All inspections: Tees, Esk and Wear Valleys NHS Foundation Trust

Tees, Esk and Wear Valleys NHS Foundation Trust provide mental health and learning disability services in County Durham and Darlington, Teesside, North Yorkshire, York and Selby. The trust have 167 services across 66 locations. The trust provide 10 core services:

Specialist community mental health services for children and young people
Community mental health services with learning disabilities or autism
Community-based mental health services for older people
Community-based mental health services for adults of working age
Mental health crisis services and health-based places of safety
Wards for people with a learning disability or autism
Forensic inpatient or secure wards
Long stay or rehabilitation mental health wards for working age adults
Wards for older people with mental health problems
Acute wards for adults of working age and psychiatric intensive care units

The trust also provide one specialist service.

We carried out unannounced inspections of 4 of the inpatient mental health services provided by this trust, and short notice (24 hours) announced inspections of 2 of the community services.

We also inspected the well-led key question for the trust overall.

We inspected acute wards for adults and psychiatric intensive care units and community mental health services for adults of working age because we had concerns about the quality of care provided relating to serious incidents occurring in the services.

We inspected inpatient wards for people with a learning disability and or autism because at our last inspection in 2022 we rated the service as inadequate overall and needed to ensure the quality of care had improved.

We inspected inpatient forensic secure services because at our last inspection of this service in 2022, we rated this service requires improvement overall and inadequate in the safe key question and needed to ensure that the quality of care had improved.

We inspected wards for older people with mental health problems and community mental health services for people with a learning disability or autism because of the length of time since we last visited these services and due to the potential high-risk nature of these services.

We did not inspect long stay/rehabilitation mental health wards for working age adults, mental health crisis services and health-based places of safety, or community-based mental health services for older people because we have not been in receipt of information of concern since our last inspection of these services.

We did not inspect specialist community mental health services for children and young people because the services had not had time since our last inspection to make the improvements necessary to meet legal requirements as set out in the action plan the trust sent us after the last inspection.

We are monitoring the progress of improvements to these services and will re-inspect them as appropriate.

Overall, we rated safe, responsive and well led as requires improvement and effective and caring as good.

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

At this inspection we rated 3 of the six services core services we inspected as requires improvement overall and 3 as good. In rating the trust, we took into account the current ratings of the four services we did not inspect this time.
We rated 7 of the trust’s 10 core services and one specialist service as good and 4 as requires improvement. We rated 9 core services as requires improvement in the safe key question and 5 as requires improvement in the responsive key question. We found effective leadership and management at local level in most services, however we found that some of the trust’s systems and processes did not operate effectively at a senior level. This meant that whilst we rated well-led as good in most core services, we rated the trust as requires improvement for the overall well led key question.
The trust did not always have enough suitably trained staff to deliver safe care in all services. This was due to high vacancy rates, high sickness rates and significant reliance on temporary staff in some services. There was low compliance with specific modules of mandatory training. This included modules directly related to patient safety such as moving and handling, positive and safe care (restraint) and resuscitation.
Some areas of the trust’s estate continued to present risks to quality and safety. Action plans to remove environmental ligature risks had not all been completed. Seclusion facilities were not always fit for purpose. Some wards had blind spots which had not been identified or mitigated, the trust acted on these at the time of the inspection.
The trust’s reducing restrictive practice programme for 2022-23 had failed to reduce overall rates of restraint. The use of restraint had increased by 17% in the trust’s services since the previous year. The trust continued to use prone and mechanical restraint without appropriate challenge and oversight by senior leaders. However, there had been a reduction in the use of prone and supine restraint, with an increase in less intensive forms of restraint.
Staff did not always consistently take appropriate action to reduce risk to people using services. Some patients in acute mental health services were able to access leave from wards without appropriate risk assessment. Some patients’ physical health was not always monitored appropriately in acute mental health, forensic and learning disability inpatient services. Risks were not always shared and handed over effectively between shifts on some wards.
People continued to wait too long to access services. Waiting times for community mental health services had not improved since the last inspection. There were significant waiting times in child and adolescent mental health services and for neurodevelopmental assessments. The trust’s locality model had introduced variation where some patients faced inequity of access to services because of where they lived. The trust needed to work with both integrated care boards to improve access to services.
Staff did not always receive, or record that they had received regular supervision and appraisal. This meant that the trust did not have effective systems in place for oversight of whether staff received appropriate opportunities for support and development.
The trust did not have effective systems to consistently collate, analyse and present information about quality and performance in a way that identified risks and challenges, or supported effective decision making. There were examples of early warning signs in frontline services which had been missed by the trust’s risk management and audit processes.
The trust had a backlog of 100 serious incidents requiring investigation. There were further backlogs in incidents requiring routine investigation and in incidents resulting in patient deaths requiring review through the trust’s learning from deaths processes. The trust’s backlogs delayed opportunities to learn lessons and make improvements to prevent incidents recurring. The trust had experienced several similar incidents where learning was not evident. The trust were receiving external support to manage the incident backlog.
The trust had experienced several high-profile incidents. The impact of the incidents had resulted in lasting and persistent changes to the culture of the trust which included an over-cautious approach from senior leaders to recognise and celebrate improvement.
Where there had been incidents or treatment which caused harm to patients, the trust’s approach had not always ensured staff and leaders reached out to people who had been harmed by its practices. The trust missed opportunities and appeared reluctant to consistently engage with people who used services, staff and others who had negative experiences or had been involved in incidents.
The trust did not always act in accordance with the requirements of the duty of candour by failing to make an apology without delay for incidents resulting in harm.

However:

Forensic inpatient secure wards, wards for people with a learning disability or autism and wards for older people had all improved since our last inspection. The trust no longer had any services which were rated inadequate. The leadership and safety of community mental health services for working age adults had improved since our last inspection in December 2021 and ratings had improved to a rating of good overall.
Leaders were experienced, visible and approachable. Leaders at all levels had ensured that improvements were made since our last inspection. The trust had made improvements to its fit and proper persons’ process.
Executives and non-executives were passionate about the trust’s delivery of safe, high-quality care and were aware most of the trust’s challenges, risks, and issues.
The trust had a clear vision and strategy, understood by all staff and driven by the chief executive. We were able to see progression towards the trust’s achievement of its strategic goals. Staff demonstrated the trust’s values in the care they provided.
Staff felt supported and valued and had confidence in the trust’s freedom to speak up process. The trust had undertaken work to understand the risks of closed cultures across the services it provided.
The trust was making improvements to its information management systems which included a refreshed patient record system which had been co-created with staff, service users and carers and was clinically designed.
There continued to be good and improved engagement with staff, stakeholders, and partners. The trust was ambitious about co-creation and had several programmes in place to enhance opportunities for involvement.
The trust had implemented a recognised methodology with a clear and embedded approach to quality improvement which involved staff at all levels, we were able to see examples of where quality improvement approaches had been used to improve services and processes. However, we saw that the trust's approach to quality improvement was sometimes related more to problem solving than innovation.
The trust had sought feedback on its governance processes and had made significant changes to governance arrangements which had made it easier for services to escalate risks to the board

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about the trust. During the inspection visit, the inspection team:

visited all 42 of the trust’s forensic inpatient secure wards, acute wards and psychiatric intensive care units, wards for older people and wards for people with a learning disability and autism.
visited two of the trust’s learning disability respite units.
visited 14 of the trust’s community locations.
spoke with 292 members of staff.
spoke with 131 people using the trust’s services.
spoke with 31 carers or relatives of people using the trust’s services.
reviewed 217 care records including 115 medicines administration charts.
carried out 6 short observational framework for inspection (SOFI2) observations.
observed several meetings including multi-disciplinary team meetings and safety huddles.
observed four sub-committees of the board as well as one board meeting.
held three focus groups with staff and governors.
spoke with 25 members of the trust’s leadership team including members of the board, the chair and the chief executive.
sought feedback from a range of stakeholders including health watch and the integrated care board.
reviewed the trust’s process for fit and proper persons employed.

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

What people who use the service say

In wards for older people with mental health problems.

Patients told us that staff were kind and considerate and that they were always around to support them whenever they needed. They said that staff managed very well at busy times, and they said that they dealt with difficult situations very well. Patients said they felt safe whilst they were being cared for on the wards. Patients told us that the wards were always kept clean and that they felt the facilities met their needs. They said that they valued the range of support available and sessions and activities that were taking place. They said that food and drinks were good quality and available at all times.

In forensic secure inpatient wards.

Patients talked positively about the activities they were involved in including cooking, drama, pet therapy and fitness. Patients told us staff were supportive and kind and that they felt safe on the wards. One patient talked about the comprehensive support they were receiving in their transition to their future placement. Another patient talked about the service meeting their cultural and faith needs and facilitating access to the Imam.

In wards for people with a learning disability or autism.

People told us staff were friendly and nice. They told us staff supported them to carry out activities that were of interest to them. People showed us their accommodation and described how they had personalised it. One person was happy to tell us about their future plans. Relatives and carers of people using the service told us that environments were clean and fit for purpose. They told us people usually had a stable staff team who knew and understood the person well. They told us they felt their relatives were safe using the service. One family member told us there had been a significant reduction in the number of incidents involving their relative. They told us people received high standards of person-centred care.

In acute wards for adults of working age and psychiatric intensive care units.

Patients were mostly positive about the care and treatment they received. Most patients told us that staff were very friendly, kind and supportive and were very complimentary about the quality of care they received. They told us that staff always treated them with dignity and respect. Most patients told us that staff were responsive to their needs and had regular 1:1s with nursing staff.

Most patients were very complimentary about the quality and choice of the food available.

Patients told us they had access to activities during weekdays.

Patients felt involved in their care and treatment and that staff involved their carers as appropriate.

In community services for people with a learning disability or autism.

Patients told us they were actively involved in discussing and planning their care needs along with their social care needs. One patient told us their care was “really really good, I like my nurse and psychiatrist”. Other patients told us that the service “couldn’t be better” and was “great”. Carers and relatives told us that the service helped them identify what support was available for them and their relative and the team “moved heaven and earth for us”.

In community mental health services for adults of working age.

Patients who used the service told us they were actively involved in coproducing, writing, and planning their care and were involved in decisions about their care and treatment. One patient told us their care support worker was ‘better than therapy, or medicines’. Another patient told us ’I’m striving, not surviving and feel valued’. Other patients told us that the service “did what it said on the tin and exceeded my expectations’ and ‘the service saved my life’. Carers and relatives told us that the service supported them, and they had access to carer support champions and could attend carer support groups.

Trustwide

We reached out to the trust’s stakeholders to give feedback for the inspection and received it from Healthwatch York.

Healthwatch York noted that in children’s services more recently they had been hearing and receiving positive feedback on the service including improved communication with parents, improved information and signposting in the letters parents receive when their referral has been acknowledged.

Healthwatch York also shared that they had noted a recent willingness from the trust to help them understand more about their approach to service provision and a want to link Healthwatch York to people around the system. Healthwatch York had been invited to speak to the trust about their mental health crisis care work, including the invite to host conversations with the crisis team staff. They also noted that leadership within the trust had been open to conversations around needs for improvements and the challenges they were facing.

They shared some positive comments from patients and staff in relation to quick responses from the crisis team and improved access to the crisis team’s telephone in York.

However,

In community mental health services for adults of working age

Patients said getting through to teams in York and Middlesborough was difficult, because the phone lines were constantly busy.

Some patients told us that the trust’s approach to care did not feel person centred and inclusive.

In forensic secure inpatient services

We spoke with 41 patients. One patient told us that staff did not understand their needs, particularly unfamiliar staff and this meant that staff misinterpreted their communication. Eleven patients told us that the food was of poor quality. Seventeen patients told us the staffing levels were low, this impacted on them being able to pursue activities, access leave and have the staff support that they required. Patients on Brambling ward told us that they couldn’t use the safes in their rooms, either because they were broken, or staff had not helped them to set them up. A patient told us and records confirmed for another patient that they had not received a debrief following incidents. Four patients told us that some staff do not protect their privacy and dignity by entering their room without knocking.

In wards for people with a learning disability and autism

Two family members raised concerns about the number of agency staff working in the service. One family member said there weren’t enough meaningful activities.

In acute wards for adults of working age and psychiatric intensive care units.

We spoke with 47 patients. Six patients told us that staff could be busy, they told us that sometimes nurse staffing levels caused delays in dealing with requests specifically those that needed the support of a registered nurse. 10 patients across all the sites told us they did not know who their named nurse was and/or they were not having proactive regular and meaningful 1:1 conversation with nursing staff to talk about their mental health, wellbeing and progress. They reported that this was due to nursing staff being too busy as the wards were short staffed. Patients did say if they asked to speak to a nurse themselves this was facilitated.

They told us that there was less to do in the evenings and at weekends. Some patients told us that there was too much focus on physical activities such as walking and going to the gym. Some patients were not aware of the activities available as there wasn’t always an updated activities timetable.

