Livewell Southwest CIC

Updated 3 January 2020

Not used

Updated 3 January 2020

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

• We rated all five of the key questions ‘are services safe, effective, caring, responsive and well-led’ as good. Our rating for the organisation took into account the previous ratings of services not inspection this time.
• Staff in the organisation had worked hard to address concerns we had raised in the last inspection. Two services that were previously rated as requires improvement at the last inspection were now rated as good. Community end of life care and child and adolescent mental health wards had both improved.
• Livewell Southwest had strong leadership who had the appropriate range of skills, knowledge and experience to deliver community health and mental health services. Staff felt they were visible and approachable. There was a rolling programme of visits scheduled to services by the executives. Executives used these visits to engage with staff and also listen to their views on the services.
• There was a positive, open and honest culture throughout the organisation. Staff at all levels of the organisation were proud to work at the organisation and morale among staff was very good. both leaders and staff across the organisation put patients at the centre of everything they did.
• The organisation had recently refreshed and published its new strategy which had been coproduced with staff and stakeholders. The organisation had worked hard to ensure it forged strong strategic alliances with partner organisation. Its contribution to the wider health economy was highly valued by partner organisation and it was now seen as equal partner.
• Livewell Southwest had effective systems and processes in place to support delivery of the services it delivered. There was an appropriate sub board committee structure and escalation to board through the structure. Non-executive directors (NEDs) chaired committees and were confident to raise any concerns or challenge to the executive team. The organisation was financially stable and there was relevant financial expertise among the executives and NEDs.
• There was a strong emphasis, from both leaders and staff across the organisation for putting patients at the centre of everything they did.
• There was also a strong emphasis on listening to staff and providing opportunities for staff at all levels to develop and a strong emphasis on Quality Improvement. The organisation had appointed two Freedom to Speak Up Guardians (although there is no requirement for a CIC to do so). The organisation were using innovative ways to develop its existing staff and to attract new staff.
• Staff treated all patients with compassion, respect and kindness. The privacy and dignity of patients was maintained at all times. Patients were supported by staff to understand and manage their care and treatment. Staff actively involved families and carers of patients in their care appropriately.
• Across the organisation clinical areas and premises where patients received care were clean, well equipped and maintained.
• Services had enough medical and nursing staff. Teams in the organisation had access to a full range of specialists required to meet the needs of patients in their care. Care was planned and provided in a way that met the needs of local people and the communities it served. Staff met the needs of patients with a protected characteristic. Staff supported patients with communication, advocacy and cultural and spiritual support.
• Generally, staff across the organisation knew their roles and responsibilities under the Mental Health Act 1983, Mental Health Act Code of Practice and the Mental Capacity Act 2005. Staff assessed and recorded capacity clearly for those who might have impaired mental capacity.
• The organisation managed incidents well and staff understood how to report them appropriately. Incidents were investigated, and lessons learned were shared with staff.
• The organisation treated concerns and complaints seriously. The organisation investigated concerns and complaints and shared lessons learned with staff. Patients were included in the investigation of their complaint.

However:

• Patients on Cotehele ward, part of the wards for older people with mental health problems service, did not have access to their bedrooms during the day without a staff member escorting them. This limited their ability to be as independent as possible, which is important for older people in hospital. There were also blanket restrictions in relation to the time patients went to bed in the evening which meant that patients had to go to bed at set times.

• Staff did not undertake a risk assessment of patients at the time of referral to the community mental health teams and did not monitor patients on the waiting lists prior to their initial assessment. This meant that they did not know whether a patient’s mental health deteriorated whilst waiting for an assessment. Staff assumed the GPs would monitor them but there was no agreement in place as to who should monitor patients on the waiting list.

• In the community health services for inpatients staff on South Hams ward were not assessing pressure ulcers and wounds adequately and in line with the organisation’s policy. Some staff were also unaware of the organisation’s policy on safeguarding in relation to the development of pressure ulcers and when notifications should be made to the Care Quality Commission.

• There was further work needed by the organisation on equality and diversity.

Updated 19 October 2016

We rated the community health services for adults as good overall because:

• There were effective incident reporting systems in place and staff reported they received feedback and learning from these.

