was at full capacity with two patients. The place of safety could be split so that patients were kept separate although there was only one bedroom which is not in line with Code of Practice guidance. The trust did not have a written process in place for managing multiple patients in the health-based place of safety. It was not clear how the trust was assured that the place of safety would be safe during these periods. The walls were not sound-proof and it was not clear how the trust was assured that the privacy and confidentiality of patients was maintained in these situations.
The teams responsible for managing the health-based places of safety at Atherleigh Park and Hollins Park were based at offices off-site. This meant there could be avoidable delays in staff attending the places of safety when needed. The Wigan Assessment team were under pressure at the time of the inspection.
We observed inconsistent recording in care and treatment records. The 136 records at Atherleigh Park had not been fully completed. At the assessment and home treatment teams, care plans, crisis plans and capacity assessments had not been completed in some of the records reviewed.
Governance processes were not always operating effectively at team level and performance and risk were not always managed well.

However;

The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training and appraisals. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
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 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. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.

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

The service did not provide 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.
Leaders did not ensure that the ward team included the full range of specialists required to meet the needs of patients on the wards. Staff did not receive specialist training for their role.
There was an occasion where staff did not protect the confidentiality of patients, by talking about them in front of other patients.
Staff did not always understand the individual needs of patients.
Staff did not inform and involve families and carers appropriately and keep them updated on their loved one’s care.

However:

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 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.
Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
Improvements had been made since the last inspection in June 2018. Managers ensured that staff received positive behaviour support training, supervision and appraisal. The governance processes ensured that ward procedures ran smoothly.

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. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
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 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 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.
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 the governance processes ensured that ward procedures ran smoothly.

However,

On Golborne and Rydal wards the most up to date fire risk assessment was not in the fire folder. We requested the most up to date assessments and found that Golborne wards had been completed on time but was not in the relevant folder. Rydal wards had been delayed to facilitate a fire audit by the local fire service of the whole building. The risk assessment had been completed on 1st November 2019.
Despite the fact the trust had worked hard to ensure that mixed sex accommodation breaches were reported, there were high levels of incidents across the service.
Some of the furniture on Rydal ward was worn and in need of some attention.

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

The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The 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 understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
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 service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However,

Two services were outside the trust targets for referral to treatment time so patients had to wait for their treatment.
At Knowsley, the reception desk was open plan exposing the clinical staff office directly behind the receptionist. Visitors to the service had a clear unobstructed view of the office and could hear staff talking.
Staff only had access to personal alarms at two locations. Staff at Wigan told us they felt particularly vulnerable as the design of the building meant consultation rooms were away from staff offices.
The number of staff receiving appraisal and supervision was below the trust target of 90%.
Not every location had a functioning young person’s group and there was no consultation group for adults.

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

Wards were clean and tidy. Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff had completed and kept up-to-date with their mandatory training. Staff completed risk assessments for each patient on admission / arrival, using a recognised tool, and reviewed this regularly, including after any incident.

Staff developed comprehensive care plans for each patient that met their mental and physical health needs. Care plans were personalised, holistic and recovery-orientated. Staff provided a range of care and treatment suitable for the patients in the service. Staff made sure patients had access to physical health care, including specialists as required.

Patients said staff treated them well and behaved kindly. Staff supported patients to understand and manage their own care treatment or condition.

Staff made sure patients had access to opportunities for education and work, and supported patients. The service had a full range of rooms and equipment to support treatment and care. Staff and patients could access the rooms.

Staff felt respected, supported and valued. Staff felt positive and proud about working for the provider and their team.

However:

There was no ligature risk assessment completed on Tennyson ward in the last 12 months.

There was no timescale for work to be completed on Marlowe ward to reduce the risks identified in the ligature risk assessment.

Patients within the step-down service were not able to self-medicate as there was no provider policy or procedure for this.

Staff did not all have completed yearly constructive appraisals of their work.

The provider’s senior leadership team had not successfully communicated the provider’s vision and values to the frontline staff in this service.

Patients and carers were not involved in decision-making about changes to the service.

Patients and staff did not meet with members of the provider’s senior leadership team and governors to give feedback.

We rated three of the five services we inspected as good overall. Of the 12 core services provided by this trust, 10 were rated good overall following this inspection. We rated well led for the trust overall as good.
There was effective leadership across the organisation. The trust had an experienced leadership team with appropriate skills and abilities. The board and senior leadership team had set a clear vision, values and behaviours that were at the heart of all the work within the organisation. The newly developed trust strategy was linked to the vision and values. Staff in most services knew and understood the provider’s vision and values and how they were applied in the work of their team. There was a clear five year plan to provide high quality care and financial stability. This included a plan of the trust being acquired by another health and social care provider.
Staff provided care that was personalised, holistic and recovery-oriented. Staff treated patients with compassion and kindness. Staff in most services supported and involved patients, families and carers.
The services had enough nursing staff, who knew patients and received statutory and mandatory training to keep patients safe from avoidable harm. In most services, staff regularly assessed and managed risks to patients and themselves and achieved the right balance between maintaining safety and providing the least restrictive environment possible in order to facilitate patients’ recovery.
The trust made sure that it included and communicated with patients, staff, the public, and local organisations. The trust was focused on improving engagement with a new engagement strategy. Patients and carers were able to give feedback and contribute to improvements. The trust was committed to improving services by learning from when things go well and when they go wrong.
There was a values-based culture which was positive and open. Work on equality and diversity had progressed and workforce race equality was monitored. Staff were able to speak up and were supported with their well-being. Staff felt respected, supported and valued.
The trust had effective governance structures, systems and processes. Committees worked well with set agendas and had the ability to be responsive if additional items needed to be reviewed. The board had oversight of risk. Teams had access to the information they needed to provide safe and effective care and used that information to good effect.
The trust had systems in place to identify learning from incidents, complaints and safeguarding alerts and make improvements. There had been recent improvements in investigating serious incidents. Staff understood how to protect patients from abuse and the services worked well with other agencies to do so.
The trust had appropriate arrangements in place in relation to Mental Health Act administration and compliance. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.
Information on service quality and sustainability was used and reviewed. Staff could access the data they needed and had the information technology to undertake their roles. The trust had invested in information technology through being part of the Global Digital Exemplar programme.

However,

On the ward for people with a learning disability or autism, there was not the sufficient range of staff with the required skills to provide safe care and treatment in line with best practice or national guidance. The service did not involve patients and their families in their care and staff did not always review risk in line with trust policy. There were occasions where the inspection team observed staff did not give patients help, emotional support and advice when they needed it or maintain patients’ confidentiality.
In the mental health crisis services and health based places of safety, there was a lack of clear and consistent policies and procedures to support safe care and treatment. The environment at Atherleigh Park did not maintain the privacy and dignity of patients when caring for two patients at the same time. Staff did not always complete patient records in line with trust policy. There was a lack of specialist training for staff and learning was not shared across the service.
In the specialist community services for children and young people, waiting times from referral to treatment were too long and not meeting trust targets.
Vacancies for medical staff had improved but remained high and were having an impact on some services. Not all staff had access to clinical supervision. Some teams had not met the trust target for non-medical staff appraisals. Complaints were not always responded to in a timely way.