One patient told us that staff had refused to follow a specific aspect of their care plan and that this had caused them distress, they also told us that they were not given a copy of their care plan and information about their rights.

Trustwide

Healthwatch York told us that in children’s services there continued to be a need for improved communication around services available to help with ‘waiting well’ and prevention. Also, a need to address inefficient administration systems.

They told us that findings in March 2023 in relation to care of older people with mental health problems suggested; discrepancies in diagnostic wait times, discrepancies in experiences of health care and a lack of coordination between providers, concerns around how ‘user friendly’ accessing support can be, lack of formal information and guidance support. They said that the public and partners told them about ‘blockages’ at every stage of the diagnosis process.

We carried out this unannounced focused inspection to see whether improvements had been made since our last inspection in June 2021. On that inspection, we issued a warning notice under Section 29A of the Health and Social Care Act.

On this inspection, we checked whether improvements had been made to address the concerns identified. These included ensuring that; there were enough staff so that care and treatment was delivered in a safe way, patients were safeguarded from abuse and treated with kindness, dignity and respect, staff were appropriately trained, the use of restraint within the service was proportionate and individualised, incidents were being reported in line with the trusts incident reporting policy, staff attended regular team meetings and received regular supervision and patients had access to activities and psychological interventions. This is in line with our published guidance to follow up inadequate ratings and section 29A warning notices. Our overall rating of the service improved. We rated them as requires improvement because:

The service did not always provide safe care. The wards did not have enough nurses to carry out all clinical duties to meet the needs of the patients. The service did not always have enough staff to provide a timely response to patient safety incidents. There were not always enough staff who knew patients well to keep patients safe.
The service did not follow good practice with respect to safeguarding. Staff did not always make safeguarding referrals when appropriate and governance processes were not adequate to identify improvements in this area.
Staff did not always assess and manage risk well. Not all ward environments were safe, clean and fit for purpose.
The service was using restrictive practice that was not care planned for or reviewed in line with trust policy. Restrictions were not always based on individual risk assessments and there were blanket restrictions in place. When patients were in seclusion, staff did not always complete required reviews in line with the trust policy or best practice as outlined in the Mental Health Act Code of Practice.
Staff did not always report and record incidents appropriately. Staff did not always report incidents when they occurred and sometimes reported multiple incidents within a single incident record. This meant that there was not appropriate oversight of the scale and nature of incidents which were happening within the service.
Staff did not ensure that patients’ health was appropriately monitored, in relation to high dose antipsychotic treatment, blood glucose and where appropriate bowel monitoring.
The service provided a range of treatments, but staffing levels meant that patients did not always have access to activities, psychological interventions, occupational therapy or escorted Section 17 leave, and staff could not always take their breaks. Staff could not always engage in clinical audit to evaluate the quality of care they provided due to staffing pressures.
Managers did not ensure that regular team meetings took place on all the wards within the service to ensure key information was shared and escalated.
Managers did not always ensure staff had the correct skills and experience to work on mental health and learning disability and autism wards. Managers did not ensure that temporary or unfamiliar staff received a comprehensive induction before working on the wards or that staff received mandatory and statutory training and regular supervision.
Staff did not always treat patients with compassion, kindness and respect.
Staff did not always plan discharge well or liaise well with services that would provide aftercare. As a result, discharge was delayed for other than a clinical reason.
The service was not always well led, and the governance processes did not ensure that ward procedures ran smoothly.

However:

The service used systems and processes to safely prescribe, administer, record and store medicines.
Staff mostly understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment.
The ward teams had access to the range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team.
Staff actively involved patients and families and carers in care decisions. Staff supported patients well to live healthier lives.
Culture within the service had improved since out last inspection, staff felt more supported by managers and mechanisms had been put in place to allow staff to escalate staffing concerns.

What people who use the service say

We spoke to 34 service users and their families during our visit. Feedback from them was mixed.

Fifteen patients we spoke to raised concerns regarding there not being enough staff on the wards. Patients told us staff spent a lot of time in the office which sometimes made them feel neglected. Two patients told us that they had not received their prescribed medication on the day we arrived due to staffing. Another patient told us they did not know who their key worker was. However, most patients said that staff were caring towards them.

In the last patient satisfaction survey completed, the average satisfaction score across the service was 75%. Out of 109 comments received, 64 were negative and 30 were positive.

We spoke to 10 families of service users who told us they felt involved in the care of their relative. However, most families raised concerns related to staffing impacting on the continuity of care for their relative and the ability to facilitate patient leave. Half of the families told us they were unaware of any discharge planning.

From the most recent surveys filled out by family, carers and friends the average satisfaction score across the service was 61%.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

Staff did not support some people to have the maximum possible choice, control, and independence over their own lives. Most people were being nursed in long term segregation and some people had very limited interaction with staff.

Staff were using high levels of restrictive practice including seclusion, restraint and rapid tranquilisation for some people. Restrictive practice was not always recorded, and staff did not learn from those incidents to reduce the levels or restrictions in place for some people.

Staff did not always support every person to make decisions following best practice in decision-making. Staff relied on some people asking to go on leave or take part in activities, with limited encouragement from staff.

Right care

The service did not always have enough appropriately skilled staff to meet people’s needs and keep them safe. The wards at Lanchester Road regularly fell below the required number of staff. There were also two people who were cared for with an agreed agency staff team which had been contracted by the Clinical Commissioning Group. This arrangement was supported by core staff members from the trust.

People did not always receive kind and compassionate care and staff did not always understand and respond to their individual needs. Staff did not always understand how to protect people from poor care and abuse and three people at Lanchester Road had been injured during restraints.

People’s care, treatment and support plans did not always reflect their range of needs and promote their wellbeing and enjoyment of life. Several support plans had not been updated and were not always readily available to staff. Staff did not always encourage and enable people to take positive risks.

Several people did not receive care that supported their needs and aspirations, that was focused on their quality of life, and followed best practice. Most people had stayed in hospital for too long as there was limited access to appropriate community provision.

Right culture

People did not always lead inclusive and empowered lives. Management had failed to effectively respond to significant concerns at Lanchester Road and there was a culture of fear among staff.

People were not always supported by staff who understood best practice in relation to the wide range of strengths, impairments or sensitivities that people with a learning disability and/or autistic people may have. This meant that some people did not receive compassionate and empowering care that was tailored to their needs.

Staff sickness was high at 15% and some staff at Lanchester road told us they were leaving or considering leaving which meant that people did not always receive consistent care from staff who knew them well.

SUMMARY

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

The service did not meet all the principles of ‘Right support, right care and right culture’.
People were not always protected from abuse and poor care. The service at Lanchester Road did not have sufficient, appropriately skilled staff to meet people’s needs and keep them safe. There were high levels of vacancies and sickness with managers and members of multi-disciplinary team often falling into numbers for each shift. Two people were cared for by a full core agency staff team due to absence of an appropriate alternative in-patient provision.
Three people had been injured during restraints at Lanchester Road Hospital and 32 incidents of injury were reported for health care assistants with some requiring treatment.
Staff did not receive the right training to ensure that they had the skills and knowledge to meet people’s needs. Training in learning disabilities, autism and alternative communication methods was not mandatory for non registered staff and a low proportion of staff had completed training in these areas. Several mandatory training courses and overall rates of supervision and appraisals fell below the trust target.
People were not always supported to be independent and have control over their own lives. For some people their human rights were not upheld, and they were being secluded without the appropriate safeguards in place.
Some people did not always receive kind and compassionate care from staff. Some staff did not always protect and respect people’s privacy and dignity and did not always understand each person’s individual needs.
Some people’s risks were not always assessed regularly and managed safely. Some people were not always supported and involved in managing their own risks.
For six people, staff applied restrictions which were not proportionate to the level of risk. There was no clear rationale or plans to end these restrictions. In some instances, managers had failed to recognise the restrictions and reviews were not in place to try and reduce the use of these practices.
The use of restrictive practice including restraint, and seclusion was high for some people. There was limited evidence of learning from incidents and multi-disciplinary team discussions about how to reduce people’s restrictions. One person was given regular intra-muscular injections with no clear plan to reduce this.
Several people were staying in hospital for too long with no clear plans in place to support them to return home or move to a community setting. Staff attempted to work with services to ensure people received the right care and support, but the lack of community provision delayed this.
Some people did not always receive care, support and treatment that met their needs and aspirations. Peoples care and treatment did not always focus on good quality of life and did not always follow best practice. Staff did not routinely use clinical and quality audits to evaluate the quality of care.
Staff did not always understand their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, Mental Health Act 1983 and the Mental Capacity Act 2005.
Leaders were not always visible and approachable. Staff at Lanchester Road did not feel respected, supported and valued by managers. Staff had raised concerns about the safety across the wards to senior managers who had failed to appropriately respond to the serious concerns. Governance processes had failed to keep people safe, protect their human rights and provide good care, support and treatment.

However,

Some people made choices and took part in activities which were part of their planned care and support. Staff supported them to achieve their goals.
Some people’s care, treatment and support plans, reflected their sensory, cognitive and functioning needs.
Most people and those important to them, including advocates, were actively involved in planning their care. At Bankfields court a full multidisciplinary team worked together to provide the planned care.
People’s care and support was provided in a clean, well equipped, well-furnished and well-maintained environment which mostly met people's sensory and physical needs.

Background to the inspection

Tees, Esk and Wear Valleys NHS Trust was created in April 2006, following the merger of County Durham and Darlington Priority Services NHS Trust and Tees and North East Yorkshire NHS Trust. In July 2008 TEWV achieved foundation trust status under the NHS Act 2006.

The trust provides a range of mental health, learning disability and eating disorder services for the people living in County Durham and Darlington, the Tees Valley and most of North Yorkshire and York.

The trust provides care to adults with learning disabilities and/or autistic people at Lanchester Road Hospital and Bankfields Court in Middlesbrough.

These locations are registered to provide the following regulated activities:

Assessment or medical treatment of persons detained under the Mental Health Act 1983.
Treatment of disease, disorder or injury.
Diagnostic and screening.

The service comprised of;

Lanchester Road

Bek, Ramsey and Talbot wards in Durham provide 11 acute assessment and treatment inpatient beds for adults with a learning disability and/or autistic spectrum disorder. At the time of the inspection there were three people being nursed in long term segregation on the wards.
Harland ward - was a bespoke environment which had been adapted for one person who was nursed in long term segregation.

Bankfields Court in Middlesbrough provides assessment and treatment for adults with learning disabilities who also have associated mental health problems, challenging behaviour or severe epilepsy. It contains five smaller units:

Unit One Bankfields Court is an assessment and treatment unit for adults with a learning disability. There was one person in long term segregation on this unit during the inspection.
Units Three and Four Bankfields Court are assessment and treatment units for adults with learning disabilities. Unit four has five beds and unit three has three beds.

Each unit had two people on the ward at the time of the inspection with two of these people in long term segregation.

The Flats at Bankfields Court is a six-bed inpatient assessment and treatment unit for adults with learning disabilities. There were four people on the flats during the inspection with two being cared for in long term segregation within their own flats.
The Lodge at Bankfields Court is a single occupancy inpatient assessment and treatment unit for adults with learning disabilities. There was one person in long term segregation on this unit.
Unit Two Bankfields is a respite/short term care learning disability service
We did not inspect the respite at Baysdale and the Holly Unit.

The wards were last inspected in September 2019 as part of the core service inspection. The core service was rated good overall with requires improvement in safe and good in the other four domains.

CQC carried out a responsive inspection in response to information of concern and extended this to a full comprehensive inspection because of the concerns we identified. The inspection took place across both Lanchester Road and Bankfields Court over three weeks between the evening of the 29 May to 24 June 2022.

What people who use the service say

We spoke to four people while we were at Bankfields Court. Three said that they felt safe and that staff supported them to do activities. One person said the staff played games and took them for ice cream. One person showed us a roller-coaster game that they had made with a staff member and described how they used this to help express how they were feeling. One person showed us around their flat and described the music they liked to listen to. One person said that they would like more interaction with staff. We were unable to speak to people at Lanchester Road due to one person being asleep, another person being involved in an incident and two people did not want to speak to us.

We spoke to six family members. The families of people at Bankfields Court were happy with the service. Families felt supported and involved in the care and treatment and said that staff understood how to care for their loved ones. One family said that the persons quality of life had improved and that incidents had reduced. One family told us that staff had managed to cut the persons hair and get them to shower.

However, the families of people at Lanchester Road were unhappy with the care and treatment. Two families told us their loved ones had been hurt during restraints and that they were worried about the safety on the wards. They did not feel listened to or reassured by managers especially after restraints and injures. They felt that people had stayed in hospital for too long.

How we carried out this inspection

Our inspection team comprised of one head of inspection, one inspection manager, three team inspectors, and one specialist advisor. An expert by experience supported our inspection remotely.

