All inspections: Isle of Wight NHS Trust

The Isle of Wight NHS Trust is the only integrated acute, community, mental health and ambulance health care provider in England. Established in April 2012, the trust provides a full range of health services to an island population of about 143,000 people.

Overall, the trust provides 23 core services for acute, community, mental health and ambulance services.

Acute services are based at St Mary’s Hospital Newport with 245 beds. Services include emergency department, urgent care service (by referral only), emergency medicine and surgery, planned surgery, intensive care, paediatric services, a special care baby unit (SCBU), and maternity care services. Along with diagnostic and screening, pathology and pharmaceutical and outpatient services.

The community division provides a variety of supported care services within patients' homes, community settings, GP practices and clinics, as well as providing physiotherapy, occupational therapy and podiatry support within the acute setting. The community clinical provision is based in three localities of the Isle of Wight: Northeast, West and Central, and South Wight, with district nursing provision in each area. There is also support offered for children and young people through the paediatric therapy, occupational therapy, physiotherapy and speech and language therapy services.

The mental health division provides community learning disability services; inpatient and community based mental health care. With 32 beds for working age and older adults, supported by a home treatment team and a community mental health team for adults and child and adolescent mental health services.

The ambulance service division includes operational delivery units for the 999 emergency ambulances, NHS111 and patient transport services based at the St Mary's Hospital site.

We carried out this announced inspection of a range of the mental health, acute and community services provided by this trust as part of our continual checks on the safety and quality of healthcare services. We did not inspect ambulance service division on this occasion. At our last inspection we rated the trust overall as requires improvement and remained in quality special measures. No use of resources review was carried-out for this inspection.

We inspected the following core services and rated them individually for the five key questions of safe, effective, caring responsive and well led. We also inspected the well-led key question for the trust overall. We rated 11 out of 11 services inspected as good.

At this inspection, overall, we rated safe, effective, caring, responsive, and well-led as 'good'. Our separate rating of well-led for the trust was good.

Acute

Diagnostic Imaging: all five key questions were rated good. Good overall

Medical Services: all five key questions were rated good. Good overall

Surgical Services: safe, effective responsive and well led were rated good, with caring rated as outstanding. Good overall

Gynaecology Services: safe, effective, caring and responsive were rated good and well led rated was rated requires improvement. Good overall

Children and Young People: all five key questions were rated good. Good overall

Mental Health

Acute wards for adults of working age and psychiatric intensive care units: Effective, caring, responsive and well led rated good with safe rated as requires improvement. Good overall

Wards for older people with mental health problems: all five key questions rated good. Good overall

Community based mental health services of adults of working age: safe, effective, caring and well led rated good with responsive rated as requires improvement. Good overall

Mental health crisis services and health-based places of safety: effective, caring, response and well led rated as good with safe rated as requires improvement. Good overall

Community

Community adults: safe, effective, responsive and well led rated as good with caring rated as outstanding. Good overall

Community inpatients services: safe, effective, responsive and well led rated as good with caring rated as outstanding. Good overall

On this occasion, we did not inspect the ambulance service division. In rating the trust, we took into account the current ratings of the 11 core services we did not inspect this time but had rated previously.

Our rating of well led improved. We rated them as good because:

The trust leadership demonstrated the delivery of improvement plans over time and had plans for a strategy refresh to progress the quality of care delivery for the future.

There was a clear vision for now and the future of healthcare on the island.

Across the trust teams were determined to meet the needs of patients and the public.

The executive team showed the drive to make the trust a better place for staff to work in.

Staff were mostly satisfied with working at the trust which was the island’s main employer.

Staff were able to directly influence the quality of services and make changes in their own areas.

There were quality improvement objectives and audits to identify progress and next steps.

Recruitment internally and externally, including from overseas, had benefited the trust services.

Engagement with staff, patients, partners and the system were much improved and were effective.

New approaches for communication were introduced and there was renewed vigour to continually improve the communication for patients and their relatives.

There were established systems and partnership working for the sustainability of the organisation which was for the benefit of the population of the Isle of Wight.

The partnership links were contributing to the success of supporting patients to have good care and treatment on the island.

The culture, enthusiasm and energy for the quality of patient care showed significant improvement.

There was a greater patient focus than seen before.

There was established support for staff care and wellbeing as confirmed by the improved staff survey outcomes and as seen throughout all areas inspected.

The strategy for equality and inclusion was far more developed and was working towards meeting the needs of people with protected characteristics.

There was a developing research team and projects underway.

However:

Delays in mandatory training delivery, such as for safeguarding and resuscitation, could impact on patient care.

The trust had identified information technology systems needed new investment, the continued delays affected the cohesiveness and modernisation of the trust’s information management.

The trust’s non-executive directors lacked visibility in some services which had previously been identified before the pandemic restrictions.

Recruitment to some key roles was filled on an interim, fixed term or locum basis reducing the stability of the trust.

The trust application of the equality and inclusion strategy across the range of staff and patient protected characteristics was better in some departments than others.

The referral to treatment times waiting lists, both pre- and post-pandemic, remained a challenge for the trust.

The fit and proper person checks for directors were not always completed in a timely way.

There needed continued investment in the estate to ensure appropriate care and support was provided to all patient groups.

How we carried out the inspection

During the core service inspection, we visited the location and sites for the 11 core services inspected, and we spoke to a range of staff, patients and key stakeholders. We also inspected the well-led key question for the trust overall. We conducted well-led interviews remotely.

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

We undertook an unannounced, focused inspection of community-based mental health services for adults of working age following concerns identified at our last inspection in May 2019. During that inspection, we found the provider was not fully meeting the required standards of care and issued a warning notice under section 29a of the Health and Social Care Act 2008. We undertook this inspection to check whether the provider had made the required improvements to the safety of the service. This inspection was a focussed inspection so therefore did not provide a change to the existing rating.

The provider had made the following improvements:

Staff caseloads were a safe size. The overall team caseloads had significantly reduced. Waiting lists had reduced and patients’ risk was reviewed regularly. The number of patients with an up to date risk assessment had increased significantly. The trust had an agreed timeframe for staff to complete risk assessments and team leaders monitored this.
The trust had agreed two clinical care pathways and staff used identified tools to review patients’ needs to ensure they were discharged to alternative services when ready. Team leaders were reviewing staff members caseloads to agree with staff when patients were ready for discharge.
The waiting time for psychological therapies had reduced.

However:

There was no set timeline for additional care pathways to be introduced.
Staff morale remained low.

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

We noted positive changes since our last inspection in January 2018.
There was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses.
Staff were clear about their safeguarding responsibilities and if there was a concern about a child’s wellbeing safeguarding procedures were followed and understood. All staff we spoke with had completed the appropriate level of training in safeguarding.
Care was planned and delivered in line with evidence-based guidance, standards and best practice and the individual needs of the child and family were met through the careful care planning.
Staff received annual appraisals and new staff were supported when completing their competency assessments, helping to maintain and further develop their skills and experience.
There was good multidisciplinary team working evident across the service including working with external agencies.
Parents and children gave feedback about the care and kindness received from staff, which was positive. All the children and their carers we spoke with were happy with the care and support provided by staff. We observed staff treated children, young people and their families with compassion, kindness, dignity and respect. Staff worked in partnership with children, young people and families in their care.
Guidance on how to make a complaint was readily available across the community children and young people’s service and was on the trust’s website.
Managers at local levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
In general staff gave clear advice in line with national guidance on health promotion.

However:

The service did not always have oversight of medicines management.
Some environments were not, in their design, child friendly and the service had not adapted them to meet the needs of the child and young person. However, patient’s privacy and confidentiality was not always maintained in the sexual In two areas of the service, staff did not consistently perform daily checks of a resuscitation trolley and a grab bag as per trust policy.
The services IT systems did not all alert staff if a child, young person or family were on a child protection plan or if there was a risk to practitioners for home visiting. Therapy staff did not always complete a safeguarding assessment when meeting a child, young person or family.
The 0-19 service did not have standardised protocols for recording visits on the electronic records system to ensure consistency across the service.
Staff did not always provide advice to children, young people and their families based on national guidance for bottle feeding.

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

The emergency operations centre was still in the early stages of embedding new governance structures, systems and processes into the service. Therefore, it was too early to fully establish whether new strategies and quality improvement programmes were effective or working well.
The service did not always meet the Ambulance Response Programme quality indicators for the time to answer each call. We found there was no long-term service planning or solution identified to tackle increased demand. Resources were deployed by dispatchers by 9.30am on both days of our inspection, causing delays to treatment.
There was still a lack of sustainable staffing levels for clinical support staff on the night time shift and this had not improved since our last inspection.
The audit team did not have access to the new CAD system within their department, so had to move when asked to assist with taking calls.

However:

The service had introduced a new CAD system, and this meant better quality real time information was now available for the service to monitor trends and themes. This was an improvement since our last inspection.
The service had recruited more performance support officers, clinicians and dispatchers. 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. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff cared for patients with compassion and took account of their individual needs. Feedback from patients confirmed that staff treated them well and with kindness.
The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. This was an improvement since our last inspection.
Staff had received training in the Mental Capacity Act 2005 and the compliance rate for mandatory training was 90%. This was an improvement since our last inspection.
The service policies were up to date and standard operating procedures (SOP) had been reviewed and updated. This was an improvement since our last inspection.
There was a new meal break policy and staff now received 30 minute meal breaks during their shifts. This was an improvement since our last inspection.

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

Managers at all levels in the service were developing the right skills and abilities to run a service providing high-quality sustainable care.
The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
Managers across the service promoted a positive culture that supported and valued staff. The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.
The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
Staff cared for patients with compassion and took account of their individual needs. Feedback from patients confirmed that staff treated them well and with kindness.
The service had a process for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
There was a new meal break policy and staff now received 30-minute meal breaks during their shifts. This was an improvement since our last inspection.

However:

The service strived to improve the quality of its services. However, we found issues regarding the governance and oversight of medicines management and some concerns regarding security of paper patient records.
Systems to analyse, and use the information were now available to the service to support service development were under development. New reporting and governance system were in the early stages of being embedded into the service, Therefore, it was too early to fully establish whether new strategies and quality improvement programmes were effective or working well.
The long-term plans for divisional and reporting structure under which the ambulance service would be managed were not yet clear.

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

The service did not control infection risk well. Ambulances were not cleaned effectively to ensure the risk of cross contamination issues were minimised.
Managers could not routinely monitor the performance of the service. Available computer systems did not support the collection and analysis of information to allow for the continuous improvement and delivery of a quality service.
Risk management processes had not always identified and escalated risks appropriately to ensure mitigating action could be taken to minimise risks associated with service delivery.

However:

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 provided good care and treatment and ensured patients had enough to eat and drink. Managers made sure staff were competent for their role 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 extreme 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 taking action to ensure their individual needs were known and met.
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 transport.
Leaders ran services well 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. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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

We noted positive changes since our last inspection in January 2018.
We found monitoring, analysis and feedback of safety issues by the senior team took place in a comprehensive and timely way, this was an improvement since our last inspection.
Staff told us there had been change and improvement in the culture of senior leaders across the division.
The IT skills and the use of the new electronic system had been a challenge for staff. Since our last inspection, extra training and support had been completed and we saw how community nursing teams used the electronic system safely in their day to day care planning and to complete audits.
The majority of patients had good outcomes because they received effective care and treatment.
The majority of people’s needs were met through the way the services were organised and delivered.
Community multidisciplinary staff in different teams worked together supporting patients to improve their health and wellbeing.
The community team identified and captured risk with clearly defined mitigation and action plans. While there was a process for the escalation of high risk it was not clear all such risks had been escalated.

However:

Some of the mandatory training levels although improved since our last inspection, were still under the trust target, for example training on medicines management, practical assessment.
Staff did not always fully complete the paper medicines administration record.
Clinical supervision was available and was being utilised, however the service had not yet devised mechanisms for monitoring supervision levels.
Generally, the service had systems and processes to ensure patient information was kept confidential and secure. However, the Arthur Webster clinic did not always store records securely.
Access to assessment and treatment did not always meet the patients’ needs.