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

We rated and safe, caring, effective and well led as good and responsive as requires improvement. In reaching an overall rating for the trust, we took into account the previous ratings of the services we did not inspect this time.
The trust had a strategy for engagement and involvement and worked with stakeholders, patients and the public.
The trust had a programme of innovation and new initiatives that they engaged with and celebrated at staff events.
The trust had a cost improvement plan that was reviewed and managed with quality impact assessments undertaken to ensure quality of care was not compromised.
The trust leadership team had established a vision and set of values which was well embedded within the organisation. Staff were able to talk about the vision and values in their work and senior leaders described the vision and values as a golden thread which ran through the organisation.

There was a person-centred culture across the trust with patients at the centre. Staff recognised this was a top priority which was reflected in the staff survey results.
Staff at all levels knew how to report incidents and had access to systems that allowed them to do this. The trust had systems in place to identify learning from incidents and to ensure the learning was disseminated across the trust.
We saw evidence of good physical health monitoring in the mental health core services.

However:

The trust had introduced new structures and lines of accountability to deliver its strategy and services but these had not been fully embedded at the time of the inspection. Our inspection found that, in some instances, the governance system had not provided the necessary assurance of safety and quality.
There was a lack of senior leadership oversight regarding systemic issues affecting patient safety in two of the core services that we inspected on this occasion. These were wards for older people with mental health problems and wards for people with learning disabilities or autism. We rated wards for older people as inadequate for safe because the wards were poorly maintained and staff did not take the steps necessary to separate the accommodation for men and women. The trust managers had failed to provide staff with guidance on how to eliminate mixed sex accommodation. The ward for people with learning disabilities was not functioning as an assessment and treatment ward. Staff did not have positive behaviour support training, however, the trust management had a plan in place to train staff.

Staff on some wards imposed blanket restrictions on patients that were not based on an assessment of the patients’ individual risks or needs. On the wards for older people with mental health problems, these included placing restrictions on patients’ access to the ward gardens and the female only lounges. On wards for people with learning disabilities or autism, staff did not allow patients to have free access to drinks when they wished and patients bedroom doors were routinely locked during the day. On the child and adolescent mental health ward young people had restrictions placed on their mobile phone and internet access.
Waiting times in three of the community based mental health services for adults of working age were of an unacceptable length. The wait was up to two years for the attention deficit hyperactivity disorder service, six weeks in the Wigan assessment team and 100 days for psychological interventions in the recovery teams.
Feedback from stakeholders who worked with the trust was mixed. Some described a picture of developing services with a reactive rather than proactive response to identifying and addressing issues in an open and transparent way.

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

Staff were caring and supportive of the young people in their care, showing respect and kindness to patients. The young people told us that they were treated with kindness, dignity and respect.
All young people underwent an assessment of need and care planning was holistic, recovery oriented and included their physical health needs.
Multidisciplinary meetings were held and attendance by outside agencies and carers was encouraged. Good communication between outside agencies was evident and carers told us they were kept up to date with their relative’s progress. This included in care planning and review meetings.
Advocacy services were accessible and available to all young people. The advocate was active in the ward area and supported the young people to have a voice in meetings including community meetings.
The ward was clean and tidy and staff followed infection control procedures. The ward environment was checked regularly.
Environmental observational and ligature risks were identified and regular environmental checks were conducted. Action plans were in place to mitigate against these risks.
The clinic room was equipped to support healthcare needs and emergency equipment was available to staff. Medical equipment was subject to regular maintenance checks.
Medicines were dispensed and stored securely in line with trust policy. Regular medicines management audits took place.
Young people were supported by a skilled multidisciplinary team which included nursing, psychiatrist and psychology staff. The ward had recruited to the vacant occupational therapy post. Young people also had the opportunity to continue with their educational development.
Treatment practices including physical healthcare was based on nationally recognised guidance.
Care planning was holistic, individual risks were reviewed regularly. Young people and their carers were encouraged to be involved in this process.
Safeguarding processes were in place and understood by all staff. There was a clear reporting structure and staff had undertaken level 3 safeguarding training. Any concerns relating to child protection were communicated to the relevant protection agencies.
Young people and carers knew how to complain and were aware of the complaints procedure.
An admission criteria was in place and referral waiting times, delayed discharges and length of stay was monitored.
Staff were trained in the Mental Health Act and Mental Capacity Act. Staff had support from a Mental Health Act administrator and young people were given information and support in understanding their rights.
There were systems in place with clear lines of accountability in the operational delivery of the service with an established governance structure supporting decision making. Performance management and quality reporting and monitoring which included identified risks were discussed in governance forums with action taken to address these.
Staff were aware of the visions and values of the trust and were committed to improving and developing quality services with the young people in their care.

However:

The Mental Health Act Code of Practice was not being fully followed, with a number of blanket restrictions present across the service.
Individual clinical supervision and team meetings were not regularly recorded. This meant it was not possible for the service to monitor if staff had been fully supported.
When young people had been restrained, records did not consistently give full information to describe the intervention used.
There were gaps in cleaning records for the service.
Required medication was not reviewed every 14 days as stipulated by the trust guidance in order to ensure appropriate medication usage.
Patient choice at meal times could not always be facilitated.
Activities had been limited whilst the activities coordinator and occupational therapist posts were being filled. This had impacted upon the young people’s satisfaction with finding activities to fill their time on the ward.
Leaflets and information available to young people were not always available in a child friendly format.

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

Progress had been made following the last inspection in 2015, where we stated the trust should improve in several areas. We reviewed these as part of the inspection and found staff fully understood and followed the lone working policy, staff were reviewing patients on a CPA with the introduction of nurse-led reviews in between consultant reviews, staff received regular supervision and appraisal and the medicine storage concerns at Warrington and Halton home treatment team had been resolved.
Patients and carers that we spoke with were happy with the service they received. Progress had been made in the involvement of patients in their care, by facilitating service user groups and activities they could participate in. These included anxiety education sessions and the recovery, education and support time group to increase patients understanding of their conditions and treatment options.
Staff were passionate and positive about their roles. They reported enjoying working for the trust and felt supported by their managers.
Record keeping was to a good standard, with comprehensive risk assessments, care assessments and care plans in the records we reviewed. Staff had made the transition to working with the new electronic record system successfully.
The service delivered safe care and treatment to patients, with physical health screening taking place and the treatment provided was in line with best practice and national guidance.
Innovations were in place with the street triage service in Warrington, trust wide perinatal service and secure outreach service. Teams had changed ways of working to provide efficiency with the introduction of the telephone triage service at the assessment teams and assessment practitioners at the early intervention teams. This reduced the waiting time for patients to access the service.
Services were well managed with regular team meetings and supervisions taking place. There were a variety of methods of sharing information. Managers were involved in reviewing their team’s performance.

However:

We were concerned about the access and waiting times for three of the services. At the Attention Deficit Hyperactivity Disorder service, patients were waiting for up to two years for an appointment. Wigan assessment team had 319 people on the waiting list. Face to face assessment appointments were being booked in for six weeks away.