This inspection followed our methodology for inspecting services for people with learning disabilities and autistic people and the quality of life tool.

During our inspection, we:

toured the care environments and observed how staff were caring for people
received feedback from four people in the service and six carers
interviewed 22 staff including: pharmacists, ward manager, modern matron, nurse consultant, registered nurses, clinical leads, occupational therapist, speech and language therapists, occupational therapists, psychologists, behavioural support practitioner, a specialty doctor, consultant psychiatrists and nursing assistants
reviewed seven people’s care and treatment records
reviewed four incidents including a review of CCTV footage
observed four meetings including handovers and a daily report out meeting
reviewed a range of policies and procedures and documents relating to the running of the service.
we also received feedback from three commissioners and three advocates.

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

We carried out this unannounced focused inspection to see whether improvements had been made since our last inspection in June 2021. On that inspection, we issued a warning notice under Section 29A of the Health and Social Care Act.

On this inspection, we checked whether improvements had been made to address the concerns identified. These included, ensuring there were enough staff to meet the demands of the service, staff were appropriately trained, waiting lists were managed, there was clear oversight of any patient risks, the service could be accessed promptly and any issues were promptly addressed by senior management. This is in line with our published guidance to follow up inadequate ratings and section 29A warning notices.

The service provides specialist community mental health services for children and young people. We inspected the following teams:

Easington Community Team
CAMHS North Durham
CYPS Getting More Help Stockton
CYPS Getting More Help Middlesbrough
CYPS Scarborough
CAMHS York East and West

We provided 24 hours’ notice of the inspection to ensure someone would be available at each of the team bases. We inspected on 6-7 July 2022. This was a focused inspection looking at the safe key question only. Our rating of this core service improved. We rated them as requires improvement because:

Although improvements had been made since the previous inspection, there were still not enough staff in every team to meet the demands of the service. Some teams still had a high number of vacancies and high caseloads.
Not all staff were appropriately trained in the mandatory skills required to fulfil their roles.
Despite improvements made, some children and young people were still waiting a long time for treatment.
The majority of children and young people had safety plans in place but where safety plans hadn’t been created, there wasn’t always justification recorded for this.
Staff did not have access to personal alarms at North Durham and not all rooms at Middlesbrough and York were sound proofed.

However:

The service was achieving its targets of maintaining contact with children and young people on waiting lists.
The premises were clean, well maintained and well furnished.
We found the trust senior management team had responded promptly to address issues identified at the previous inspection and in the section 29A warning notice. However, this work was ongoing and had not been fully embedded in the service.

How we carried out the inspection

On this inspection, we assessed whether the service had made improvements in response to the concerns we identified during our last inspection. We therefore only looked at the safe key question.

Before the inspection visit, we reviewed information that we held about the service. During the inspection visit, the inspection team:

visited six team bases;
reviewed the quality and safety of the environment;
attended six meetings;
spoke with 48 members of staff, including team managers;
reviewed 47 care records;
spoke with one young person and 19 parents or carers;
looked at a range of audits, policies, procedures and other documents relating to the running of the service.

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

What people who use the service say

We spoke with one young person and 19 parents or carers.

Everyone we spoke with told us staff treated them with respect and spoke with them in a way they could understand. They told us they always saw the same member of staff and clinicians could be accessed quickly when needed.

Most of the parents, carers and young people we spoke with told us they did not have to wait long for treatment. Four told us they waited longer than two months.

Parents, carers and young people told us the facilities were clean and comfortable.

We carried out an unannounced inspection of forensic inpatient wards because we were made aware of a number of issues including unsafe staffing numbers and poor culture within the service.

We also carried out short notice (24 hours notice) announced inspections of community mental health services for working age adults, crisis and health based places of safety and community child and adolescent mental health services because we received information giving us concerns about the safety and quality of these services.

We inspected the well-led key question for the trust overall.

Following this inspection, we issued a warning notice, under Section 29A of the Health and Social Care Act 2008, on 23 August 2021. This identified specific areas that the trust must improve and set an overall date for compliance of 1 March 2022. Some areas for improvement had a compliance date of 1 November 2021. The trust had taken steps to make the required improvements. For more information on action we have taken, see the sections on Areas for improvement

We will check that the trust takes the necessary action to improve its services. We will continue to monitor the safety and quality of services through our continuing relationship with the trust and our regulatory processes.

At this inspection we rated one of the four services core services we inspected as inadequate, two as requires improvement and one as good.

Overall, we rated safe, responsive and well-led as requires improvement, effective and caring as good.

We did not inspect child and adolescent mental health wards because the trust no longer provided this service and we have removed this core service from our report.

We did not inspect wards for older people with mental health problems, wards for people with a learning disability or autism, community based mental health services for older people, community mental health services for people with a learning disability or autism or specialist eating disorder services. We did not have information that meant we needed to visit these services this time.

We did not inspect acute wards for adults of working age and psychiatric intensive care units, because we had carried out two recent inspections of this service. The first inspection was in January 2021, in response to a significant incident which sadly resulted in the death of a patient. Following this inspection, we issued a warning notice under Section 29A of the Health and Social Care Act, which required the trust to make significant improvements in relation to assessing and managing patient risk.

We carried out a follow up inspection of this service in May 2021 and found that, whilst the trust had made significant improvements to comprehensively assess and mitigate patient risk on the wards, these had not been fully embedded at the time of our inspection.

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

We rated safe, responsive and well-led as requires improvement, effective and caring as good. In rating the trust, we took into account the current ratings of the five services not inspected this time. As the trust no longer provided child and adolescent mental health wards, this was removed from the ratings aggregation.
Two of the trust’s services had worsened since the last inspection; we rated forensic inpatient services as inadequate and community mental health services for working age adults as requires improvement.
The overall rating for specialist community mental health services for children and young people stayed the same as the last inspection, however the rating for safe went down to inadequate.
The trust recognised that their organisational and governance structures were not fit for purpose. They had embarked on a significant change programme and were about to consult with staff on these changes. As a result, not all of these changes were in place or embedded at the time of our inspection.
Whilst the leadership team displayed an open and honest culture, the culture across the trust was variable. Senior leaders had not ensured that action taken within localities had positively impacted to improve culture within services. There was a lack of oversight of the effectiveness of action plans to address poor culture. Not all staff felt able to raise concerns without fear.
Systems to identify, understand, monitor and reduce or eliminate risks were not always effective and required further development. This meant there was a lack of oversight risk and adequate assurance at board level. Mechanisms to escalate performance and risk issues from ward/team level to board did not function effectively. The trust had started to develop an integrated performance and assurance framework, but this was not in place at the time of our inspection.
Not all wards and teams had enough staff who knew patients well and were able to care for them safely. In forensic inpatient services, staffing levels negatively impacted on the quality of care provided to patients. In some community teams, staffing levels were not sufficient to meet the demands of the service.
Patients were not always appropriately safeguarded from abuse. There was no trust-wide policy for safeguarding adults. The trust had a procedure for safeguarding adults, which did not clearly outline the governance and accountability at each level of the organisation. The trust did not have a named doctor for adult safeguarding. Staff did not always make safeguarding referrals when appropriate. In forensic inpatient services, staff did not always treat patients in a kind, respectful and dignified way. There were high levels of restrictions placed on patients’ freedoms.
There were not always enough staff who knew patients well to keep patients safe. In some services this impacted on the safety and quality of care and meant that staff were not always meeting the needs of patients. In some services, this impacted on timely access to treatment.
There were high waiting times in community mental health services for children and young people. There was a lack of oversight of the waiting list management process and risks to children and young awaiting assessment and/or treatment were not reviewed.
Although overall compliance with mandatory training was good, there were pockets of poor compliance. This meant that some staff did not have the required essential skills needed to deliver safe care.
Governance systems at a locality level were insufficient to ensure the quality and safety of the service. Local leaders did not always have oversight of appropriate performance measures to ensure good quality care.
Staff did not always report and record incidents appropriately. Staff sometimes did not report incidents when they occurred and sometimes reported multiple incidents within a single incident record. This meant that there was not appropriate oversight of the scale and nature of incidents which were happening within services.
The trust required continued improvement in its approach to equality and diversity. Staff with disabilities or from a black and minority ethnic background were more likely to experience harassment, bullying or abuse. Staff network groups identified a huge variation in approaches and level of support by middle-managers across the trust in relation to equality and diversity concerns.
Investigations into complaints and serious incidents were not always carried out in line with trust policies. Systems and processes to identify and implement learning from serious incidents were not effective. Actions had not been taken to tackle common themes identified within serious incidents to embed learning and prevent future serious incidents.

However;

The trust had established a new committee of the board (people, culture and diversity committee) and appointed an executive director for people and culture, to embed a more strategic approach to people and culture within the trust.
Staff completed annual appraisals, which included discussions on development and career progression. Leadership development opportunities were available and some staff had worked for the trust for many years and had been promoted into more senior positions.
There was good engagement with staff, staff side, governors and external partners. The trust had completed a significant consultation and engagement process to inform development of their new strategy.
The trust had taken action in response to enforcement action following our inspection of acute and psychiatric intensive care wards. As a result, simplified and introduced more effective systems to assess and manage patient risks within inpatient services. The trust had extended these systems to include community mental health services. Work continued to embed these systems and ensure their effectiveness.
The board had approved further workforce investment for inpatient services and there was an ongoing recruitment process in response to staffing challenges.

There were robust systems in place in relation to the effective management of medicines and controlled drugs.

How we carried out the inspection

During this inspection we;

talked to service users and their carers about their experience of using these services
visited nine forensic inpatient wards
visited crisis teams and three health-based places of safety
visited community mental health services for adults of working age
visited community child and adolescent mental health services
spoke with a variety of staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, managers, executive directors, non-executive directors and governors
reviewed a number of records relating to the care and treatment of patients
reviewed a variety of documents relating to the management of the trust and the services it delivers
held focus groups with; staff network groups, staff side and Hospital Managers
reviewed a variety of information we already held about the trust
sought feedback from a number of the trust’s stakeholders such as Healthwatch, NHS England and clinical commissioning groups.

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

What people who use the service say

We spoke with over 100 service users and their carers across the four services we visited and also spoke with staff and governors who were users of trust services. We spoke with Healthwatch to obtain information about what people said to them about the trust’s services.

Feedback from service users and their carers was mixed.

In community child and adolescent mental health services, most people described not feeling listened to in relation to their views on medication prescribed to them. They also spoke about a lack of medical reviews, a lack of medical oversight in relation to the side-effects of medication and a general feeling of not being supported. People described very long waiting times for autism assessments and not feeling supported whilst they were waiting. Communication was highlighted as a particular concern, with people telling us that staff did not always return telephone calls and some information was provided to children and young people in a format they could not easily understand. Other people told us that although they had waited a long time to access services, once they received treatment this was of good quality and staff had given appropriate and helpful advice.

In forensic inpatient services, patients told us that they were unhappy that leave off the ward did not always happen as planned due to staffing shortages. Some patients were unhappy that they had been seen by a number of different doctors, although patients did receive regular one to one time with their named nurse. Patients told us that some staff were disrespectful to them and used derogatory terms and we viewed one incident of abuse by a member of staff towards a patient on CCTV footage. Some patients told us their needs were not being met by staff, including some of their physical health needs. Carers of people who used the service said they did not receive sufficient contact and information from staff, including not receiving invitations to key meetings and not receiving information about the ward when loved ones had been admitted. Patients did tell us that they were able to provide feedback and suggestions on how to improve the service through community meetings which took place on the wards. During our observations of the care of people received, we saw some interventions which were not always respectful and kind.

In community mental health services for working age adults and community crisis services for adults, most people we spoke to who used the service were positive about their experience of care. Some negative comments related to waiting times and access to face to face appointments.

Feedback from patients through trust surveys indicated that at the end of 2020/2021, 90% of patients reported their overall experience of care as excellent or good. Eighty four percent of patients reported that staff treated them with respect and dignity, 89% of patients would recommend the trust service to friends and family if they needed similar care or treatment. The trust target for all of these indicators was 94%.

In inpatient settings, only 65% of patients reported feeling safe on the wards, against a trust target of 88%. Sixty eight percent of inpatients reported they were supported by staff to feel safe, against a trust target of 65%.

We carried out this unannounced focused inspection to see whether improvements had been made since our last inspection in January 2021. On that inspection, we issued a warning notice under Section 29A of the Health and Social Care Act.

On this inspection, we checked whether improvements had been made to address the concerns identified. These include, the systems to comprehensively assess and mitigate patient risk on the wards, monitor and audit patient risk assessment processes and to learn fully from serious incidents. This is in line with our published guidance to follow up inadequate rating and section 29A warning notices.

The trust has 12 mental health acute inpatient wards and two psychiatric intensive care units located in five hospital locations. The service provides treatment for people who are acutely unwell and whose mental health problems cannot be treated and supported safely or effectively at home.