• Staff had good knowledge of safeguarding procedures and felt supported in raising any safeguarding concerns. Staff had a good understanding of consent and deprivation of liberty safeguards. Consent to treatment was gained in line with legislation.

• There were good medicine management systems in place to keep patients safe.

• Relevant equipment was available, had been checked and was serviced regularly.

• Good infection control systems were in place and staff were seen adhering to them.

• The community adult’s service provided care in line with best practice guidance. Staff were given time to attend mandatory training and reported that this was supported by the organisation

• Multi-disciplinary and collaborative working was evident throughout the service. Working in the same building as other teams and social care colleagues had improved information sharing.

• Feedback from patients was positive.

• Patients received care from staff who treated then with dignity and respect. Staff ensured that options were explored to respect the patient’s wishes and requests

• The needs of patients were taken into account when planning and delivering services. Staff were flexible

• Teams worked together to provide the most appropriate care at the most appropriate time for patients. Care and treatment was coordinated between the community adult services.

• Patients were given information about how to make a complaint or raise a concern. There were systems in place to investigate complaints and systems in place for disseminating learning.

• There was strong leadership in place. The executive team was visible and staff felt comfortable in approaching them.

• A positive culture was evident in nearly all the services we visited.

• Staff felt they had a voice and we heard examples of when changes had been made following discussions and involvement of staff members.

However:

• Staffing levels were an issue across the community teams and had an impact on staff’s ability to manage caseloads, waiting times and morale.

• There was variable access to information and connectivity via the IT system.

• There were issues with the waiting times and waiting lists in some specific areas

• Since patient records had been completed using the electronic patient record system there had been no consistent audit of the records.

Updated 19 October 2016

Overall rating for this core service Good

We rated this service as good because:

• Plymouth Community Healthcare CIC provided support for children, young people and their families to promote healthy choices. They provided information in a way people could understand and supported families to access health care when they needed to. They identified vulnerable families and offered specialist support for them.

• Safeguarding processes were in place and followed by staff with children and young people’s health, wellbeing and safety at the heart of the workforce.

• There was a positive attitude among the staff who learned from incidents and comments to improve their service where they could.

• Risks were identified and reviewed by senior managers for their action.

• Staff were appropriately trained to ensure they were competent to provide care for children, young people and their families and displayed skill and compassion to engage them in their care.

• Staff were open and honest with their clients and ensured they were informed of options for their care and helped to make their own choices.

• Staff worked with other agencies to support families and ensured appropriate advice was available. Care pathways supported families to access the right support at the right time.

• Nationally approved guidance was used to ensure services were safe and effective.

• Technology was provided for staff to maintain their safety and share information securely in a timely way.

• Professional supervision was available for staff to ensure they were supported in their practice.

• Staff engaged with opportunities to contribute to planning how their services were delivered

However

• Health visiting staffing levels were decreased in 2016 to meet financial constraints that had been imposed by commissioners. Some health visiting teams with high caseloads were unable to offer vulnerable families additional support using the Maternal and Early Childhood Support Home visiting programme.

• School nursing and children’s speech and language therapy services did not assess the acuity of their caseload to determine how many staff were needed to meet the needs of the children they provided care for.

Updated 3 January 2020

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

• The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. The service controlled infection risk well. Staff managed medicines well.
• Staff provided good care and treatment, gave patients enough to eat and drink 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. Key services were available seven days a week.
• 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.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Managers did not ensure that management and reporting for incidents of pressure ulcers was completed in line with policy. Staff at South Hams ward did not fully assess and document care plans for patients with pressure ulcers. Staff did not raise pressure ulcers as a safeguarding concern and did not document discussion and decision making in relation to this. Managers did not submit notifications of serious injury to the Care Quality Commission for pressure ulcers grade 3 and above.

Updated 3 January 2020

Our rating of this service improved. 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. The service controlled infection risk 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 provided good care and treatment, gave patients enough to eat and drink, 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, supported them to make decisions about their care and had access to good information. Key services were available seven days a week.
• 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.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• There was room for improvement with the recording of patient wishes, including the use of treatment escalation plans (TEPS) and do not attempt cardiopulmonary resuscitation (DNACPR) orders, and supporting patients with advance care planning.
• Not all staff were familiar with the end of life care strategy and how this applied to them in their work.