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

Staff on both wards did not undertake post rapid tranquilisation checks to detect any adverse effects of the medication as frequently as recommended by the National Institute of Health and Care Excellence. Patients could be put at serious risk of harm if side effects are not responded to in a timely manner.
Staff on Osbourne ward did not update risk assessments following incidents involving patients. Staff did not document the rationale for using prone restraint as an intervention or document the length of time patients were in a prone position during restraint.
Staff did not give appropriate consideration to reviewing and reducing blanket restrictions on the wards. Areas on Seagrove ward such as the male lounge, the female lounge and the garden had limited access and could only be accessed following risk assessment and/or supervision from staff. The trust had not prioritised estates work to remove ligature anchor points which meant patients had limited access to these areas.
The trust did not provide psychologically based therapies as recommended by the National Institute of Mental Health Excellence.
Patients’ rights were not always explained as frequently as they should have been.
Patients sometimes had to be transferred to other wards such as the rehabilitation ward and the older person’s wards due to beds not always being available for patients requiring admission.
Staff on Osbourne ward did not consistently ensure that vision panels on patients’ doors were left closed when patients had expressed that preference which compromised their privacy.

However:

Staff on both wards completed regular checks of the environment to make sure it was safe.
Staff on both wards ensured the clinic rooms contained all the equipment necessary. Resuscitation bags and equipment was checked accurately and regularly. The seclusion suite was now fit for purpose and met the requirements of the Mental Health Act code of practice.
Staff on both wards knew how to recognise abuse and were aware of how to record and report it.
Staff used recognised rating scales to assess and record severity and outcomes.
Staff treated patients with compassion and kindness. Staff involved patients in care planning and risk assessment and encouraged families to visit and give feedback.
Each patient had their own bedroom with an ensuite bathroom and could keep their personal belongings safe.

Leaders were well respected. Staff felt supported and valued and morale across both wards was good.

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

The service did not always provide safe care to patients. For example, patients admitted to the ward that should have been cared for on acute wards did not always receive an assessment of their needs and risk before admission, and their risk assessments did not recognise and mitigate for all the risks present within the environment. The service had no protocols or policies to support Woodlands staff to manage acute patients. Staff were experienced in caring for patients with mental health needs, but staffing numbers did not always enable staff to provide adequate support to both the acutely unwell, and rehabilitation patients present on the ward.
Patients did not receive the full range of recommended care and treatment interventions suitable for patients requiring rehabilitation care and consistent with national guidance on best practice. For example, patients were not able to store medicines in their room and self-administer in preparation for discharge, and the ward had only recently recruited a psychologist, and was yet to embed psychological input into the wards treatment programme .
Ward teams did not have access to the information they needed to improve the service and provide effective care. For example, the service did not have any clinical key performance indicators to evaluate the wards effectiveness, and the service did not track and report when patients’ discharges had been delayed.
Leaders did not ensure all staff received regular one to one or group supervision, and not all staff felt supported. Staff were not provided with training on how to manage and prevent violence and aggression, which at times would be required to safely manage the higher risk patients from the acute wards.

However:

Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. Staff developed holistic and recovery-orientated care plans.
The ward team included or had access to the full range of specialists, having recently recruited a psychologist, required to meet the needs of patients on the ward. Managers ensured staff received an annual appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare. Staff engaged in clinical audit to evaluate the quality of care they provided.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

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

Safety concerns identified at the last inspection had not been fully acted upon by managers or the trust. For example, staff had not fully completed risk assessment documentation for all patients being seen by home treatment and the health-based place of safety had not been fully refurbished.
Risk assessments completed by home treatment staff were brief and lacked detail. Staff manning the HBPoS were not consistently recording that they had gathered a risk history from the patient record meaning that staff were not taking all risks into account.
The psychiatric liaison service covering the ED had a band six vacancy which had not been filled for six months leading to one band six manning the service alone. This issue had been raised via incident reports, however the post was still vacant at the time of the inspection.
The home treatment team staff were not receiving Mental Health Act training although we were told that training was due to be delivered in the near future.
Incidents of self harm were not routinely reported through the incident reporting system. The trust policy does not state that such incidents should be reported. Learning from incidents was not consistently identified and shared with the staff team.
The service still did not have psychological input from a clinical psychologist resulting in patient care lacking a direct psychological focus. A psychological lead had been appointed but they were not working with teams directly.
The paper patient group directives (PGD) were not authorised copies, they lacked doctor, pharmacist and governance authorisation signatures. Therefore, the document trail was not compliant with the Human Medicines regulations 2012. However, we could find no evidence that staff did not know the correct process or hat harm had been caused.
The HBPoS had not been refurbished following our last inspection and was still unfit for purpose. This results in patients were detained in an area which was poorly decorated and lacked an appropriate room in which to be assessed.

However:

Staff were professional, caring and supportive. The interactions we observed demonstrated a positive attitude towards patients and their families.
Patients we spoke with were positive about staff and services. They felt that they were treated with respect and were involved in decisions about their care.
Patients and carers were given details of expected visits and had a number to call 24 hours a day in the event of a crisis.
Several team members were trained as DBT therapists which helped ensure a psychological approach was taken when meeting patient need.

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

Following our previous inspection in January 2018, CQC rated wards for older people with mental health problems as inadequate in safe and well-led key questions, requires improvement in effective and responsive key questions and good for the caring key question.

At the inspection in 2018 we told the trust they MUST:

• The trust must ensure Shackleton ward has a dedicated female-only day room which male patients do not enter. (Regulation 10)

During this inspection, we found that Shackleton ward now has a female-only day room that male patients do not enter.

• The trust must ensure staffing is at a safe level on Shackleton ward and that running of electro-convulsive therapy clinics does not adversely affect all wards minimum staff levels. (Regulation 18)

During this inspection, we found that staffing levels on Shackleton ward had improved and the running of electroconvulsive therapy clinics did not have an impact on staffing on the ward.

• The trust must ensure staff follow post-rapid tranquilisation protocols. (Regulation 12)

During this inspection, we found that staff were following post rapid tranquilisation protocols.

• The trust must ensure they comply with legislation around the seclusion of patients on the ward. (Regulation 12)

During this inspection, we found that staff were compliant with legislation around the seclusion of patients on the ward.

• The trust must ensure they comply with medicines management legalisation including the storage of controlled drugs. (Regulation 12)

During this inspection, we found that staff complied with medicines management in relation to the storage of controlled drugs.

• The trust must ensure staff are inducted, supervised and appraised. (Regulation 18)

During this inspection we found that staff on Afton ward received regular supervision. However, staff supervision levels were not sufficient on Shackleton ward.

• The trust must ensure staff apply the principles of the Mental Capacity Act and support patients to make decisions about their care. Patients must be cared for in the least restrictive way (Regulation 11)

During this inspection we found that staff on both wards were not correctly applying the Mental Capacity Act in relation to Deprivation of Liberty Safeguards.

• The trust must ensure patients can access fresh air. (Regulation 10)

During this inspection, we found that staff were supporting patients to access fresh air on a regular basis.

• The trust must ensure patients have access to food and fluids (Regulation 14)

During this inspection, we found that patients had access to food and fluids including snacks throughout the day.

• The trust must ensure patients’ records are stored securely. (Regulation 17)

During this inspection, we found that staff on Shackleton ward did not keep patients’ confidential records safe.

• The trust must ensure that when staff are in leadership positions, they are trained and supported to carry out their roles effectively. (Regulation18)

During this inspection, we found that managers on Shackleton ward had not been supported by the trust to carry out their roles effectively.

• The trust must ensure the privacy and dignity of patients on Shackleton ward is maintained, by addressing the windows. (Regulation 9)

During this inspection, we found the trust has applied a film to the windows which ensured patients’ privacy and dignity.

Following our inspection in June 2019, we served a warning notice as we had serious concerns about the care and treatment of patients of patients using the service. In addition, the trust had not made a number of improvements to safety that we told it that it must make at the previous inspection We required the trust to make significant improvements to the safety of the service by 26 July 2019. In response to our concerns the trust told us they would take immediate steps to keep patients safe on the wards. On 6 August 2019, we completed a follow-up inspection to determine if the trust had met the requirements of the warning notice. We found that although there had been some improvements, the trust had not met all the requirements of the warning notice. Following the inspection, the trust took the decision to close the ward to new admissions. Patients on the ward during the follow-up inspection were discharged to other placements and the ward was empty and closed to admissions. The trust informed us they would be discussing future service provision of Shackleton ward with partners and stakeholders and would not reopen without notifying CQC.
Risk assessment on Shackleton ward were not detailed enough to ensure all staff were aware of and could manage all risks. Staff did not assess, monitor or manage risks to people who use the service. Staff had not been supported to manage the ligature risks on the ward and 10 days following the reopening of the ward, staff were still unsure of where the ligature risks existed on the ward. Staff on Shackleton did not prioritise the security of the ward by keeping the clinic room locked and by storing the ward keys securely.
Staff on Afton ward did not effectively identify and manage patients’ physical health needs. Staff did not complete holistic personalised goal focussed care plans to support care delivery.
The trust did not ensure patients on Shackleton ward received therapies in line with national guidance. There was no psychological therapy or occupational therapy available to patients and we were not assured that there was any meaningful activities or engagement being delivered on the ward. There were no activities on the day of our inspection or follow-up inspection.
Staff on both wards did not make appropriate referrals under the Deprivation of Liberty Safeguards. Staff on Shackleton ward did not consider best interests and administering medicines covertly to a patient with ongoing infections that had been refusing treatment for four days. Staff on Afton ward had not recorded, assessed and documented mental capacity status in relation to medicines. At the follow-up inspection, a patient had a covert medication plan in place but did not have a mental capacity assessment or best interests meeting recorded.
Staff on Shackleton ward did not keep patients’ confidential records safe. This remained the case at the follow-up inspection. In the communal area of the ward we found a filing cabinet containing confidential records unlocked.
On Afton ward, clinic room fridge temperatures had been outside of the recommended temperature range and no actions had been identified. On both wards, oxygen was stored in the clinic room without a sign on the door to inform fire officers that compressed gas was stored there.
On Shackleton ward the governance arrangements and their purpose were unclear. Governance arrangements are important to ensure managers have oversight of key items such as the strategy, clinical audit, complaints, incidents and safeguarding are reviewed and learned from.
Leadership on Shackleton ward was poor. Staff were unaware of the ward action plan for reopening Shackleton ward. There was a lack of clinical managerial support for managers. trust leaders were not visible on the ward.

However,

Both wards had undergone significant improvements to the environment which had improved some standards of care. There was now a female only lounge on Shackleton ward that was only used by females. The garden on Afton ward had reopened since the last inspection in January 2018, it was unlocked throughout the day, contained wheelchair friendly flowerbeds and there was a range of plants, flowers and vegetables. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Each patient had their own bedroom with an ensuite bathroom and could keep their personal belongings safe.
Patients on Shackleton ward were regularly taken to the garden for fresh air.
Staff on both wards showed kindness and respect towards patients. Patients said that staff were friendly and kind. Staff on Afton ward had gone the extra mile to understand patients’ individual needs and preferences.
Staff on Afton ward supported patients with a range of needs that fell outside of the scope of functional mental illness. Staff had changed and adapted their training to ensure they met patients’ needs.
On both wards, the food was of a good quality and patients could make hot drinks and snacks at any time.
Staffing levels on Shackleton ward had improved.
Staff on Shackleton ward were no longer secluding patients in the corridor and understood the legislation around seclusion in the Mental Health Act code of practice.
Medicines management on Shackleton ward had improved, controlled drugs were stored correctly and staff followed national guidance on physical health monitoring post administration of rapid tranquilisation. During the follow-up inspection the clinic room remained locked throughout the day and the ward keys were stored securely. We also found that the ward manager was now being adequately supported by other managers in the trust.

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

The adult community teams waiting lists and caseloads were high. There was limited risk assessment of patients on the waiting list. Review of waiting lists by senior managers had only began in the five weeks prior to the inspection and was limited to high risk Care Programme Approach patients. Staff caseloads were higher than the guidelines set by the trust. Patients ready for discharge remained on caseloads instead of being discharged. Staffing vacancies continued to lead to patients being put back on the waiting list before being reallocated to staff. Staff had not received mandatory training in line with the trust required targets and fell well below these. Risk assessments and crisis plans were not always completed. Staff did not keep a record of when equipment had been cleaned and serviced.
Physical health needs were not always identified. Not all patients had care plans and when present their quality varied. There were no defined pathways, for staff to follow when planning and providing care, or outcome measures, to measure how effective the treatments had been, being used by the adult community teams.
Patients could wait years for treatment. Senior managers told us that there were patients with a greater need on the waiting list then patients who remained on staff caseloads. Staff rarely discharged patients and the nurse led clinic had no clear pathway for discharging patients. Group sessions were often cancelled.
Staff did not have confidence that senior trust managers would address their concerns and they felt detached from the trust. Morale was low across all the adult community teams. The electronic record system remained difficult to use.
Managers were not measuring the services quality and effectiveness against clear standards.