We inspected the following nine wards from the acute wards for adults of working age and psychiatric intensive care unit services:

Bilsdale ward – 14 bed male acute admission ward at Roseberry Park, Middlesbrough
Bedale ward – 10 bed mixed gender psychiatric intensive care ward at Roseberry Park, Middlesbrough
Overdale ward – 18 bed female acute admission ward at Roseberry Park, Middlesbrough
Elm ward – 20 bed female acute admission ward at West Park Hospital, Darlington
Cedar ward – 10 bed mixed gender psychiatric intensive care ward at West Park Hospital, Darlington
Tunstall ward - 20 bed female acute admission ward, Lanchester Road Hospital, Durham,
Esk ward – 13 bed female acute admission ward at Cross Lane Hospital, Scarborough
Ebor ward – 18 bed female acute admission ward at Foss Park Hospital, York
Minster ward – 18 bed male acute admission ward at Foss Park Hospital, York

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. We inspected on 25 to 27 May 2021.

This was a focused inspection looking at the safe and well led key questions. Our rating of this core service improved. We rated them as requires improvement because:

We rated the safe key question as requires improvement as we have identified a breach of a regulation and issued a requirement notice. The rating will normally be limited to ‘requires improvement’ at best.
We rated well-led as requires improvement because although the trust had better systems in place to comprehensively assess and mitigate patient risk on the wards, these had not been fully embedded yet.
Patient risks were still not always fully reflected within the written patient safety summaries in a small number of files we looked at.
Staff had not always flagged current incidents, so these did not pull through into the written overview section of patient records. Information across other parts of the record usually showed that staff were mitigating these identified risks.
Despite the improvements the trust had made, we found staff were not always following the trust’s policy and expectations. We found staff had not locked one window into position on Ebor ward presenting a potential ligature risk; staff had not updated the written environment risk assessment on Tunstall ward to reflect changes to the environment and practice following a significant incident and leaders at Cross Lane Hospital were using a paper file system for safety briefing reports, but this did not include all recent reports and staff were unaware of intranet version of these recent incident reports. The trust addressed these very quickly.
Staff were not always mitigating the risks of operating mixed sex accommodation to fully promote patients’ safety, privacy and dignity as some incidents went unobserved and staff did not always fully consider the grouping of patients when allocating bedrooms.

However:

We found that the trust had made improvements in the areas in the section 29A warning notice to the extent that we no longer had serious concerns about systemic failings relating to the governance arrangement around the management of patient risks.
The trust now had better systems in place to comprehensively assess and mitigate patient risk on the wards.
Staff now had better understanding regarding the risk assessment process and what was expected of them when updating documentation.
The trust now had mechanisms in place to monitor, audit and ensure oversight of the patient risk assessment process.
The trust now had an effective procedure and process in place to review and learn from serious incidents.

How we carried out the inspection

On this inspection, we assessed whether the service had made improvements in response to the concerns we identified during our last inspection. We therefore only looked at some of the key lines of enquiry relating to the ‘safe’ and ‘well-led’ key questions.

Before the inspection visit, we reviewed information that we held about the service.

During the inspection visit, the inspection team:

visited nine wards;
looked at the quality and safety of each ward environment;
spoke with 16 patients;
spoke to 41 members of staff including ward managers, a consultant psychiatrist, nurse consultants, qualified nurses, health care assistants, a clinical psychologist; an occupational therapist, activities co-ordinators and a pharmacist technician;
spoke in a focus group with five modern matrons responsible for the acute and PICU wards;
attended six multi-disciplinary report out handover meetings;
reviewed 30 patient care and treatment records;
observed care on the wards; and
looked at a range of audits, policies, procedures and other documents relating to the running of the service.

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

What people who use the service say

We spoke to sixteen patients. We received limited feedback from patients about risk assessments and risk management which was the focus of this inspection. Most of the patients were detained under the Mental Health Act and some felt they did not need to be in hospital and raised concerns about other aspects of being kept on the ward. Patients were aware of their rights as detained patients.

Most patients we spoke with found nursing and support work staff to be supportive and caring. Patients commented that they sometimes found it difficult to cope on the ward as the wards were very busy and some patients were acutely mentally unwell. Patients reported that there were often several incidents each day with, and between, other patients. However, they reported that staff worked hard to keep patients safe.

Eight patients we spoke to said that they felt that the wards were short staffed, especially at night or at weekends. Some reported that staffing levels directly impacted on patient care either because escorted leave was delayed or there were not enough activities available on the wards throughout the day. This was particularly the case at Roseberry Park. We did not specifically look at staffing levels on this inspection as it was a focused inspection. As a result of patient concerns, we asked the trust for information and looked at the trust’s safe staffing data. These showed that the wards where most concerns were raised were usually staffed at or above the expected staffing numbers. We also saw that additional staff had been employed or were being recruited to increase the staffing establishment including activities co-ordinators on the wards.

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services. The inspection was prompted by an incident that had a serious impact on a person using the service. This indicated potential concerns about the management of risk in the service. While we did not look at the circumstances of the specific incident, we did look at associated risks.

We inspected five wards from the acute wards for adults of working age and psychiatric intensive care unit services. The service provides treatment for people who are acutely unwell and whose mental health problems cannot be treated and supported safely or effectively at home. The trust provides the service across 14 wards. During this focussed inspection we inspected the following five wards to include at least one ward from each locality:

Bransdale ward – 14 bed female acute admission ward at Roseberry Park
Stockdale ward – 18 bed male acute admission ward at Roseberry Park
Elm ward – 20 bed female acute admission ward at West Park Hospital
Danby ward – 13 bed male acute admission ward at Cross Lane Hospital
Overdale ward – 18 bed female acute admission ward at Roseberry Park

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

This was a focussed inspection looking at the safe and well led key questions. We did not rate key questions at this inspection. However, due to enforcement action taken in safe and well led these key questions have been limited to inadequate.

Our rating of services went down. We rated them as inadequate because:

We issued a warning notice under Section 29A of the Health and Social Care Act in relation to this service. This limited the rating of this service to inadequate.
The systems the trust had in place were not robust enough to comprehensively assess and mitigate patient risk on the wards.
There was a lack of understanding from staff regarding the risk assessment process and what was expected of them when updating documentation. The harm minimisation policy the trust had in place did not provide a structured framework or sufficient guidance to assist staff in carrying out risk assessments for patients effectively.
There were gaps in information and discrepancies in patient risk documentation across the five wards we visited. Scoring of patient risk did not always reflect the narrative in the patient risk profile and the documented handover of patient risk between staff was inconsistent or information was omitted.
Staff were not aware of what the trusts’ ‘Observation and Engagement’ policy stipulated regarding night-time checks of patients. None of the wards we visited were following the trusts’ own policy in planning and documenting patient observations during the night.
The mechanisms the trust had in place to monitor, audit and ensure oversight of the patient risk assessment process were not effective and were not sufficient to identify areas for improvement.
The trust did not have an effective procedure and process in place to review and learn from serious incidents.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about the service.

During the inspection, the team:

Visited three wards at Roseberry Park, one ward at Cross Lane Hospital and one ward at West Park hospital.
Spoke to 23 members of staff including clinical managers, a consultant, qualified nurses and health care assistants.
Attended four multi-disciplinary handover meetings.
Spoke with two patients.
Reviewed 16 patient care records.

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

What people who use the service say

We spoke to two patients during our inspection who told us they felt safe at the service and did not have any complaints about their care.

Our rating of this service stayed the same. 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 cared for in a mental health rehabilitation ward 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.
Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed.
The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.

However:

Patients on Talbot ward did not have access to call alarms although the trust told us these would be installed during January 2020.
At the Orchards, patients could not access take home medication when they went on leave unless it had been planned.
On Oakwood it was not clear how staff identified medicines when the shelf life had been reduced due to high fridge temperatures.
On Oakwood and Talbot wards, some patient care records contained the wrong ward names.
At the Orchards, patients could not operate the vistamatic window from inside the room. This meant their privacy and dignity may be compromised.
On Willow ward, we found little evidence of therapeutic activity.
On Willow ward, care plans focused on patients’ immediate support needs with no connection to a longer-term formulation of what was necessary for discharge.

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

Staff did not consistently act to manage or mitigate risks identified for patients and this had not been identified or addressed through governance processes.
There were gaps in patient observation records, so it was not clear if observations had taken place. We found examples of where staff were not mitigating risks in line with the environmental risk assessments, such as locking rooms to prevent patient access to keep them safe.
Improvements were needed to maintain fire safety. Some patients did not have personal emergency evacuation plans and some actions related to fire risk assessments were not completed in a timely manner.
Some patients did not have a documented risk assessment completed prior to taking section 17 leave.
The service did not use systems and processes to safely prescribe, administer, record and store medicines. Some clinic room temperatures and fridge temperatures were too high and appropriate action had not been taken by staff to mitigate this. There were missing checks of emergency bags on two wards.
The service did not comply with guidance relating to mixed sex accommodation in five of the eight mixed sex wards where there was an inadequate level of separation between the male and female sleeping areas. We observed male patients in female bedroom areas. Male patients were using designated female lounges.
Staff did not follow trust policy or best practice guidelines to ensure they were using and clearly recording the use of seclusion appropriately on Rowan Lea ward.
Not all staff had easy access to clinical information as agency staff could not access patient electronic records and on Rowan ward paper files did not contain the most up-to-date information.
Local audit schedules varied across teams and where staff did engage in local audit it was unclear whether staff always acted on findings or fed these up to management.

However:

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 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.
All patients had their physical health assessed and regularly reviewed during their time on the ward. The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and the wider service.

Our rating of the trust went down. We rated it as requires improvement because:

We rated safe as inadequate for one of the core services and requires improvement in six of the 11 core services. We rated effective as requires improvement in two of the 11 core services. We rated responsive as inadequate in one core service and requires improvement in two of the 11 core services. We rated well led as inadequate in one core service and requires improvement in three of the 11 core services. In rating the trust, we considered the current ratings of the core services we did not inspect this time. We also inspected one non-core service, a specialist eating disorder service. The eating disorder service ratings were not aggregated into the overall trust ratings.
We rated well-led for the trust overall as good.
Risks were not always managed effectively. In specialist eating disorder services risks were identified in the environmental ligature risk assessment but these did not always say how these would be mitigated. In specialist community mental health services for children and young people, patients waited long periods without contact, waiting lists were not reviewed to assess risk changes and staff did not know which children were waiting for treatment or receiving treatment. In wards for older people with mental health problems there were gaps in patient observation records and identified risks were not always mitigated.
Staffing did not always meet the needs of patients. Patients assessments were delayed in mental health crisis services and health-based places of safety due to lack of availability of staff. In specialist community mental health services for children and young people, there were not enough staff to meet the number of referrals, complete assessments or deliver interventions and staffing levels were disproportionate across teams. Case loads were excessively high in some teams and staff and managers had no control over caseload size. In forensic inpatient/secure wards section 17 leave was regularly cancelled on Mallard and Linnet wards due to staffing issues.
Medicines were not always effectively managed. In mental health crisis services and rehabilitation wards staff were not ensuring the correct temperature for safely storing medication at two locations visited. In acute wards for adults of working age and psychiatric intensive care units there was no rational for prescribing medication used 'as required’ in some patient records. In wards for older people with mental health problems the service did not use systems and processes to safely prescribe, administer, record or store medicine and didn’t always follow infection control policy when dispensing medication.
In some services, the poor physical environments were adversely impacting on the safety, privacy and dignity afforded to patients. There were examples of this in the health-based places of safety and CAMHS offices. In the learning disability and older people inpatient services, the trust was not achieving an acceptable standard of gender separation.
Equality and diversity for staff and patients was not fully integrated into all areas of the work of the organisation. This was particularly needed for people who are LGBT+.
Disciplinary and grievance processes were not always completed in line with trust policy. Timescales weren’t always met and there were missing documents in the grievance files. This was an issue at the last inspection and continues to be the case.

However:

We rated, effective and caring, as good.
The trust had a talented and experienced leadership team. The board was working together well to respond appropriately to the ongoing challenges following the closure of the wards for young people at West Lane Hospital. The importance of the leadership team being visible and approachable was recognised. There were well structured arrangements to visit services across the wide geographical area served by the trust.
The trust continued to provide leadership development for staff, a strong focus was still placed on creating a coaching culture that supported recovery and wellbeing. The trust continued with its leadership programme for staff from a black, Asian and minority ethnic background.
The board and senior leadership team had developed a clear strategy and staff were aware of what it was. It was evident that staff and patients had been engaged during the formation of the strategy. The trust continued to embed the strategy as it developed its ongoing operational priorities.
The trust had a values-based culture which was positive and open. There was a high degree of openness and transparency in the senior leadership team. Staff spoke about the positive culture during the inspections of services.
The trust was making increasing use of digital technology to support the delivery of services to patients. The trust was introducing a new clinical information management system (CITO) which aims to allow staff to complete key pieces of information and store them in one place and link directly to the patient record.
The trust engaged positively with patients, carers and staff. This included a wide range of co-production work. The trust was also extending the number of peer support workers. However, it would be helpful to have a trust strategy for user involvement to ensure this was embedded throughout the organisation.
Staff were skilled and supported. Compliance with mandatory training was high. Staff engagement was positive. The making a difference programme included a number of workstreams to promote a positive working experience for staff. This included initiatives to improve staff health and well-being.
The quality improvement programme was well embedded across the trust. There were a number of trust wide quality improvement priorities including work to increase the proportion of inpatients who feel safe on the wards.

