Care Quality Commission demands action after report identifies failings at Cambridgeshire and Peterborough NHS Foundation Trust

28 February 2011

Trust is failing to meet five essential standards.

The Care Quality Commission (CQC) has told Cambridgeshire and Peterborough NHS Foundation Trust that if it does not take immediate steps to improve standards of its mental health services, enforcement action may follow.

The demand for action comes as the regulator publishes a responsive review report and a Mental Health Annual Statement (December 2010) report which highlight findings and recommendations for improvements to care.

The responsive review was triggered by concerns which led the regulator to examine the trust’s compliance with their essential standards of quality and safety through assessing information held about the trust and carrying out three visits to the trust.

CQC inspectors found the trust to be in breach of five regulations covering:

• care and welfare
• staffing
• safeguarding people
• assessing and monitoring service provision
• safety and suitability of premises

The Mental Health Act Annual Statement report 2010 outlines a series of MHA Commissioners' recommendations on how the trust must continue to comply with the Mental Health Act and Codes of Practice when detaining patients under the Act.

The Annual Statement reflects the findings of Commissioners during visits over eight months between February and October 2010. Commissioners reported that the trust had responded constructively to the findings from those visits. However, some concerns had not been fully addressed and these have been taken into account in CQC’s recent review.

Failing to meet five essential standards

The CQC inspectors found that the trust was not meeting five essential standards and has concerns in these areas:

Care and welfare of people who use services

• Not all care plans were person centred or included information regarding each individual’s wider care and inclusion needs.
• The seclusion suite on one ward is not meeting environmental requirements or the requirements of the Mental Health Act 1983 Code of Practice.

Safeguarding vulnerable people who use services from abuse

• Policies in relation to adult safeguarding and incident reporting do not clearly set out arrangements that ensure consistent reporting, investigation and dissemination of learning in relation to matters regarding cases of abuse allegations and incidents.
• Incident reporting and auditing systems are not robust.

Safety and suitability of premises

• Poorly designed fixed furniture and the presence of potential ligature points in some parts of the premises pose a risk to people who use services.
• The standard of décor and maintenance of one ward does not promote the dignity and wellbeing of people using services.

Staffing

• There are not always sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience available to meet the needs of patients.

Assessing and monitoring the quality of service provision

• There is a lack of consistency in grading of incidents and no safety mechanism to ensure that inconsistencies are identified and resolved.
• There are delays in the time it takes between staff reporting incidents and their managers signing off the processes.

CQC East Regional Director Frances Carey said: “The trust has already positively responded and submitted action plans which set out how they intend to meet essential standards.

“We will be monitoring this trust closely and won’t hesitate to use our enforcement powers if these improvements are not made swiftly.”

Ends

For further information contact Nicola Stewart on 0121 600 5344 or out of hours on 07917 232 143

Notes to editors

Under the Health and Social Care Act 2008, the Care Quality Commission has a number of enforcement powers that enable it to act swiftly when services are failing people. These include issuing warning notices, restricting the services that a provider can offer or the way it is provided; or, in the most serious cases, suspending or cancelling a service. CQC can also issue financial penalty notices and cautions or prosecute the provider for failing to meet essential standards.

Background

The trust declared non compliance with outcome 16 (assessing and monitoring the quality of service provision) at registration; CQC reviewed the trust in May 2010 and found that further work was required to ensure that people who use services are not harmed as a result of unsafe care, treatment and support.