However:

There were safe lone working practices and alarms were available to staff seeing patients at the team bases. Staff understood how to safeguard patients and recorded incidents correctly. Managers were using creative ways to fill vacancies and agency staff were on longer contracts.
Patients mental health needs were assessed and staff planned to meet patients’ needs. There was specialist training available to staff to help them meet the needs of patients. There was a range of staff who met regularly to discuss patients’ needs.
Patients reported that staff were caring and that they were involved in planning their care. Staff encouraged patients to give feedback about the service. Families and carers were involved when appropriate and had ways to feedback about the service.
Target times were met by the single point of access team (SPA). Services offered appointment times to suit patients and there were processes to check patients who missed appointments. The were suitable rooms for group sessions at the early intervention in psychosis team (EIP).
Local leaders had clear plans to improve the service. Morale was good at single point of access team (SPA) the early intervention in psychosis team (EIP). There were systems in place that allowed the staff to feedback to the trust and for the trust to advise staff about service developments. Staff received clinical supervision.

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

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

Staff on Shackleton ward compromised the privacy and dignity of female patients by allowing male patients to use the female lounge. The lounge for the use of female patients was not clearly identified with signage.
Staffing levels on Shackleton ward were insufficient to meet patients’ needs. Ward based activities were frequently cancelled and patients were not able to access the garden for fresh air.
There was no clinical psychologist within the multidisciplinary team. Patients were not receiving psychological input to meet their needs.
Staff were not applying the principles of the Mental Capacity Act to their practice. Mental capacity assessments were not being completed for specific decisions such as covert medication and decisions around accommodation.
Staff on Shackleton ward were not effectively supervised. Supervisions were frequently cancelled due to staffing shortages.
The environment on Shackleton ward was not dementia friendly. There was very little stimulation or meaningful activity.
Managers on Shackleton ward were not supported effectively to carry out their roles. Managers were not trained to perform their acting roles and were working outside of their comfort zones.

However:

Staff demonstrated kindness, compassion and patients felt they were cared for and treated with dignity and respect.

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

The service did not always offer safe care for patients. For example, staff did not always record assessments as to whether a patient was safe to access the community, before they started their leave. Only 60% of staff had received Mental Health Act (60%) training, the trusts’ target is 80%. Only 10% of staff had received Mental Capacity Act training and staff did not understand their responsibility for assessing patients’ capacity. The ward did not have a female only lounge.
The ward was not offering effective care for all patients because, there was no psychological input and they did not enable patients as part of their recovery and discharge plan to self-administer medication. The ward did not use any outcome measures to see if their care was effective. Staff did not receive regular supervision or annual appraisals.Staff allowed patients to freely access the office. This compromised confidentiality because staff displayed information about named patients on the walls of the offices.
The trust did not follow generally accepted practice in monitoring whether patients discharge was delayed. There was a patient ready for discharge but there was no plan in place to discharge them and the ward did not recognise this as a delayed discharge.
Visitors had to meet with patients in communal areas or their bedrooms.
Staff were not aware of any learning from concerns from other services in the trust.
There were no targets set for the ward to help measure its performance. There were no action plans to address the findings from audits and staff were unaware of what audits the trust carried out.

However:

The ward environment had improved since our last inspection. There was a comprehensive ligature assessment in place that identified and managed risks and staffing had been increased. All patient risks had a risk management plan.
Care plans were personalised and patients were involved in planning their care. Staff assessed and managed physical health issues.
Staff had built good relationships with patients. Staff gave patients information about the service and what treatments were available. Patients could involve their families in their care.
Patients could feedback to the ward via a patient survey.

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

There was evidence that the waiting list was monitored and patients were assessed and prioritised according to risk. Staff could see Service users quickly if there were any concerns about any deterioration in their presentation.
Staff delivered a range of evidenced based care and treatment interventions that were suitable for people with a learning disability. Care plans were personalised, holistic and considered the service user’s needs.
Staff discussed risk in multi-disciplinary team (MDT) meetings and responded promptly to the service users need. Risk assessments were individual to each service user.
Staff demonstrated a clear focus on service users physical health needs and considered its impact in their interventions in all records reviewed
All staff had received an annual appraisal. Staff appraisals included conversations about career development and how it could be supported.
Service users we spoke with said that staff treated them with dignity and respect and understood their care needs. Staff involved families and carers to understand service users likes, dislikes and specific needs where appropriate. All service users and carers reported feeling involved in their care.
All areas were clean with good furnishings.

However:

Service users were not having standardised risk assessments completed. A clear picture of a service users risks was not immediately apparent in the electronic notes. Information was not easily accessible on the electronic records system and was stored in different areas. Clinical information about the service user was difficult to find.
Regular management supervision which included caseload supervision was not formally documented. Management supervision was not completed monthly in line with the trust supervision policy.
Mental Health Act (MHA) specific training was not provided.
Staff had not been involved with the transformation plan. Staff reported feeling out of the loop and did not know what was happening.
Conflicts between staff were not managed quickly by senior managers
The service was not taking positive action to support the national Transforming Care programme

We rated it as inadequate because:

The single point of access team did not have enough qualified nurses to safely staff the services.
Administrative staff were triaging referrals without training or support.
Staff had not completed mandatory safeguarding, Mental Health Act and Mental Capacity Act training.
The medical staffing was not sufficient within the home treatment team and single point of access team.
The out of hours on call cover for staff working in the service was not adequate.
Staff were not provided with a suitable system to safely operate as lone workers.
Risk assessments were incomplete and inconsistent across the service.
Governance processes were not embedded in the service to monitor performance and quality of the crisis services.

However:

Staff enjoyed working in the service and overall the morale was good.
The Serenity project had developed good working relationship with the police and there had been a reduction in the use of Section 136 of the Mental Health Act.

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

Staff had access to up to date, accurate and comprehensive information about children and young people in their care and treatment plans. They ensured that care plans and crisis plans were up to date and comprehensive, assisting the teams’ deliver of safe care and treatment to young people. Staff members ensured there was an effective system in place to assess the risks to all young people
The staff team had reviewed and improved the way they reported incidents. They ensured incidents were consistently reported and there was learning from each incident.
Staff involved children and young people and those close to them in decisions about their care and treatment. Children and young people spoken with were very positive about the care and treatment they received. The team listened to feedback from parents and young people, supported them and made changes because of the feedback.
There was no waiting list for the service and young people were seen quickly.
Staff were well trained to carry out their roles. There was suitably skilled and experienced staff to support children and young people’s needs.
The manager promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff morale was good and staff felt positive about their team.

However:

Young people could not always access the service when they needed it. There was no out of hours provision for young people. Young people admitted to hospital at the weekend had to wait until the following Monday before being assessed by CAMHS staff.
The service did not deliver all the psychological therapies recommended by NICE.
There was no provision for young people with attention deficit hyperactivity disorder or autism spectrum disorder. Whilst there were discussions with the clinical commissioning group about the pathway, these young people were excluded from the service and had been for several years.
The service did not ensure that the premises were safe for children and young people. They had access to domestic knives in the unlocked kitchen.
The manager did not ensure staff were competent for their roles because staff members did not all receive sufficient regular one to one managerial supervision.
The staff team did not treat all complaints seriously because they did not investigate verbal complaints from children, young people or their families.

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

There were considerable concerns around the high turnover of staff and vacancies within the team. This meant patients were regularly reallocated to new agency staff. Agency staff did not always receive an effective handover of patient care.
There were extensive waits for evidence-based psychological therapies. There was a lack of oversight of risk for patients on internal waiting lists.
The service was not set up to provide effective and prompt interventions based on National Institute for Health and Care Excellence (NICE) guidance. Assessments were not always fully complete and did not contain in depth information essential to patient care. There were a high number of re-referrals taking place that showed treatment had not been effective. There was no psychologist working within the community mental health service.
We had serious safety concerns over the management of medicines in the Chantry House clinic room. There was no oversight of the management of medicines.
We found serious safety concerns for patients accessing support for an eating disorder. Staff were not providing safe care to patients with an eating disorder. The service accepted people with an eating disorder onto their caseload but did not have the skills to provide the specialist interventions that such patients required..
Staff completed risk assessments of patients, however there was variation in the quality and they were not always comprehensive. Staff did not regularly use crisis plans to mitigate risks for services users in the event of experiencing a mental health crisis. Care plans we reviewed did not meet the criteria set out in the standard operating procedure
The electronic records system continued to be a problem for staff due to its complexity. The previous inspection in November 2016 found that the system was not fit for purpose.
The electronic records did not always demonstrate that care plans were shared with patients and did not always show patient involvement. Care plans were not always holistic and person-centred.
The service had not embedded individual service-user rating scales and outcome measures as part of standard practice.
Nurse led clinics aimed at patient’s that were mentally stable were created to assist in the management of the caseload had no clear remit.
Patients who did not meet the referral criteria of the service were not offered alternative support due to a lack of other community support.
Staff were not always effectively responding to patients that did not attend their appointments.
While staff received mandatory training there was little specialist training available to them.
The community mental health services did not have stable or clear leadership and there was a lack of support for the interim team. There were quality concerns identified during the inspection that showed a gap in governance. Staff felt that it was not a supportive culture despite trying their best to support each other. Morale was consistently low.

However

Oversight of the mental health services had improved since the previous inspection in November 2016. Staff felt that mental health was now being given attention by the senior leadership team within the trust with the appointment of a director for mental health.
Training was provided in order to safeguard children and vulnerable adults from abuse. Staff reported incidents using an electronic incident reporting system.
Staff were caring, they treated patients with dignity and respect.
The service had set up a physical health clinic in order to assess patient’s health when prescribed antipsychotic medicines.
The service had taken positive steps to manage staff caseloads. Staff received caseload management supervision to review their caseloads and identify risks and treatment progress.
Staff attended regular multidisciplinary team meetings. Daily meetings allowed staff to identify those most at risk on the caseload and shared the risk within the team.
Staff were confident in their knowledge of the Mental Health Act and Mental Capacity Act and were aware of how to seek support and advice.
The service recruited ex-patients as volunteers to aide with the group activities. In-house training was provided regarding managing risk and working in groups.
The duty worker responded well to patients phoning or attending the service outside of appointments times.

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

The wards had undergone some significant renovations and had plans in place for further improvement to address the concerns from our last inspection. The trust had made improvements to the management of ligature risks on the wards. The wards were clean and tidy and the furniture was well-maintained. Staff also carried out regular environmental audits.
There was good physical health screening for patients on the wards. Seagrove ward had recruited a dual qualified nurse to lead on physical health screening and care plans of patients. A dual qualified nurse is qualified in both mental and physical healthcare.
Care plans had improved significantly since the last inspection. Care plans were more holistic, person-centred and had detailed daily care records, and a good correlation with risk assessments of patients.
The service had improved its out of hours medical cover arrangements. Junior doctor cover was in place day and night, and doctors were easily accessible in an emergency.

However:

The seclusion room on Seagrove ward did not have toileting facilities and staff ended seclusion for patients to use the toilet outside of the seclusion room or provided them with a disposable pan. The trust had agreed building works to correct this.
We found some errors in the operation of both clinic rooms on the two wards.
The care plans we looked at on both wards were not always recovery orientated.

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

There were some significant safety concerns across the service and some risks had become normalised.
There were multiple records systems in place which did not always allow staff to access full and up to date information about children, young people and their families. The electronic patient record system was not reliable or fit for purpose, and paper records had not been scanned onto the system.
Medicines in some areas were not stored or prescribed appropriately and some staff did not follow inflectional control procedures.
There was inconsistency in the reporting and management of incidents across the service. Whilst staff did recognise incidents they did not always report them and were not always confident that action would be taken.
Services did not always have competency frameworks in place for staff
Whilst local leaders were regarded highly by teams, senior leaders in the clinical business unit did not always understand the risks to services and support staff to address them.
The service did not have an effective system for identifying risks, planning to eliminate or reduce them and coping with both the expected and unexpected. Significant safety risks had not been adequately addressed.
There were not sufficient governance arrangements in place for oversight of safety and quality the children, young people and family service.
There were insufficient processes for accessing, sharing and using performance and quality information across services.
There was no evidence of engaging children, young people and their families in the design or implementation of the service.

However:

There were robust safeguarding procedures in place and staff worked well with other agencies to ensure children and young people were protected from avoidable harm or abuse. Staff were aware of their responsibilities to seek appropriate consent from children and young people.
Staff across the service worked well as a multidisciplinary team. Services provided health information and advice for children and young people in a way they could understand.
Staff were kind and compassionate and placed children and families at the centre of their work.
Children and young people could access most services when they needed it. However, there were delays in accessing outpatient appointments in occupational therapy particularly for children with autistic spectrum disorders.
The service treated concerns and complaints seriously but children, young people and their families were not always given information on how to make a complaint. There was no child friendly complaints process within the service.

