Cheshire and Wirral Partnership NHS Foundation Trust

Updated 14 December 2023

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

• The rating for safe increased since our last inspection in both community and mental health areas of the trust.
• We continued to rate effective and responsive as good.
• We continued to rate caring as outstanding.
• The trust’s GP surgeries and the trust’s GP out of hours service continued to be rated as good overall.
• The overall rating for child and adolescent mental health wards went from good to outstanding. The wards for people with learning disability and/or autism continued to be rated as outstanding. 
• Leaders had addressed the shortfalls we found on previous inspections. For example, improved staffing and incident management in community health and staff undertaking qualitative audits in relation to seclusion and rapid tranquilisation which showed improvements in practice.
• The trust board and senior leadership team had the appropriate range of skills, knowledge and experience to perform its role. The trust board and leadership team demonstrated a high level of integrity. High priority was placed on doing the right thing for patients, staff and the organisation as a whole.
• Leaders had worked hard to relocate mental health in-patient wards in East Cheshire into much improved ward environments for patients that were fit for purpose.
• In the majority of services we inspected, leaders were visible in the services and approachable for patients and staff. Staff felt supported by their managers and felt they could raise concerns or approach managers for support.
• The trust’s strategy, vision and values underpinned a culture that was person centred. There was a strong commitment to patient and carer involvement and the trust was moving toward co-designing policy and process with patients and carers.
• The staff in all areas had adopted and embedded quality improvement initiatives and were using data to improve the quality of service.

However:

• We rated well-led as requires improvement in community health services for adults as we found the governance systems were not always fully effective in identifying shortfalls.
• There continued to be pockets of areas where the percentage of staff receiving supervision was below the trust’s target.
• A focused inspection of the adult attention deficit hyperactivity disorder service was carried out into concerns about waiting times. The other areas of this community based mental health core service for adults of working age were not inspected as part of this inspection programme. The waiting times for patients to access and receive treatment from this service were very long and patients on the waiting lists’ safety were not being fully monitored. Due to the limited focus of this inspection, we did not aggregate these ratings into our overall ratings assessment. 
• In some services, compliance rates for mandatory training were below the trust target. There were plans in place to address this in particular with training in safeguarding children level 3 for relevant staff.
• Executive and non-executive directors’ description of strategic risks and the trust’s strategic direction were not always consistent with the trust’s strategy, achievements and programmes of work.
• Despite the trust’s drive to be person centred, we found that complaints and grievance investigations did not reflect fully the values of the senior leaders as they did not show resolution and person-centred approaches respectively.

Updated 18 June 2020

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

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, checked that patients ate and drank enough, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Staff from community mental health teams were regularly visiting community health teams to provide advice and support for patients presenting with co-morbid mental health issues.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Staff understood the service’s vision and values, and how to apply them in their work. Staff were focused on the needs of patients receiving care. Staff were committed to improving services continually.

However

• The trust’s governance systems were not fully effective. We found some minor shortfalls that had not been fully identified or addressed by the trust’s own governance systems. These included cleanliness in one clinic, lone working arrangements, supervision uptake rates, clinical photographs, consent and capacity recording and deferment of appointments.

Updated 4 December 2018

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

• The trust had addressed the recommendations identified by the CQC at the last inspection and made significant improvements across the service.
• The trust electronic patient record system was shared across all services and anyone with access to the system could see the full patient history.
• Staff were aware of the importance of raising incidents and there was a positive culture of incident reporting.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The service provided care and treatment based on national guidance and evidence of its effectiveness.
• The service made sure staff were competent for their roles and there were excellent professional relationships across all services.
• There was an exceptional family focused approach to care delivery and staff had extensive knowledge about their patients.
• Caseloads across all services we visited were very well managed and care was tailored to meet individual needs.
• The trust planned and provided services in a way that met the needs of local people and worked well with external organisations.
• There was a diverse knowledge base among managers that was utilised across the services.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• There was an improvement in the way services were delivered and staff felt this was due to the new ways in which the teams worked.

Updated 3 December 2015

Staffing levels were well managed by the team leader, with low levels of sickness and no current vacancies due to recent recruitment. However, trust managers had not taken a systematic approach to establishing the required staffing levels and acuity (level of patient need) of caseloads.

Appropriate equipment was available to patients. Medicines were managed appropriately. Information in relation to patient care and treatment was available to staff and records were adequately completed. There was a sufficient number of staff who had received appropriate high level training.