Updated 19 October 2016

Overall we rated the organisation as requires improvement for community end of life care services because:

• Treatment escalation plans (TEPs) that included do not attempt cardiopulmonary resuscitation (DNACPR) decisions were not always completed in line with organisational policy. This included poor records of discussions relating to DNACPR and a lack of clarity on whether discussions were taking place with patients and family members. Incomplete mental capacity assessments relating to DNACPR meant that it was unclear that mental capacity was being considered when decisions were made.
• Poor records management following reviews of TEPs and DNACPRs resulted in duplication of forms and had the potential to cause confusion about whether a patient was or was not for resuscitation.This presented a risk of a resuscitation decision not being followed.
• There was a lack of holistic evidence-based end of life care guidance in use across the organisation.
• It was unclear how the service was monitoring patient outcomes specific to end of life care.
• Not all nursing staff delivering end of life care had received syringe driver training or competency assessments.
• There was no completed strategy for end of life care.
• There was no lay person or non-executive director overseeing end of life care and end of life care was not discussed at board level meetings.
• Quality measurement in relation to community end of life care services was limited and there was no clear plan for measuring or improving the quality of end of life care in relation to patient outcomes.

However;

• Equipment for use at the end of life, including syringe drivers, was readily available and there was good use of anticipatory prescribing and monitoring of symptoms for patients at the end of life.
• There was good evidence of incident reporting, learning and improvement and staff were consistently aware of reporting procedures. Lessons were learned from incidents and were shared with all staff.
• We saw evidence of outstanding practice in the development of innovative projects relating to improving the quality of end of life care for people living in vulnerable circumstances. The organisation had developed a resource of end of life champions.
• Feedback from patients and relatives told us that staff treated people with dignity and respect and we observed staff caring for patients in a way that built rapport.
• There were examples of staff going the extra mile to support patients and their relatives at the end of life and to promote individual choices about care.
• Services were planned and delivered to meet people’s needs and Plymouth CIC staff were actively engaged with other providers within the locality to improve services
• There was clear, motivated and enthusiastic leadership at service delivery levels within the organisation.
• There was good collaborative working with other providers to improve end of life care through joint working within the locality.

Updated 3 January 2020

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the young people 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 young people on the wards. Managers ensured that these staff received training, clinical supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
• Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. They actively involved young people and families and carers in care decisions.
• 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 was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• The provider did not have a blanket restrictions policy and although had lifted the blanket restrictions found during our last inspection, were not allowing young people outside unsupervised due to a perceived risk of absconsion.

Updated 7 August 2018

Updated 19 October 2016

We rated community mental health services for people with a learning disability or autism as outstanding because:

• The team had won a national award for their successful repatriation of patients.
• Feedback we received from patients, carers and stakeholders described staff going the extra mile and providing compassionate, focused, respectful and attentive patient care. The team asked for feedback from patients and responded to the feedback. Surveys showed high levels of satisfaction.

• The service was fully staffed. Staff worked together across a range of disciplines to provide holistic and individualised care to patients.

• Staff were well trained and experienced. They were up to date with mandatory training and were able to access specialist training.

• Patients could access urgent care when they needed it through bespoke out of hours packages, crisis plans or by contacting the team and requesting help. Patients that needed it were assessed urgently and psychiatrists were available for ad hoc consultation.

• Waiting times were within the target for the service of 18 weeks. The team could assess patients sooner if they felt they could not wait although there was no target for providing urgent assessments. However, staff did not monitor patients for potential increases in risk while they were waiting for an assessment. Patients who were care coordinated by another agency did not always have a risk assessment produced by the team. A new practice of producing threshold assessment grids for every patient was addressing this.

• Care planning was highly individualised, holistic and person centred. Patients and carers were actively involved in care planning.

• The team used medicines and psychological therapies that were recommended by the National Institute for Health and Care Excellence. Psychological therapies were adapted to make them accessible to the patient group.

• Staff had good knowledge and understanding of the Mental Capacity Act.

• The service had good working links with a wide range of teams and services inside and outside of the organisation. This enabled patients to receive holistic and joined up care and to have access to mainstream services. The team carefully planned transitions between services as patients came into or left the service.

• Staff were respectful, caring and compassionate. They treated patients as individuals and provided care that was tailored to meet individual needs.