There was limited assurance about safety. Monitoring, analysis and feedback of safety issues by the business unit senior team was not taking place in a comprehensive or timely way.
The leadership, governance and culture within the senior leadership team of the AUCC business unit did not assure the delivery of high quality care.
There was no understanding of the importance of culture in ensuring high quality, sustainable care. Senior business unit nurse managers did not promote a positive culture that supported and valued staff.
Changes were made to the services without due regard to their impact. For example, the care of long-term patients following the changes to community matrons and the IT skills of community nurses.
Although many community vacancies had been recruited to, agency and bank staff were not consistently used to cover gaps due to sickness and absence. Not all staff had the right qualifications skills, knowledge and experience to do their jobs.
Despite improvements in medicine protocols, numerous insulin administration errors were reported, corresponding to low numbers of medicine administration competency assessments being achieved.
Electronic systems to manage care records on the Isle of Wight were uncoordinated with issues regarding sharing information between services. There was variability in the use of the new electronic patient record, with reassessments of patient’s risks not routinely taking place.
Many community nursing staff became stressed and anxious when talking about their roles. We found that community staff felt undervalued, unsupported and unappreciated by the AUCC business unit senior team.

However:

The majority of patients had good outcomes because they received effective care and treatment.
Community multidisciplinary staff in different teams worked together supporting patients to improve their health and wellbeing.
People cared for in the community were usually supported, treated with dignity and respect and are involved in decisions about their care and treatment.
The majority of people’s needs were met through the way the services were organised and delivered.
People knew how to give feedback or concerns about their care in a variety of accessible ways.
Staff felt local supported by the team leaders and welcomed the new executive team.

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

The service could not always demonstrate they followed safe practice.
Staff had not received the required mandatory training required for their role including Safeguarding and Mental Capacity Act training.
Appraisal rates for staff, across the service, were low.
The service was non-compliant with some National Ambulance Resilience Unit requirements.
Staff and patients were placed at risk because the computer aided dispatch system was not providing accurate real time information regarding the location of vehicles and crews.
Staff knew how to report incidents. However, learning from incidents had not been documented and staff did not receive feedback to ensure the risk of a repeat incident was minimised.
Staff reported they did not always meet the 15 minute window for handover of patients once they arrived at the emergency department.
Complaints were investigated but not responded to in a timely manner which met the providers own identified and published guidance.
The service was not always well led. The provider did not demonstrate effective succession planning and did not have an identified vision and strategy for the direction of the service which was known by staff.
The governance arrangements for the service were not fully clear. The trust did not have effective systems for identifying risks, several policies were out of date at the time of the inspection and there were no ambulance specific policies in place for the service.
The service had an up to date risk register but did not effectively manage and mitigate risks. There was no process for review of key items such as the strategy, objectives and plans.
Audits were not completed fully as a means to improve the quality of the service provided.

However:

The service and staff controlled infection risk well. Staff uniform, equipment and premises were visibly clean.
Staff apologised and were honest with patients when things went wrong.
Staff and managers maintained and monitored security of the premises, vehicles and medicines.
The service recruited and trained co-responders and community first responders to support frontline crews.
The service used national performance indicators to benchmark themselves against similar NHS trusts.
Patients physical, emotional and mental wellbeing needs were met by staff who demonstrated a caring and compassionate approach in their work.
Staff told us they felt supported by local management and that morale within the service was improving.

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

The service could not always demonstrate they followed safe practice. Staff had not received the training required for their role.
Equipment used by the service had not been regularly serviced to ensure it remained fit for purpose. Out of date items were found in use on the ambulances.
Incidents, whilst documented, were not completed fully. Learning from incidents had not been documented and staff did not receive feedback to ensure the risk of a repeat incident was minimised.
The service was not monitoring the publication of national best practice guidance to ensure staff were following the most up to date practices in the completion of their role.
Evidence relating to effective staff induction procedures could not be provided to offer assurances staff were identified as fully competent before starting their employment.
The service did not ensure that people with communication needs such as those experiencing a sensory impairment or those who did not have English as their first language were able to communicate fully with staff.
Complaints were investigated but not responded to in a timely manner which met the providers own identified and published guidance.
The service was not always well led. The provider did not demonstrate effective succession planning and did not have an identified vision and strategy for the direction of the service which was known by staff.
Audits were not completed fully as a means to improve the quality of the service provided.
The service did not evidence effective governance processes. A change in senior management of staff had not been finalised at the time of the inspection and meetings were not always minuted to identify performance actions were discussed and raised where appropriate.

However:

Staff knew and took positive action when they identified concerns regarding patient’s wellbeing or incidents occurred. Risks to patient safety were managed appropriately.
The service had sufficient numbers of staff and ambulances in order to meet patients’ needs.
Patients physical, emotional and mental wellbeing needs were met by staff who demonstrated a caring and compassionate approach in their work.
The service was responsive to changing and increasing patient transport needs introducing an additional shift to minimise waiting times for patients.
Staff felt supported by their immediate managers and felt integrated with the Trust and their colleagues in other departments.

Our rating of this service stayed the same. We rated well led as inadequate, safe, effective and responsive as requires improvement and caring as good

We rated it as requires improvement because:

There were limited assurances about safety. The service did not give safeguarding training sufficient priority and the service did not always have enough staff to provide the right care.
People were at risk of not receiving effective treatment due to shortfalls in staffing for the clinical support desk.
The delivery of high-quality care was not assured by the leadership, governance or culture. There was a lack of stable leadership, no vision or strategy for the service and a complex governance structure.

However:

Staff cared for callers well and treated people with kindness, dignity and respect.
The service was planned and delivered to the needs of the local population.

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

Overall trust wide we rated safe, and well-led as inadequate; effective and responsive required improvement. We rated seven of the trust’s 23 services as inadequate, and 11 as requires improvement. The findings of focused inspection of safe and well led in gynaecology services, an additional core service are in a separate report and not included in the overall trust rating.
We did not rate acute services in November 2016 as not all services were inspected at that time. The overall rating of acute services went down to inadequate since inspection in 2014. Five services were rated as requires improvement. Three services, emergency care, medical care and end of life care services, were rated as inadequate. Safe, effective and well led was rated as inadequate across acute services overall, with responsive as requires improvement.
The overall rating for mental health services remained as inadequate overall. Three of the seven services inspected were rated as inadequate, one was rated requires improvement. Safe, responsive and well led was rated as inadequate across mental health services overall, with effective as requires improvement.
Our rating of community services overall went down to inadequate. Community services for children, young people was rated inadequate overall with community services for adults requiring improvement. Safe and well led was rated as inadequate across community services overall, and effective as requires improvement.
The rating of ambulance services was requires improvement overall, however well led was rated inadequate across two of the three ambulance services and the 111 service. Safe and effective was rated as requires improvement for the ambulance and 111 services.
The GP out of hours service was rated requires improvement overall, with well led inadequate and safe, effective and responsive requiring improvement.
We rated well-led for the trust overall as inadequate

However:

All services were rated good for caring, with one service rated outstanding for this domain.
Two acute services, critical care and outpatients, were rated good overall.
There were improvements in some mental health services. Acute adult wards and PICU, and specialist community mental health services improved to a rating of good overall. Community mental health services for people with a learning disability or autism remained good overall. Long stay rehabilitation wards, had improved from inadequate to requires improvement.
The overall rating of ambulance services had improved, from inadequate in November 2016 to requires improvement

We undertook this inspection to find out whether the Isle of Wight NHS Trust had made improvements to the inpatient and community mental health services following the comprehensive inspection of the trust in late November/early December 2016. At that inspection we rated the trust ‘inadequate’ overall and ‘inadequate’ overall for mental health services.

Following that inspection, we served a Section 31 Notice of Decision that imposed conditions on the trust’s registration. This required the trust to take action to address safety concerns at both its community and inpatient mental health services.

At this inspection (May 2017), we found that there remained a significant amount of work still to do for the conditions of the Notice to be fully met including:

further work on the ward environments to ensure they are fit for purpose
addressing staffing levels and the size of consultant caseloads
addressing the quality of patient records
providing staff with access to supervision
ensuring decisions are made about the future of some services, and
implementing good governance systems to ensure the board can effectively assure itself that the required improvements are being made in a timely manner.

However, there had had been some progress on a number of conditions in the Notice, most notably:

work had been carried out and was progressing on the physical ward environments, in order to make them more safe
there was positivity and enthusiasm from the staff on the Sevenacres site at being fully involved in planned improvements to their wards
there was an increased awareness of staff about the potential risks on the inpatient wards.

At the time of this inspection (May 2017), a new Chief Executive Officer had been in post just over a week and there had been a number of major changes to the senior leadership team and the way the trust was organised. In addition, the trust was also receiving input and support from a number of external organisations, including NHS Improvement.

Despite there still being much to do, we were assured that the new Chief Executive Officer had a good understanding of what was required to make the required improvements. The addition to the executive and senior leadership team, of experienced mental health and quality improvement specialists, should, given time, enable the trust to clearly progress the required improvements..

Following this inspection, we agreed with the trust to make some minor amendments to a number of conditions detailed in the Section 31 Notice of Decision. These amendments were related specifically to how and what information the trust would submit to us to allow us to continue to monitor the trust closely.

We will continue to closely monitor the trust’s progress in meeting the conditions detailed in the Section 31 Notice and we will inspect the trust again in the near future. The Section 31 conditions on the trust’s registration remain in place at this time and will remain so until we are assured those conditions have been met. We will not hesitate to take further action should we find that patients, staff and the general public are at risk of harm.

We rated this service as good because.

The building was accessible, with a clean and well-maintained environment. The clinic room contained appropriate equipment for physical health monitoring; for example, there was a couch and an electrocardiogram machine to check clients’ heart rhythm and electrical activity.
There were sufficient numbers of staff to meet the needs and safety of the clients using the service. The trust provided all staff with mandatory training. There was a robust staff induction programme and staff attended mandatory training. Staff morale was good despite recent pressures of redesign and reductions in staffing.
Staff interacted with clients in a respectful and supportive way. Staff were warm, kind, respectful, enthusiastic and positive. Full risk assessments and risk management plans were in place. They were clear and comprehensive. Staff discussed risk with partner agencies on an ongoing basis. Staff used a robust assessment tool called ‘client evaluation of self’ at the point of referral. All the care records we reviewed were comprehensive and clear. Staff assessed the physical and mental health of the clients and continued to review and update the records. Where appropriate, staff involved clients and family members fully in care planning.

Staff supported clients in line with ‘drug misuse and dependence: UK guidelines on clinical management (2007)’ during detoxification treatment, and followed the trust’s ‘operational guidelines for alcohol and opioid prescribing’ as well as the Royal College of General Practitioners guidelines (first edition 2011). All the guidelines for interventions and prescribing pathways were adapted from appropriate National Institute of Clinical Excellence (NICE) guidelines. Prescribers recorded appointments and outcomes on the electronic records and a client’s prescribing pathway was clear and legible.

There was a good choice of activities to suit individual needs such as the 12-step programme, and informal group sessions designed to help clients discuss and improve skills in coping with dependency and avoiding relapse, although the service did not have access to a psychologist

The provider had a robust incident reporting process. Staff knew how to report incidents. Staff were open and honest when things went wrong.

However,

Although the service had a detailed health and safety environmental risk assessment, including fire risk assessments, and staff told us their policy was to review the document annually, the environmental risk assessment had not been updated since January 2015 and staff had not monitored progress against the identified actions. Staff had also not updated all other policies, including for children visiting the service.

Although supervision took place, this was not regular and documentation was of poor quality.

Staff did not formally document a daily handover of client information at the end of each shift, which meant staff did not evidence how they monitored client progress.

Staff did not have a clear system in place for documenting when they administered medication

The service operated in isolation from the rest of the trust and staff did not feel the service was an integral part of the trust.

The ambulance service is an integral part of Isle of Wight NHS Trust. . The ambulance station and headquarters are based at St Mary’s Hospital, in Newport. The service responds to 999 calls, 24 hours a day, 365 days a year. The trust also provides a Patient Transport Service (PTS) which provides transport 7 days a week for service users in cases of medical need for outpatient appointments, admissions, discharge and transfer.

The Isle of Wight covers 147 square miles. There is a fluctuating population throughout the year with a resident population of approximately 140 000, swelling to upwards of 230 000 throughout the summer months and during island based events.