Patients received care and treatment according to national guidelines. Staff were patient focused on achieving the best outcomes possible for the people they cared for. Multi-disciplinary care was being provided and links were well established with good communication between disciplines.

Patient records were of a good standard and stored correctly in the patient’s home. There were no serious incidents reported relating to end of life care in the community within the 12 months prior to the inspection. Patients told us they felt safe.

End of life services for adults were delivered by staff who were committed and enthusiastic about their roles. We saw evidence that staff took the time to familiarise themselves with patients and were welcoming and helpful. They were also very supportive to each other.

Staff showed an awareness of people in vulnerable circumstances and gave examples of how to make care more accessible to them. People had the opportunity to comment on the service they received. Complaints were dealt with primarily at local level.

The diverse needs of people were met and there were appropriate provisions of care for patients and their families in line with their personal or religious wishes.

There was no overarching performance quality dashboard for end of life care. Staff measured quality locally which helped staff steer the direction of the service. However, staff felt that some of the changes put in place across the trust had been rapid and on occasion had been difficult to deal with.

Audits results for ‘do not attempt cardio-pulmonary resuscitation’ forms go to the end of life steering group and then to the overarching safety and quality group. However, we found no evidence of action plans and learning as a result of these audits.

Whilst some staff had seen members of the board once or twice, some had never come into contact with any of them which supported the feeling that teams and services were locally driven.

Updated 18 June 2020

We last inspected Cheshire and Wirral Partnership NHS Foundation Trust’s child and adolescent mental health wards in August 2018. On that inspection, we rated this core service as good overall with ratings effective, responsive and well led domains rated as good, safe as requires improvement and caring as outstanding. An action plan was developed by the provider to address the issues raised in the safe domain.

We visited both wards in this core service.  

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

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

During the inspection visit, the inspection team:  

• visited both wards, looked at the quality of the ward environment and observed how staff were caring for patients; 
• spoke with patients who were using the service; 
• spoke with carers; 
• spoke with the acting ward manager of Indigo and Coral wards;
• spoke with other staff members; including support workers, doctors, nurses, occupational therapy staff, psychologists, participation worker and nurse consultant; 
• attended and observed one listen up group; 
• attended and observed one multi-disciplinary meeting; 
• looked at 12 care and treatment records of patients; 
• attended and observed ward based activities;
• carried out a specific check of the medication management on both wards;  
• reviewed 15 prescription charts and 
• looked at a range of policies, procedures and other documents relating to the running of the service. 

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

• The service provided safe care. The ward environments were safe, clean and specifically designed with the patient group in mind. This had considered the risks this group may pose. 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.
• The service had their own website which was developed in collaboration with patients and carers. This allowed them quick access to help and information using information technology.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They involved patients and families and carers in every care decision. Patients and carers were involved in every change that was due to take place on the wards and changes were led by patients. For example, patient panel at interviews, questions devised by patients, new forms and leaflets were designed by patients and there were numerous groups where patients could give their ideas for ways to improve the service. There were monthly carer meetings where carers could raise any concerns or ideas about the service and feedback was always given at the following meeting. We saw evidence of how changes were made to the service following engagement with patients and carers.
• Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason. The service had worked hard to ensure that the wards were part of the local community. There were lots of ways this was done including involvement in the local nature reserve, members of the community coming in regularly to speak to patients such as the police, local MPs and even a Paralympian. The building had been designed with the help of patients. The bedrooms had mood lighting which patients could use to signal to staff how they were feeling. For example, using the red light if they were struggling. The wards had access to a large outdoor space with room for growing fruit and vegetables which were later used in cooking groups. There was a gym and staff had been trained as instructors.
• The service was well led, and the governance processes ensured that ward procedures ran smoothly. Many of the senior leadership team had worked in child and adolescent services for several years. Ward managers had access to a wide range of information about their service monthly which allowed them to pick out themes and trends. The senior leadership team in conjunction with ward-based staff had a clear vision for the future of the service. This had allowed them to plan by putting extra funding into training for the staff team. The wards were applying for accreditation to be an autism friendly ward and staff were making changes to make the environment and paperwork more autism friendly. The wards had been involved in several quality improvement projects which had featured in the trust quality improvement report. The ward was accredited with the quality network for inpatient child and adolescent mental health services and the team had also won an award for inpatient services at the positive practice awards in 2019.

Updated 3 February 2017

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

• Following our inspection in June 2015, we rated the service 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.