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

The wards provided a safe environment. The seclusion room at St Helens had been moved into a quieter area away from reception. Staff carried out ongoing risk assessments on patients. Staff and clinicians were better at recording and managing the risks when patients went on section 17 leave and went absent without leave. Where incidents had occurred, staff took appropriate action to address them, change their practice and learnt lessons.
Patients received input from a full multidisciplinary team and in line with national standards. Staff provided a range of interventions for patients with specific types of problem, including a self-injury pathway. Staff provided support to ensure that patients received appropriate physical health care. There were good systems in place to support adherence to the Mental Health Act and there had been improvements on areas we raised such as consent to treatment recording. Where staff carried out mental capacity assessments, these were decision specific and followed the principles and stages set out in the Mental Capacity Act.
Many patients were positive and were happy with the quality of care and support. We observed staff providing support to patients in a caring manner and staff knew patients well. Patients were encouraged to be involved in decisions that affected them and developing their care plans. There were wider patient involvement initiatives such as the secret diner initiative. Patients had access to independent advocacy input.
Most patients were receiving care close to home and patients could access a bed in their local area. Staff discussed discharge plans with patients routinely throughout their admission. The wards had a range of rooms and facilities for patients with the wards at Atherleigh Park also having an activities hub with many more facilities. There had been low numbers of complaints across the acute wards and patients knew how to complain.
There was good local leadership and most ward staff felt well supported with the exception of some staff at Atherleigh Park. The trust had identified pressures on some wards with staff vacancies and low numbers of experienced qualified staff. This was reflected on the trust risk register. Governance arrangements and audit checks were largely good, with good adherence to requirements relating to staffing, training and mental health legal requirements. There were a number of good practice initiatives such as the self-injury pathway.

However:

Some seclusion rooms did not have controllable heating, subdued lighting or blinds at the window. There were a small number of reported delays of doctors attending seclusion episodes initially especially at night.
On some wards there were a number of staff vacancies and higher numbers of preceptorship nurses but patient care was not adversely impacted. Some staff at Atherleigh Park did not feel fully supported and faced challenges of high acuity of patients and high numbers of admissions and discharges but this was reflected on the trust risk register. Bank staff did not routinely have prevention and management of violence and aggression training but there was always enough staff on the wards to manage incidents.
Some wards were using initiatives to further reduce restraint on patients but this had not been rolled out across all wards and locations.
While staff were managing most medicines appropriately, on some wards, there were a small number of opened medicine bottle and creams which were not labelled to state when they were opened.
Although most care plans were of a good standard, some were not always fully personalised and holistic. Written discharge care plans were completed by staff but these were not always updated to reflect discussions in ward rounds where discharge was discussed.
The wards were not displaying the correct CQC ratings poster but there were difficulties pulling the trust’s correct ratings through on our website.

The ward was not delivering care in line with national guidance and best practice. The service was not operating as an assessment and treatment ward. The ward did not have a robust framework to deliver positive behavioural support. However, the trust were aware of this and were rolling out a framework at the time of our inspection.
There was no coherent and consistent approach to reducing the use of restrictive interventions such as restraint and seclusion. There were restrictive practices on the ward that had not been identified or reviewed.
We observed inappropriate and aggressive behavior towards a patient. We observed one patient wait 15 minutes for assistance to change their clothing following a period of incontinence.
Some clinical equipment was overdue trust mandated maintenance checks. Personal emergency evacuation plans were not in place.

However:

The service had reviewed its staffing establishment and managed staffing levels to ensure patient safety. Staffing levels were reviewed in daily safety huddles. The ward manager was able to access bank and agency staff and staffing levels were adjusted to meet need.
Staff assessed and monitored the physical healthcare needs of patients. They referred patients to appropriate specialist services when indicated and supported them to attend appointments.
Patient and carer feedback on staff was generally positive. However, carers we spoke with told us they would like to see improved communication.
Patients had access to a range of facilities. Activities were provided seven days a week. Patients were encouraged to maintain contact with families and to engage with the community.
Staff morale was positive. Staff told us they felt valued and supported. Staff worked well together as a team.

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

There were considerable issues with safety of this service. Patients were at risk because mixed sex accommodation was not managed safely. There were infection and contamination risks when incidents were not promptly managed and equipment was not maintained. Moving and handling plans were not in place for those patients who needed them. Staff did not have all information needed to manage risks because ligature risk audits did not capture all risks and environmental risk assessments were out of date. Staffing levels on one ward were too low.
Bed occupancy rates were high and patients were moved between wards. Beds were not always available in the nearest service to patients’ homes. There were high levels of delayed discharge from wards and high levels of readmission shortly after discharge.
On all wards, there were issues with food choices and the availability of sufficient food to enable patients to choose meals that they wanted.
There was a lack of senior management oversight of these wards in terms of identifying and addressing systemic risks. This included addressing the ongoing staffing shortages on Kingsley ward. Whilst audits were completed, the frequency of these was too far apart, for example, mattress audits every six months where not all mattresses were examined. When issues were identified, these were not checked more quickly (for example, infection control audits on Rydal ward were carried out annually, despite there being issues at audit and the same issues still present at the re-audit). Issues were escalated to the risk register for prolonged periods with no action taken, for example, a garden which patients could not use without staff present had been on the risk register for 18 months.

However:

Nursing staff completed thorough risk assessments and care plans. There was adequate medical cover and good physical healthcare. There was innovative practice in relation to falls prevention.
Staff were kind and caring, and carers gave positive feedback about care of loved ones. There was excellent provision for activities on all wards, with occupational therapy staff and activity co-ordinators providing a varied range of activities and exercise.
Ward managers were described as supportive and valued, and staff described a good morale within their teams.

Our overall rating of this service stayed the same.

We rated it as good because:

Staffing levels within the community nursing service were sufficient and staff had the right qualifications, skills and training.
The service prioritised patient protection and there were defined systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.
There was good compliance with mandatory training in most services however a few services were significantly below trust target in some areas of training.
We saw evidence of an open and transparent culture in relation to incident reporting. Staff were able to learn from the feedback received from managers and were comfortable reporting their concerns or any near misses.
Staff treated patients in compassionate, dignified, and respectful ways. Staff were hard-working, caring and committed to delivering a good quality service. They spoke with passion about their work and were proud of what they did.
Staff reported that managers were available, visible, and approachable. They also told us that leadership of the service and staff morale were good, and staff across the services felt supported and valued by their peers and managers.
There was an effective governance structure for formal escalation of risk where appropriate.
Staff were competent, knowledgeable and responded to the needs of patients and of their patients carers.
Staff understood their roles and responsibilities under the Mental Capacity Act. They could describe when to use it for patients who appeared to lack capacity to make decisions about their care.

However:

Although the trust monitored and had taken action to address delays in referral to treatment, some services were not achieving the referral to treatment targets.
The servicing of equipment was not always performed and consumables were not always within date.
Staff were not supported by the systems and processes in place to consistently monitor and mitigate patient’s risks.

Following the inspection in July 2015, we rated the core service as good for the key questions of effective, caring, responsive and well-led. We did not inspect these key questions during the most recent inspection in July 2017 and we have not changed these ratings.