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

Staff did not effectively manage risk to patients. In 13 of the 18 care records that we looked at risk assessment and risk management records were brief and generic, staff were not always making use of the safety summary section of the care record,
Staff were not managing the safe storage of medication effectively at two locations we visited,
In 13 of the 18 care records that we looked at it was not clear that staff had developed individual care plans and updated them when needed,
We found that there were delays to assessment of patients admitted to health-based place of safety because of staff availability,
There were several issues that compromised the privacy and dignity of patients being admitted to health-based places of safety,
A number of governance processes did not operate effectively,
The multi-agency arrangements in place to support the operations of the health placed places of safety were not always effective.

However:

Staff working for the mental health crisis teams provided a range of care and treatment interventions that were informed by best practice guidance and were suitable for the patient group. They ensured that patients had good access to physical healthcare.
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 treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition,

We rated it as good because:

The service provided safe care and treatment for patients under its care and there were enough nurses and doctors to facilitate this. The ward environment was safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices and managed medicines safely.
The staff team included or had access to the full range of specialists required to meet the needs of patients. Managers ensured that these staff had access to training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward including community teams who would have a role in providing aftercare.
Staff developed comprehensive holistic, recovery-oriented care plans which were informed by a comprehensive assessment which involved a number of professionals. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
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 well led and the governance processes ensured that ward procedures ran smoothly.

However:

Though there were clear processes for reviewing incidents and complaints, the awareness of three of the staff we spoke with about lesson sharing was limited.
Though risk management plans were captured through individual patient risk assessments, the ligature risk assessment used by the service did not include management plans for each risk or detail contingencies respectively on the ward ligature risk assessment.

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

The ward environments were safe and clean. The wards had enough nurses and doctors. Except for environmental risks, staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability (and/or autism) and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, 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 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.
Although two wards did not meet the mixed sex accommodation requirements as specified in the Mental Health Act Code of Practice, staff understood and discharged their other roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
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 or lack of suitable placement for the patients.
The service worked to a recognised model of mental health rehabilitation.

However:

Staff had not assessed and managed all potential risks posed by the environment on Aysgarth ward.
Two wards did not meet the same-sex accommodation guidance specified in the Mental Health Act Code of Practice.
Staff did not always maintain the confidentiality or secure information held about patients.
Staff did not always identify incidents or record and report them appropriately.
Systems and processes were not fully established to support all wards with the transfer of patients to psychiatric intensive care units if a patient required more intensive care.
Governance processes did not always ensure that care delivered met national guidance.

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. Managers ensured that these staff received training, supervision and appraisal. 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, 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 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.

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

The service did not provide safe care. Clinical premises where patients were seen were not all safe or fit for purpose. The number of patients on the caseload of the teams, and of individual members of staff, were too high and staff could not give each patient the time they needed. There were not enough staff to manage the volume of patients. Staff did not manage waiting lists to ensure that patients who required urgent care were seen promptly.
The service was not easy to access. Staff were not always able to assess and treat patients promptly. Patients waited too long to start treatment.
Care plans were not always personalised, holistic or recovery-orientated.
Staff did not record decisions relating to consent well. There was no consistent approach to recording consent. Consent information was located within the electronic recording system and paper notes.

However:

Staff assessed and managed risk well and followed good practice with respect to safeguarding.
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.
Managers ensured that these staff received training, supervision and appraisal. 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.
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 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:

There were variations in the monitoring and recording of supervision. Although staff said that they were having regular supervision five wards reported under 70% compliance.
Ensuite bathroom doors had been removed as an interim measure to keep patients safe. The trust was correctly trying to find a more permanent solution to this issue.

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

All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Each ward was individualised and decorated by the patients.
The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s mental and physical health.
Staff provided a range of treatment and care for patients based on national guidance and best practice. This included access to psychological therapies, support for self-care and the development of everyday living skills and meaningful occupation. Staff supported patients with their physical health and encouraged them to live healthier lives.
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Each patient had their own bedroom with an ensuite bathroom and could keep their personal belongings safe. There were quiet areas for privacy.
Staff supported patients with activities outside the service, such as work and education opportunities.
Staff had the skills, or access to people with the skills, to communicate in the way that suited the patient.
Teams had access to the information they needed to provide safe and effective care and used that information to good effect.
Staff collected analysed data about outcomes and performance and engaged actively in local and national quality improvement activities.

However:

Patient section 17 leave was regularly cancelled on Linnet and Mallard wards due to staffing issues.
Not all patients had access to personal alarms in the case of an emergency, in line with national guidance. Patients had been offered personal alarms, if they refused staff would review alarms with patients regularly.
Patients informed us that the hourly care rounds in the evening were impacting on their physical and mental health

We rated safe as inadequate following the inspection in June 2019. We did not rerate safe, for wards for children’s and adolescent mental health at this focussed inspection.

We found the following issues that the trust needs to improve:

Staff did not always record observations of young people with the 24-hour time frame in line with the trust’s policy. As such, we found some gaps when observations were not documented in the young people’s records, which was not in accordance with the trust policy.
Service managers had not implemented an effective control system to record the names of staff responsible for young people on each shift. Not all of the days that we reviewed had a record to provide an effective audit trail.
Staffing levels over a two week period prior to our inspection were not always in line with the agreed staffing establishment, although had improved since our last inspection. There was still a heavy reliance on agency staff .

However:
There was an improvement in the quality of young people’s care records, intervention plans, and risk assessments. These were present for each young person and reviewed and updated regularly.

Due to the concerns we found during this inspection, we used our powers under section 31 of the Health and Social Care Act to take immediate enforcement action and placed conditions on the trust’s registration. The conditions we placed upon the trust’s registration have closed the wards we inspected meaning that all the young people need to be moved to alternative services to ensure they receive safe, good quality care.

We rated the service as inadequate following the inspection in June 2019. We inspected this service again on 6 August 2019 and did not re-rate the service. This inspection on 20-21 August 2019 did not re-rate the service. We found the following issues of significant concern:

The service was not delivering safe care. Staff did not record young people’s observations in line with trust policy, so it was unclear whether staff were undertaking observation as they should. Many of the nursing staff, including both registered nurses and support workers did not have the knowledge or experience to provide safe care to young people with complex needs. The trust did not ensure that the wards were not staffed at all time with staff who had completed the required mandatory training. Staff at all levels told us that they were struggling to maintain the right balance between managing safety and implementing the principles of least restrictive practice. Staff did not consistently report incidents accurately, including whether physical interventions had been used to restrain young people.
The service was not delivering effective care. Staff did not deliver care in accordance with the young people’s intervention plans which detail the care that young people should be receiving. We saw examples of where care being delivered was not in line with intervention plans. One of the intervention plans contained contradictory information. There were limited therapeutic activity on the wards. Staff told us that they were spending most of their time trying to maintain safety and therefore did not have time to deliver therapies that would aid recovery.
The service was not well-led. Some staff described the service as ‘traumatised’ and told us that there was a divide between managers, the trust and staff working directly with young people. Audits were not effective and did not identify areas of concern in relation to observation records and incident reports. Managers had not ensured that all staff were familiar with young people’s intervention plans. There was limited oversight of the wards from senior managers who understood how quality care for young people should be delivered. In addition, the service did not have effective governance systems in place to ensure that the young people received high-quality care.

However:

During the inspection we saw a number of interactions between staff and young people that were kind, caring and compassionate.

Due to the concerns we found during this inspection, we used our powers under Section 31 of the Health and Social Care Act to take immediate enforcement action and placed conditions on the provider’s registration. We also issued a warning notice using our powers under Section 29A of the Act in response to other concerns we had at the time of inspection.

Because of the enforcement action we have already taken, the ratings for some key questions are limited to a rating of inadequate.

We rated child and adolescent mental health wards as inadequate because:

The service was not delivering safe care. Patients were not safe and were at high risk of avoidable harm. Substantial and frequent staff shortages increased risks to people who used this service. Staff did not adequately assess, monitor or manage risks to patients and opportunities to prevent or minimise harm were missed. Where patients demonstrated higher levels of risk, staff did not follow processes and procedures to mitigate these through appropriate observation and engagement. Staff did not follow the trust’s policy or the Mental Health Act Code of Practice when using restrictive interventions. People were at risk because staff did not store medicines safely and there were out of date medicines still in use. Staff did not report all incidents or categorise the level of harm correctly and did not always learn from incidents. There was little evidence of learning from events or action taken to improve safety. Blanket restrictions were in place that were not based on an individual assessment of risk and need.
The service was not always delivering effective care and treatment. Care and treatment did not always reflect current evidence-based guidance, standards or best practice. The provider did not offer sufficient therapeutic activity to patients. There were vacancies in the multi-disciplinary team and the service did not have a social worker as recommended by national guidance. Not all staff had the right qualifications, skills, knowledge and experience to do their job. Staff awareness and understanding of the Mental Capacity Act and Gillick Competence was limited. Staff were not sufficiently skilled to support patients with a diagnosis of autism spectrum disorder. Compliance rates for supervision were low. Staff did not always complete and store Mental Health Act documentation in line with the Act and the trust’s policy.
The service was not always caring. There were times when people did not feel well-supported or cared for. Staff did not always involve patients in their care and treatment. Carers at West Lane Hospital reported they did not feel involved in their relatives care and that staff and managers did not communicate effectively with them. Patients and carers were not always involved in the development of their risk assessment, which was not in line with trust policy. However, patients on all wards said staff were kind and caring. On Holly Unit and Baysdale Unit, carers felt fully involved and spoke of the service as being like part of the family.
The service was not responsive to the needs of individual patients. Staff at West Lane Hospital did not make reasonable adjustments for patients with a diagnosis of autistic spectrum disorder. Patient attendance at education was poor at West Lane Hospital.
The low secure ward, Westwood Centre, admitted patients who had not been assessed as requiring a low secure ward. Carers reported that despite raising numerous complaints with the service, they did not feel their concerns were addressed. The positioning of some of the closed circuit television equipment at West Lane Hospital did not protect the privacy and dignity of patients.
The service was not well led. Systems and processes were not effective in ensuring that wards were safe and clean and that patients were assessed and treated well. Managers did not have sufficient oversight to enable them to assess and monitor issues and identify areas to improve the service. Staff did not feel respected, valued, supported or appreciated. There was poor collaboration and cooperation between teams. The service strategy had not been translated into meaningful and measurable plans and was developed without staff engagement.

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

There were gaps in the recording of the administration of a patients’ covert medication.
Nurse call alarms were not present in all patient bedrooms.
Some beds were provided in dormitory style accommodation, separated only by a curtain.
Refusal of observations were not always recorded in line with the trust policy following the administration of rapid tranquilisation.
The consideration of patient’s capacity and best interest decision was not always reflected in patient records.

However:

There was positive practise in the formulation and review of patient risk assessments.
There was a daily multidisciplinary review of all patients.
There was effective psychological input in the development of individual formulation from the point of admission.
There were effective practices in the monitoring of patients physical and mental health.
Care planning extended beyond the ward and in to discharge, staff supported and trained other care providers in the patient’s needs to support effective discharge.
Quality improvement systems were embedded across the service and all staff were encouraged to be part of a quality improvement project.