• We re-rated the safe question from requires improvement to good following this inspection. This was because the provider had taken action to make improvements. We found that staff followed the trust and local lone working procedures, that the environment at the team bases were safe and that team managers monitored waiting lists.

• We also found that patients' risk assessment and management plans were up to date and completed to a high standard. Safeguarding procedures were followed. Serious incidents were reported and investigated.

Updated 18 June 2020

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 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 and staff and managers managed waiting lists and caseloads well. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly and those who did not require urgent care did not wait too long to receive help.
• The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However;

• We identified items of equipment that were overdue maintenance checks. However, the trust responded immediately to this.
• Although staff considered patient capacity, we found that staff did not always document assessments of capacity within clinical records.

Updated 3 February 2017

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

• Following our inspection in June 2015, we rated the services as ‘good’ for safe, 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.
• Following this focused inspection, we amended the rating for effective from “requires improvement” to “good”. We found that the provider had taken action with regards to the findings of the previous inspection.

Updated 18 June 2020

• The service provided safe care. Clinical premises where patients were seen were safe and clean and the physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff ensured that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff working for the mental health crisis teams 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.
• The mental health crisis teams included or had access to a 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 and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The mental health crisis service and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams. The services did not exclude patients who would have benefitted from care.
• The service was well led and the governance processes ensured that services ran smoothly.

Updated 18 June 2020

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
• Staff undertook functional assessments when assessing the needs of patients who would benefit. They worked with patients and with families and carers to develop individual care and support plans and updated them as needed. Care plans reflected the assessed needs, were personalised, holistic and strengths based. There is a truly holistic approach to assessing, planning and delivering care and treatment to all patients who use the services. This includes addressing, where relevant, their nutrition, hydration and pain relief needs. The safe use of innovative and pioneering approaches to care and how it is delivered are actively encouraged. New evidence- based techniques and technologies are used to support the delivery of high-quality care.
• 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. 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. Feedback from people who used the service, those close to them was always very positive about the way staff treated people.
• They supported patients to understand and manage their care, treatment or condition. Relationships between people who use the service, those close to them and staff are strong, caring, respectful and supportive. These relationships are highly valued by staff and promoted by leaders. People who use services and those close to them are active partners in their care. Staff are fully committed to working in partnership with people and making this a reality for each person.
• Staff planned and managed discharge well and liaised with services that would provide aftercare. There are innovative approaches to providing integrated person-centred pathways of care that involve other service providers, particularly for people with multiple and complex needs. There is a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that meets these needs, which is accessible and promotes equality. This includes people with protected characteristics under the Equality Act, and people who are in vulnerable circumstances or who have complex needs. Staff helped patients with communication, advocacy and cultural and spiritual support.
• It was well led, and the governance processes ensured that ward procedures ran smoothly. Carers had been involved in a qualitive study to explore how family members experienced their involvement, with a view to shaping service development. The trust had created a centre for autism, neurodevelopmental disorders and intellectual disability (CANDDID). CANDDID has also worked with families and carers to coproduce the development suite of online training for people who care for people with learning disabilities or autism.

However;

• Figures provided following the inspection indicated that only 77% of staff at Greenways had received training in managing violence and aggression including rapid tranquilisation and immediate life support. On Eastway ward only 68% of staff had received training in fire ward evacuation and on Greenways ward only 74% had receive the same training.
• Not all staff had received management and clinical supervision necessary for their position.
• The trust did not have full oversight of patients who were subject to a Deprivation of Liberty Safeguards authorisation, though the trust responded immediately and put a system in place.

Updated 4 December 2018

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

• Staff knew about any risks to each patient and acted to prevent or reduce risks. Staff and managers worked to keep the use of restrictive interventions to a minimum. The service had low levels of the use of restraint, rapid tranquilisation and seclusion.
• The service had enough staff with the right skills, qualifications and experience for each shift. Patients had regular one to one sessions with their named nurse. Patients rarely had their escorted leave cancelled, even when the wards were short staffed. The service had enough daytime and night time medical cover and a doctor was available to come to the ward in an emergency.
• Staff completed a comprehensive mental health assessment of each patient either on admission or soon after. All patients had their physical health assessed soon after admission and regularly reviewed during their time on the ward. Staff developed a comprehensive care plan for each patient that met their mental and physical health needs.
• Staff delivered care in line with best practice and national guidance. Staff used recognised rating scales to assess and record the severity of patient conditions and care and treatment outcomes.
• The Mental Health Act was implemented effectively. Staff received training about the Mental Health Act and knew how to access advice.
• Staff were aware of the Mental Capacity Act, and knew how it worked in relation to best interest decision making.
• Care plans were holistic and recovery orientated. There was a programme of activities for patients, which were based on their individual needs and preferences.
• Staff were respectful and responsive when caring for patients. The patients we spoke with were generally positive about the staff. Patients knew how to raise concerns. Patients gave feedback about the service through a weekly meeting called ‘my service, my say’. Patients had personalised bedrooms, which they could access with an electronic key. There were facilities on the wards such as an activities of daily living kitchen and a gym.
• The trust had clinical governance structures that the secure wards fed into. Information packs were generated for each of the services in the trust, which contained key information such as staffing and incidents.