• Carers were supported to be involved in patients care. They were offered group and one to one support.

• The team made it easy for patients to access the service by seeing them in the city centre, at home or in other familiar places. They made documents easy for them to understand by including pictures and using easy to read language.

• Team morale was good and staff were happy. They were supported by accessible and approachable managers and had regular appraisals and supervision.

• There was a strong commitment to quality improvement and staff were encouraged to be innovative. The team took part in research and audits. They also trained others in working with people with learning disabilities and mental health difficulties.

Updated 19 October 2016

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

• Staff had completed mandatory training. Staff updated their mandatory training on an annual basis. Staff received supervision every 12 weeks, in line with the organisational policy and staff appraisals were up to date.
• All care records we reviewed had comprehensive, up to date risk assessments were in place. Staff updated risk assessments regularly. Staff had completed comprehensive assessments of all those using the service. Care plans were holistic, personalised and included a crisis plan.
• All staff were aware of safeguarding procedures, what would constitute a safeguarding alert and how to make a referral. Staff shared lessons across the whole service following incidents. Staff practice had changed as a result of learning from incidents.
• Psychological therapy was available to people using the service. People using the service had access to a psychiatrist for diagnosis and medicine reviews. The prescribing psychiatrist carried out high dose anti-psychotic monitoring. Staff considered the physical health care of people using the service.
• The staff team included nurses, physiotherapists, occupational therapists, psychologists and psychiatrists. Social workers were employed by the organisation, but they were not located within the team. In order to access social workers staff made referrals to the adult social care department of the organisation.
• The multidisciplinary team meetings were comprehensive and considered the needs of carers as well as those of people using the service. Staff from the Alzheimer’s Society were based in the team office which ensured good relationships and joint working.
• Staff demonstrated a dedicated approach and put the needs of those using the service first. We observed staff demonstrating kindness, dignity and respect to all people using the service. Carers spoke very highly of the service and reported that they felt consulted in care planning and treatment. Care records we reviewed showed that people using the service had an active role in the care they received.
• Staff completed assessments in a timely manner. Staff from both pathways were meeting the organisation’s target waiting time of 18 weeks from referral to treatment. Staff saw urgent referrals within 24 hours, or sooner if required and responded promptly to any deterioration in the mental health of anyone using the service. Each team provided duty cover during working hours. The memory service pathway introduced additional memory assessment clinics to reduce the waiting list.
• The teams had good governance systems in place. For example, team managers had systems in place to ensure mandatory training was up to date, supervision and appraisals were completed within organisational timescales and incidents were reported and learnt from. The team manger had good administrative support.
• The complex dementia service was involved in research into diagnoses of Alzheimer’s disease in people aged under 65 years old.

However:

• The functional team was on the organisation’s risk register due to the high level of staff sickness. The manager had submitted a request to the executive team to recruit agency nurses to cover absences due to sickness.
• Social workers were not fully integrated into the service.
• Staff did not demonstrate knowledge of the organisation’s values. Staff reported feeling disconnected and removed from the wider organisation.
• Staff reported the organisation made changes to the service without any form of consultation. Staff did not know when they would be moving to permanent premises.

Updated 7 August 2018

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

• During our previous inspection in June 2016 we rated mental health crisis services and health-based places of safety as good overall. We rated safe, caring, responsive and well-led as good and rated effective as requires improvement. In 2016 the provider was not meeting all requirements under Regulation 17 HSCA (regulated activities) Regulations 2014 (good governance). We found that the provider had met these requirements during this inspection.

• The policies for both adults and young people’s health-based place of safety had not been updated since the revised Mental Health Act Code of Practice had been introduced in April 2015. During this inspection this had been rectified.

