All inspections: Cheshire and Wirral Partnership NHS Foundation Trust

Cheshire and Wirral Partnership NHS Foundation Trust (CWP) is a combined NHS provider of mental health services, learning disability services, community mental and physical health services and primary medical services. The trust has services across Wirral and Cheshire, as well as Trafford, Warrington, Bolton, Halton and Liverpool. It also commissions specialist eating disorder services for the North West. The trust was formed in 2002. In June 2007, the trust became the first mental health trust in the North of England to become a foundation trust. The trust has over 14,700 members and employs more than 4,500 staff across 73 sites, serving a population of over 1 million people and highly specialist services for 2 million.

We undertook a trust-level assessment (well-led review) of the trust which included an on-site visit on 2-4 July 2024. We undertook further visits to observe the trust’s board and committee meetings on 31 July, 2 September, 11 September and 17 September 2024. We assessed all 8 of the quality statements in the well-led key question used when assessing an NHS trust in the Single Assessment Framework. We found areas for improvement within three of the eight quality statements and positive findings within five of the eight quality statements. We have asked the trust for an action plan in response to the concerns found at this assessment.

The well-led review followed several assessments of the trust’s frontline services (assessment service groups). The initial assessment of the trust’s services was triggered following two serious incidents (inpatient deaths) in Bowmere Hospital. This resulted in an assessment of the trust’s acute mental health wards at Bowmere Hospital, and the psychiatric intensive care units at Bowmere Hospital and Springview Hospital. The assessment found significant concerns regarding the staffing levels across Bowmere Hospital and a letter of intent was served on the trust requiring them to take immediate action to ensure a reduction of the risk of harm to people who used services. The trust responded to the letter of intent and addressed our concerns through an action plan detailing how the issues would be resolved.

Further assessments included wards for older people; community mental health services for working age adults; mental health crisis services and health-based places of safety; community end of life care and Willaston Surgery. We undertook these assessments to ensure we had a thorough understanding of the full range of services provided by the trust ahead of our well-led review.

We assessed all 8 of the quality statements in the well-led key question used when assessing an NHS trust in the Single Assessment Framework. We found areas for improvement within three of the eight quality statements. The trust had a strategy however it was not supporting a shared direction within the trust. There was work in-progress to reframe and reset the trust’s strategy to focus on the highest priority objectives. Governance systems, particularly the systems in place to identify and manage risk, quality and performance, did not always operate effectively to sight leaders on all emerging risks within services. Information systems were in development which meant the board did not always have consistent systems in place to capture, analyse and present information. There was work in-progress to strengthen freedom to speak up processes. However, the trust had a clear statement of vision and values. These were well-embedded within the trust. Leaders consistently demonstrated their commitment to compassionate and inclusive leadership. Leaders were visible within the trust and there was strong evidence of the commitment of the board to the equality, diversity and inclusion agenda. The trust’s commitment to learning, innovation and research was clear, particularly the focus on patient outcomes. There was strong evidence of both the commitment and passion within the provider collaboratives led by the trust. There were examples of partnership working and innovation in relation to involving communities and co-production.

Date of assessment 04 June 2024 to 11 June 2024.

We assessed 16 quality statements across safe, effective, caring, responsive, and well-led key questions and have combined the scores for these areas with scores from the last inspection.

Staff showed good understanding of the Mental Health Act and Mental Capacity Act and this was integrated in to their every day practices. Staff had a clear understanding of patients' risks and care requirements. The service maximised the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

The service treated people with kindness, empathy and compassion and respected their privacy and dignity. They promoted people’s independence, so they knew their rights and have choice and control over their own care, treatment and wellbeing. Staff felt well supported by managers and felt confident approaching them. However, we found issues around the administration and management of medication on Cherry ward.

We interviewed 26 staff across 3 wards and observed MDT meetings and the care and treatment of patients. We spoke with 9 patients and 10 carers.

We assessed Cheshire and Wirral Partnership NHS Foundation Trust's mental health crisis services on 21-23 May 2024. During this assessment we visited services in Cheshire East, Cheshire West and the Wirral. We assessed 18 quality statements across the safe, effective, caring, responsive, and well led key questions and have combined the scores for these areas with scores from the last inspection.

We assessed this service between 7 and 13 March 2024. The Trust failed to ensure the service consistently had enough staff to keep patients safe, to support patients to access all aspects of their care created unnecessary restriction on 'quality of life of patients and placed them at risk of avoidable harm.

The service's culture was not consistently centred on the needs and experiences of patients, and staff told us they found difficulty forming relationships with patients due to staffing pressures. Patients were complimentary about the care and compassion provided by staff toward them and we observed staff caring for patients with kindness and compassion.

Following our last inspection the Trust provided an updated action plan to manage staffing pressures and had a workforce plan in place aimed at growing their own staff and the retention of existing staff. Staff told us they consistently raised concerns with senior managers about safe staffing levels on the wards and they did not see significant improvements despite the Trust action plan.

The Trust was experiencing staffing pressures across most services as a result of high levels of absence and vacancies. This impacted on patient’s access to therapeutic activities and on staff wellbeing. Care plans were not always individual to the needs of the patient.

Systems and processes were in place so staff could report incidents and receive information about serious incident outcomes and learning from these. Ward managers had set up local communication processes to check staff were receiving important information, but told us they did not have sufficient time to read this due to staffing pressures.

Cheshire and Wirral Partnership provides community mental health services across Cheshire and Wirral. We carried out assessments at 4 community teams across this footprint. We assessed 20 quality statements across safe, effective, caring, responsive, and well-led key questions on 8-10 May 2024. We interviewed 22 staff across the sites and observed meetings and care onsite at community locations as well as out on home visits. We spoke to 20 patients on and off site and 7 carers remotely.

We found patients were treated with kindness and compassion across all sites. Key workers knew patients well and continuity of care was maintained. The creation of a high-risk board and morning handover meeting was supporting good oversight and management of current and emerging risk within teams. These meetings also promoted shared risk management within teams. There was a focus on safety and concerns or incidents were managed and investigated appropriately. Learning from incidents was regularly shared. Staff teams were also happy and well supported and workloads were generally manageable. However, we noted some inconsistencies in case note documentation across all sites in risk and safety plans. This was of particular note in consultant led caseloads, which were large across all sites. It was also clear within key worker caseloads that the level of care being provided was not always accurately reflected in the case notes. There had also been notable difficulties across sites in recruiting psychologists, leading to a marked reduction in or absence of psychology provision within teams. Teams also raised concerns about increasing acuity in their caseload and an increased need to provide crisis support for their patients.

Community End of Life Care services for Cheshire and Wirral Partnership NHS Foundation Trust are based at The Hospice of the Good Shepherd in Backford, Cheshire. The trust is registered CQC to deliver the regulated activities: Treatment of disease, disorder or injury.

This assessment was prompted due to the time since the last inspection of the service (2015). At the time of this assessment a wider review of services was also undertaken.

We carried out this assessment on 11, 12 and 13 June 2024. We looked at quality statements in key questions safe, effective, responsive and well-led. The service remains re good in all these areas and we have rated the service good overall.