Following the inspection in July 2016, we rated safe as good. As a result of this most recent inspection, we have revised this rating to requires improvement. This was because:

There was no current written guidance for staff to follow when patients went missing, as required by the Mental Health Act Code of Practice.
Following incidents of patients going absent without leave, records did not always indicate that staff took timely and clear action to ensure patients safely returned to the ward
Psychiatrists were not always clearly recording section 17 leave decisions, did not always provide clear conditions of leave and did not clearly record a proper risk management rationale for continuing patients’ leave following recent incidents of patients going absent without leave.
Patients on Westleigh unit did not routinely receive a copy of any section 17 leave authorisations to enable them to fully understand their leave and any conditions.
Following completion of a risk assessment for each patient, staff did not always complete a robust risk management plan and instead the risk management plans usually consisted of a simple chronology of events and incidents.
The trust had not completed a recent audit of section 17 leave and therefore had not fully considered and addressed the wider shortfalls.

However:

There had been recent reduction in the numbers of patients going absent without leave directly from the ward as there had been several changes to the ward environment to try and reduce these incidents.
Staff discussed measures to reduce patients going absent without leave directly at team meetings and there had been changes to staff practice.
Patients were given a wristband on admission which allowed them to unlock and access their bedrooms or other patient accessible rooms.

We rated Community end of life care services at 5 Boroughs Partnership NHS Foundation Trust as good because:

The service had made significant improvements since our last inspection and had addressed all areas of concern effectively.
Staff delivered end of life care in the community setting that was caring, compassionate and supportive of patients and their families.
The service had a comprehensive and credible framework and strategy for end of life care and this was monitored through regular meetings.
The advanced care plan document developed to replace the Liverpool Care Pathway in July 2014 was comprehensive and person-centred.
The trust had appointed a board member and non-executive board member with a specific lead role for end of life care and staff were aware of who these executive leads were.
Safety was a high priority and there was routine measurement and monitoring of safety and performance within the service.
Risks were appropriately managed and identified.
We found that the care delivered to patients was evidence-based and in line with key documents such as National Institute for Health and Care Excellence guidance and priorities of the dying person, particularly personalised care.
There was routine monitoring of patient outcomes of care and treatment, and patient feedback was actively sought on a regular basis.
The training for staff involved with the delivery of end of life care was appropriate and provided on a regular basis.
The end of life care team worked effectively and engaged with other professionals to ensure patients received the required level of care and support.
Staff appraisals were completed and staff had sufficient clinical supervision.
Staff spoke positively about the support they were given by seniors and management.
Staff worked with local hospices, hospitals, GPs and specialists to seek advice when needed.
When we talked with patients and staff and observed care, we found that staff were passionate and committed to providing good end of life care.
There was a strong culture of innovation and improvement and staff were actively encouraged to put forward ideas for improving the service.

Following the inspection in July 2015, we rated mental health crisis services and health-based places of safety as good overall. We rated the service as good for the key questions of safe, effective and responsive. We did not rate caring. We did not inspect these key questions during the most recent inspection in July 2016 and we have not changed these ratings.
Following the inspection in July 2015, we rated well-led as requires improvement. As a result of the most recent inspection, we have revised this rating to good.

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

Following the inspection in July 2015, we rated the core service as good for the key questions of effective, caring, responsive and well-led. We did not inspect these key questions during the most recent inspection in July 2016 and we have not changed these ratings.
Following the inspection in July 2015, we rated safe as requires improvement. As a result of the most recent inspection, we have revised this rating to good.

We rated wards for older people with mental health problems as good because:

Following the inspection in July 2015, we rated the core service as good for the key questions of effective, caring, responsive and well-led. We did not inspect these key questions during the most recent inspection in July 2016 and we have not changed these ratings.
Following the inspection in July 2015, we rated safe as requires improvement. As a result of this most recent inspection, we have not revised this rating.

We rated forensic inpatient/secure wards as good because:

The forensic wards were clean, tidy and well maintained. Environmental risk assessments were in place that included ligature risk assessments. Ligature points were mitigated against adequately and staff knew where they were. There was a plan in place to remove all of the identified risk points, however the timescale for this work to be completed had not been identified.
Staffing across the wards was sufficient to meet the needs of the patients. Most staff were up to date with mandatory training, supervision and appraisals, any additional training needs identified were provided. This in turn led to effective multidisciplinary team working and challenge. The trust had set a target of 90% for compliance with training and at this inspection, immediate life support was below this target at 61% and 75% for basic life support.
Clinical rooms were well stocked with equipment for physical health care and emergency lifesaving equipment and medicines were available to staff. Patients received a physical health care examination on admission and routine physical health care checks throughout their admission.
Patients had care plans and risk assessments in place that reflected their needs. Patients were involved in their care planning and risk assessments and staff had considered their views when writing them. Staff understood what constituted a safeguarding incident, and how to report safeguarding incidents. Staff received feedback from incidents in a variety of ways, including supervision, ward meetings and debriefs to ensure that any lessons learned were shared.
Medicines were prescribed within best practice guidelines that ensured that they were administered safely. There was a significant increase in the access to psychological interventions, both one to one and group session for patients that met the National Institute for Health and Care Excellence guidelines.
Outcome measuring tools were used to assess clinical outcomes for patients on all units. Chesterton unit had developed a patient own data base, that recorded individual patient’s rating scales. These were used to have meaningful discussions both in one to one sessions and in the multidisciplinary team meetings.
Staff were seen to be kind, caring and respectful in their interactions with patients. Staff were knowledgeable about their patient’s needs. Patients gave positive feedback about the staff on the units, and they told us that they felt safe on the units.
Referral and discharge pathways were in place that gave clear criteria for admission and the pathway to discharge. The average length of stay for patients on the secure units did not exceed the average for low secure services.

The units all provided environments that supported patients’ recovery. Activity workers provided activities on and off the ward seven days a week. The units supported the needs of patients from a diverse background and provided a range of information for patients to support them in understanding their rights.
Complaints were managed both locally on the units and formally. Patients and staff all knew how to raise complaints. There was improvement in the units overall leadership, and staff reported an increase in team morale and felt more supported to perform their role. Improvement plans that had been put in place were monitored through regular meetings that sought assurances for on-going improvements. Support systems for staff were in place and effective.
Clinical audits were conducted regularly in areas that were seen as hot spots to ensure that action was taken quickly to rectify any problems. Key performance indicators were used to review and improve the services performance. The trust also had a corporate risk register that identified on-going risks to the secure services.

However:

Marlowe unit’s ligature risk assessment identified ligatures within the patient bedroom areas. There was not an identified time scale for when these would be removed.

Tennyson unit’s clinical room often rose above the required temperature for the area. This compromised the integrity of medications. There was a system in place to manage this and ensure medicines were safe to use.

Care plans were not always written in a way that fully showed the level of a patient’s involvement in their care plan as they were not written from their perspective

There were complaints about the food quality and the portion sizes of the food, that this was being served cold or not receiving what they ordered.