• The adult place of safety was separate to the children and young people place of safety. Staff in both services managed risk well both in the environment and clinically. Staff knew patient risks and managed them appropriately. There were robust lone working procedures in place.
• The home treatment team caseloads were significantly reduced since the previous inspection, making the workload more manageable for the team. Managers reviewed and monitored caseloads regularly.
• Care records showed that patients received good care. Staff completed risk assessments and comprehensive assessments based on their needs.
• Staffing levels were good in the health-based places of safety and the home treatment team. Managers used a robust model to ensure staffing levels met the needs of the service.
• There was good medicines management practices in all locations. All teams had access to medical support out of hours.
• Staff followed the Mental Health Act Code of Practice when receiving and assessing patients detained in the health-based place of safety. They also ensured patients understood the reason for their detention. Both units collected regular data on response times for all section 136 (MHA) information.
• Staff in all teams demonstrated good knowledge and skill in their relevant field. Staff had opportunities to develop. Staff received annual appraisals and regular supervision.
• Staff in the health-based place of safety demonstrated good partnership working with relevant agencies. Regular multi-agency meetings were held to ensure robust partnership working.
• The teams were caring and compassionate and treated people with dignity and respect. Patients in the home treatment team described their care and support as positive and kind.
• The home treatment team provided 24 hour a day, 7 days a week support to people. Other professionals could access the service for advice and the team worked well as part of the wider crisis pathway. The children and young people’s health-based place of safety was due to undergo a refurbishment to provide a purpose built suite.
• There was good, clear leadership on both health-based places of safety. The overall manager was enthusiastic and driven to provide a quality service. The leaders in the home treatment team were knowledgeable and experienced and were supportive of the team. Managers provided supervision and appraisals, which was a requirement following the previous inspection.

However:

• The home treatment team was located in an environment that was clean but not ideally suited for their purpose. Access to security was poor, particularly out of hours.
• Patients were not always involved in the development of their initial care plans.
• Due to inability to recruit to additional posts, this specific service could not provide the enhanced crisis service out of hours. Their model was to work as part of a partnership between the CMHT and the mental health liaison service to provide this service.
• There was confusion within the home treatment team around their identity and overall place in the wider crisis pathway. Staff told us they did not feel involved in discussions around the teams’ future.
• Discussion around risk within multi-disciplinary meetings was not structured.
• Identified risks were not consistently translated to care plans.

Updated 19 October 2016

We rated forensic inpatient/secure wards overall as Good because:

• Staff were actively involved in clinical audit on the ward.

• We observed good medication management on the ward.
• We saw that the service listened to staff and patient feedback and made changes to the way the service was delivered.
• The ward areas were visibly clean and well maintained.
• All staff and patients told us they felt safe on the ward and felt that the number of staff was suitable to meet the needs of the patient group. 
• We observed positive and caring interactions between the staff and the patients. Staff were courteous and responsive to patients’ requests.
• Patients were risk assessed on admission and had up to date risk assessments which were linked to their care plans. 
• Care plans showed good evidence of involving patients in their care.
• Staff supported patients to complain and helped them to resolve complaints.
• Patients spoke positively about their regular contact with the chaplaincy service who visited the hospital on a weekly basis or more frequently if required.
• Ward systems were effective in ensuring that staff had received appropriate mandatory and statutory training and local guidance to enable them to undertake their roles effectively.
• The ward was also committed to reducing the impact of restrictive practices.
• Staff felt confident to use the whistleblowing procedure and to raise concerns with their colleagues and line managers.

Updated 7 August 2018

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

• On both wards staff had built good relationships with patients. Staff gave patients information about the service and what treatments were available. The information was provided in a number of formats and was available to patients and upon their request at any later date.
• The service had been re-designed with regular fortnightly ward rounds that focused on multi-disciplinary and multi-agency working. There had been recruitment on the wards to improve staffing numbers since our last inspection in 2016. New staff were provided with induction and a personal development program with regular reviews with managers and supervisors.
• Both ward used staffs from clinical support team to cover sickness and vacancies. The clinical support team work across the service to fill shifts.
• Staff assessed the needs of patients. Assessments were updated regularly.
• Staff assessed and managed physical health through weekly monitoring.
• Patients said that staff were kind and caring. They said they felt safe on the wards.
• Staff had access to services in the organisation and external services to help meet patients’ needs. These included regular visits by the independent Mental Health Act advocacy service (SEAP – Support Empower Advocate Promote).
• Staff understood safeguarding and when to report safeguarding and followed the organisation's safeguarding policy.
• There was good leadership from ward managers.

However:

• There was no adapted bathroom or toilet facility for people with physical disabilities at Syrena house. The showers were 'walk in' showers, but there was no other adaptation for people with impaired mobility.
• Visitors, including children could only meet with patients in communal areas or staff meeting rooms on the female ward.
• Patients care plans at Syrena House were not holistic and lacked patients views and involvement.