The ambulance service employ around 145 people including approximately 52 paramedics, 29 emergency vehicle operatives (emergency care assistants), 11 PTS staff 12 clinical advisors and 36 dispatch staff /call centre staff. They have at their disposal, 10 emergency ambulances, 10 rapid response vehicles (RRVs) and three co-responder vehicles.

Between April 2016 and September 2016 the PTS provided 4677 journeys, an average of 780 journeys per month. For the year 2015/16 the ambulance service took 24597 calls.

We carried out an unannounced comprehensive inspection of the ambulance service including the emergency control centre, the urgent and emergency care service and the patient transport service on 22-24 November 2016

We rated the ambulance service provided from St Mary’s Hospital part of the Isle of Wight NHS trust as Inadequate overall.

Although staff knew how to report incidents the trust could not be assured that all front line staff were reporting all incidents and learning was cascaded. There was a mixed understanding of the principle of the duty of candour.
The ambulance station was not secure. The mobile data terminal used to provide staff with patient information and navigation was unreliable. Confidential information, medicines and cleaning products were not always securely stored in the urgent and emergency care service.
On the front line, emergency and urgent staffing levels meant shifts operated at minimum levels. On the EOC staff worked flexible to maintain a safe service although they were not consistently staffed to the planned levels. Staffing levels for the PTS service were well managed
Mandatory training was not always completed to the level expected by the trust and and not all staff had received an annual appraisal. However, all permanent staff in the PTS had received an appraisal in the previous 12 months. There were a comprehensive induction programmes in place for staff. Not all staff with professional registered had an individual learning plan in place to support their development. There was no formal system for ensuring those Community First Responders registering for duty were competent in their role. Call handlers had not had training in the Mental Capacity Act (2005), or learning disability, or dementia awareness. Front line staff had not had specific training on supporting patients experiencing a mental health crisis and had not completed the required refresher training on resilience in the event of a major incident.
For patients, for whom English was not their first language or who were not able to communicate verbally, there were no communication aids on the ambulances. Staff had access to language line and the SMS system in the control centre to help with communication with all patients.
There was no clear vison or strategy for the service. The governance framework used to monitor the quality and risks of the service was not effective. The risk register did not reflect all of the current risks of the service.
Delays in handover at the emergency department and the service running at minimum capacity meant people could not always access the service in a timely way. The trust response times were consistently below the expected target and patient outcomes where not as expected for patients suffering a heart attack. The proportion of emergency calls resolved by telephone advice was lower than expected and calls abandoned before being answered was consistently higher than expected. However, the trust consistently had the shortest waiting times of any trust in England for call answering. The proportion of patients who re-contacted the service following discharge of care, by telephone within 24 hours was lower than the England average.
The trust had processes in place to respond to feedback from patients and members of the public. Complaints were investigated with a written response to the complainant. However, complaints were not always responded to in the agreed period of 25 days.
Morale was low amongst ambulance staff. While they spoke highly of the support they were given from their direct line managers and were proud of the strong sense of team work, they felt there was insufficient knowledge and experience amongst the senior managers within the clinical business unit to effectively manage the service. A number of managers were in interim roles and staff felt this impacted on their ability to be effective.
In general, vehicles were clean with deep cleans taking place. Infection control policies with in the patient transport services were not consistently adhered to particularly concerning hand hygiene.
The service co-ordinated effectively with other emergency and community healthcare services. The multi-agency hub was used to co-ordinate care with other agencies when patients were discharged at the scene.
Staff treated people with dignity, respect and kindness during all interactions. They were compassionate and kind and showed empathy when caring for patients.
The PTS service was able to meet the individual needs of patients and was accessible to patients who met the eligibility criteria set by commissioners. There was good use of risk assessments to reduce the risks to patients and staff.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

All ambulance staff are provided with training on Duty of Candour regulation and this is adhered to
The ambulance station door is repaired to ensure the station is secure.
Vehicles are kept locked and secure at all times
There are sufficient numbers of suitable qualified and competent staff, and managers, to provide a safe, effective and responsive ambulance service.
Cleaning products are securely stored in line with the Control of Substances Hazardous to Health (COSHH) requirements.
Risks across the ambulance services are identified, assessed and managed appropriately. Risk registers are current, with a responsible person allocated to monitor completion of each action.
A review and action to ensure the ambulance service and trust are meeting all national requirements in relation to emergency preparedness, resilience and response.
Patient records are stored securely at all times.
Improved response times and performance on key performance indicators and national targets for urgent and emergency ambulance service.
Staff observe good hand hygiene practice and this is audited.
The quality and performance of the patient transport service is monitored, including the national KPI for arrival and collection time of patients attending for dialysis.
Staff are able to report incidents and learning is shared and implemented.
All staff have an appraisal and individual learning plans.

In addition the trust should:

Complete a review of the storage of medical gases at the ambulance station and ensure all gas bottles are stored securely and in line with national guidance.
Regularly changes the codes for medicines cupboards on vehicles
Ensure the practice in patient transport services and trust medicines policy are aligned.
Review the system provided on the mobile data terminal to ensure it is reliable and fit for purpose.
Review the provision of equipment for the safe transportation and care of children.
Provide adequate staff training in mental health and dementia awareness, which is updated at regular intervals to ensure that mental health knowledge is current.
Ensure a multi-lingual phrase book is stored on all vehicles at all times to support patients to receive safe care and treatment.
Consider providing a communication aid to support patients who are unable to communicate verbally.
Implement actions in response to the investigation reports and improve the ambulance service culture.
Implement a formal system for ensuring those Community First Responders registering for duty are competent in their role.
Provide training for all staff in Mental Capacity Act (2005).
Ensure timely response to complaints.
Monitor staff are up to date and compliance with mandatory training is monitored.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Isle of Wight NHS Trust is an integrated trust that includes acute, ambulance, community and mental health services. Services are provided to a population of approximately 140,000 people living on the island. The population increases to over 230 000 during the summer holiday and festival seasons. St Mary’s Hospital in Newport is the trust’s main base for delivering acute services for the Island’s population. Ambulance, community and mental health teams work from this base, and at locations across the island. The trust also provides a GP led urgent care walk in centre and NHS 111 services which were not included in this inspection and will be subject to separate inspection and rating in 2017.

We carried out this short notice inspection of the Isle of Wight NHS Trust to follow up on some areas that we had previously identified as requiring improvement or where we had questions and concerns that we had identified from our ongoing monitoring of the service or if we had not inspected the service previously. We undertook site visits 22-24 November 2016 and an additional inspection of mental health services 18-19 January 2017.

We undertook a comprehensive inspection of the following core services across acute hospital, ambulance, community and mental health services:

Accident and emergency, medical care (including older people’s care) and end of life care.
Community health services for children, young people and their families, community adult services and community inpatient services.
Acute inpatient mental health, psychiatric intensive care unit, rehabilitation wards, community mental health, community learning disability services, community children and adolescent mental health services, older adults wards, and substance misuse services.
Urgent emergency ambulance, emergency operation centre, patient transport services

We also inspected and assessed the ‘well led’ domain, which covers the overall leadership and management of the trust.

Overall, we rated this trust as inadequate. We rated the safe, responsive and well led domain as inadequate overall. We rated effective as requires improvement overall. The trust was rated good for caring. We rated ‘well led’ as inadequate.

We rated mental health and ambulance services as inadequate overall. Community services were rated as requires improvement overall. Acute services urgent and emergency care and end of life care were requires improvement overall, medicine was rated as inadequate.

Immediately following our inspection, we issued a notice of decision under Section 31(HSCA 2014) to urgently impose conditions on the trust’s registration in relation to mental health services, as we had reasonable cause to believe a person would or may be exposed to the risk of harm unless we did so. We also formally wrote to the trust asking for a report on urgent action to address a number of other serious concerns across all services.

Our key findings were as follows:

Since our last inspection in 2014, some services had seen deterioration in safety and quality, including care for patients with mental health conditions.
The trust had not made sufficient progress to improve services as required at the last inspection and there was continued non-compliance with regulations that had been identified at the last inspection.
Inpatient mental health wards were not safe, and the ambulance station was not secure
There were deficiencies in organisational structures, processes and the trust leadership which prevented staff from providing good services
Staff in many services were disillusioned and suffering work overload; some described bullying and harassment. Morale was low among many groups of staff.
We found staff shortages, outdated practices, bureaucratic processes, limitations in information systems or use of information.
Staff felt senior managers had insufficient knowledge and experience. Some services had managers in interim roles and staff felt this impacted on their ability to be effectiveHowever staff spoke highly of the support they were given from their direct line managers and were proud of the strong sense of teamwork.
The trust did not have strong risk management and governance processes at all levels which affected the quality and safety of services. The executives were out of touch with what was happening at the front line.
There was a top-down culture with senior managers attempting to direct change. Senior managers did not appear to understand what was needed to make necessary changes or to implement their vision and strategies. Staff did not feel part of this process as managers had sought a high number of external reviews.
The trust recognised the need to work with partners to provide high quality and sustainable services for the island population. However there had been little progress in delivering that vision, so the trust and the wider system were not keeping pace with the actions and improvements needed to meet increasing demand for services and financial pressures.
The trust did not know whether all front line staff were reporting all incidents and learning from incidents was shared. There was a mixed understanding of the principles of the duty of candour and its application.
Patient care and safety was affected as all services had teams or wards that were significantly understaffed. Some trust wide key posts were vacant and the trust employed many locum medical staff
There was inadequate risk assessment of patients and risks were not adequately monitored or managed.
Key groups of staff were not up to date with safeguarding training. Staff did not always identify or report safeguarding incidents. Safeguarding and ‘looked after children’ teams were stretched and there were not sufficient monitoring of adult safeguarding.
The records systems across community services did not support patient safety.
Care and treatment did not reflect current evidence based practice in all services.
Staff did not regularly monitor patient outcomes and some services did not participate in national data collection schemes. Outcomes for stroke patients were poor.
Some staff did not have appropriate competence and skills, particularly in medicine services. Many staff across services did not receive regular appraisal or appropriate supervision.
Staff did not always seek patients’ consent for treatment, observation or examination.Staff awareness of the Mental Health Act (2005) and the Deprivation of Liberty Safeguards was variable and it was not always applied.
The trust did not plan or deliver services in a way that met people’s needs.
Patients’ privacy and dignity was not protected in mental health services wards and acute service escalation beds. Staff did not always report incidents where mental health wards had people of both sexes sharing bathrooms, which is a breach of the regulations.
Staff did not manage access and flow through services adequately. This led to delays in ambulance handovers and discharge from the emergency department. There were also multiple patient moves for non-clinical reasons across acute services, including end of life care patients and late evening or night time.
Staff did not plan patient discharge effectively leading to extended length of stays across acute and mental health inpatients services. Staff did not make sure end of life care patients were not discharged in a responsive manner and most were not transferred to their preferred place of death.
Partnership working between the trust and organisations such as the local authority and hospice was not always effective.
The trust missed targets in referral to treatment times and cancelled operations.
The trust needs to improve the collation, timeliness and quality of response to complaints, and put in place improved process for sharing the learning that comes from the complaints..
There was some evidence of staff responding to patients’ individual needs and the dementia passport worked well where it was used, but this was not consistent.
The trust board was not effectively monitoring how the needs of vulnerable patients were being met.
Staff treated people with dignity, respect and kindness during all interactions. They were compassionate and kind and showed empathy when caring for patients.
The Mental Health Act Code of Practice was appropriately followed, although the trust was an outlier for second opinion appointed doctor (SOAD) requests, when there were treatment changes for service users.

We saw some areas of outstanding practice including:

‘Post discharge medicines optimisation support to reduce readmission’, known as MOTIVE, resulted in a statistically significant reduction in 30-day readmissions. For every two patients referred by the hospital to the community pharmacist, three admissions per year were prevented.

However, there were also areas of poor practice where the trust needs to make improvements.