In a small number of files, the most up to date T2 and T3 forms were not correctly filed in the medication charts.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

Following the most recent inspection in July 2016, we have changed the overall rating for the trust from requires improvement to good because:

In July 2015, we rated eleven of the thirteen core services as good. We have received no intelligence since to suggest that these services have deteriorated in quality.
In response to the findings of the July 2016 inspection, we have changed the ratings of a further two core services from requires improvement to good: forensic inpatient/secure wards and community end of life care.
Following the July 2016 inspection, we have revised the rating of the following key questions from requires improvement to good:
- safe: acute wards for adults of working age and psychiatric intensive care units, forensic inpatient/secure wards and community end of life care
- effective: forensic inpatient/secure wards and community end of life care
- caring: forensic inpatient/secure wards
- responsive: forensic inpatient/secure wards and community end of life care
- well-led: forensic inpatient/secure wards, mental health crisis services and health-based places of safety and community end of life care.
In community end of life care, we have revised the rating for caring from good to outstanding.
The trust had taken effective action to meet the requirement notices we issued following our inspection in July 2015.
The trust had strengthened how it monitored and reported on the quality of care. Monthly operational reports provided details on how each area was performing so that the board had real time reports on quality measures.
The trust had developed an end of life strategy and framework with an identified board lead.
Staff felt supported and, particularly in end of life care, were very positive about how the executive team had managed the concerns identified at the last inspection.

However:

In wards for older people with mental health problems safe remains requires improvement. This is because the bedroom doors had viewing panes that only staff could open and close. During the inspection we saw that these were left open. This meant that patients would have to ask staff to close the viewing panes to ensure privacy in their bedroom. This had been raised as a concern in the inspection in July 2015 and we had told the trust that they should take action to address this.

We rated the health-based places of safety as good because:

The health-based places of safety were clean, tidy and well maintained.
A member of the assessment team was available to respond to section 136 detentions, 24 hours a day and coordinate assessments in the health-based places of safety.
Staff knew how to report incidents via an electronic reporting system. Lessons learnt from incidents were shared within teams.
The majority of staff had completed their mandatory training.
There was evidence of good inter-agency working and partners described good working relationships around the use of the health-based places of safety.
New initiatives between the trust and the Cheshire and Merseyside police forces had resulted in fewer people being detained under section 136. Issues were being resolved in the community, meaning that people did not need to be taken to a health based place of safety or to a police station.
Arrangements were in place with the child and adolescent mental health service teams to complete assessments for any people aged 16 to 18 detained under section 136.
We found staff to be respectful and kind in their dealings with patients and their carer/family members.
Managers were enthusiastic about the service and keen to further develop initiatives such as the street triage.
There were joint policies and procedures in place with Cheshire and Merseyside police, local authorities and the ambulance service. All agencies attended an established mental health law strategy steering group to coordinate working practice.
Between 2014 and 2015, no-one being assessed under section 136 was placed in a police cell in Merseyside as a place of safety.
There were referral pathways in place for additional support, including support from home treatment and recovery teams as an alternative to a hospital admission.
Referrals were made to specialist drug and alcohol services when needed for further support.
There had been no complaints received in the six months prior to the inspection.

However the trust was unable to provide data to give assurance that the health-based places of safety were being used in line with national guidance around waiting times for assessment, attendance of an approved mental health professional (AMHP) and doctor and time spent in the health-based place of safety. The trust data was held in paper format and cannot be easily obtained through electronic systems.

We found that 5 Boroughs Community Health Trust staff delivered end of life care that was caring, compassionate and supportive of patients and their families. However, there were significant areas for concern.

The trust did not have an overarching framework or strategy for end of life care. The advanced care plan document developed to replace the Liverpool Care Pathway in July 2014 was comprehensive and person-centred, this plan was not yet in use and this had led to inconsistent care being provided. We observed examples of how this had negatively affected patients’ care. The trust had appointed a board member with a specific lead role for end of life care but there was not a non-executive director taking a lead on end of life care and we noted that staff did not know who the executive lead was.

Safety was not a sufficiently high priority and there was limited measurement and monitoring of safety and performance. Ineffective systems of risk identification and management meant that opportunities to prevent or minimise harm had been missed, particularly in relation to medicines management, mandatory training and record keeping.

We found that the trust was not always delivering care to patients that was evidence-based and in line with key documents such as National Institute of Clinical Excellence guidance and priorities of the dying person, particularly personalised care, identification of the dying person and coordinated services. There was limited monitoring of patient outcomes of care and treatment, and patient feedback was not actively sought.

A review of the data and speaking with staff showed a lack of robust monitoring systems to ensure that the end of life care service was delivered effectively.

The training for staff involved with the delivery of end of life care was inconsistent and in areas the training compliance was very poor. A large number of staff had not had recent up to date end of life training.

The end of life care team worked effectively and engaged with other professionals to ensure patients received the required level of care and support but a stronger senior management support framework was needed.

Staff appraisals were completed but there were inconsistencies in staff supervision. Staff spoke positively about the support they were given by seniors and management.

It was evident that the individual teams delivering end of life care were trying hard to achieve partnership working despite the difficulties of different services being provided under different trusts. A consultant with a responsibility for end of life care who was shared with other local trusts provided good clinical leadership and support to the palliative care team. Staff worked with the local hospice, hospitals, GPs and specialists to seek advice when needed. The hospice team provided specialist advice and support as requested and they coordinated and planned care for patients at the end of life in the community.

When we talked with patients and staff and observed care, we found that staff were passionate and committed to providing good end of life care. Staff were observed providing care to patients with kindness, compassion and dignity.

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

Staff had received safeguarding training and had a clear understanding of safeguarding and their responsibilities in relation to identifying and reporting allegations of abuse. They followed the lone working policy and when they carried out home visits they kept other staff informed of their whereabouts.

Information about any adverse events had been cascaded to staff within the trust. This was done through the trust intranet, which all staff had access to. Incident recording and reporting was effective and embedded across all services. Staffing levels within both teams we visited was up to the level they were commissioned for. At the children and adolescence mental health services (CAMHS) we looked at the design, layout and cleanliness of all the areas where young people were cared for and found the environments were safe and suitable.

Staff worked in a multi-disciplinary and collaborative approach to care and treatment. This meant they worked with other professionals including social workers, a general practitioner, occupational therapist and a psychologist. Supervision was completed monthly. Several staff told us this was booked in advance and it was expected that staff attended. Staff were appropriately qualified and competent at the right level to carry out their work.

The CAMHS services were developing and implementing person centred pathways of care that detailed locally agreed evidenced based clinical standards for a defined care group. These pathways adhered to national institute for health and care excellence guidelines.

The team manager reviewed referrals and risk assessed them daily. During the assessment, a clinician would work with the young person and/or family to think about their difficulties and what might help them.

All information needed to deliver care was stored securely and available to staff when they needed it and this was in an accessible form.

Each service had collected feedback from young people, their parents and carers. The trust provided us with young peoples’ and their carers’ feedback, which was collected in each of the waiting rooms using a computer.

There was a participation group called ‘shout’ that was open to current patients, former patients and other young people who wanted to make a difference to mental health services. There were six ‘shout’ groups in the trust and young people involved were able to log volunteer hours, do training and receive personal references.

Staff involved patients and their families as partners in their care and in making decisions. The patients’ agreement was sought throughout. Family were involved as appropriate and according to the patient’s wishes and, where appropriate, information was shared with families.

Staff listened to the concerns and complaints of patient’s and families. We saw evidence of the information available to patients and their families on how to make a complaint and other agencies such as the patient advice and liaison service that supported people with complaints.