During our assessment we found systems and processes were in place to ensure safe care and treatment was provided to end of life care patients. However, for well-led there was not fully effective oversight of risk. Action was being taken to address this at the time of the assessment.

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.

We carried out this unannounced focused inspection because we had concerns about the safety and quality of the service. These were specifically about Mulberry ward at Jocelyn Solly (Millbrook) at Macclesfield and Brooklands and Lakefield wards at Clatterbridge Hospital on the Wirral.

The trust has five acute mental health wards for working age adults and two psychiatric intensive care units wards across three locations. On this inspection we only inspected:

Mullberry ward, a 26-bed ward which was an acute mental health wards for working age adults and older adults with functional mental health problems at Jocelyn Solly (Millbrook) at Macclesfield.
Lakefield ward, a 20-bed ward which was an acute mental health wards for working age adults and older adults with functional mental health problems at Clatterbridge Hospital Psychiatric Services on the Wirral
Brooklands ward which was a 10-bed psychiatric intensive care unit at Clatterbridge Hospital Psychiatric Services on the Wirral.

The wards cared for both male and female patients.

We last inspected the trust’s mental health acute wards in August 2018 where it was rated good overall and in all key questions apart from the safe key question which was rated as requires improvement. As this was a focused inspection, we did not follow up the shortfalls we found in August 2018 to check whether improvements had been made.

This was a focused inspection which looked at parts of the ‘safe’, ‘caring’ and ‘well led’ key questions. The rating of ‘safe’ and ‘well-led’ has changed from requires improvement to inadequate. We issued a warning notice to ensure the trust made appropriate improvements as the environment used for seclusion, seclusion practice, and the governance of seclusion incidents needed significant improvement:

There was no designated seclusion environment at Jocelyn Solly (Millbrook) at Macclesfield. Patients were secluded in their bedrooms or rooms not designated as seclusion rooms. These rooms were not safe or appropriate environments to seclude patients as they did not fully lock, could be overlooked by other patients and did not meet national guidance.
The seclusion room at Brooklands ward at Clatterbridge Hospital Psychiatric Services was not fully clean.
Staff were not recording key tasks when patients were placed in seclusion, so we were not assured that the required safeguards were met for each episode when someone was put in seclusion.
Staff were not categorising incidents of seclusion properly. The trust’s internal safety reviews into seclusion episodes were not always robustly identifying key issues in relation to seclusion incidents.
Staff did not ensure that a patient who needed to have access to communication cards and tools, always had access to them .

However:

Through observations and speaking to patients, patients were treated with dignity and respect.
There was no ward manager on Brooklands as the previous manager had resigned but the other ward managers were providing regular input and we did not identify any significant impact. The trust had put a supportive team and improvement plan around the Brooklands ward team.
In some cases, we saw evidence of learning (especially following serious incidents), and improvements made. The policy and practice of observation had improved with upgraded systems, better observations recording and observing staff wearing tabards so they were not distracted.
While the layout of Lakefield ward did not fully afford observations across the whole ward, this was mitigated by patient observations, deployment of staff and parabolic mirrors.

This was a focused inspection. Because of its limited scope, we did not set out to rate at this inspection. However, where we have identified a breach of a regulation and we issued a warning notice to an NHS trust, the rating linked to the area of the breach will normally be limited to ‘inadequate’. You can view previous ratings and reports on our website at www.cqc.org.uk.

How we carried out the inspection

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

During the inspection visit the inspection team:

visited three wards and looked at the ward environment
observed how staff were caring for patients
spoke with 11 patients and eight carers
spoke with ward managers or the most senior nurse on duty
spoke with 18 other staff including nurses, health care assistants, consultant psychiatrists and trainee doctors.
Reviewed 15 care records of patients and other care related documents
reviewed fully seven episodes of seclusion
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

We spoke with 11 patients and eight carers. Patients told us that the wards were kept very clean. Most patients stated that staff cared for them well and were very friendly. They said staff were very understanding towards patients and helped them as much as they could.

Most patients felt safe and staff helped to keep them safe. One detained patient told us about an incident of restraint but understood why staff needed to restrain them as they were trying to leave the ward. One patient did not have access to communication cards to help them communicate how they were feeling. We passed this on the nurse in charge to ensure that despite any restrictions placed on them, patients were able to use communication aids. Where patients raised less positive concerns, they were in the context of not wanting to be in hospital or they did not provide enough detail for us to pass on to the trust to look into the concerns properly.

None of the current patients we spoke with had experienced being placed in seclusion.

All the carers we spoke to were complimentary about the care their loved one received stating staff were respectful and polite. They stated that staff were responsive when they asked for information. Two carers told us that when their loved one was restrained; they were informed about it soon afterwards. They were not concerned about the restraint episode and said staff were lovely, caring and they could not fault them. One carer told us they felt listened to and their concerns were taken seriously. Some carers said that it was sometimes difficult to speak with staff on the phone on Lakefield ward as the phone wasn’t always answered.

We carried out this unannounced focused inspection because we had concerns about the safety and quality of the service. These were specifically about Rosewood ward at Bowmere Hospital, and this was the only ward we visited as part of this inspection.

Rosewood ward is an 18-bed high dependency rehabilitation service for men and women of working age. The ward is divided into male and female areas with 10 beds for women and 6 beds for men. There are two self-contained flats, which patients from the ward may move to before they are discharged into the community.

The long stay or rehabilitation mental health wards for working age adults core service was last inspected in June 2015 and was rated as good. This inspection included Rosewood ward.

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

This was a focussed inspection which looked at parts of the ‘safe’ and ‘well led’ key questions. The rating of ‘safe’ has changed from good to requires improvement. This has not changed the overall rating of this core service which remains as good.
The ward was clean and maintained. In most instances the ward was designed to reduce the risks to patients, but the environmental risk assessments were not comprehensive. The service effectively operated the trust’s governance processes, but risk was not always managed well.
The service did not always have enough staff, who knew the patients and received basic training and supervision to provide safe and consistent care.
Staff assessed and managed risks to patients, however not all patients had an up to date risk assessment. Staff achieved the right balance between maintaining safety and providing the least restrictive environment possible in order to facilitate patients’ recovery.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Incidents were recognised, reported and investigated.
Leaders had the skills, knowledge and experience to perform their roles. However, there had not been stable leadership over the last year.

This was a focused inspection. Because of its limited scope, we did not set out to rate at this inspection. However, where we have identified a breach of a regulation and we issued a requirement notice, the rating linked to the area of the breach will normally be limited to ‘requires improvement’ at best. You can view previous ratings and reports on our website at www.cqc.org.uk.

How we carried out the inspection

Before the inspection visit we reviewed information that we held about the service. This included information from a Mental Health Act reviewer visit in June 2021.

During the inspection visit the inspection team:

visited the ward, looked at the ward environment and observed how staff were caring for patients
spoke with four patients
spoke with managers of the service
spoke with five other staff
reviewed ten care records of patients and other care related documents
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

Patients told us there were not enough staff. They were generally positive about the actual staff on the ward, and felt able to talk with them. However, there were a lot of temporary staff who didn’t know them or their needs.