Updated 3 January 2020

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Edgcumbe ward had cared for a patient on the end of life pathway so that the person did not have to be moved to a different ward potentially causing confusion and distress. The ward demonstrated an ability to be flexible and responsive the needs of the patient and family allowing the experience to be a peaceful and dignified as possible.
• The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Patients on Cotehele did not have access to their bedrooms during the day or the main ward area overnight and were all taken to their rooms at a set time of the day.
• Patients complained that they were disturbed by staff shining torches on them during the checks overnight and staff could be overheard talking, disturbing patients.
• The garden areas on Cotehele ward were not fit for purpose.
• Some patient files were not being securely stored on Edgcumbe ward.

Updated 19 October 2016

We rated acute wards for adults of working age as outstanding because:

• The Glenbourne Unit was well-led with a positive, supportive and motivated management team who ensured their passion for improving mental health services for patients was shared with the team members. 
• Patient records were of very high quality. Care plans and risk assessments were up to date and thorough.
• The wards kept blanket restrictions to a minimum and ensured any blanket restrictions in place were justified by risk assessments.
• The 2015 mental health inpatient survey had rated nurses at the Glenbourne Unit highest in the country for treating patients with dignity and respect.
• All of the patients we spoke with were extremely positive and complimentary about the support they received from the ward staff.
• Patients were involved in their care and treatment plans, their opinions were respected and their views were recorded.
• The redesign and refurbishment of the unit was well thought through, prioritised improving patient care and the patient experience on the unit and had delivered a greatly improved ward environment.

Updated 19 October 2016

We found the following areas of good practice:

• The clinic room used by the staff but was managed by the co-located organisation, was kept locked and was very clean and tidy.

• No agency or bank staff were used at this service.

• Risk assessments were completed on referral and reviewed regularly.

• All staff worked to the National Institute for Health and Care Excellence guidance in regards to their detoxification practices.

• Mandatory training rate for staff was 100%.

• All staff used Skyguard lone worker protection devices.

• All care records reviewed had a comprehensive assessment.Care plans were reviewed and updated every three months.

• All staff had line management supervision every six weeks with group supervision quarterly this was led by the clinical lead. All staff had staff development plans.

• The interactions between staff and people using the service were friendly, respectful and kind.

• From accepting a referral, a client was seen within one week by a care manager. At the time of inspection, there was no waiting list for services.

• The building had electronic door access for people with restricted mobility.The service had a lift for people with mobility issues that allowed them to access the waiting room and interview rooms.There was an adapted toilet that people were easily able to access.

• Staff informed us that they thought the team worked well together and everyone was willing to help and support each other.Staff thought morale was very high within their team and they were all very happy to work there.

Updated 3 January 2020

• 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 assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. Staff 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.
• The organisation was piloting a primary care mental health team to fill a gap in mental health provision who don’t meet threshold to receive support from secondary mental health services but require more support than GPs can offer. Stakeholders provided unanimously positive feedback about this service and praised the team’s ability to work with patients promptly and effectively as well as providing support to local GPs.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was well-led and the governance processes ensured that that procedures relating to the work of the service ran smoothly.

However:

• Staff were not assessing risk prior to patients accessing the service. Patients were not risk assessed at the point of referral, therefore staff could not prioritise patients waiting for an initial assessment based on level of risk. A basic risk assessment was completed during initial assessment and only when accepted to the service did patients receive a comprehensive assessment. Staff did not monitor patients who were waiting for their initial assessment. Staff told us that it remained the responsibility of the patient’s GP to monitor and contact the service if the patient deteriorated further during this wait.
• The duty team reviewed the suitability of referrals for the community mental health team but were concerned that they were rejecting a high number of referrals due to pressures in the service to keep waiting lists down. Feedback from local GPs who weren’t able to access the primary mental health team stated that a high number of their referrals were being rejected. There was no auditing process to ensure referrals were not being rejected incorrectly.
• GPs who had referred into the service were not always receiving a rationale for why their patient had been rejected from the community mental health teams. Some received advice to signpost patients to other services however GPs commented that often their patients had already accessed those services and required further support.
• Not all staff had completed training in Mental Capacity Act and Mental Health Act.