Staff considered the patients and their families’ spiritual, ethnic and cultural needs and their care and treatment was planned and delivered to reflect these needs, as appropriate. At the two services we visited, we looked at the design and layout of all the areas where patient’s were cared for and found the environments promoted dignity and confidentiality.

Any child or young person who presented with self-harm at accident and emergency (A&E) were seen by the children's and adolescent response team on the day of admission. This service was a 24 hour response team. Referrals to the service were made by other professionals, such as GPs, teachers and social workers. These were reviewed each day and prioritised by a member of each CAMHS team.

The 5 Boroughs CAMHS was accredited with excellence in February 2014 by the quality network for community CAMHS. Key performance indicators were used to monitor progress and quality. Management held regular quality performance meetings.

Staff described strong leadership at team level and said they felt respected, valued and supported. Monthly team meetings were held, where information was shared with staff. The management structure was clear and understood by staff.

We saw evidence that staff had clinical and managerial supervision in the CAMHS service. Staff were aware of the trusts vision and values. Despite staff concerns about resources they were motivated and dedicated to give the best care and treatment they could to young people and children.

However:

At the St Helens and Knowsley office, it had been recognised that the décor needed updating. This was in the process of being addressed.

We rated community-based mental health services for older people as good because:

Both the community mental health services (CMHS) we visited had safe, clean facilities that were suitable for delivering care to older people. There were robust systems to ensure security and safety for patients and staff.

Managers planned and reviewed staffing to ensure patients received safe care and treatment. They ensured caseloads were manageable and staff received support to deal with complex issues.

Staff understood their responsibilities regarding safeguarding patients from abuse and the process for reporting safeguarding concerns.

Staff knew what constituted an incident and how to report it. They told us they felt supported and would take responsibility for incidents of harm or risk of harm. After high-level incidents, the trust sent out safety alerts to ensure that staff were aware of incidents and risks and learning was shared.

The care records we saw were of good quality. They included the patient’s views, covered the full range of the person’s needs and were recovery based. Physical health care was well planned and documented.

Although the teams had access to a range of disciplines to support patients, there was no input from clinical psychologists as recommended by the National Institute for Clinical and Health Excellence (NICE).

We found examples of practice designed to improve services; for example, the memory service was accredited by the Royal College of Psychiatrists and there were good examples of work being carried out to meet patients’ diverse needs.

The staff were clear about their responsibilities in undertaking assessments of patients’ mental capacity to make decisions about their treatment. They understood how to ensure that patients were able to understand and agree to decisions or that decisions made by others were in the best interests of the patients.

Staff demonstrated good knowledge and understanding of patients. We observed staff treating patients with respect, kindness and dignity, and it was clear they had a good understanding of their needs. We saw people were comfortable both in the services we visited and when staff visited them at home. Patients we observed taking part in activities appeared relaxed.

The patient, carers and family members we spoke with all told us they felt involved in planning care. They told us staff listened to their views and included them in the care plan. The care records we saw showed that patients and their carers were involved in making decisions about care. Carers said they were offered support when they needed it.

People were supported to maintain their independence as far as possible; for example, by attending neighbourhood groups.

The teams focused on helping people to remain in the community and avoid being admitted to hospital where possible. They made efforts to meet people’s individual needs, including their cultural, language and physical needs. We saw staff engage with patients with kindness and respect. They made plans for people’s continuing support from the start of their treatment.

Patients and their carers and families were involved in planning care and treatment and in making decisions. They told us staff listened to them and supported them. Issues people raised were shared with the teams so they could learn from people’s experiences.

We saw clear examples of strong local leadership. Staff told us they felt respected, valued and supported. They were clear about the vision and direction of the service and about how their work linked into the trust’s vision and values.

We rated the service as good because:

There were care plans in all of the care records that we reviewed. Three of the wards were completing the ‘my recovery story’ with patients with the aim of setting goals and the patient having more insight into the reason for their admission and focus on their recovery.
The ward environments were clean and in good repair.
Staff were qualified and had the skills they needed to carry out their roles effectively and in line with best practice. Regular clinical supervision was being undertaken on all wards except Coniston ward.
A clear admission process was in place to ensure admissions to the PICU were appropriate. There were good working links with the community mental health teams (CMHT) to facilitate discharge from the wards.
The acute and PICU wards used a number of measures to monitor the effectiveness of the service provided. The wards had access to systems of governance that enabled them to monitor and manage the ward and provide information to senior staff in the trust. Most of the acute and PICU wards were accredited by the Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI) accreditation scheme called AIMS.
Staff reported that morale was generally good. Staff spoke positively about their roles and told us they felt supported by managers across the services we visited.
Patients were treated with compassion and empathy. Feedback received from patients was mostly positive about their experiences of the care and treatment provided by the staff. Patients were actively encouraged to participate in a wide range of activities. Patients’ diversity and human rights were respected. Patients were supported by advocacy services. Complaints and concerns were taken seriously and responded to in a timely way.
The trust’s vision and strategies for the service were evident and most staff considered they understood the vision and direction of the trust.

However:

Lessons learnt from serious incidents were not routinely shared with ward managers and their teams. The timely and appropriate dissemination of learning following a serious incident is core to ensuring that incidents are not repeated. We were not informed of any clear and timely trust-wide dissemination or action planning following a serious incident.
Attendance at medicine management training was low and incidents relating to medicines management were high. The high temperature in the storage of medicines on Weaver ward compromised the stability of the medicines.
The seclusion rooms in the Taylor, Grasmere and Coniston wards did not meet the Mental Health Act (1983) code of practice requirements. Also, the lack of toilet facilities in the seclusion room on Taylor ward compromised patient dignity.
Environmental difficulties and blind spots were noted in all ward areas and mitigation was in place in an attempt to address these difficulties. Stand-alone ligature risk assessment was only completed in one ward area following a high volume of ligature incidents. These identified risks had been awaiting resolution for over 6 months. We found that staff were unable to locate environmental risk assessments in some of the ward areas presenting a risk to patient safety.
Blanket restrictions were in place on Austen and Sheridan wards where patient bedrooms were routinely locked without individual risk assessments taking place. In response to a serious incident relating to ligature risks, for instance from grab rails, accessible bathrooms were locked across all the wards. However, Austen, Sheridan, Cavendish and Grasmere wards routinely locked not only the accessible bathrooms, but also all shared toilets in communal areas.

Overall, we rated the forensic inpatient secure units as requires improvement. This was because:

The service did not always identify and manage risks adequately. Not all patients had comprehensive, complete and up to date risk assessments. Chesterton unit operated blanket restrictions. On Chesterton unit, there were blind spots that were not observable from nursing stations or by staff located in communal areas.
There were high levels of incidents involving violence, aggression and self-harm on Chesterton unit. Staff were not confident in managing patients’ needs. Recruitment and retention were difficult, which had resulted in a heavy reliance on bank and agency staff, and failure to have enough staff to fill every shift.
Supervision and support for staff was inconsistent and staff were not confident they had the right skills, knowledge and experience to meet the needs of some patients. Staff were not up to date with all their mandatory training.
Care and treatment did not always reflect current evidence-based practice. For example, Chesterton unit had not fully implemented a recovery-based model of care, and there was no care pathway in place for the treatment of personality disorders.
Patients were not always involved in the planning of their care. Patients and relatives expressed concerns about how some staff treated patients on Chesterton unit. Some care records contained comments that lacked dignity and respect for patients. Not all patients had discharge plans in place.
Patients and staff expressed concerns about the suitability of the facilities on some units for meeting the needs of all patients.
Chesterton and Auden units did not adequately record and deal with complaints received from patients and relatives.
The governance systems did not identify gaps in service provision and did not produce sustained improvements to the care delivered.