The occupational therapist led on activities, and patients had mixed views about the value of these. Patients told us activities were not always available, and it was sometimes difficult to have escorted leave, which they attributed to there not being staff available.

Patients had mixed views about the level of involvement they had in their care plans, and how much recovery, rehabilitation, physical wellbeing and discharge were monitored and planned for. Some patients were involved in and aware of aspects of this, but others were not. All the patients we spoke with had different views of what improvements could be made to the ward.

Patients felt that decisions were made about them without their involvement. They provided information to a weekly multidisciplinary ‘board round’ but were not allowed to attend. They did attend the monthly ‘ward round’. Patients had had their medicines explained to them, and were able to ask questions about this.

Patients told us they felt safe most of the time, but they sometimes felt intimidated by other patients.

Patients gave similar feedback to a CQC Mental Health Act reviewer who visited the service in June 2021 and spoke with 13 patients.

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.

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.

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.

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.

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.

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.

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.

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

Ligature risk assessments for patients and the wards had been carried out and had been updated. Staff members had personal alarms and patients had access to nurse call buttons in each room. Clinic rooms were clean and had equipment that had been recently calibrated and maintained, and drug cupboards were in order. Fridge temperatures were monitored, and emergency equipment was checked daily and all equipment in date. Seclusion rooms met specifications of guidance, and recording of seclusion events followed policy. Staff knew safeguarding policies and applied them when required, keeping patients from harm or neglect. Staffing levels were sufficient for the service, with use of bank nurses familiar to the wards. Risk assessments were completed on each patient on arrival on the wards.
Care plans were created within 72 hours of admission, and were comprehensive, holistic and considered the views of the patients. Physical health monitoring was being recorded regularly, with specific health problems monitored and treated accordingly. Clinical audit was being undertaken by staff on wards and reflected in practice. The Mental Health Act was being adhered to and the Code of Practice was available to all staff on each ward. Mental Health Act paperwork was regularly audited, patients were being read their rights, and there was a dedicated team who monitored all aspects of the Mental Health Act. Capacity was being assessed for each patient, and best interest meetings were taking place on the wards.
Staff interacted positively with patients across the service. Patients described staff in positive terms, with no complaints made about staff. Carers and patients were given opportunities to feed back into the service through several channels. Patient led assessment of the care environment results put the service at above the national average. Patient meeting minutes showed consideration and actions by the service in respect of patient suggestions. Patients could get involved in decisions about the service, with the trust running an expert patient programmed designed to involve patients in aspects of the service.
The wards were clean and well furnished with appropriate furniture for the service. There were enough rooms for therapies and social activities to take place. Patients were happy with the quality of the food and choice available. There was information across the service regarding medication and treatment that was available to patients. Patient complaints were being acted upon when received, with feedback taking place. There was reasonable adjustment of rooms across the service for patients with physical disabilities.
The multi-disciplinary teams across the service worked well together, and the relationship with ward staff and management was good. Ward managers were experienced and knew the role and purpose of their wards, as well as relevant policies and protocols. Trust values were integrated into ward philosophies, and all staff knew the trust values when discussed. The trust used locality data packs to keep the service informed of performance within the service, and to guide staff to areas of improvement or good practice. The service had acted on feedback from the last inspection, and had made improvements based on that feedback.

However,

Staff did not follow trust policy or national guidance in relation to rapid tranquilisation, several care records did not show monitoring of physical health after intra-muscular administration of medication.
Work to eliminate mixed sex accommodation had been undertaken since the last inspection, but more action was required. On Adelphi and Bollin wards, some rooms contained beds for two people, separated only by a curtain in the middle of the room.

Bed management was taking place, although the wards were admitting over the 85% trust target for occupancy. This meant that when patients returned from episodes of leave they could not always return to the same ward.
Risk assessments were taking place but not always being updated to reflect changes in patient risk.
Mandatory training was taking place, but staff were not all completing the required training.
Supervision was not happening regularly for clinical staff, and the trust did not have a target level.

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

There were sufficient numbers of skilled staff to provide direct care and treatment. Most staff had completed ongoing mandatory training. Managers carried out detailed reviews of restraint and prone restraint episodes. Following a review of incidents, managers had increased staffing levels to try and prevent incidents from occurring at these times.
Staff completed detailed goal based care plans and risk management plans for each patient. Staff followed national guidance in the routine prescribing of medication for children and young people and the care and treatment of patients with eating disorders. There was good multidisciplinary working with clinical psychologists, family therapists and occupational therapists. Staff had improved their recording of patient rights and competence and capacity decisions following our Mental Health Act monitoring visits.
Patients were mostly happy with the quality of care and support. Staff made great efforts to involve patients and carers in the building of Ancora House, their own care and treatment and the running of the wards, including patients coproducing a dedicated website. There was a high response and satisfaction rate from surveys of patients and carers.
The building at Ancora House provided an exemplary environment for the care of children and young people. The assessment and outreach team completed detailed admission assessments and managed patient admissions well. Staff had paid attention to meeting the needs of all patients with disabled access and leaflets translated into different languages. Patients spoke highly of the school attached to Ancora House which had very well-equipped classrooms to meet young people’s educational needs.
There was good morale among the staff team. The trust produced locality data pack, which provided detailed information to managers on key indicators. Staff completed regular audits which promoted good practice. Managers took immediate action on the gaps in auditing around seclusion and rapid tranquilisation which we identified. The wards had been assessed through the Royal College of Psychiatrists’ peer accreditation scheme and were awaiting the results.

However:

Staff had not always ensured that they were recording their responsibilities under the Mental Health Act Code of Practice relating to seclusion as we found gaps and shortfalls in the records. Staff had not always fully recorded whether they had considered the threshold between seclusion and long-term segregation in cases where patients were in seclusion for long periods due to sustained risk.
There had been no audits of staff practice relating to seclusion or rapid tranquilisation to benchmark practice against national guidance with the aim of improving safe practice and recording of responsibilities.
Although there were only a small number of complaints, we saw one complaints response which did not clearly state what stage the complaint was, the patient had not been given a full decision to enable them to understand the outcome and the patient was not signposted where to go if they were unhappy with the latest response.
While there was a commitment to quality improvement, ward staff did not articulate the ward’s future objectives, improvements following audit or a clear clinical governance framework to drive quality.

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.

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.

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.

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

We rated well-led for the trust overall as good. The trust board and senior leadership team had the appropriate range of skills, knowledge and experience to perform its role and the non-executive directors provided robust and constructive challenge to the trust board. 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.
We rated effective and well led as good, safe as requires improvement and caring as outstanding. In rating the trust, we took into account the previous ratings of the services we did not inspect this time.
We rated 14 of the trust’s 15 services as good overall, and one as outstanding overall.
The rating for safe and well led for community health services for children, young people and families had improved from requires improvement to good. The rating for caring had improved from good to outstanding.
Leaders were visible in the service 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.
Staff completed thorough assessments of patients’ needs, including physical health and mental health assessments.
Care was provided that was in line with national guidance and staff were skilled to deliver care.