However:

• Not all care plans were person centred, and some described what the patient would do (“you will”) rather than involving the patient (“I will”).
• Capacity decisions were recorded, but they were not always easy to find in the care record.
• Most patients we spoke with thought the food was of poor quality.

Updated 3 December 2015

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

The wards had systems in place to manage patient safety. The ligature risk management plan identified ligature points and how they might be used by patients who were suicidal. This made sure that staff were fully aware of the risk presented. The suicide prevention environmental risk assessment clearly documented where the risks were, the level of risk and how they were to be mitigated

The service generally had sufficient numbers and the appropriate skill mix of staff on duty to meet patients’ needs. Ward managers could increase staffing levels when appropriate. There was access to a regular cohort of bank staff.

There were clear processes in place for reporting safeguarding concerns. Staff had a good understanding of procedures and were confident in applying trust policy. Safeguarding was a standing item on the team meeting agenda.

Staff delivered care and treatment that was underpinned by best practice and a recovery focused theme was evident across the service.

Supervision and appraisals took place in line with trust policy. This meant that staff were supported by managers and colleagues and received the professional development needed to carry out their duties effectively. Managers were able to assess the quality of staff performance.

Peer support workers helped support patients, carers and staff. A peer support worker is a person with direct experience of mental illness.

The admission process informed and oriented patients to the wards. Each patient received an information pack before admission. Staff organised a series of pre-admission visits that gradually introduced the patient to the ward environment. Both patient and carer were included in these visits. On the day of admission patients were met by a member of staff who was familiar to them.

There was effective management of complaints. Patients discussed informal concerns during community meetings and nursing staff discussed any actions arising from these discussions during hand over. The ward manager investigated formal complaints in line with trust policy.

The service captured the ethos of the trust’s vision and values and this was evident in the care and treatment provided by the staff. Senior management had a visible presence on the wards and supported ward managers and staff.

There were good governance systems at a local level. Ward managers routinely monitored key performance information. Team meetings included governance issues as standing items on the agenda.

However, the service was struggling to enforce the nicotine management policy relating to the restriction of tobacco related products. Staff were aware that patients were bringing tobacco and lighters on to the ward and had been reminded about the trust’s search policy. In spite of this, we found little documented evidence relating to the searching of patients or their rooms for contraband items.

We were concerned about the confidentiality of patient and carers information due to the location of the office whiteboard on Rosewood. Information contained on the board, which included home contact numbers for patients and their relatives/carers was visible to anyone who passed by the office on their way to the dining area.

There was not enough emphasis on adhering to the Mental Health code of practice in respect of section 132 rights and access to an independent mental health advocate (IMHA).

Updated 4 December 2018

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

• The service provided a range of care and treatment suitable for patients in line with best practice and national guidelines. Staff involved patients, families and carers in patients’ care and treatment. Staff used therapeutic drug and physical health monitoring, nutritional screening, podiatry services, speech and language and occupational therapies.
• Each ward had enough staff to provide care and treatment for patients.
• Clinical areas were clean and stocks and equipment were maintained.
• Staff assessed risks, including the risk of ligature points (places to which those intent on self-harm could attach something to strangle themselves) and took action to remove or reduce risks.
• Recent patient-led assessments of the care environment (PLACE) (2017) showed that the service had scored higher than other similar trusts for cleanliness, condition, appearance and maintenance of the wards and for the food provided on the wards.
• There was good teamwork among staff and staff were happy to work in the service. Staff felt able to raise concerns. They said managers supported and encouraged them to access further training to develop their skills.
• Families and carers were involved in the patients’ treatment from the admission stage through to discharge.