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

The services ensured their community environments were clean, well maintained and appropriately risk assessed. The service used a staffing tool to ensure caseloads were manageable and all patients’ records we reviewed had appropriate risk assessments and crisis plans. Staff understood their responsibilities under safeguarding, and there were appropriate processes to support them doing so. We saw staff were regularly reporting and learning from incidents.
The service used a range of biopsychosocial interventions recognised by best practice, with good access to different types of psychology, occupational therapies, education, and medication. There was robust physical health monitoring for patients who required this and staff had access to specialist information systems which meant they could access blood results. There was a wide range of skilled staff who worked closely in a multidisciplinary setting. Staff received regular supervisions and annual appraisals, they felt well supported through these processes.
Staff had a good working knowledge of the Mental Capacity Act and Mental Health Act. We found the Community Treatment Order documentation was up to date and appropriately documented within care plans. Staff were regularly discussing issues around patient capacity and least restrictive practices.
We spoke to 40 patients and 18 carers, all of whom were positive about the care and treatment received by staff. We observed kind and compassionate care through interactions between staff and patients within their homes and community bases. The service offered a holistic service which ensured patients and carers were at the centre of their treatment. Patients and carers were involved in the delivery and improvement of services through various platforms.
The community mental health services for adults had a clear referral criteria and care pathway into the service. Services were meeting their 28 day referral to assessment target, and there was no wait times to access support once the patient met the criteria. Access to psychology was excellent across the community teams with a maximum wait time of three weeks. The service was learning from complaints and improving their services as a result. The teams were able to meet patients’ disability, accessibility, learning disabilities, cultural and religious needs.
The service was well led. Staff, managers and senior managers told us how supported they felt within the organisation. Staff were able to demonstrate the values and understood the direction in which services were going. Teams had good oversight of risk and there was an escalation process. The trust had a clear governance structure which demonstrated how information flowed up the organisation to the executive team and back down to operational staff.

However:

The service was in the process of reviewing its use of emergency equipment during clinics therefore most of the clinics within the community mental health teams did not have emergency equipment in place. The trusts senior leadership team and oversight of the risks and had a process in place to mitigate them.
Teams within Durham and Darlington did not always accurately document information on patients’ paper medical records in line with their electronic records.
The trust had recently introduced Mental Capacity Act and Mental Health Act training in April 2018 as mandatory. Although staff had a good working knowledge in both areas, the community mental health teams had not yet achieved the trusts target of 90%. The trust projected this would be complete in May 2019.
Although staff received regular annual appraisals and regular annual supervision, recording of clinical supervision was not always accurate, the trust figures did not reflect what staff told us in some teams.
The trust did not use a recognised risk assessment tool in line with best practice.

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

There were sufficient numbers of trained, supervised and appraised staff to meet the needs of patients within the service.
Staff made safeguarding alerts, reported incidents where appropriate and received relevant lessons learned. Staff understood the duty of candour and were open and transparent with patients. Staff and patients knew how to complain and received feedback following complaints made. Staff knew how to contact the trust Freedom to Speak Up Guardian and could access the trust whistleblowing policy.
Staff interacted with patients in a kind and caring manner. Staff involved patients in decisions about their care and treatment and communicated with patients using their preferred communication methods. Carers were positive about the service and told us they felt involved in patients’ care. Teams had effective working relationships with both internal and external providers in order to enhance patient care.
Consultant psychiatrists did not prescribe or recommend antipsychotic medication for behaviour as a first response and would only prescribe if other non-medical interventions were insufficient. When medicines were administered on site staff followed good practice in medicines management.
Staff understood and applied the trust vision and values in their work and engaged in quality improvement work to improve the service for patients. Effective systems ensured good governance.

However:

At The Orchard capacity assessments were not always completed or documented and staff did not regularly or consistently use the National Early Warning Scores tool to monitor patients’ physical health. Also risk assessments were not always updated following a change in risk presentation or reviewed within the required timescales. At Lancaster House adult autism service patients were waiting an average of 13 weeks for an appointment, with the longest wait being 58 weeks, which is not in line with the National Institute for Health and Care Excellence guidance.

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

Low staffing levels impacted on section 17 leave and restrictions on the wards.
The service did not always reflect safe practice in their processes and adhere to the trust policies in relation to medicines management. Clinic room temperatures were consistently high with no action taken.
There were no activity schedules or therapeutic activities taking place on the weekend on the majority of the wards, which goes against National Institute for Health and Care Excellence Guidance. There were no processes in place to measure the outcomes of activities being carried out or what impact they were having on the patients.
There were blanket restrictions in place on two of the wards. The restrictions were not reviewed as part of the trusts restrictive practice monitoring process.

However:

The service encouraged and promoted healthier lifestyles for patients. There was good access to exercise equipment and physical healthcare. The trust had implemented changes throughout the service to try and support patients in making healthier food choices by using a traffic light system in vending machines and cafes.
The service had regular input from a full multi-disciplinary team, offered a range of psychological therapies to patients and involved the patients in their care.
Service and ward managers had good oversight on key performance indicators. Staff felt supported, respected and valued in their roles and felt they contributed to change throughout the service.

Staff did not adequately identify and mitigate all the risks to patients. Some ligature risk assessments were incomplete and mitigations were not specific to the ward.
Risk management plans did not address the risks identified in assessments, were not person centred, were of very poor quality or were absent. We had concerns about physical health monitoring after rapid tranquilisation and recording of seclusion.
Care plans were not always personalised, holistic or recovery-oriented. They contained generic statements, clinical terminology and did not reflect the patient’s voice.
Recorded clinical supervision attendance was low. There was no standardised approach for feeding information on clinical supervision from ward level into locality reporting systems for senior management oversight.
Activity provision on wards varied. On some wards, there was limited activity for patients when occupational therapy staff were not present. Cedar ward at West Park Hospital had very limited occupational therapy and psychology input and these disciplines did not attend report outs.

However:

Staff knew and understood the provider’s vision and values and these were evident in how staff worked with each other and patients. They were discreet, respectful and responsive. Staff were skilled at de-escalation, knew the patients they worked with well and provided personalised, compassionate care.
Staff had high training compliance, received yearly appraisals and felt supported by managers and the teams they worked with. Staff had access to a range of support programmes including mindfulness courses, trust retreats, and an employee psychology service.
The wards followed a purposeful inpatient admission process to ensure that every patient had a clear reason for admission, a formulation and clear goals to achieve to support discharge.
The trusts quality improvement system was embedded across the service and we saw outstanding and innovative practice including the PICU pyramid, the recovery at home service and report outs.
The service followed the ‘Triangle of Care’. Carers felt involved and attended meetings related to their loved ones. They felt supported by staff.

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

We rated, effective, caring, responsive and well-led as good, with safe as requires improvement. We rated three of the trust’s 11 services as good and three as requires improvement. In rating the trust, we took into account the current ratings of the five services not inspected this time.
We rated well-led for the trust overall as good.
The trust had an effective leadership and governance structure. There were groups and committees at all levels and across the specialities to facilitate this. The trust board and senior leadership team had the appropriate range of skills, knowledge and experience to perform their respective roles. There was appropriate challenge at board meetings which was accepted and responded to in a positive way by the executive team.
The trust had a strong quality improvement culture which was well developed and embedded across all services and localities. There were examples of where the trust had developed its services by applying this methodology.
The trust had an effective incident reporting system that analysed trends, captured learning and shared this learning across the services and localities.
Staff were skilled and supported. Compliance with mandatory training was high. Staff had access to other training suitable for their role and the trust had leadership and development training which targeted specific groups of staff.
In wards for older people and child and adolescent services there was good patient risk assessment practice for both formulation and review of risk.
Report out meetings were effective and used across the services. They provided an effective system for ensuring care was patient focused, therapeutic, informed by risk and formulated with a discharge focus. They also provided an effective means of information flow through the organisation.
Morale was high across the trust. Staff felt motivated, supported, valued and displayed a positive attitude about their role and the trust as an organisation.
There was good engagement with patients and carers and the trust sought feedback to inform the performance and development of the service.
The trust engaged well with its stakeholders. Stakeholders spoke positively about the trust performance and interactions they had with them.

However:

We rated safe as requires improvement in four of the 11 core services and responsive as requires improvement in two of the 11 core services.
There were some privacy and dignity issues on some wards with dormitory style accommodation and only a curtain between beds. Although the majority of bedrooms had ensuite facilities not all rooms were ensuite.
Some wards were short staffed which had an impact on patients accessing leave from the ward, staff observation of patients and access to meaningful activities.
Staff supervision records did not reflect what staff described. Despite some compliance records being low we found that staff were well supported by their managers and received regular supervision. The trust also had a plan in place to address this.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RX3/reports.

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

The trust had made improvements since the last inspection in January 2015, as seclusion records contained a clear step by step account of any episode of seclusion in accordance with the Mental Health Act Code of Practice.

The trust had made improvements since the last inspection as continued to monitor the use of restraint on Newberry and Westwood wards. The numbers of restraint on both wards have increased which management attributed to the acuity of patients. However, in 2015 prone restraint was 25% and 50% of total restraints on the respective wards however this had reduced significantly to the current figures of 3% and 6% of all restraints on these wards. Staff understood that the use of restraint was a last resort. They used de-escalation and low levels of restraint to manage incidents of aggression wherever possible. Staff ensured they documented episodes of restraint, and rapid tranquilisation in accordance with trust policy.

The trust had also improved the recording of staff supervision since the last inspection. Current records for this core service showed trust policy was being followed. Staff told us they were well supported and listened to by managers.

Wards were led by skilled, knowledgeable and experienced managers. Ward managers and senior managers were highly visible on the wards and staff told us that managers at all levels were approachable. There were good systems and processes in place to assess and monitor quality and safety on the wards, which managers used on a day to day basis to keep informed and to organise staff to ensure good care was delivered.

Staff treated patients with kindness and compassion and involved families and carers. Patients described staff in positive terms highlighting their caring, friendly and supportive approach. Staff encouraged patients to give feedback about their care and experience via electronic devices and in regular community meetings. Staff acted on feedback.

There were good patient risk assessments on each ward. The service provided a safe environment and managed risks well. Patients told us they felt safe. Risk assessments included monitoring of existing and potential physical health risks.

However:

Baysdale unit, Newberry centre and Westwood centre did not have a system in place to call staff in the event of an emergency.

We found the following areas of good practice:

Staff had the experience, skills and qualifications to do their jobs, received an induction, mandatory training, regular supervision and were appraised. Staff risk assessed patients, were kind and caring, encouraged patients to lead healthier lifestyles, used de-escalation techniques to reduce the need for restraint, were knowledgeable about the Mental Health Act, Mental Capacity Act, safeguarding and the duty of candour and knew how to handle complaints.
Staff helped patients to access education and work opportunities and supported patients during referrals and transfers to other services, catered to patients’ specific communication needs and received feedback on lessons learned from incidents and complaints which they used to improve the service. Staff implemented recommendations from reviews of deaths, incidents and safeguarding alerts and engaged in clinical audits.
Staff were respected, supported and valued. Staff spoke positively about working for the trust, felt supported in their career progression and were aware of the trust’s vision and values. Staff could provide input and contribute to changes within the service and were given time and support to consider opportunities for improvements and innovation.
The wards had input from psychiatrists and junior doctors. There were effective working relationships with teams, both within and outside the organisation.
The people who used the service could provide feedback on the service they received and were involved in decisions about care and treatment. Patients could personalise their rooms, had access to outside space and quiet areas, snacks and drinks at any time and had food choices to meet their dietary needs. Patients could make calls in private, were given information to help them orient to the ward and knew how to make a complaint about the service.

We found the following issues the service needs to improve:

Staff had not identified ligature risks and patients did not have access to nurse call points.
On one of the wards, there were gaps in the recording of temperatures and no examination couch in the clinic room.

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.

After the inspection in January 2017 the overall rating for the trust has not changed from good because:

All ratings in the provider report and core service report key questions remained the same except; long stay/ rehabilitation mental health wards where there was a change of rating from requires improvement to good in safe; community services for people with learning disabilities or autism was not previously rated and following this inspection has a rating of good; wards for older people with mental health problems ratings have changed from good to requires improvement; the provider quality report ratings have changed in well led from outstanding to good.

Staff engaged with patients in a caring, compassionate and respectful manner throughout our visits to the wards. Feedback received from patients and carers was positive in relation to the care and treatment they received and they felt involved in care planning. Patients had access to advocacy services. The trust actively sought the views and experiences of patients across all the services we visited.

Staff had a good understanding of the Mental Health Act and applied this in practice. The trust had a system for monitoring and reducing restrictive physical interventions with a ‘force reduction programme’, this was trust wide. The trust was making a positive effort to reduce blanket restrictions on wards and had started to share effective findings with other parts of the trust. Patient’s capacity and consent to treatment was recorded and staff regularly explained patient’s rights to them.
Staff managed medicines well on acute wards, psychiatric intensive care units and long stay rehabilitation wards. Staff completed the correct documentation when they administered covert medication to patients on older people’s wards. Staff carried out a comprehensive assessments of patient’s needs and reviewed patient’s risks regularly.

The trust worked actively to promote the wellbeing of staff. As a result, the overall sickness rate was low and staff morale was generally high. The trust was undertaking a ‘staff engagement pilot’ with the aim of increasing the engagement of staff working in the trust. It had also set up a residential retreat programme for staff which aided participant’s wellbeing and helped staff to make the most of their lives.