However:

We rated safe as requires improvement in four of the 15 services. Ratings in the safe domain for child and adolescent mental health wards and wards for older people with mental health problems went down from good to requires improvement.
Generally, staff felt well supported and many said they had clinical supervision. However, there was no trust target for clinical supervision and recorded rates were low.
In some services, compliance rates for mandatory training were below the trust target.
There had been no qualitative audits of staff practice in relation to seclusion and rapid tranquilisation. In one service, physical health checks following rapid tranquilisation had not been carried out in line with trust policy. In another service, there were gaps and shortfalls in seclusion records.

We rated forensic inpatient/secure wards as good because :

The wards were clean, spacious and well maintained. Clinical rooms were well stocked and had emergency equipment available. Security procedures were in place to manage the environment safely. There was adequate staffing to manage the ward environment and patients’ needs. There was low use of bank and agency staff, which meant that there was a consistent staff team to deliver care.

Care plans and risk assessments were in place. They were detailed, comprehensive, and met the individual needs of patients. There was limited use of blanket restrictions. Where restrictions were implemented, these were detailed in individual patients’ care plans.
Staff followed the Mental Health Act Code of Practice in maintaining accurate records around seclusion. This was particularly evident around the decision to seclude and to continue to seclude patients. Staff had good knowledge of the Mental Health Act and the Mental Capacity Act. Staff knew where to go for advice and support.
Staff were aware of safeguarding procedures and could describe what to do should they be concerned about abuse of an adult or child. Effective multidisciplinary team meetings took place weekly and were multi professional and patient focused.

Staff received feedback from incidents and complaints, and learning was shared across the trust. Staff received supervision and an annual work performance appraisal in line with the trust’s policy. Ward staff were qualified and skilled to perform their role and received a corporate and local induction on commencing their role. Staff were compliant with their mandatory training.

Patients spoke positively about staff. We observed the staff to be professional in their interactions with patients and knowledgeable about their patients’ needs. Patients had access to an independent mental health advocate who was easily accessible. Daily morning meetings, and ‘my service, my say’ meetings took place. Patients felt that they were listened to and gave us examples of changes that had been made following their feedback.
The service had good access and discharge procedures in place; we saw that discharge plans were in place that contained the patient’s view on their discharge from hospital.

Therapeutic and diversionary activities were available seven days a week. Hot drinks and snacks were available throughout the day. Patients had access to their own mobile phones. The service met the spiritual needs of patients as there was a multi faith room available for patients to access and patients who had leave off the site were able to attend their designated place of worship.
Staff were aware of the vision and values of the trust and could demonstrate how these were embedded in their practice. Staff knew who the senior managers in the organisation were and told us that the modern matron was highly visible on the wards.
Good governance systems were in place, and there were regular clinical audits to ensure quality and standards were maintained. Ward managers accessed their key performance indicators through bimonthly safety metrics. This allowed ward managers to monitor their performance and make improvements where necessary. Staff felt supported by their managers and felt that they worked well within their teams. Regular team meetings took place to allow staff to give feedback on their service. The secure wards were part of the Quality Network for Forensic Mental Health.

However;

The trust had not put adequate mitigation in place to manage the two blind spots on Saddlebridge Recovery Centre. This increased the risk to patients of unwitnessed incidents occurring.

Additional training in learning disabilities was not provided by the trust to the staff working on Alderley unit.

We rated substance misuse services as good because:

There was good risk management. Clients had their risks assessed on admission and on an ongoing basis. There were appropriate risk assessments around prescribing substitute medication including home condition assessments. Building and health and safety risk assessments were in place. Lone working protocols were followed.
Staff were knowledgeable around safeguarding and understood trust policies and procedures in this regard. Staff with active safeguarding cases received specialist supervision. There were good links with local safeguarding bodies.
Clients had care plans in place. Care plans were up to date and comprehensive. Clients were involved in decisions about their care and treatment. Care plans included client views and objectives.
The team monitored the quality of the service and client outcomes. Care record audits were in place and the team completed treatment outcome profiles as part of the national drug treatment monitoring service.
Staff treated clients with respect and compassion. Feedback from clients about the staff and the treatment they provided was positive. Clients were able to give feedback about the care they received and get involved in decisions about the service.
There were clear referral pathways into the team. There was a dedicated team to review and prioritise referrals. Staff followed up with clients post discharge.
Staff morale was positive. There was good team working and mutual support. Senior management were a visible presence and staff felt comfortable raising concerns.
There was a governance structure in place to support the delivery of care. Performance monitoring was in place. The service met quarterly with partner agencies to review performance.

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.

We have rated community-based mental health services for adults of working age as good overall 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.
We re-rated the effective question from requires improvement to good following this inspection. This was because the provider had taken action to make improvements. We found that staff read patients their rights under the Mental Health Act 1983 routinely throughout treatment. We also found that staff assessed patients’ capacity when there was a reason to do so and involved family members in making decisions when patients lacked capacity.

However:

Copies of capacity to consent to treatment forms were not kept with medication charts at both of the teams we visited.
It was not clear whether all patients had been offered a copy of their care plan.

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.

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

Patients had a comprehensive assessment which included their mental, physical and social needs, and any potential risks to themselves or others. Following the assessment, patients had a recovery focused care plan. Care plans were person centred and reflected the individual’s needs. Patients had a risk assessment carried out, and the findings of this were included in their care plans. Patients had discharge plans and care programme approach meetings.

Patients were generally positive about the service and care they received. Patients told us that overall staff were helpful and treated patients with respect. There was patient and carer information on all of the wards.

There were adequate numbers of nursing and medical staff to provide care for patients. Staff had an induction when they were employed by the trust, and received appraisal, supervision and training. The occupational therapy service provided assessments and activities on the wards. The pharmacy team provided advice and support, and carried out medicines reconciliation when patients were admitted.

Staff prescribed, stored, administered and disposed of medication safely. Staff were trained to respond to medical emergencies. Resuscitation and other medical equipment was available, and in working order.

Staff were familiar with the trust’s values, which centred on the “6 Cs”. These were: care, compassion, commitment, competence, communication, and courage. Staff were mostly positive about their teams and managers. Data packs were produced for each ward that included key governance information about patients, staff, practice issues, and audits. This supported managers to monitor the performance of the service.

Serious incidents were responded to, reported, investigated and followed up on. Lessons learned were shared amongst staff.

Although there were potential ligature points in high risk areas of the wards, the trust had a plan of action for monitoring and taking action or mitigating against these risks.

Following the June 2015 inspection we told the trust that it must take action to improve acute wards for adults of working age and psychiatric intensive care units. It had taken this action with regards to the governance arrangements for the oversight of the Mental Health Act, and the recording of rights of detained patients, promoting access to an independent mental health advocacy service, recording the use of seclusion, recording capacity and consent to treatment, and recording and managing risks.

However:

The rating of the safe key question remains as requires improvement, and a requirement notice was issued with regards to breaches of the Department of Health’s guidance on same sex accommodation. The trust had taken action to improve the provision of same-sex accommodation, but there were still repeated breaches.
The trust had a nicotine management policy, and smoking was not allowed in the trust's services. There had been a number of incidents related to patients bringing lighters and tobacco on the wards.