Overall, we rated the wards for older people with mental health problems as good. This was because:

There were good multidisciplinary teams in place on each ward, which included nurses, doctors, physiotherapists, occupational therapists and other skilled staff.
The teams worked well together and had good links with community services.
The inpatient services focused on helping people with their physical health, nutrition and maintaining mobility, as well as their mental health needs.
The staff we saw were kind and courteous in all their dealings with patients and carers.
Patients and their family members told us that they were happy with the care they received and were involved in assessing and planning care. They also told us that staff would let them know if things were not right as soon as possible and always kept them informed.
The wards complied with same sex guidance for accommodation by providing en suite bathrooms. On Sephton ward, where same sex dormitories were provided, there were designated male and female bathrooms and toilets.
There was a good range of activities and things to do on the wards.
Staff understood and demonstrated the visions and values of the trust.

However,

Women-only lounge areas were not available on Grange or Kingsley. The clinic room on Grange ward was warm and staff told us it can vary between 25 – 30 degrees. This could affect the quality of the medications stored there.

We rated child and adolescent in-patient mental health wards as good because:

Staff delivered person centred care in a kind and respectful way.
Staff completed care programme approach patient assessments and reviews in a timely manner.
Patients and carers told us they were involved as partners in care.
Patients told us they were satisfied with the care they received and felt supported.
Patients had current care plans and risk assessments.
Care plans were recovery and outcome focussed.
Patients had a physical health assessment on admission to the ward.
The ward staff worked effectively as a team with professionals from various backgrounds.
Staff showed a clear understanding of the Mental Health Act 1983 and issues relating to the capacity of young people to make decisions about their care.
Patients and carers told us that staff treated them with kindness, dignity and respect.
Staff told us they felt supported and they could raise concerns without fear of recriminations.
There was a training plan in place and good development opportunities.
The team reported incidents of harm and risk of harm and had a clear system to share learning.
Staff told us they were happy and felt valued as team members.
Local leadership was available to staff and supportive of role development.

However, not all prescription charts for ‘as required’ medication had been reviewed within the last 14 days in line with current guidance. Patients did not have access to a female-only lounge on the ward.

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

Staffing levels were adequate to meet the needs of people who use the service. Staff had access to additional bespoke training in learning disabilities. We saw systems and processes for staff to ensure the safety of services.

Staff completed risk assessments and kept them up to date and relevant to the people who used the services.

Staff were able to identify abuse and safeguarding concerns and follow the correct procedures for their service. Staff knew how to report incidents or harm or risk of harm, and were aware of lessons learned from other areas of the trust when things had gone wrong

People who use the service were involved in their care planning. Staff understood the individual needs of the people using the service and knew how to support them and involve them in their care using a variety of communication aids to maximise their involvement.

Care pathways gave clear guidance on referral and assessment We saw evidence that National Institute for Health and Care Excellence guidance and best practice was followed and shared within the teams.

Staff from a wide variety of disciplines worked in the teams and communication between them was effective.

People detained under a community treatment order were told their rights in a format that they understood.

People who use the services and their carers spoke positively about the care received and interactions they had with staff. People said that advocacy services were available should they want to access them.

The trust and the teams sought feedback from people and carers in a variety of ways.

There was a responsive triage/ duty system that allowed people to have contact with the service for advice and support when needed. People referred to the service were seen the same day if their need was were urgent.

Team managers monitored waiting lists and there was a clear rationale for those waiting more than 10 weeks for care.

Facilities were accessible for people with physical disabilities. Easy read information was available on noticeboards in waiting areas.

People and carers we spoke to said they would feel able to make a complaint if they had one and felt that they would be listened to. We saw team meeting minutes that showed lessons were learned from complaints.

The core values of the trust were used as part of the appraisal process. There were good governance structures for reporting up to the trust and staff knew how to use the system.

The service level leadership and management structures were good. Teams felt that they were well led and supported and there were good monitoring systems for training, supervision and appraisals.

We saw clear commitment to improving services through research and audit. There was also open communication with commissioners to develop key performance indicators metrics focused on learning disabilities.

We gave an overall rating for community based mental health teams for adults of working age as good because:

The teams assessed, monitored and managed patient risks on a day-to-day basis. There were effective handovers and shift changes, to ensure staff can manage risks to people that use services. Staff took steps to prevent abuse from occurring and responded appropriately to any allegations of abuse.
Staff, patients and carers were able to escalate concerns if a patient’s condition deteriorated to the appropriate teams ensuring risks to people who use services were managed effectively. Staff worked collaboratively to understand and meet the needs of their patients.
Staffing levels were managed and routinely reviewed by the managers and the trust. This ensured the services had the staff they needed with the right skill mix.
Staff demonstrated a good understanding of the Mental Health Act (MHA) and Mental Capacity Act (MCA) and applied these in the protection of patients’ rights.
There was participation in relevant local and national audits within the community mental health teams to monitor their services.
Staff were caring and compassionate to patients’ needs, treated patients with dignity, respect and compassion, and recognised their individual needs. There were mechanisms in place to capture feedback from patients and carers who used the service. Staff helped patients to maintain and develop their social networks and community and, where possible, were enabled to manage their own health and care.
The trust had complaints processes in place. Staff told us they were able to speak openly about issues and incidents, and felt this was positive for making improvements to the service.
The trust had a clear statement of their vision and values, and staff were aware of these. There were governance arrangements in place to monitor performance, quality and risk. The trust proactively engaged with staff and provided systems to seek feedback from them to improve their services.

However,

The trust should ensure that the lone working policy is fully embedded and reviewed throughout the community teams and specifies who is required to check staff safety following visits and to improve the regularity of the checks.
The trust should review and monitor their community bases where staff work alone and see patients in visiting rooms or within the community against the trust’s associated policies and procedures for lone working to ensure staff and patients are safe.
Clinical supervision and appraisals were not fully implemented in all of the teams we visited.
The trust should continue to review and monitor patients who are subject to the Care Programme Approach to ensure patients receive planned reviewed and coordinated care they need.
The trust should ensure that each team’s operational guidance is updated to reflect the services provided by mental health services for adults of working age in the community.
The trust should ensure staff receive clinical supervision and appraisals.
The trust should provide the Care Quality Commission’s contact details alongside the MHA patient information, so that patients know where to make a complaint regarding the application of the MHA.
The trust should ensure that the Warrington and Halton home treatment team review the use of their medicines cabinet to ensure their medicine storage facility is fit for purpose.

We rated wards for patients with learning disabilities or autism as good because:

· The ward had systems, processes and practices in place to keep patients safe and safeguard them from abuse. Staff understood their roles and responsibilities to raise concerns and report incidents.