However:

• Meadowbank and Croft wards were not compliant with the Department of Health guidance on eliminating mixed sex accommodation. The service reported 29 breaches in the year to 30 April 2018 on Croft and Cherry wards, mainly due to urgent admissions of male patients onto female areas of the wards.
• Patients did not have personal emergency evacuation plans in place to assure safety in the event of an emergency evacuation. The wards admitted frail older people, some of whom had significant mobility issues. There were no plans in place for patients to set out how they would be evacuated in an emergency.
• Patients were not able to close the observation windows from inside their bedroom doors. This could compromise their privacy and dignity.
• The accessible bathroom did not have a shower curtain around the bath to protect patient’s dignity and privacy and laundry was being stored in there which could present an infection control risk.
• Care plans on Meadowbank ward were not personalised.
• There were low compliance rates with mandatory training, including fire evacuation.

Updated 14 December 2023

We carried out this unannounced focused inspection because we had concerns about the safety and quality of the service, and wanted to see if the trust had made improvements following our last inspection.

The trust has 6 acute mental health wards for adults of working age and 2 psychiatric intensive care units (PICU) across 3 locations.

• Bowmere Hospital – Beech ward (22 beds), Juniper ward (24 beds), Willow ward (PICU, 7 beds)
• Clatterbridge Hospital Psychiatric Services – Brackendale ward (20 beds), Brooklands ward (PICU, 10 beds), Lakefield ward (20 beds), Riverwood ward (13 beds)
• Jocelyn Solly (Millbrook/Macclesfield DGH) – Mulberry ward (25 beds).

All 3 locations were visited by either inspectors or Mental Health Act reviewers. We visited 5 wards: Beech, Juniper and Willow wards at Bowmere Hospital, Brooklands ward at Clatterbridge Hospital, and Mulberry ward in Macclesfield. We reviewed information and documents about all 8 wards.

Our rating of services improved. We rated them as requires improvement because:

• The service did not always have enough nursing and medical staff, and not all staff were up to date with their mandatory training.
• Although staff had access to the information they needed to provide safe and effective care, records were not always fully completed, and the information was not always consistently recorded in the same place, which could make it difficult to monitor that it had been completed correctly.
• Patients were not always secluded in a suitable environment.
• Governance processes were in place, but they were not always effective.

However:

• Staff assessed and managed risks to patients and themselves and used restraint and seclusion only after attempts at de-escalation had failed. However, records of interventions were not always completed fully.
• Staff understood how to protect patients from abuse and the service worked with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health. Patients had a physical health assessment on admission, but this was not always fully completed.
• The wards were generally safe, clean, equipped, furnished, maintained and fit for purpose.
• Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.
• Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Most staff felt respected, supported and valued, particularly by their teams and local managers, and were able to raise their concerns.
• Staff engaged actively in local and national quality improvement activities.

At our last inspection on 8, 9, 14 and 15 November 2022 we issued the trust with warning notices and rated this core service as inadequate overall, and inadequate for safe and well-led. At this inspection we found that the trust had taken actions to address the concerns outlined in the warning notices. However, although we found that the trust had made progress against the warning notices we issued in November 2022, they had still not fully met the regulations.

How we carried out the inspection

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

During the inspection visit we:

• visited 3 of the 6 acute wards for working age adults and both PICUs, and looked at the ward environments and observed how staff were caring for patients
• spoke with 11 patients or their relatives
• spoke with staff on all the wards we visited
• spoke with senior managers covering all parts of the service
• reviewed 17 care records of patients, and other care related documents including observation and seclusion records
• looked in detail at the use of seclusion and enhanced observation
• attended 2 meetings
• looked at a range of 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

The patients we spoke with had mixed views about the service, but their feedback was broadly positive.

Patients were generally positive about staff, with most finding them available, approachable and respectful. Some patients said there were not enough staff and that one-to-one sessions did not always happen, but most said there was someone to talk with if they needed support. There were mixed views about access to activities – for patients on the acute wards these tended to take place off the ward, so they were more accessible for patients who did not need to be escorted off the ward.

Patients who needed physical healthcare generally had their needs met.

Patients had mixed views about how involved they were in their care, and how much information they had about medicines. Some patients felt very involved and informed, others less so.

Patients told us that the wards were usually clean.

Updated 18 June 2020

• There were long waiting lists for attention deficit hyperactivity services across all three geographical service areas.
• Staff did not fully monitor exisiting patients on the waiting list. This meant we could not be assured that staff were able to identify, respond and manage a deterioration in a patients’ health or a change in their risk level.