Although some staff used a psychological approach in their work with patients, there was limited access to psychology on the wards.

Our overall rating for this service was Requires Improvement because:

Staff were familiar with how to report incidents and the relevant policy and procedure. However, the level of incident reporting was low, which could be indicative of staff not raising concerns appropriately. This was supported by examples of incidents that weren’t reported, which limited the opportunity for learning. When incidents were reported, lessons learned were not shared consistently with the teams.

The service did not maintain accurate, complete and contemporaneous records in respect of each service user. Records were not accessible to authorised people as necessary in order to deliver people’s care and treatment in a way that meets their needs and keeps them safe.

There was both a paper and electronic record for the majority of children in the service; however, there was no summary within the electronic record to identify historic concerns or issues. We also found that there was no reference in either paper or electronic records to alert professionals that there was another set of records for the child. In addition, it was identified that it would take a minimum of 24 four hours for staff to retrieve archived paper records. Managers were not able to give assurance that staff would be able to identify historic concerns written in paper records and share the information with the relevant services in a timely manner.

Safeguarding and other alerts could not be removed from the electronic record system, which meant the system did not provide an accurate reflection of which children had a child protection plan in place or where there were current child protection concerns.

The risk identified in relation to the management of records was not on the divisional risk register and no risk assessment had been completed in anticipation of the records being moved into deep storage with an external company. Managers were aware of the concerns relating to removal of alerts from the electronic record but this had not been raised on the risk register and no risk assessment had been completed for this.

However:

Care and treatment was delivered in line with national guidelines and evidence based practice. Maternal mental health assessments were completed appropriately and fully documented using a recognised assessment tool.

There was effective multidisciplinary working evident across the service. School nurses had developed good working relationships with the schools in their areas. There was a health visitor attached to each GP practice to ensure effective working relationships. There were systems in place to ensure breast feeding mothers received the required support from suitably trained staff.

The children and young people’s service was delivered by caring, committed and compassionate staff that treated people with dignity and respect. Staff actively involved young people and their parents and carers in all aspects or their care.

A range of services was provided by the division teams both in the community and in schools. The teams aimed to provide a flexible service where possible. The school nursing service was in the process of designing a website called ‘my wellbeing’. The work on this website was being undertaken with input from young people and the aim was for this to be launched in September 2015.

New initiatives had been established to meet the needs of people that use the services. Speech and language waiting times were being achieved with children waiting on average 11 weeks from referral to treatment which was better than the trust target of 13 weeks.

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.

We gave an overall rating for acute wards for working age adults and the psychiatric intensive care unit (PICU) as requires improvement because:

Brackendale and Beech wards did not comply with the Department of Health required guidance on same sex accommodation.
Acute wards were mixed gender. Not all bedrooms were en-suite and on some wards, female patients had to pass a male area to access toilet and bathroom facilities.
Not all wards had designated female-only lounges.
There were not clear lines of sight within the corridors housing patients of different genders.

We observed a male and female patient going into a bedroom area, unobserved by staff.

Some of the seclusion records either did not record the time the doctor was informed and attended or did not explain the reasons why the doctor was delayed. This meant it was not always clear that the safeguards for seclusion or segregation were being met. Some of the restraint records did not record the time patients were restrained in the prone position.

Some patients’ risk assessments were lacking in detail and some identified a list of past risk incidents without detailing how current risks would be managed.

There was variable adherence to the MHA Code of Practice particularly around significant delays in recording of rights, capacity to consent for treatment for mental disorder and seclusion recording.

The trust’s governance arrangements relating to the oversight of the Mental Health Act was not effective. Our MHA reviewers had raised many of these concerns on previous MHA monitoring visits, but issues continued to be found.

Patients on Beech ward were not receiving regular input from the responsible clinician (RC), with some patients not seeing their RC for weeks.

However:

There were plans to improve the seclusion environment at the Jocelyn Solly (Millbrook) Unit as the current rooms used for seclusion did not meet the enhanced standards prescribed by the new Mental Health Act Code of Practice. There were significant efforts to reduce and review all episodes of prone restraint through various trust initiatives. Staff knew about potential risks to patients’ health and safety, and how to respond to and manage these. There were clear systems in place for reporting safeguarding concerns and staff understood what they had to do.

Services were evidence-based and focused on the needs of patients. However, there was a lack of psychology input on the wards. Staffing levels were generally safe.

The trust provided a caring service for patients across the acute wards and the PICU. We saw examples of staff treating patients with kindness, dignity and compassion. The feedback received from patients was generally positive about their experiences of the care and treatment provided by the staff on the acute wards and the PICU.

Wards employed peer support workers so patients were supported by a staff team that included suitable people who had direct experience of mental illness. Ward managers were supported in the day-to-day management by a resource manager who managed the non-clinical aspects of running the ward. This enabled ward managers to focus on ensuring the wards provided good quality clinical care.

Patients were able to access beds in their local acute psychiatric service within reasonable timescales. Whilst there was some pressure on beds, this did not significantly affect patient care.

Patients told us they knew how to make a complaint should they need to.

The wards and PICU were committed to provide high-quality care and continuous improvement in line with the trust’s stated values and strategy. Staff reported they felt well supported by their managers.

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).

We rated mental health crisis services and health based places of safety as good because:

Teams were fully staffed and carried a caseload which was monitored and assessed daily with input from the consultant psychiatrist or junior doctor. Risks were considered from the point of referral to discharge and clearly documented within service users records. Workflow was discussed in handover. Work was prioritised by the teams and co-ordinated through a dedicated member of the team responsible for triage and shift co-ordination. This helped to ensure the teams worked efficiently to meet the daily demands of the service each day.
We saw good working relationships between teams: crisis care, street triage, liaison psychiatry, community teams, accident and emergency staff. The hospital inpatient wards and a dedicated member of the crisis team communicated on a daily basis to offer a structured approach to support people who use services. Care plans and crisis intervention plans were present and up to date. Staff understood the guiding principles of the Mental Health Act. We saw evidence of this in practice where staff always looked to provide the least restrictive care options, in collaboration with the person and their family/carer.
Teams received mostly positive feedback from people who use the service with regard to their care and treatment. The Care Quality Commission carry out an annual survey of community mental health service users, sending a questionnaire to service users who are in receipt of care from community teams. The survey carried out in 2014 showed the trust scored better than average overall in comparison with other trusts.
We observed a collaborative approach between teams to support people being referred to crisis services. This helped to prevent inappropriate admissions to inpatient services and supported timely discharge from hospital with home treatment packages. Staff had a good awareness of the timeframes for urgent admissions and recorded times from referral throughout the process in individual service user records. Trust data showed a low number of complaints received into the service. Staff made us aware that any issues were often dealt with at a local level and did not get escalated through the complaints process. In support of the crisis care concordat, street triage teams were introduced to East and West Cheshire in November 2014 on a one year pilot scheme. This had resulted in a 92% reduction in the number of people detained under the Mental Health Act under section 136 and a subsequent reduction in the use of the health base place of safety.
Staff we spoke with were aware of the organisations vision and values. The trust was working to embed aspects of the Crisis Care Concordat through improvements in service design and delivery. All staff reported enjoying their work but in teams where there had been lots of change, morale varied. Staff training was mostly up to date.