· Staff monitored individual and environmental risks and managed them appropriately. Staff carried out comprehensive risk assessments for patients and risk management plans were in line with national guidance. Staff monitored and reviewed risks this enabled staff to understand risks which gave them a clear picture of safety.

· Staff took an holistic approach to assessing, planning and delivering care and treatment for patients. Patients’ individual care and treatment were planned using best practice guidance. The outcomes were monitored to ensure changes were identified and reflected to meet their care needs.

· We saw evidence that patients, carers and family members were involved in the decisions about the care and treatment planned. Staff monitored, reviewed and recorded patients’ consent practices and proactively involved them in making decisions about their care where they could. Patients’ consent to care and treatment was sought in line with the Mental Capacity Act 2005 legislation. Patients who were subject to the Mental Health Act 1983 were assessed, cared for and treated in line with the Mental Health Act and Code of Practice.

· Staff were highly motivated and inspired to offer care which was kind and promoted patient dignity.

· Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff were supported by means of supervision and appraisal processes, although it was recognised that this had slipped within recent months due to the vacancy of the deputy ward manager. The supervision and appraisal process was used to identify additional training requirements and manage staff performance.

· Feedback from patients, carers and family members was consistently positive about the way staff treated them. We observed patients being treated with dignity, respect and compassion whilst receiving care and treatment. Staff recognised patients’ emotional and social needs and were embedded in their care and treatment plans.

· Staff planned and delivered services to take into consideration patients’ individual needs and circumstances. Access to care and treatment services were timely. Delays in discharge were minimal and managed appropriately.

· Staff took a proactive approach to understanding the needs of the different groups of patients and to deliver care in a way that met those needs.

· Complaints were actively responded and managed locally. The ward listened to the patients’ or their carers’ concerns with a view to improve the services being provided. Patients and carers were involved in that review and resolution were appropriate.

· The ward had a good structure, processes and systems in place to monitor quality assurance to drive improvements.

· The service had the processes and information to manage current and future performance. The information used in reporting, performance management and delivering quality care was timely and relevant. Performance issues were escalated to the relevant monitoring committee and the board through clear structures and processes.

Community services for adults were delivered by staff who were committed and enthusiastic about their roles, and who felt proud to work for the trust. Staffing levels were managed and there were low levels of sickness and few vacancies.

Patient experiences were positively reported and although data was captured relating to patient outcomes, there was sometimes a lack of feedback to staff about the results of data analysis, or learning from incidents.

An new IT system was being implemented in planned phases to improve the overall experience for patients and make services more streamlined. The implementation inevitably caused some delays and reduced the number of some clinic appointments which lengthened the time taken to be seen.

Referral and discharge processes worked effectively except in one area, where the cessation of a Clinical Assessment and Treatment service in June 2015 had lengthened the process of referral because patients had to be referred via their GP rather than being directly referred from the service.

There was a system in place to monitor mandatory training levels and staff showed us evidence that they completed training regularly. In some small teams there were deficits in the uptake of particular training such as infection control, the Mental Capacity Act, and moving and handling in specific teams. Medicines management training was also poor across district nursing teams, two of which reported that no one was up to date.

In most of the services provided, people received appointments in a timely way. Clinics were visibly clean, tidy and organised. Patients said the standard of care was good and that the staff were friendly. This was reflected by the low levels of complaints received.

We gave the community health services for children, young people and families an overall rating of good.

The level of incidents reported show low risk of harm and safe systems for care and treatment of patients. Staff understood how to report incidents. There were processes in place to help staff provide patients with safe care and support in clean and suitably maintained premises. There were enough staff with the right mix of skills to meet patients’ needs.

The community health services provided effective care and treatment that followed national clinical guidelines. Staff knew how to use care pathways effectively. The services participated in national programmes, such as the healthy child programme.

Most patients experienced positive outcomes following their care and treatment. However, breastfeeding initiation and six week continuation rates were below national averages. The services planned to improve compliance through engagement at baby clinics and breastfeeding peer support sessions, and through raising awareness of these services.

Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team. Staff sought consent from patients before delivering care and treatment. However, the immunisation team did not always apply the Gillick competency principles when providing treatment for young people in special schools and routinely sought consent from their parents or carers instead of identifying whether the young person had the capacity to consent.

Patients’ relatives spoke positively about the care and treatment provided by staff. Staff treated them with dignity and compassion. Staff kept patients and their families or carers involved in their care. Patients and their relatives were supported with their emotional needs, and there were bereavement and counselling services in place to provide support for staff, patients and their relatives or carers.

Services were planned and delivered to meet the needs of local people. Complaints about the service were shared with staff to aid learning. Most patients received care and treatment in timely manner. However, the trust target to treat patients within 18 weeks of referral was not always achieved by the speech and language therapy and occupational therapy / physiotherapy teams. A service transformation plan was in place to improve the delivery of services.

The trust vision and values had been cascaded and staff understood them. There was clearly visible leadership in place through local team leaders and business managers and staff were positive about the culture and support available. Routine meetings took place to review incidents, key risks and monitor performance.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We found that the provider was performing at a level which led to a judgement of requires improvement overall. In mental health services, we rated nine of the ten core services we inspected as good, with the forensic service rated as requires improvement. In acute community services which the trust provided in one borough, we rated two of the three services as good with end of life care rated as requires improvement.

The trust had identified that its governance system needed improving and was in the process of strengthening this. The trust had also taken steps to improve clinical input at a senior level with the introduction of new roles.

The areas where improvements were needed were:

In end of life care there was no formal strategy, policy and framework for the delivery of care.
Policies and procedures that should have ensured that all staff delivered a similar safe, caring, effective and responsive service were not always ratified or in date.
In end of life care, medicines were not managed safely. Records were not correctly completed and there were discrepancies in stock levels. Staff were not following trust policies and procedures for handling medicines. Across the trust, only 22% of staff had completed medicines management training.
Learning from incidents and complaints was not consistent across the trust which meant that the same problem could recur. The trust had taken steps recently to address this but the actions taken were not yet embedded sufficiently to deliver a robust learning culture across all services.
Governance systems were not always identifying shortfalls or variations in quality of care.There was a lack of consistency of quality of care across services which meant that patients could have different experiences of care depending on which ward they were admitted to. This was seen in acute wards for people of working age and in the forensic service. Risks were not always identified and acted upon.

The trust took immediate action to reduce risks in response to concerns raised at the time of the inspection. It is our view that the trust needs to take steps to improve the quality of their services and we find that they are currently in breach of regulations.

Areas of positive performance included:

Staff were committed and passionate about providing good care and were proud to work at the trust.
There were a number of ways for patients and their carers to be involved in the running of their trust. Governors spoke highly of the way the trust involved in them.
The trust worked with the community and worked hard to promote positive attitudes towards people living with mental health needs.
In mental health services, medicines were generally well managed with a culture of high reporting of errors.
The chief executive was visible and accessible.
The trust visions were known by most staff working across the trust and they understood how this informed their work
The leadership team recognised the importance of strong engagement with patients, staff and external stakeholders and were working to develop this further.
The trust worked hard to reduce the stigma of mental health in the local community.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment and promote a consistent quality of care across services.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

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

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

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

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