For details of actions for specific services please see the core service inspection reports

Importantly, the trust must ensure :

Trust-wide

That the leadership improves at all levels from board to service level.
that there is an achievable strategic vision and staff are clear of their role and actively involved in delivery of meaningful plans to achieve this.
There is a systematic review and revision of hierarchical and bureaucratic processes, and clinical business unit leads are supported to work autonomously in the provision of high quality and sustainable and integrated services for patients.
There are improvements to the collection and use of information to support the monitoring of quality and safety.
Community records systems are fit for purpose, accessible to staff and support the delivery of safe services for patients.
There are clear, uncomplicated governance arrangements that support monitoring of quality, safety and performance across all services.
There are arrangements in place for identifying, assessing and managing risk at all levels and staff are appropriately trained in this.
The board develops and embeds an effective assurance framework to identify and take early action on any concerns arising in any services.
There is effective staff engagement and work to progress organisational development and culture change, so that candour, openness and challenges to poor practice are improved.
improvements are made to human resources processes, including clearly defined and consistent management of poor performance.
Staff and service leads are trained and supported in making quality improvements and innovations they identify are needed to support sustained quality services.
Improvements are made to the equality and diversity programme within the trust, so as to ensure equality for all staff and patients.
Improvements are made to partnership working with the local hospice and local authority, to facilitate effective access and timely flow along patient pathways.
There is a clear procedure and full range of checks are undertaken prior to the appointment of both executive and non-executive directors as set out in the fit and proper persons regulation of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Improvements are made to collation, timeliness and quality of response to complaints, and the learning arising from complaints.

On the basis of this inspection, and the overall rating of inadequate, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated the service as requires improvement because:

Medicines were not stored safety and securely which may pose risks to patients.
Equipment was not always managed safely and in line with the trust’s operating procedures. These included pressure relieving equipment which had not been serviced.
There was a lack of lifting equipment which impacted on the care and treatment people were receiving.
Patents’ records were not stored safely which posed risks of data protection breaches.
Patients told us that at times staffing caused delays to the timeliness of care.
Some of the nurses did not have a clear understanding of the Mental Capacity Act 2005 (MCA). Mandatory MCA and Deprivation of Liberty Safeguards (DoLS) training for all registered nurses was below the trust target, which may impact negatively on care. Appraisal compliance was below the trust target on the stroke unit and general rehabilitation unit.
Therapy staff did not work seven days a week so stroke patients were not always able to have specialist assessments within 72 hours.
Patients were sometimes moved at night, and experienced delays leaving hospital.
There were high levels of nursing staff sickness on the stroke unit.
Managing risks was not robust. Senior staff were not always aware of the current risks and issues, so there was no plan to address them.
Formal feedback about the stroke service was limited from patients and their families.

However

Staff understood their responsibilities to raise concerns and report incidents, and learning actions were identified.
The trust took part in local and national audits to measure and promote improved outcomes for patients.
Patient pain was managed effectively, and patients varied dietary and nutritional needs were met.
Since the inspection in September 2014, the service had developed admission criteria for the general rehabilitation unit, which supported the staff in admitting appropriate patients.
On the general rehabilitation unit safeguarding adult level 3 training was 100%.
There was a multidisciplinary approach on the stroke unit and the general rehabilitation unit. Nursing, therapy and medical staff were caring, compassionate and patient centred in their approach.
Patients were involved in making decisions about their care and treatment.
There was evidence the trust used learning from complaints to improve the quality of care.
The service promoted equality, supported people to be independent and met the needs of people in vulnerable circumstances.

We rated community-based mental health services for adults of working age inadequate because:

• We identified a number of serious concerns in relation to patient safety. We served and urgent requirement notice letter and issued a section 31 notice of decision to urgently impose conditions on the trust as we had reasonable cause to believe a person would or may be exposed to the risk of harm unless we did so.

• An action plan developed by the community clinical quality, risk and patient safety committee identified some of the key issues around caseload management, care pathways and care records, in July 2016. In addition to continued non-compliance, the variation in performance and quality and gaps in critical aspects of service provision, demonstrated to us that the governance of community-based mental health services for adults was not sufficiently robust or effective. The executive team of the trust were unable to demonstrate that they had sufficient understanding of the risks in community mental health services. There had been no additional resources and/or senior managerial oversight to support the operational manager in reviewing the service, or the teams in reviewing their caseloads. This meant that the service was not able to implement required changes effectively, or in a timely manner whilst operating a safe service.

• The operational manager implemented a business continuity plan (a plan developed to respond to significant risks facing a service) in September 2016 as the service was identified as having serious challenges and was unable to safely meet the needs of service users. The business continuity plan (BCP) was required to address the risk of caseload management and staff capacity. This plan covered the West, Centraland South Wight team localities. The North locality had informal arrangements of reduced service capacity. Board meeting minutes reflected that this had been noted and therefore the executive team were aware of this plan. We found that governance arrangements were not effective in design and operation to plan, monitor and provide assurance that community mental health services were managing risks to patients. There were no governance arrangements in place, or executive input that provided oversight or assurance about the use of the BCP. The plan was not on the corporate risk register.

• There was limited capacity to deliver and to access essential psychological therapies. There was no psychologist in either team which meant the service could not consistently provide a full range of support and therapies in response to people’s needs. There were no evidence based care pathways in place and patients were not allocated appropriately or consistently to the care programme approach framework. We reviewed 23 care records and all lacked detail, had gaps and omissions in the core assessment, care plans and/or risk assessments. The majority of the care records we viewed were not person-centred, and very few of the records we viewed contained evidence of people’s involvement in planning their own care.

• The electronic care records system was not fit for purpose and there were concerns with lack of guidance in relation to how staff should complete the records. The system was time consuming to use, requiring staff to constantly come out of one part of the system to access information and updates from other teams. There was no contemporaneous flow of information and there were clear risks that important patient information was not easily available to staff.

However:

Patients we spoke with were very complimentary about the treatment they received from the staff. They described staff as being kind, caring, considerate, thoughtful, hardworking and extremely dedicated. Patients and carers acknowledged that staff were dedicated to delivering this level of care and service despite persistent staff shortages and lack of funding within the team.

Staff at the West, Centraland South Wight team had notably better morale than the North East locality. Staff at the West, Centraland South Wight team told us that they felt well supported by their team manager and that they had a good understanding of the challenges they faced. They reported they generally worked well as a team. Staff also highlighted that they felt well supported by the operational manger and they frequently met with the staff and attended the offices.

January 2017:

We returned to the trust in January 2017 to seek assurance that these urgent risks were being addressed effectively. We found there was limited appreciation of the current risks and needs in the community teams. The trust demonstrated limited understanding of the service demand, capacity and working with other services. It was our view that the trust required significant support in understanding the issues, prioritising and implementing effective change at pace - in addition to the much larger, challenging piece of work around creating a sustainable model of community mental health services. We met with partner agencies, including NHS Improvement, NSH England and the clinical commissioning group, to ensure an effective plan of support and change was established.

We rated for long stay/rehabilitation mental health wards for working age adults as requires improvement because:

Staffing issues had affected the services ability to admit patients to the ward. There was low morale among the staff due to the staffing issues.
There were issues with the safety of the environment inside and outside of the hospital. The staff’s knowledge of ligature points was very poor. The environment made night-time observations disruptive.
Risk assessments did not translate into risk management plans. Despite regular reporting of incidents there were recurring themes that were not being managed or escalated accordingly.
Care plans were not individualised. The paper notes were disorganised and hard to navigate making it difficult to find important information.
Staff were not provided with regular supervision or specialist training to improve skills for working with patients requiring rehabilitation.
There were limited ward based activities and input from occupational therapy. There was no psychologist employed at the service.
Discharge was not effectively planned.
There were blanket restrictions in place throughout the unit. These included restrictions on access to food.
There was no record kept of complaints that were made to the service.
There was poor management oversight of complaints and supervision and recurring incidents were not managed effectively.

However:

Staff were up to date with their mandatory training. There was good practice around the management of medicines.
There was appropriate use of bank staff.
The ward complied with guidance on same sex accommodation.
Staff adhered to the principles and requirements of the Mental Health Act and the Mental Capacity Act. Staff used recognised assessment tools and outcome measures.
There were effective shift to shift handovers.
Patients were encouraged to be independent as part of their recovery and discharge.
We re-inspected the service in January 2017 and found that staff had addressed a number of risks identified with the environment as a result of the issuing of an urgent requirement notice.

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

Both wards had multiple ligature risks. We were concerned to learn that there had not been a full comprehensive assessment of ligature risks on either ward since 2012. An assessment had been completed that focused only on some risks and did not contain information relating to the mitigation of risks or levels of severity. There was no oversight or ownership by immediate and higher management about the ligature risks on either ward.
As a result we issued a notice under Section 31 of the Health and Social Care Act 2008. We asked that the trust ensure that a comprehensive ligature assessment and an action plan to mitigate the risks be completed and produced by Wednesday 28 December 2016.
In addition, we issued the trust with a Regulation 17(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 notice. This notice required the trust to respond within 28 days of receipt because of the following findings:
Osbourne ward held responsibility for the crisis service out of hours. This impacted on the ward staff being able to undertake safely their core ward duties. Although overall morale was high, staff on Osbourne ward described feeling stressed and unable to do their ward duties safely due to the additional demand placed on them by the crisis service. We were also concerned to learn that Osbourne ward admitted patients beyond their 19 bed capacity. Osbourne ward will admit up to 21 patients by using an interview room and a male lounge as bedrooms. Bedrooms on both wards shared interconnecting bathrooms. On Seagrove ward men and women would have to share the same bathroom if they occupied the adjoining bedrooms, although staff told us if this occurred they would restrict the men having access to the bathroom by locking the doors. In addition, each patient could access the other patient’s bedroom without being seen by staff. Although the trust had called engineers in to look at the personal alarm system, the system on both wards did not work properly and failed on occasion to sound when activated and lead staff to the correct area where incidents were occurring. Patient care plans on both wards were incomplete and on occasion missing. Care plans were not patient centred, personalised, holistic or goal orientated. Some information relating to physical health assessments was missing.

In addition we found that:

The seclusion room on Seagrove ward did not allow for free access to the toilet and shower. In order for patients who were secluded to use these facilities, seclusion would have to end. In the event that this was not possible, disposable apparatus for elimination purposes were provided in the seclusion room. In addition, some medical devices on Seagrove ward had not been tested in the past 12 months.
Rapid tranquilisation of patients was not being done in line with national guidance and legislation. Not all safeguard incidents were reported correctly. Adherence to statutory and mandatory training did not meet the required level in all areas.
The reception area at Sevenacres, before you entered the ward areas, was dirty and there was an unpleasant smell.
Staff we spoke with described a disconnect form the trust board. Staff told us that trust board representatives rarely visited the wards.

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

Following our inspection visit we issued a Section 31 notice of decision to urgently impose conditions on the registered provider as we had reasonable cause to believe a person would or may be exposed to the risk of harm unless we did so. The notice was in respect of the provider, the Isle of Wight NHS Trust, and covered failings identified at a number of the provider’s core services. In respect of the provider’s mental health inpatient services, including its wards for older people with mental health problems, the notice related primarily to the safety of the physical ward environments.
We identified issues in relation to the safety of the environment at both wards. Although some of these issues had been identified by the trust’s staff, they had not been effectively addressed and the provider did not have appropriate plans in place to address them at the time of inspection. We found significant concerns with Shackleton ward’s seclusion room which, although required to meet strict legal requirements, was unfit for the purpose of seclusion. We also had serious concerns about further specific issues with the environments on each ward which impacted greatly on the dignity and privacy of patients. Neither of the wards visited was an appropriate environment for effectively promoting the recovery, comfort and dignity of patients. When we revisited the wards on 18 and 19 January 2017, we found the trust had taken steps to address the most immediate concerns with the environments on both wards to better ensure the safety, dignity and privacy of patients.
We were not assured that shifts were covered by sufficient numbers of staff of the right grades and experience for the acuity of patients. An earlier safer staffing pledge had not been realised, which left both wards down on assessed nursing staff levels. About a third of the front line staff had not received or were out of date with essential training in physical intervention.

We were concerned that potentially inconsistent and inaccurate recording and reporting of incidents meant that the provider could not be assured that incident data collected was accurate and reflected the actual number or detail of incidents, or the current risks within the service.
Wards were not able to offer or provide a range of appropriate psychological therapies as recommended by the National Institute for Health and Care Excellence (NICE). Afton ward had to take on increasing numbers mental health patients with organic conditions, largely due to the lack of specialist dementia places on Shackleton ward and in the island’s residential and nursing homes. Staff on both Shackleton and Afton wards had not received training in caring for patients with dementia. Not all patient risk assessments had been regularly updated. Care plans were not holistic or sufficiently person centred or recovery orientated. Not all assessments were regularly reviewed. We saw insufficient evidence to demonstrate that patients were fully and effectively involved in their own care.
There were significant problems related to the availability of specialised dementia places on the island. Although this was largely beyond the control of ward staff, it was impacting directly on the care they were able to provide. The seven beds on Shackleton were generally occupied by long-term patients. As a result of beds on Shackleton being continually occupied, people with dementia were being increasingly admitted on to Afton ward. This was causing difficulties with the patient mix, leading to unrest among patients.
Staff had a sense of disconnect between themselves, the wider trust and the senior management team. They were unclear as to the trust’s vision and values, and felt that mental health provision was not a priority for the trust. Morale had been badly affected because they felt little or no action had been taken by the trust in response to their concerns about issues such as staffing and the ward environments. Similarly, clinical staff felt there was insufficient understanding, at a senior trust management level, of mental health and the pressures the services were under.