However:

The Crisis Care Concordat and Royal College of Psychiatrists recommend that teams are multi-disciplinary in composition but the teams at Cheshire and Wirral Partnership NHS Foundation Trust were mainly composed of registered nursing staff.
The health based place of safety at the Countess of Chester Hospital was basic. The toilet facility was not easily accessible or assessed as safe for people in an acute phase of a mental health crisis.
Staff did not always understand their role with regard to assessing mental
capacity and consent to treatment. This was not always clearly documented within patient records.
Service users did not always feel involved in their care planning. We observed that some plans lacked detail and evidence of patient involvement. Staff did not routinely offer copies to service users.
Management information was not available to support the monitoring, analysis and evaluation of referral, or triage and treatment times. This meant teams could not effectively review their performance levels or ensure adherence to trust policy and recommendations included within the Crisis Care Concordat.
Staff supervision and appraisal was low in some areas where there had been changes within the teams. This was also highlighted as an issue at trust level. Enhancing the skills of appraisers, supervisors and line manager’s formed part of the overall trust strategy.
Team managers acknowledged that teams had different strengths and different ways of working. Previously team managers held meetings on a quarterly basis but there was no current link to unite the teams and share best practice.

The child and adolescent mental health wards had a good track record of safety. Staff were aware of the process of reporting and acting upon incidents. There was a clear understanding of the safeguarding process within the team. Staff took a proactive approach to safeguarding and this was explored with patients early into their hospital admission. Effective work took place with the local authority in relation to child protection and safeguarding concerns.

Staffing levels have been reviewed by the trust and increased to reflect the needs of the service. Thorough handovers took place with the multidisciplinary team to ensure relevant information was shared to support patients effectively.

The environment was clean, welcoming, and young person friendly. Patients were fully involved in the décor of the wards with their art work on display.

Patients’ care and treatment was planned and delivered in line with best practice as recommended by National Institute for Health and Care Excellence. A number of psychological therapies were offered as well as family therapy. Patients were fully involved in their care. Young person friendly documentation was in use including “my anxiety plan”. Comprehensive assessments were completed which included “my moving on plan” to focus on the future and discharge.

Patients completed self assessments upon admission and reviewed these during their stay.

The service was involved with the Quality Network for Inpatient CAMHS, which accredited them as excellent. Internal peer review took place with other wards.

Feedback from patients, their parents and carers was excellent about the care they received.

We observed young people were treated with dignity and respect. Staff interactions with patients were positive, nurturing and encouraging. Staff genuinely cared about the patients and respond appropriately to their needs.

Information about medication and treatment was freely available in a format that was meaningful to young people.

Education was an important and embedded part of the service. The education sessions were tailored to the needs of the patients. Ofsted rated the education provision as outstanding.

The trust had a clear vision and values which the staff and patients were aware of. Information from the executive board was disseminated to the staff team via team meetings. Regular email updates were used for all staff.

The ward managers were approachable. Staff reported, and we saw, an open door policy. Staff were confident at seeking guidance from the ward managers.

Regular supervision took place both individually and group supervision.

The facilities for delivering care and treatment were clean and safe.

Managers planned and reviewed the staffing skill mix to ensure patients received safe care and treatment. They allocated referrals among staff based on caseload, complexity of cases and expertise of staff and they monitored caseloads during supervision. Staff understood their roles and responsibilities to raise concerns and report incidents and near misses.

Staff talked about their work in terms of the recovery model. Their focus on supporting people to remain in the community was clear. However, some care plans, while containing elements of a recovery based approach, were mainly generic. There was inconsistency in care pathways and structure for care. We found little evidence of processes and systems being embedded into practice. Some staff were unclear about whether systems were in place or not. Systems to ensure care plans were reviewed regularly were not robust or effective.

We did not find evidence to show how patient’s views and experiences were gathered locally so that they could be used to drive improvement or influence service development.

Best practice guidance was not embedded consistently. Outcomes were not being measured and at Vale House, physical health needs were not being assessed routinely.

People who were subject to the Mental Health Act (MHA) 1983 were assessed, cared for and treated in line with the Act and the MHA Code of Practice.

Capacity assessments carried out under the Mental Capacity Act 2005 were not always specific to the decision needing to be made.

We gathered information from a range of sources to gain feedback from patients and their carers. Their feedback was positive, particularly about the way staff treated them. Patients and their family members were treated with kindness and respect. They felt they were involved in decisions about their care. They told us they were listened to and supported during their care and treatment. Staff were sensitive and respectful of patients’ wishes and were committed to providing personalised care based upon their needs.

The teams focused on assisting people to remain within the community and avoid admission to hospital where possible. They facilitated early discharge by offering people intensive support during the move from hospital to the community. Patients were enabled to participate in the activities of the local community so that they could exercise their right to be a citizen as independently as they were able to. The teams made efforts to meet people’s diverse needs.

Staff felt respected, valued and supported. There was a meeting structure to escalate and cascade information through all levels of staff. This included governance and incidents. We found some good examples of practice designed to improve services. However, there was little evidence of local audits being carried out which could be used to ensure that systems were working and drive improvement, and the strength of local leadership differed significantly in the teams.

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

Cherry ward, Meadowbank ward and Croft ward were all located in different areas and had completely different layouts. However, all three wards were clean, tidy and were free from odours. We found that staff were delivering care that was safe, effective, caring, responsive and well led. Staff were passionate about caring for older adult patients and they ensured the privacy and dignity of them.
Action was taken to mitigate all ligature points on the wards following environmental ligature risk assessments.
All three ward managers had sufficient authority to increase staffing levels if they required extra nursing care and there were always enough staff to carry out interventions safely.
All of the clinic rooms were clean and tidy.The wards had good medicine management practices. There was good storage, dispensing, reconciliation and destruction of medication.
The wards followed many national guidelines related to the care and treatment of the older adult. The advancing quality dementia measures were in place. This quality standard covered care provided by health and social care staff in direct contact with people with dementia in hospital, the community, home-based, group care, residential or specialist care settings. This standard was recommended by national institute for health and care excellence. There was also a dementia specific e-learning package in place that staff working in older adults services had to undertake.
Staff knew and agreed with the organisation’s values. Ward managers were engaged in the organisational values and staff felt supported by their immediate line manager. There was a sense of teamwork in the wards and staff reported close teams that supported each other while on shift, recognising that they were working with a challenging patient group.
Resuscitation equipment including automated external defibrillators was available and checked regularly. All equipment was in date and had clearly identified expiry dates on them.
There were ligature points on windows and some doors. However, over the door alarms had been fitted in bedroom areas that would be activated if pressure was put on the door. Action was taken to mitigate all ligature points on the wards following environmental ligature risk assessments.
All patient notes had up to date risk assessments in place and care plans generally showed the involvement of patients and carers.