However:

The trust did not take all necessary action to ensure the safety of patients under its care. Staff on the wards did not always undertake annual environmental audits to reduce the risk of suicide nor were all staff aware of the risks in the ward environment. The Orchards had no nurse on call system for patients to summon staff in an emergency. Rowan ward and Wingfield ward did not comply with Department of Health guidance on eliminating mixed sex accommodation because they did not provide a seprate lounge-space for women. Few staff on the wards for older people with mental health problems had completed the training that the trust considered essential and only one-half of staff across the trust had completed training in resuscitation.
The trust was not fully complying with the requirements of duty of candour. There were some omissions in the records showing when medication had been administered and recording physical observations when rapid tranquilisation had been used.

The trust had not fully updated all of the policies and procedures listed in annex b of the Mental Health Act code of practice 2015. The mental health legislation committee, who was responsible for assuring the Mental Health Act code of practice was implemented, had not adequately monitored annex b of the code. Seclusion recording in some parts of the trust was not fully available in the electronic record.

The trust had not included external feedback in its equality delivery system 2 report as part of the workforce race equality system.
The trust had not made significant progress in a number of patient safety areas detailed in the action plan for the York and Selby locality.

The full report of the inspection carried out in January 2015 can be found here at http://www.cqc.org.uk/provider/RX3?lk

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

Systems were in place to monitor and manage patient risk. Staff carried out comprehensive risk assessments in a timely manner and regularly reviewed these.
Assessments of risk from potential ligature points (a ligature point is a place where a patient intent on self-harm might tie something to strangle themselves) were in place, along with policies to support the management of these risks.
Staff were aware of their responsibilities to report and raise any incidents and safeguarding issues.
Staff had received mandatory training.
Managers assessed and reviewed staffing levels to keep patients safe.
Feedback from patients was positive. We observed staff treating patients in a respectful manner, and with a caring and compassionate approach. Most patients said they were involved in their own care planning.
Managers evaluated feedback from patients to improve patient care and treatment at the hospital.
Senior managers were visible and staff felt supported and consulted about their roles.
There were good governance structures with audits in place to support and deliver safe care and to monitor the performance of the service.

However:

The Orchards did not have a nurse call system. This meant patients had no means of summoning staff help or support in an emergency. Staff did not routinely carry personal alarms at The Orchard.
Clinic room temperatures on three of the wards were consistently above acceptable limits. On Lustrum Vale blood collection tubes and blood spill kits had expired. The blood spill kit had also expired on Kirkdale ward.
On The Orchards, care plans did not always reflect the involvement of patients or include detailed and personalised information. Expired section 17 leave forms were still on file and not scored through to indicate they were no longer current.
There were trip hazards in the patient’s courtyard on Fulmar ward.
Discharge planning was not clear in care records.

We rated the community services for adults with learning disabilities or autism as good overall because:

Four of the five service sites we visited were clean, tidy and well maintained.
There was a sufficient number of staff in place at all sites we visited to ensure the needs of people using the service were met safely.
Staff assessed and treated patients promptly after they had been referred to the service. Staff achieved the trust target of meeting patients in person within 28 days of referral.Staff often saw patients within two weeks of referral. Most patients had a comprehensive assessment completed within a month of being referred to the service.
Staff had either completed their mandatory training or had training sessions booked to take place within the next few weeks.
Adverse events were thoroughly investigated and processes were implemented to prevent them happening again. There were no serious incidents at any of the five services we inspected within the last 12 months. Staff reported incidents and any lessons learned following investigations of incidents was shared with staff to inform best practice. Staff acted upon complaints and lessons learned were used to inform best practice.
Clinical pathways were based on National Institute for Health and Care Excellence guidance.
Staff were highly skilled, motivated, undertook mandatory and statutory training and were able to access specialist training. Staff had a good understanding of the Mental Health Act and Mental Capacity Act and their responsibilities.
Carers and patients spoke highly of staff and the service they received. The interaction between patients and staff we observed was friendly, reassuring and caring.
During home visits, we saw staff develop a timetable with picture cards to address a patient’s communication difficulties and undertake research to find appropriate equipment and resources for other patients’ needs.
Staff always took patients’ individual preferences into consideration when planning care and took a person centred approach during all meetings and discussions about patients.
Some of the services provided activities for patients including groups around dementia, men’s health, football, autism and, for older patients, personal safety awareness.
Services worked with external care providers, GP services and communities to raise awareness of issues around learning disabilities.

However:

There was an area of carpet at the York & Selby service, which was very dirty due to a recent boiler leak, although the service manager told us a new carpet had been ordered.
At the York & Selby service, staff had not carried out a fire drill since March 2015 and some rooms did not have alarms, placing staff and those using the service at risk if an emergency arose. Staff were not wearing personal alarms.
At the York & Selby service, there were two patient risk assessments that staff had not updated between October 2015 and July 2016 and a third patient who entered the service in December 2016 had no risk assessment in place. A patient survey carried out in December 2016 showed that only 67% of respondents at the York & Selby Service felt they had been involved in their care plan.
At the York & Selby and Hambleton & Richmondshire services, some care records contained little evidence of patients’ views or opinions being taken into account.
Nurses were not invited to team meetings known as ‘huddles’ at the South Durham service.
The South Durham and Hambleton & Richmondshire services did not run any activities or groups for patients.
Staff in all but the Hambleton & Richmondshire service were unsure as to whether the trust had a risk register.

We have rated acute inpatient wards and psychiatric intensive care units as good overall because:

Following our inspection in January 2015, we rated the services as ‘good’ for Effective, Caring, Responsive and Well led. Since that inspection, we have received no information that would cause us to re-inspect these key questions or change the ratings.

However:

Our rating of the Safe key question remains requires improvement. This was because staff did not always adhere to trust policy in documenting and monitoring the seclusion of patients. Staff did not always observe and monitor patients following rapid tranquilisation in line with trust policy. Some staff were not up to date with their mandatory training in life support and rapid tranquilisation. Staff did not consistently document their management of patients’ risk. Six wards did not have a current environmental risk assessment survey in place. One ward was unable to control temperatures in certain areas and the environment of one ward did not enable staff to fully maintain the privacy and dignity of the patient.

We rated Tees, Esk and Wear Valleys NHS Foundation Trust wards for older people with mental health problems requires improvement because:

We had concerns about the safety and cleanliness of some ward environments. Worsley Court was not clean and the visitors room at Cherry Tree House was not clean, and this compromised the dignity and safety of patients. There were some areas of the environment at Worsley Court, which were unsafe for patients and could cause significant harm. Ward 14 at The Friarage and Rowan ward at The Briary Unit used dormitory style accommodation which patients told us made them feel unsafe and had a negative impact on their recovery. However the trust had made plans to refurbish and relocate these wards to resolve this concern. Cherry Tree House did not have privacy glass in all bedroom doors, which compromised patients’ rights to privacy and dignity. We found out of date equipment on a resuscitation trolley at ward 14 at the Friarage. Suicide prevention audits were out of date on two wards we visited despite the wards containing significant ligature risks and areas where staff could not observe patients. However, staff had cleaned all other wards to a high standard and we did not have concerns about the environment on any other wards.
The trust had not ensured that it had adequately trained all staff to carry out their role safely on all wards. Staff had not received training in the Mental Health Act or Mental Capacity Act and we found areas of practice, which reflected low levels of knowledge. Staff compliance with mandatory training was below 75% in several areas, some of which had a direct impact on safe patient care, such as training in resuscitation, rapid tranquilisation, moving and handling, management of aggression and violence, and medicines management. The trust had not ensured that all staff were able to access training and did not have an action plan in place to ensure patient safety on wards where compliance with training was low. On three wards (Worsley Court, Cherry Tree House and Meadowfields) no staff were compliant with training that was required to deliver safe patient care such as manual handling, resuscitation, medication management and rapid tranquilisation. Across all fourteen wards, none had achieved over 75% of staff trained in manual handling.
Governance structures did not always ensure the wards ran safely. Staff did not undertake daily checks / audits of medication and emergency equipment consistently. Not all wards participated in clinical audits when requested by the trust, wards located in North Yorkshire and York had not been included in the full clinical audit programme between October 2015 and November 2016. The inspection team found 150 incidents, where it was not clear if patients had been given their medicines. The service had not identified these gaps in records. Staff were not recording regular supervision sessions as per trust policies and not all staff had an appraisal. We had concerns about medication administration at the previous inspection and the trust had not made improvements at Worsley Court, Meadowfields and Ceddesfeld (where the issues concerned gaps in patient information on recording cards and lack of best interests’ consultations). However, practice was good on some wards such as Rowan (Briary Unit), Oak, Roseberry and Wingfield where we found no issues with medication management.
At Roseberry, Oak, Wingfield, Westerdale North and South, Hamsterley and Ceddesfield, staff had completed detailed risk assessments and had regularly updated them. However this practice was not consistent on the remaining wards, where staff did not consistently update risk assessments and not all patients had a crisis plan in place. On these wards, staff did not relate written risk assessments to decisions and plans to give patients’ leave from hospital. The trust had not trained all staff in the use of the risk assessment on the electronic system, this meant that not all staff were able to complete it correctly and some staff were confused about which tool they should use. Care plans were not always person centred and did not contain the patient’s voice consistently. However, at Wingfield, Roseberry, Oak, Springwood, Ceddesfield, Meadowfields, Worsley Court and Cherry Tree House, we found that care plans were personalised and staff had evidenced the wishes, thoughts and feelings of the individual patients.
We were concerned that staffing levels at Cherry Tree House and Worsley Court did not meet the complexity of the patients on all wards. This meant staff were unable to adequately observe at all times patients at risk of falls and patients who needed support with personal care, and nutrition and hydration, which placed patients at risk of harm. Staff told us that staffing levels were often low. The trust data showed that sickness levels were high and there was a significant amount of bank and agency staff used on some wards. Patients admitted to these wards told us that they felt that bank and agency staff affected the continuity of their care. Managers told us that low staffing levels had an impact on staff ability to carry out other tasks such as training, meetings, audits and supervision. This was also a concern at the previous inspection of Worsley Court (under another provider) and practice had not improved on this ward. However at Wingfield and Springwood, and Meadowfields we saw that the ward environments were calm and patients were engaged in meaningful activity with staff. Staffing levels and bank and agency use was not having an impact on these wards.

However:

Most of our concerns focussed on particular wards and problems did not relate to the entire service. For example, Wingfield, Springwood, Roseberry and Oak wards were good and we had no concerns about these wards during the inspection.
We raised our concerns with the trust straight away, the trust have started to take immediate action to address our concerns.
Mandatory training compliance varied across all wards, wards located in Durham, Darlington and Teeside had completed more training. For example Wingfield, Roseberry, Ceddesfield and Westerdale North and South had all completed 100% of clinical supervision training, 85% of staff at Roseberry ward had completed management of aggression and violence training and over 80% of staff had completed medication management training at Ceddesfeld, Hamsterley, Roseberry and Oak wards.

We witnessed direct patient care that was compassionate on all wards and saw that staff teams worked closely together with significant support from the multidisciplinary teams.
Staff met each morning to discuss patient needs which allowed them to be consistently updated.

The trust ensured that lessons were learnt when things went wrong and we saw evidence of changes being made following incidents on some wards

Staff felt supported by their line managers and felt free to speak out and raise concerns if necessary.

We gave an overall rating for child and adolescent mental health inpatient wards of good because:-

Newberry and Westwood were purpose built and provided safe environments for patients.
Staff had flexible working arrangements to ensure the staffing establishment was sufficient to meet patient needs and keep them safe.
Newberry and Westwood were actively looking for ways to reduce the use of restraint. The trust responded with an immediate action plan when we found the seclusion records did not have a clear step by step account of a patient’s time spent in seclusion.
Patients had access to psychological therapies as part of their treatment and psychologists were part of the multi- disciplinary team.
Staff worked collaboratively with patients, families and local agencies to understand and meet the range and complexity of patients’ needs.
Where patients were detained under the Mental Health Act 1983, their rights were protected and staff complied with the MHA code of practice.
Most patients spoke positively about those who cared for them. Patients and relatives were informed about and involved in decisions about care and treatment.
On both Baysdale and Holly, staff liaised with the community services to provide the services at the most appropriate time for the patients and families. Staff operated a risk based bed managementand worked flexibly to enable this to happen.
Patients could make a complaint, or raise a concern, and these were responded to.
Staff felt supported by the trust and their line managers. Staff morale was good.
The trust ensured that learning from serious incidents was always shared with front-line staff.
The trust had taken steps to improve services where issues had been raised.

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 rating of Good.

Mostly patients were protected from avoidable harm or abuse, but we found some patient safety issues that need to be addressed:

There were breaches of same sex accommodation guidance on Earlston Ward, a 15 bed rehabilitation ward.
There were some environmental and ligature risks identified on Ward 15, Cedar ward, Abdale House and Primrose Lodge. On the acute wards not all risks had an associated intervention plan.
On Ceddesfeld and Hamsterley wards, medicines were being administered covertly, but the information about this was not recorded in line with the trust policy.