However:

Staff undertook physical examinations on admission and we saw evidence of appropriate ongoing physical care. Junior medical staff were well supervised, and consultants were approachable and enjoyed teaching and supervising. Mandatory training and electronic learning included areas such as safeguarding, infection control, Mental Health Act and Health and Safety, with which the majority of staff were up to date. There was generally good access to support from other teams at the hospital, including support with palliative care for patients who were nearing end of life, input from tissue viability nurses for skin care and input from the speech and language team for patients who had specific eating or dietary needs.
Staff on both wards visited were respectful and supportive to their patients, and responsive to their needs. The patients we spoke with all spoke positively of the care and support they received from ward staff, and said that their doctors were caring and listened to them. Despite limitations with the physical environments and other pressures such as staffing, staff tried hard to provide meaningful activities for their patients.
Information in different formats was displayed in prominent positions and available to patients on the wards. Wards were able to cater for all specific diets and food requirements; including for those with specific cultural or religious needs and for people with medical dietary requirements.

On a local level, staff and ward managers told us that their immediate managers supported them well. Staff told us their teams were cohesive, and colleagues were described as welcoming and supportive. Ward staff told us they felt comfortable raising their concerns or speaking up, without fear of recrimination or victimisation.
When we revisited the wards on 18 and 19 January 2017 to follow up the S31 notice we had served on the trust, we found that appropriate steps had been taken to address the most urgent safety concerns with the environment and that plans were in place to carry out further necessary major improvement works.
At the return visit, staff also spoke positively about how mental health now seemed a higher priority. Staff also told us that they felt more involved and included by the trust’s managers, who they felt were listening to them and engaging openly with them in respect of improvements taking place.

Overall rating for this core service = Requires Improvement

Patient records did not fully support safe care due to incomplete and non-contemporaneous record keeping and risk assessments.
The staffing workload and dependency tool database was not ‘fit for purpose’ with numerous incidents of lost data, visit lists and allocations being incorrect.
The allocation of community nursing staff to localities was not carried out to reflect the needs of the population, and despite considerable vacancies the assessment scale was still showing ‘green or no risk’.
Due to lack of IT connectivity, there were delays in record keeping, incident reporting and accessing information.
Community teams had no access to lone worker alarms, despite the poor phone signal, which meant that the lone worker buddy system was not effective.
There was no duty of candour training for staff; therefore, most staff were not aware of their responsibilities.
Infection control processes and procedures were not in alignment with trust policies.
There was variation in the awareness and approach of staff to safeguarding procedures, the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
Clinic emergency trolleys were not tamper proof and checked appropriately by a clinical person.
The medicines policy for the trust, did not detail the safe storage of medicines in community clinics or in patient’s homes and we saw incidents arising from the lack of guidance. Standard operating procedures submitted by the trust after the inspection were not authorised and had no implementation dates.
There was insufficient risk assessment of fasting diabetic patients and they were not prioritised in phlebotomy clinics.
There were no multidisciplinary reviews of community nurse’s patients.
The provision of supervision was variable across the community teams.
Community matrons were completing all of the continuing healthcare documentation from all patients across the Isle of Wight. They did not know most of the patients.
Staff felt the executive team were ‘unsupportive’ with unanswered requests and no updates on issues previously raised.
There was no integrated falls service on the Isle of Wight, the Isle of Wight were in the lowest quartile nationally for some aspects of best practice clinical care.
The new physiotherapy service for GPs reduced sessions to three, which meant patients often needed repeat referrals into the system, the trust system for other referrals still provided six sessions.
Patients told us of little support in repatriation after services were accessed on the mainland.
Some areas did not support the maintenance of the patient’s privacy and dignity.

However

Staff respected patients’ values and wishes. Patients gave positive feedback about the compassionate care they had received and the manner and approach of the staff. A new post organised and coordinated care around the wellbeing of the patient. Support was readily available for community patients and their carers from a variety of sources
There were many excellent examples of responsive community services and teams who worked collaboratively to meet patients’ needs. Access to equipment was good, even out of hours.
The majority of staff used trust wide systems to report and record safety incidents, near misses and allegations of abuse. These were escalated and investigated appropriately.
There was a well-embedded governance structure in place to monitor the progress of incidents, complaints, and risks. Staff knew of their local risk registers and their highest risks
Staff we spoke with told us of numerous examples of training and development that staff had accessed. Most staff had received an annual appraisal and had opportunities to develop and progress.
There were systems in place to support patient equality and diversity.
Recent national audits showed improved outcomes for podiatry patients.
The trust had implemented tele monitoring for various patient pathways to support patient care in the community.
Staff felt that local leadership was accessible, supportive and provided a working strategy for the community services based upon the ‘My Life, A full Life’ vision.
The staff were aware of their roles in dealing and responding to complaints.

Overall rating for this core service

We rated this core service as requires improvement because:

Although staff knew how to use the electronic incident reporting system, staff across children’s services did not always demonstrate a sufficient understanding of when to report an incident. The reported incident data supplied by the trust showed a significantly low number of incidents reported. There was no evidence to show learning from incidents was shared with staff.
Key staff groups working with children and young people such as some children’s therapy teams had not completed training in safeguarding children level 3. This did not meet the recommendations set out in national guidance.
There was evidence to suggest the service was not meeting the needs of looked after children. Children and young people in care had a significantly higher ‘did not attend’ rate for clinic appointments and had a lower vaccination uptake rate. The emotional and behavioural needs of looked after children were not always taken into consideration when completing health assessments.
There was a mix of electronic and paper medical records systems in place which led to duplication in records and staff could not always access important information in a timely manner. We highlighted this concern in our 2014 inspection report but no significant progress had been made to resolve this issue.
Medicines were not always stored safely. In the school nurse base office, staff had consistently recorded the fridge containing vaccines as outside the maximum recommended range but had not taken any action to resolve this. In Medina House school we found three medicine cupboards in classrooms which were either unlocked or had the keys stored in sight.
Nurses working in specialist schools were disconnected with the wider trust. Staff in the two specialist schools could not access the trust intranet, mandatory training or incident reporting system. The nurses did not receive clinical supervision and had not completed the specialist community public health nursing (SCPHN) qualification.
The school nursing service had vacancies for nursing and support staff. Some staff were on secondment and additional cover for their roles had not been put in place.
The trust did not provide mandatory training figures for all staff groups within the children and young people’s community team. The compliance with some modules of mandatory training were significantly low, for example, health and safety and disability awareness.
The children and young people’s service did not have robust arrangement for measuring the quality and effectiveness of the service. Although the children and young people’s service submitted some data to Public Health England and national audits, there were no local audit programmes in place for any of the services. Some teams such as the children’s physiotherapy team collected a limited amount of data but this had not been collated and there was no evidence this had influenced quality improvement. .
There was a trust wide clinical supervision policy, however staff told us there were no formal supervision arrangements in place for school nurses and health visitors to receive clinical supervision.
Staff did not always seek consent in line with national guidance and legislation. The community children’s nurses relied on assumed consent when delivering care and treatment to children and young people. The sexual and reproductive health service did not always record that consent to access services was assessed.
The service did not always meet the individual needs of patients and their families. Information for children, young people and their families was written in English and not readily available in other languages. There was no age appropriate or specific pain tool in place for children or young people who could not verbalise their pain.
Although the clinical business unit risk register contained some of the risks highlighted at a department level, there was no evidence to show these had been regularly reviewed and actioned. The children’s service did not have a clear strategy in place to develop services and had not improved key areas identified in our 2014 inspection report.

However,

Staff had a good knowledge of how to recognise and escalate a safeguarding concern. Key staff groups valued clinical supervision provided by the safeguarding team. The trust had recently employed a specialist nurse for looked after children. The trust identified and provided targeted interventions for children and young people at risk.
The service provided care underpinned by evidence and followed national guidance such as the National Institute for Health and Care Excellence (NICE). The health visiting and school nursing team met the healthy child programme and vaccination targets. The health visiting service had achieved the UNICEF Baby friendly breastfeeding initiative accreditation at level one.
All services worked together to meet the needs of children, young people and their families. Therapy teams carried out joint visits to reduce the number of visits a child or young person would receive. The school nursing and health visiting team worked closely with other services such as the child and adolescent mental health team (CAMHS), Barnardo’s, children’s therapy teams and the sexual health service.
There was evidence some staff had undertaken additional training appropriate to their role. Two school nurses had completed the SCPHN qualification and two more nurses had been seconded to complete this course. Health visitors had undertaken training in baby massage and prescribing nicotine replacement therapy.
Some teams had shown evidence of innovation and improvement for example, the children’s physiotherapy team had submitted a business case to provide a respiratory outreach service for children and young people. The school nursing and health visiting team had started to use a ‘health bus’ to hold clinics and health promotion events and had developed social media pages to engage with children and young people.

We rated specialist community mental health services for children and young people requires improvement because:

Care plans, risk assessments and crisis plans were not comprehensive and did not assist staff to deliver safe care and treatment to young people. Staff members recorded information and stored records inconsistently.
The service did not deliver all the psychological therapies recommended by NICE. There was no provision for young people with attention deficit hyperactivity disorder or autism spectrum disorder who were excluded from the service.
The contract with clinical commissioning group stated that they expected out of hours crisis support to be in place by June 2016. However, there was no out of hours provision for young people. Young people admitted to hospital at the weekend had to wait until the following Monday before being assessed by CAMHS staff.
There was limited evidence of learning from incidents.

However:

Staff were passionate and caring about the young people had high morale. Young people and carers were positive about the staff team. We observed interactions between staff and young people and their families that were warm, good humoured, and professional. Young people we spoke with said the staff they worked with were respectful, supportive and caring.

Treatment that was offered was effective and in line with guidance. High risk young people were managed well.

The service had a pleasant environment suitable for young people with a range of toys and story books in the waiting areas that were engaging and described how to manage mental disorders in an age appropriate way.

We rated community mental health services for people with learning disabilities as good because:

Carers/relatives of service users were full of praise for staff in the service. Staff were described as very caring. We observed interactions between staff and people who used the service and their families that were kind, good humoured, and professional. Staff showed good knowledge of individual needs of the people who used the service. Service users were involved in decisions about the service and were able to be involved in staff recruitment. There was evidence that staff actively encouraged service users about the use of an advocate.
There was a good understanding of risk. Staff understood their duty to safeguard children and vulnerable people and how to make an alert. They understood how to report an incident on the trust’s electronic recording system and they were able to describe learning from incidents.
Care plans were comprehensive and assisted staff deliver safe care and treatment of service users. The service followed national institute for health and care excellence guidance on interventions.
Morale was excellent, with all staff in the service praising their colleagues for the good work they did. Staff described good team working between their immediate team members and wider professional groups.

However:

The autism assessment service for adults was commissioned by the CCG to provide only assessments. Once diagnosed with autism, service users received no further interventions or treatment unless they were comorbid with a learning disability.
Access to the Arthur Webster clinic was difficult for service users in wheelchairs due to a large heavy door.

The Isle of Wight NHS Trust is an integrated trust providing acute, ambulance and mental health services, and community services. Mental health services are provided to a population of approximately 140,000 people living on the Island. Services include community mental health services, which includes Early Intervention in Psychosis, inpatient acute and rehabilitation services, community child and adolescent mental health services (CAMHS), a tier 3 drug and alcohol service, a memory service, a community learning disability service and an intensive outreach service for residential and nursing care homes.

We carried out this comprehensive inspection because the Isle of Wight NHS Trust is an aspirant Foundation Trust, prioritised by Monitor for inspection. We inspected this core service as part of our second phase of the new comprehensive inspection programme introduced for mental health services.

The announced inspection took place between 4 and 6 June 2014, with an unannounced visit on 21 June between 4pm and 11pm.

Overall, we rated the Isle of Wight NHS Trust mental health services as ‘good’. The trust was good for providing safe, effective, caring and responsive services. Leadership at a service level was good, but the overall trust leadership of services ‘requires improvement’.

All services were rated as “good” with the exception of community mental health services which were rated as “requires improvement”.