However:

The trust’s target for bed occupancy was 85%. All three wards exceeded this target. Leave beds were sometimes used but usually following consultation with the multi-disciplinary team.
Cherry ward had two delayed discharges in the last six months, Croft and Meadowbank had none.
We did find inconsistencies in practices around reading detained patients their rights.
Overall compliance rates for all mandatory training were 65% for Cherry ward 80% for Meadowbank ward and 85% for Croft ward. Both Cherry ward and Meadowbank wards rates were below the trust’s target of 85%.
Appraisal data supplied by the trust for the three wards showed varying rates of compliance with the trust’s target of 85%. Cherry ward was 84% compliant, Meadowbank ward was 17% compliant and Croft was 60% compliant. Ward managers informed us that these rates had now increased significantly since the submission of this data and Meadowbank had now appraised all staff who were currently at work. Croft and Cherry ward had also significantly increased their compliance.

We rated Cheshire and Wirral Partnership NHS Foundation Trust, wards for people with learning disabilities as outstanding because:

Staffing levels on the units ensured patients did not miss out on social leave and outings, and was sufficient to provide consistent care. Staff worked long days, and could adjust their routine during the day. This meant that staff were able to respond to the needs of the patients rather than impose a routine on them. The managers were extra to the staffing compliment so they could provide support if they were unable to get staff to cover short notice sickness.
Patients admitted to the units had an assessment within 72 hours of their admission. The assessment was then developed in to a care plan which was reviewed and re-written when necessary. Patients were fully involved in the development of their care plans.
The use of restraint was closely monitored, recorded and risk assessed after every incident. Staff had on several occasions used prone restraint and the trust should ensure it is only used in line with the MHA Code of Practice.
Incidents on the units were reported and reviewed on a daily basis and learning from these incidents was shared across the trust.

Staff had a good understanding of safeguarding and worked closely with the local safeguarding boards to ensure people’s right were protected.

Medicines were managed appropriately and the units received support from the trust pharmacist on a weekly basis to ensure the medicines were administered and stored in a way that protected people.

Unit managers supported staff in their roles. Staff received monthly supervision and had completed the majority of their mandatory training. Staff could also access external training to enhance their skills. Staff also received support when they needed it to ensure they were able to continue at work.

Staff had a good understanding of the Mental Health Act (MHA), the MHA Code of Practice and the Mental Capacity act (MCA) 2005. They applied the principles of the MCA in their daily practice.

There was a clear collaborative approach between patients and staff with patients treated as equal partners in decisions about their care. Interactions were positive and patient-centred, and staff responded to patients with patience and warmth.

Patients and their carers knew how to make a complaint. Staff ensured that information was available to them regarding their rights and the complaints process in various
Both units were clean and benefitted from a maintenance programme. Eastway was waiting for its décor to be upgraded and we were shown a selection of styles they had opted for.

We rated community-based services for adults of a working age overall as good because:

Risks to people using the service were assessed, monitored and managed on a daily basis and staff recognised and responded appropriately to changes in risks to people.
Staff understood their responsibilities to report on incidents and near misses and were supported when they do so.
Adults and children were appropriately protected and staff took steps to report any incidents of safeguarding to the local authorities.
All three teams reported low staffing vacancies, mainly due to maternity leave, secondment and advanced practitioner training; however, systems were in place to address the vacancies with staff being offered temporary contracts and vacant posts being filled to keep people safe.
Staff received feedback from investigations and incidents. Actions from incidents and patient alerts were regularly discussed in team meetings to ensure lessons were learnt.

People who used the service had comprehensive assessments of their needs which included consideration of their clinical needs, mental health, physical health and their well-being.
Information about peoples’ care and treatment and their outcomes were collected and monitored.
The teams participated in local and national audits and front line staff were involved.
Staff were qualified and skilled to deliver care and treatment to their people but there were some gaps in their mandatory training.
Peoples’ care and treatment was planned and delivered in line with current best practice and evidenced based guidance.

Feedback from people who used the services was positive about the way staff treated them. People reported and we directly observed they were treated with respect, kindness and were involved in making decisions about their care and treatment
People’ social needs were understood and people were assisted to maintain and develop their social networks and community support where needed.

Information about patient and carer experience was reported back to teams from information collated in relation to the friends and family test.
There was an effective process in place to identify, monitor and address risk issues.
Staff were open, transparent and were aware of their ‘duty of candour’ in relation to the NHS organisation they worked in.
There was a strong focus on continued learning and improvements for staff within the teams they worked in.
The number of staff who had completed mandatory training was below expected levels in some areas. This had the potential to put people who use the service and staff members at risk.

Systems existed to monitor and manage risk. Escalation procedures for urgent referrals were in place. Assessments were carried out in a timely manner, reviewed and reflected in care plans. Safeguarding was embedded within the service. Staff displayed a good understanding of their roles and responsibilities in this regard.
Feedback from people who use the service was positive. We observed people who use the service being treated in a respectful manner and with care and empathy. We saw evidence of involvement in their care and decisions over treatment. Where families and / or carers were involved their opinions and views were also reflected. People who use the service were routinely offered a copy of their care plan.

The trust had a clear vision and a set of values and staff were aware of these.
The trust had a quality strategy, processes and systems were in place around governance.
The teams had processes in place to manage team performance and the quality of care and treatment provided.
Processes were in place to monitor performance. Regular governance meetings were held and performance data was on display in teams. There were key performance indicators (KPIs) in place for monitoring quality initiatives.
Teams informed us they were positively supported and well managed locally and the service manager and general manager were visible and approachable.

However:

Where people were subject to a community treatment order (CTO) under the Mental Health Act there was no evidence in the paper or electronic system care notes that people were being read their rights. Records reviewed informed us people did not have their rights explained to them routinely and there was no documented evidence from the care coordinator.

Staff were not routinely assessing people’s capacity to understand the risks and benefits of treatment offered to them.

Complaints and concerns information was displayed in the waiting rooms used by people that used the service. However, the information about complaints was only displayed in English.

We rated low-secure forensic inpatient services for working age adults as requires improvement because:

Staff failed to follow the Mental Health Act code of practice or the Cheshire and Wirral NHS Partnership Foundation Trust policy in relation to seclusion and segregation. One patient had been cared for in seclusion for eight days. Records did not demonstrate the need for the patient to be nursed in seclusion for this extended period of time.
Staff working on the units were not aware of the high-risk ligature points identified in the trust annual ligature audit undertaken in July 2014.
There were additional ligature risks and a number of multiple blind spots throughout both units, which could have compromised the safety of patients, visitors and staff.
There were blanket restrictions in place and patients told us that rules changed day to day, depending upon which staff were on duty.
Patients told us that activities and planned leave had been cancelled due to staff shortages.
The vision and values of the trust were not demonstrated by all members of the staff. This could be seen in complaints about staff attitudes and behaviour.
Managers had failed to identify concerns regarding the use of seclusion, the standard of recording in the clinical records when seclusion had been implemented and the recording of incidents.