The trust strongly encouraged openness and transparency. The trust carried out a thorough investigation following serious untoward incidents. We did note that relatives and carers were not as engaged in the process as they should be. Other healthcare professionals and staff were engaged in the process of the review. Lessons were learned and improvements to safety were made and then monitored.

There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse. There was executive team leadership in safeguarding. The trust actively worked with other organisations and were engaged in local safeguarding boards and procedures.

Staffing levels were planned, reviewed and implemented to keep people safe. The trust published their staffing levels on their website.

Staff recognised and responded appropriately to changes in risks to people who use services. The trust had developed a physical restraint reduction plan and were using positive behaviour support to manage behaviours that challenge.

The trust had developed a strategy to minimise restrictive practices. We did however see some restrictive practices taking place in the trust although they were working towards improving this problem. We saw this in the acute wards and on Fulmar and Kirkdale rehabilitation wards.

Patients had good outcomes because their care and treatment was effective at meeting their needs. Patients had comprehensive assessments of their needs carried out at the point of admission. Care and treatment was planned and delivered in line with current evidence based practice. Information about patient care and treatment, and their outcomes, was routinely collected and monitored. This information was used to improve care. However in the learning disabilities wards patients did not have a comprehensive person-centred, holistic discharge plan in place to support commissioners and other authorities to find accommodation that will meet individual needs and preferences on discharge.

Patients that were detained had their rights protected. With the exception of the recording of seclusion on Ward 15, staff complied with the Code of Practice.

With the exception of 367 Thornaby Road, staff were in receipt of clinical and management supervision and appraisals. Learning needs were identified and training set up to meet those needs.

Issues about capacity and consent were mostly understood. However staff on Earlston House, the CAMHS community teams and the older peoples’ wards did not fully understand how the Mental Capacity Act and Deprivation of Liberty Safeguards applied to their work.

Patients were respected and were partners in their care and treatment. We observed and saw records that demonstrated active patient engagement in all aspects of their care. Patients also contributed to the running of the wards and changes to services. The trust participated in the ‘triangle of care’. Carers’ were seen as an integral partner, alongside the patient and staff in the care and treatment delivered to the patient. Patients’ privacy and dignity was maintained with the exception of Ward 15 and Cedar ward which were both located in acute general hospitals.

With the exception of 367 Thornaby Road, there was information available about advocacy services and Independent Mental Health Advocacy for detained patients.

Patients’ needs were met through the organisation and delivery of services. Services were planned in collaboration and consultation with health and social care partners or commissioners. We heard that the trust was willing to engage in future strategy planning and delivery of services. However we noted that patients in the learning disability wards had been in the service between 2-14 years. The service struggled to discharge patients because external authorities did not identify suitable places for patients to move to. There were delays in funding from external authorities which meant patients remained in hospital longer than necessary.

There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that met those needs and promotes equality. There were interpreting services that could be accessed easily if needed. Reasonable adjustments were made and action taken to remove barriers when patients found it difficult to access services. Lessons from complaints were discussed at ‘daily report out’ meetings, team meetings or clinical supervision. Feedback was shared with patients via the ‘you said, we did’ boards.

The leadership, governance and culture were used to drive and improve the delivery of high quality patient-centred care. Leaders had an inspiring shared purpose, were determined to deliver and motivated staff to succeed. There was ownership of the vision, values and quality improvement system throughout the organisation. There were high levels of staff satisfaction. Staff were proud of the organisation as a place to work and spoke highly of the culture. Staff felt engaged in the delivery and continuous improvement of services. The trust quality improvement system was embedded at every level across the organisation. The trust participated in external peer review and accreditation.

We have judged the service as good because:

Overall, compliance with the requirements of the Mental Health Act and Mental Capacity Act was good. However, on two wards this could be improved.
The wards had sufficient numbers and the appropriate skill mix of staff on duty at all times to meet patients’ needs.
The ward environments were clean and provided appropriate facilities to support patient’s recovery.
The wards delivered care and treatment which was underpinned by the principles of the recovery model and best practice guidance under the framework of the Care Programme Approach (CPA). Patient’s social, occupational, cultural and psychological needs and preferences were assessed and reviewed regularly. There were effective multi-disciplinary team ways of working embedded on all the wards we visited with proactive partnership working with community based services. The service had a clear pathway in place to support patient’s recovery from admission to discharge.
Overall, medication management across the service was good. However on one ward we found some special instructions regarding the administration of medicines were not recorded on two patient’s medicine administration records. The service had implemented a robust step down procedure to support patients in managing their own medicines in preparation for when they moved on from the wards.
Overall, we received positive feedback from patients and their carers in relation to the care and treatment they received from staff. Patients had the opportunity to be involved in all aspects of their care including regular reviews.
Compliance with mandatory training, supervision and appraisals was good overall across the service.
The teams demonstrated good compliance with the requirements of the Mental Health Act (MHA). Overall, staff had a good understanding of the Mental Capacity Act (MCA) although on one ward, this could be improved. The trust is addressing this.
Staff were positive and committed to the ward they worked on and motivated to continuously improve the service they provided. Two wards were AIMS accredited (Accredited for Inpatient Mental Health Services) as ‘Excellence’ through the Royal College of Psychiatrists CCQI (College Centre for Quality Improvement) network for inpatient wards and another two wards had implemented the Productive ward ‘Releasing time to care’ initiative. This demonstrated a commitment to quality improvement.
One of the six wards which provided mixed gender accommodation did not meet the Department of Health guidance on same sex accommodation (SSA). Two female patients’ bedrooms were located on the male corridor opposite the clinic room. This could compromise the privacy and dignity of patients on this ward.
Environmental risk assessments were completed and reviewed regularly although these had not identified a serious risk which a low bannister posed to patients on two wards. The trust has taken action to ensure the bannisters are now safe.
During previous visits to two wards, we identified a number of restrictive practices in place. The trust had implemented a framework to reduce these and many had ceased however we found that staff continued to search patients following unescorted leave on these wards, patients could not access the internet, have mobile phones and the bedroom windows were kept locked. These practices were not based on individual patients risk assessments.

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

Services were delivered in clean and hygienic environments. There were some environmental risks present, including ligature risks. However, there were comprehensive risk management plans in place. Where there were blind spots in some ward areas, there was CCTV present.

Staff had a good understanding of safeguarding and most people told us they felt safe. There were some wards where there was high usage of bank staff and sometimes staff were diverted to other wards to ensure the safety of the running of the hospital ,but this could affect the consistency of patient care. There were some blanket restrictions in place but the service had a work plan in place to look to reduce these and was progressing with it at the time of our inspection.

Patients had access to a wide range of psychological therapies and there were strong multi-disciplinary teams on site. There was a good understanding of best practice and NICE guidance which was evidenced in care planning documentation. Staff were supported by regular supervision and appraisals. Some wards did not have regular team meetings.

Most patients told us that they received care in a kind and thoughtful way and that staff respected them. There was a lot of a work being undertaken to involve patients in their care and in the running of the service.

Patients had access to a range of activities on site as well as trips off-site depending on their needs and progress towards recovery. There were clear pathways through the forensic services although there could be delays to discharge related to the availability of appropriate rehabilitation services. The teams in the hospital worked with forensic outreach teams locally to facilitate discharge.

Staff told us they felt supported by the trust and that senior management were visible and accessible. There were a number of initiatives which the trust were taking to encourage and support leadership training and innovative development of services.

<Summary here> Cedar at the Briary Unit and Ward 15 were located in older medical wards on acute hospital sites and therefore had environmental limitations. Therefore privacy and dignity were not always respected due to shared single sex bed bays and environments posed ligature risks. On Ward 15 there were a number of environmental concerns identified with the seclusion room and recording of seclusion episodes.

Across the acute and PICU wards intervention plans were not in place for some patients after risk had been identified. Systems in place to audit the content of care plans were not effective in picking up these shortfalls.

There were varied and inconsistent blanket restrictions in place across the acute and PICU wards.

Patients' physical healthcare was not assessed before physical restraint was used.

<additional heading 1 if needed> <Summary here> <additional heading 2 if needed><Summary here>Patients had a comprehensive assessment of their needs upon admission and care plans were recovery focused and based on best practice. Care plans were reviewed on a regular basis at multi-disciplinary team meetings. However there was a lack of evidence of patient involvement in formulating care plans.

The acute and PICU wards used a number of measures to monitor the effectiveness of the service provided.

Staff were qualified and had the skills they needed to carry out their roles effectively and in line with best practice.

The acute and PICU wards had good systems in place to ensure that the responsibilities of the Mental Health Act 1983 (MHA) and the Mental Capacity Act (MCA) were being followed. However we found a number of shortfalls which we have asked the trust to address.

Patients were treated with compassion and empathy. Feedback received from patients was positive about their experiences of the care and treatment provided by the staff. The patients we spoke with were complimentary about staff attitude and engagement.

Patients using the service had opportunities to be involved in decisions about their care. Patients told us that their care plans were discussed with them, they were encouraged to attend their review meetings and they had a copy of their plan if they wished.

All admissions had clear reason, a development of a clear formulation and a clear plan as to goals to be achieved to facilitate discharge when clinically appropriate.

A clear PICU admission process was in place to ensure this was appropriate, timely arrangements were in place to transfer patients back to the acute wards when clinically necessary. Systems enabled transfer of patients without delay.

There were good working links with the community mental health teams (CMHT) to facilitate discharge from the wards. Regular bed management meetings occurred with representatives from the CMHT to consider discharge planning.

Patients were actively encouraged to participate in a wide range of activities. Patients’ diversity and human rights were respected. Complaints and concerns were taken seriously and responded to in a timely way and listened to.

The trust’s vision and strategies for the service were evident and most staff considered they understood the vision and direction of the trust.

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.

Staff reported that morale was generally good. Staff told us they felt supported by the management across the services we visited. We saw evidence that staff at all levels had received regular supervision and appraisals. Staff spoke positively about their role and demonstrated their dedication to providing quality patient care.

Most of the acute and PICU wards were members of the Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI) accreditation scheme called AIMS and were accredited with excellence.

We gave an overall rating for child and adolescent mental health inpatient wards of good because:-

Newberry and Westwood were purpose built and provided safe environments for patients.
Staff had flexible working arrangements to ensure the staffing establishment was sufficient to meet patient needs and keep them safe.
Newberry and Westwood were actively looking for ways to reduce the use of restraint. The trust responded with an immediate action plan when we found the seclusion records did not have a clear step by step account of a patient’s time spent in seclusion.
Patients had access to psychological therapies as part of their treatment and psychologists were part of the multi- disciplinary team.
Staff worked collaboratively with patients, families and local agencies to understand and meet the range and complexity of patients’ needs.
Where patients were detained under the Mental Health Act 1983, their rights were protected and staff complied with the MHA code of practice.
Most patients spoke positively about those who cared for them. Patients and relatives were informed about and involved in decisions about care and treatment.
On both Baysdale and Holly, staff liaised with the community services to provide the services at the most appropriate time for the patients and families. Staff operated a risk based bed management and worked flexibly to enable this to happen.
Patients could make a complaint, or raise a concern, and these were responded to.
Staff felt supported by the trust and their line managers. Staff morale was good.
The trust ensured that learning from serious incidents was always shared with front-line staff.
The trust had taken steps to improve services where issues had been raised.

We rated older people’s inpatient services good because:

Safeguarding vulnerable adults, was a priority. Incident recording and reporting was effective and there was a culture of openness, transparency and learning.

Patients' care was delivered following a full assessment of their needs. Information was gathered from other health and social care professionals and family members. Patients were involved in the planning of their care. Consent was obtained or assessed for all treatments. Patients could access psychology support, occupational therapy, dietary and medical assistance when necessary.

Staff were qualified and had the necessary skills to carry out their roles effectively. Staff told us they were well supported and supervised. Staff were able to identify and access training to ensure their skills remained current. Staff were able to support patients from a diverse community. This support included the use of pictorial information, the use of interpreters and the provision of multi faith rooms, and special diets.

Patients who used the service and their relatives told us that staff provided them with information and support about their treatment. Patients told us that as they got better staff enabled them to manage their own health and wellbeing needs.

Most North Yorkshire staff told us the move to Tees Esk and Wear Valleys Foundation Trust in 2011 had been beneficial to patients and staff. We were told training had improved and they were well supported to manage the services effectively were better.

Staff were supported by the management of the trust. They were aware of the vision and values on the trust and patient care was their primary concern.

All the wards for older people with mental health problems had been purpose built or adapted to incorporate NICE guidance and Sterling Design. The advice related to the use of different colours, stimuli and layout of accommodation to provide a more relaxing environment for people with mental health problems.

However we also found the following areas for improvement:

Medicines were administered by one nurse to all patients on Hamsterley Ward before any records were signed.

Medicines were covertly administered to patients on both Ceddesfeld and Hamsterley without reference to a best interests meeting or advice from the pharmacist.

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.

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.

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