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

Staff had a thorough understanding of the safeguarding procedures and were confident in making safeguarding referrals. Lessons were learnt from the serious incidents within the service.
Progress that young people were making was measured and recorded. This was also gathered in an innovative way of an iPad remotely, and in real time, to avoid delays and ensure information was current.
Goal based care plans were in place for young people with individual aims. The care plans were co-produced by the young person and their practitioner from the CAMHS team.
Staff received supervision every four to six weeks.
Job mapping was completed with their managers to ensure equity of allocations of new referrals for the choice and partnership allocations.
We observed good multi-disciplinary working within the teams that were young person focussed.
Staff treated young people using the service, and their family, with dignity and respect. We observed several sessions with practitioners and young people, all of them showed supportive, nurturing and encouraging approaches from staff. Young people we spoke to said they felt supported, listened to and were pleased that someone showed an interest in them.
The young people who used the specialist community mental health services created the Mymind website and twitter account. The resources provided information for young people and professionals including self-help resources on addressing their mental health needs, the services that were provided by the trust and what to expect from the service in an accessible format.
Young people who used the service help to run training for professionals on topics including self-harm. Evaluation of the training was extremely positive and the most helpful part of the feedback was young people’s involvement.
There was a clear statement of vision and values. Staff were aware of this and embedded it into their daily practice. Staff felt valued and had job satisfaction and appreciated the innovative approaches and projects they had been involved in.
Senior managers had highlighted the risk of an increase in demand for the service. They introduced an innovative way of limiting the intervention in tier two services and submitted a business case to commissioners for increased funding for four new posts, which was successful.

However:

Individual risk assessments for young people using the service were not comprehensive or completed in a timely manner after the needs of a young person changed.
There was limited understanding of the lone worker policy within the service. Staff did not follow the trusts’ lone worker policy consistently.
Team mangers did not have the information they needed available to them in a centralised system. This meant they could not monitor the waiting list for the service or take into account risks to young people waiting for the service.

Whilst staff were able to articulate the process for reporting incidents, staff did not always receive timely feedback about them or details of any lessons to be learned when things went wrong.

Staffing incidents were not reported via the electronic incident reporting system in line with trust policy. Instead, staff were encouraged to report staffing issues via the management escalation process which meant that not all staffing related incidents were recorded on the electronic system, potentially giving an inaccurate picture of staffing concerns.

The level of staffing and mix of skills in the integrated teams did not match patient needs. Although the trust had been monitoring staffing and capacity, it used its own tool to determine nursing caseloads, which did not take into account the acuity (the level of severity of illness or level of need) and complexity of patients. The trust acknowledged that further work was required to enhance the capacity tool to fully assess the acuity of patients. There were also a number of vacancies within the community nursing service. Following our visit, we were told of measures taken by the service to provide support for staffing levels and to ensure the appropriate skill mix to match the needs of patients more effectively.

Care and treatment was evidence-based and was provided in line with best practice guidance. The implementation of the integrated therapy service promoted multidisciplinary and multiprofessional approach to therapies, which enabled patients and families to avoid duplication of services and receive therapy support nearer to their homes.

Patients and their families were cared for by staff who were kind and compassionate. Patients were involved in the assessment, planning and delivery of their care, and were kept informed of changes and developments by members of the multidisciplinary team.

Data provided by the trust indicated that the services were provided within the national 18 week target but staff told us they were struggling to maintain that. There was also a delay of five months in the non-urgent review of venous flow conditions clinic due to long-term sickness.

Referrals to the district nursing service were being managed and records showed that in the month prior to our visit, patient assessments and visits had been deferred to help manage the delays. We found that this could have an adverse effect on patients’ care and treatment.

There were examples of good local leadership across the individual services. However, there were a lot of staff in temporary and ‘acting’ roles across the integrated community teams and a lack of professional nursing and therapy leadership was commented on by staff. The lack of nursing leadership had been acknowledged by the trust as part of an incident investigation and the trust had plans to provide more robust clinical leadership.

We rated the community mental health services for people with learning disabilities and autism as good.

Patient care and treatment was planned and delivered in line with current best practice and evidence based guidance. We saw evidence that risk assessments were completed when patients were accepted into the service. Risk assessments were also updated regularly to reflect the changing needs of the patients.

Patient problems were picked up quickly and dealt with as soon as possible to prevent hospital admission.

The caseloads varied between staff because of patient needs and hours worked. All staff spoken to felt their caseload was manageable and all had regular supervision where caseload management was discussed.

Staff understood the lone working policy and followed it. Electronic diaries were used to help keep track of staff whereabouts.

Staff were appropriately experienced and skilled to deliver care to their patients. The overall compliance rates for mandatory training were 90%, which was above the trust target of 85%.

Patients and carers were positive in their comments about the service.

Staff that we interviewed shared the values and vision of the trust and spoke positively about how they put these into practice in their work.

All working areas were clean and well-maintained.

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 that led to a rating of ‘Good’ because;

The trust was committed to and working towards reducing restrictive practices in line with their trust-wide campaign ‘zero harm’, which started in July 2014. The campaign focusses on encouraging staff to ‘Stop, Think and Listen’ and to continually reflect and review their everyday working life to identify possible practices that could result in unwarranted harm to patients. However, in the low secure forensic services, there were a number of restrictive practices not based on clinical risk.

The trust had worked hard to improve staffing levels significantly over the six months to June 2015 although it continued to face staffing challenges on some wards. Overall, we found staffing levels were safe. Caseloads across the community teams were in line with current guidance.

The trust was committed to improving the quality of services and had governance structures to support that aim Morale was good across services, and staff teams were motivated and committed to providing good care and treatment to patients in line with the trust’s vision and values. This was shown through a number of initiatives staff had implemented to improve outcomes for patients and carers. We noted several examples of good practice where staff teams had ‘gone the extra mile’ to ensure patients’ needs were being met.

The trust board and senior managers we spoke with were open and transparent. They recognised areas that needed to be improved in addition to areas that were working well. There was a positive culture of learning and continuous improvement. When we raised concerns to the trust board about care in Saddlebridge Recovery centre during the inspection, they were very open in their responses and provided assurance that the issues we raised would be managed effectively.

The trust acknowledged that there were some difficulties with their current information technology (IT) system, which had been escalated onto the board assurance framework risk register with actions to deal with them.

We identified a number of issues regarding the way the trust dealt with complaints but the trust was aware of them and already had plans to manage complaints more effectively.

However;

Some of the seclusion rooms did not comply with the Mental Health Act Code of Practice and some staff were not following trust policy and national guidance in relation to the use of seclusion rooms.

Some of the acute mental health wards did not fully comply with the Department of Health required guidance on same-sex accommodation.

In some services, individual patient risks were not always reviewed and updated in a timely manner and environmental risks were not always identified and mitigated.

Within community (physical health) services for children and young people, the service did not maintain accurate, complete and contemporaneous records in respect of each service user. Records were not accessible to authorised people as necessary in order to deliver care and treatment in a way that meets their needs and keeps them safe.

Compliance with mandatory training and appraisal of work performance was variable across services.
Issues that had previously been raised through Mental Health Act monitoring visits in relation to patients detained under the Act had not been fully dealt with by the trust.

Compliance with the Mental Capacity Act 2005 (MCA) was variable across the trust. Although we found good practices in relation to the MCA in some services, in others staff lacked confidence in assessing patients’ capacity to make decisions about their care and did not feel that the current e-learning training sufficiently enabled them to develop their skills and confidence in this area.

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

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

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

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

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