Key findings related to the following:

People told us that they were involved in their care, and that staff were caring and working within their capacity, and treated them with dignity and respect. However, people being treated by community mental health services had less involvement in their care, and little information about the services available to them.
We received 26 comment cards from people who use the mental health service. All were negative and people felt staff were oppressive and controlling.
Staff were aware of the safeguarding processes and most had received safeguarding training.
The majority of people who used the services, and were treated by staff, said they felt safe; however, there were examples of people stating that, at times, low staffing numbers affected people’s care and treatment.
Staffing levels were considered to be adequate in most areas, but there were concerns about capacity on Shackleton Ward and in community mental health services. Staff reported that no action around recruitment had been taken for some time in these areas. A staffing review had just been completed by the trust, and a recruitment plan had been produced and signed off by the executive board.
Incidents were reported, and lessons were learned and shared across services, to minimise risks and prevent reoccurrences. However, staff in community mental health services were under-reporting incidents because of limited staff capacity within the service.
People were treated according to national guidelines, and had good access to psychological therapies and activities in inpatient settings.
Outcomes of care were monitored and reported, both nationally and locally, to improve the effectiveness of services. However, this was not evident in community mental health services, where patients were not monitored or reviewed appropriately to assess their progress or recovery.
There was effective multidisciplinary working, and innovative working in some services with social care, housing, employment, the police and GPs to co-ordinate people’s recovery and support their independence and self-care.
Staff told us that they received appropriate training; however, the uptake of this training required improvement in some areas.
Clinical, managerial and caseload supervision was offered and taken up in most areas, with the notable exception of the Rehabilitation and recovery team in community mental health services , where improvements are required.
People received care and treatment at the right time, although there were long waiting times for assessment and treatment in community mental health services.
People had good access to advocacy services.
The complaints procedure was clear, and understood by staff and people using the service.
Processes for staff to deal with incoming issues, concerns and complaints were understood, and trust-wide learning from complaints was cascaded in a variety of formats to all service areas.
Staff generally felt supported by their line manager and peers, but felt isolated and disconnected from the trust in some services. The trust had governance structures in place, which included the mental health services, but it was observed that the flow of information did not always cascade to ward and community staff.
Staff said they could approach their manager with any concerns, and said they thought any concerns would be addressed. Risks were appropriately managed, but in some services, risk issues were sometimes not addressed, or not always acted upon in a timely manner.
Mental health services did not have an overall clinical strategy, and did not have appropriate representation on the trust board to reflect the workings of an integrated trust.

Mental Health Act Responsibilities

The Mental Health Act records we reviewed were comprehensive and in order.
People’s mental health capacity was assessed at ward reviews, and recorded in the trust’s electronic recording system.
The Mental Health Act manager kept the ward staff up to date with any actions that may be required, such as adherence to the conditions of a Section 47/49, and the need to liaise with the Ministry of Justice (MOJ).
Reminders were also fed into the ward round process, so that the multidisciplinary teams could review Mental Health Act sections, ensuring good governance processes, in line with the Code of Practice (CoP).
There were posters displayed in the ward informing people of the Independent Mental Health Advocacy service (IMHA). We spoke with the ward manager, who told us that any person detained under a section of the Mental Health Act would automatically be referred for an Independent Mental Health Advocate.

We have identified areas of outstanding practice. However, there were also areas of poor practice, where the trust MUST make improvements, and other areas of practice where the trust SHOULD take action to improve. These are identified in this report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

August 2014

Isle of Wight NHS Trust is an integrated trust providing acute, ambulance and mental health services, and community health services. Community health services are provided to a population of approximately 140,000 people living on the Island. Services include community nursing teams, community rehabilitation teams, health visiting, school nursing, community equipment services and sexual health services. These services are provided across the Island in clinics, children’s centres and patient homes. Community inpatient services include general rehabilitation and stroke rehabilitation wards at St Mary’s Hospital.

We carried out this comprehensive inspection because the Isle of Wight NHS Trust is an aspirant Foundation Trust, prioritised by Monitor. The trust community services were inspected as part of the second phase of the new inspection process we are introducing for community health services.

The announced inspection took place between 3 and 6 June 2014, with an unannounced visit on 21 June, between 4pm and 11pm.

Overall, we rated the Isle of Wight NHS Trust community services as ‘requires improvement’. The trust was good for providing caring services. The safety, effectiveness, responsiveness and leadership of the services required improvement.

We rated community health services for children, young people and their families, community adult services, and community inpatient services as 'requires improvement'.

Key findings related to the following:

There was a high level of patient satisfaction across community services. The majority of people commented on the caring and compassionate approach of staff . Staff were highly motivated and committed, and treated people as individuals.
There was good multidisciplinary working, and initiatives to support people at home, and avoid admission to hospital. The trust had taken steps to improve access to appropriate services through the development of the Single Point of Access, Referral, Review and Co-ordination (SPARRCS ) team, which was based at the Integrated Care Hub. The Community Stroke Rehabilitation team worked towards specific rehabilitation objectives for patients, and facilitated early discharge from hospital.
There were elements of good practice across a range of units and teams, but this was not consistent across all services. Some, but not all, teams were benchmarking themselves against other services and taking innovative steps to improve ways of working and productivity, but this needed to be implemented and embedded across all services.
Staffing establishments were not sufficient in all areas, and there were ongoing challenges in recruiting staff. The arrangements to ensure a safe and consistent out-of-hours district nursing service needed to improve. We were concerned by insufficient medical and nursing staffing on the community inpatient wards, and this was a particular risk when there were inappropriate admissions of more acutely ill patients.
Risk management systems were in place, and staff were fully aware of their responsibilities in reporting and in implementing new practice. However, the governance of risk management needed to be more robust at all levels of the organisation, as across all core services we found examples of incidents that had not been responded to promptly or adequately.
The trust had an ongoing programme to improve access to and use of IT across community services, and connectivity issues were a known challenge. Where implemented, the IT system was still not fully functional, and incomplete electronic records created a risk.
The trust had a statement of vision and values, but community services staff were not consistently aware of these. Local leadership of most community services at team level was good. But there was a disconnect between staff in community services, and the executive team and senior managers, and this impacted upon the culture within which front-line staff were being expected to deliver services. Staff perceived that the community services had a lower profile within the organisation than the acute services.

We have identified areas of outstanding practice. However, there were also areas of poor practice, where the trust MUST make improvements, and other areas of practice, where the trust SHOULD take action to improve. These are identified in this report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

August 2014

The Isle of Wight NHS Trust is an integrated trust that includes acute, ambulance, community and mental health services. Services are provided to a population of approximately 140,000 people living on the Island, and St Mary’s Hospital in Newport is the trust’s main base for delivering acute services for the Island’s population. Ambulance, community and mental health teams work from this base, and at locations across the Island.

We carried out this comprehensive inspection because the Isle of Wight NHS Trust is an aspirant Foundation Trust, prioritised by Monitor. The inspection took place on the 4, 5 and 6 June 2014 with an unannounced visit on 21 June between 4pm and 11pm.

We inspected the following core services:

Accident and emergency, medical care (including older people’s care), surgery, critical care, maternity and family planning, services for children and young people, end of life care, outpatients services and the ambulance service.

Community health services for children, young people and their families, community adult services and community inpatient services.

Primary Mental Health Services, learning disability services, Children and Adolescent Mental Health Services (CAMHS), older adults, Acute, PICU and S136 Place of Safety, rehabilitation inpatient services, drug and alcohol services, community mental health and crisis resolution services.

Overall, we rated the trust as ‘requires improvement’. We rated it ‘good’ for providing caring services, but it required improvement for the services to be safe, effective, responsive and well-led.

Overall acute and community services were rated as 'requires improvement'; ambulance and mental health services were rated as 'good'.

Our key findings were as follows:

Overall, we found that staff were caring and compassionate, and treated patients and people using services with dignity and respect. Staff were highly motivated, and treated people as individuals. However, NHS Friends and Family Test results rated the inpatient wards as lower than the national average, and people accessing community mental health services expressed some concern that they were less involved in their care, and had little information about services.

Staff followed good infection control practices, although for community inpatient services better MRSA screening was needed. The hospital was clean and well maintained, and infection control rates in the hospital were in an acceptable range.

The hospital monitored harm-free care in all in-patient areas, and had taken action which was reducing avoidable harms, such as pressure sores and falls.

Staff were aware of safeguarding procedures, and there were effective processes in all services to safeguard people from abuse or harm.

There were clear processes for taking people’s wishes into account, and seeking their consent where they had capacity to do so. People who did not have the capacity to consent did not always have their needs considered in a safe and proportionate way, as not all staff were informed about the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

The Mental Health Act Code of Practice was appropriately followed, although the trust was an outlier for second opinion appointed doctor (SOAD) requests, when there were treatment changes for service users.

Patients were not always appropriately identified for 'do not attempt cardiopulmonary resuscitation' (DNA CPR) orders. When the orders were used, decisions were not always clearly documented or reviewed, and were not always discussed with the individual or their family. In some ward areas, staff told us that this was being avoided, as there was a reluctance to have these conversations.

Incidents were reported, and lessons were learnt and shared across services, to minimise risks and prevent reoccurrences, but this was variable. We found examples of incidents that had not been responded to promptly or adequately, some areas did not share lessons, and staff in community mental health services were under-reporting incidents because of limited staff capacity within the service.

There were risk registers to monitor and take action on risks, but these were also not consistent. Risks were not always appropriately identified or escalated, there were concerns raised by staff where no action had been taken or had been delayed, and some risk registers had not been appropriately updated for months or, as in community health services and community mental health services, for years.

Staffing levels were not sufficient in all areas, and there were ongoing challenges in recruiting staff to work on the Island. Nurse staffing areas had been reviewed, but there were insufficient appropriate qualified staff in children’s care in A&E, the acute services, community rehabilitation wards, district nursing and older adult mental health wards. Staff had reported concerns in these areas, and were disappointed that no action had been taken for some time. The succession planning in some services that would imminently be needed for sustainability, such as in maternity services, was not evident. The trust had recently signed off a recruitment plan, but the actions taken and updates were not well communicated to staff.

Medical staffing was a similar challenge for many specialities, and the trust had employed locums to cover vacancies. Some services were run by locums who had changed over several years, and this had not provided consistency of leadership or treatment for patients and services users. The trust was actively trying to recruit to these areas, but many staff told us about the inadequate and bureaucratic human resources processes within the trust. The current support, in terms of recruitment and retention, was causing delays and frustrations at a time when recruitment needed to be timely and exact.

The majority of people who used the services and staff said they felt safe; however, there were examples of people stating that at times low staffing numbers affected people’s care and treatment.

In many areas, national guidelines and evidence-based practice were being used to treat patients. In pharmacy, ambulance and mental health teams there was innovative work to embed this practice, and outcomes of care were benchmarked and monitored to improve the effectiveness of services. This approach was inconsistently applied in community health services, community mental health services, and in the acute hospital. For example, the trust had considered the relevance of National Institute for Health and Care Excellence (NICE) guidance, but this was not consistently implemented, monitored or adhered to. People accessing community mental health services were not monitored or reviewed appropriately, to assess their progress or recovery.

There was good multidisciplinary and integrated working, with GPs, community teams and social care teams, to support people at home, avoid admission to hospital, and support early discharge. There was also work with housing and employment teams, and with the police, in mental health services, to co-ordinate people’s recovery, and support their independence and self-care. The trust was working to develop three locality-based integrated teams across the Island; teams and staff had said that this had already improved communication and joint working. However, community teams were under-resourced and there was ineffective caseload management and supervision; patients did not have appropriate assessment and care, and discharge was delayed for patients with complex needs.

In March 2014, the trust mortality rates were within the expected range; there were care bundles and pathways for emergency care prior to hospital, and in use in the emergency department. Patients who were acutely ill were appropriately escalated, but care pathways and bundles were not always followed through during their inpatient stay, for example, for sepsis care. Seven-day working was developing for emergency care and pharmacy support, but this was less well developed in other areas.

The trust was working to provide services to people on the Island, where this was economically viable and appropriate, to avoid the need for people to travel to the mainland. There were good examples of innovative practice, and the use of technology and staff working flexibly to share knowledge and skills, although systems to share learning needed to improve. There was effective working with mainland services, for example, in cancer multidisciplinary teams, but the trust needed to ensure that communication worked well across all these services.

People received the right care at the right time. Ambulance services achieved national response times, patients were seen and treated in the A&E within four hours, people had surgery, diagnostic tests and outpatient appointments within national waiting times. However, in the acute hospital, the pressure on beds meant that patients were being moved several times for non-clinical reasons, and were not always on the correct ward for the care and treatment they required. Weekend discharges did not happen in some inpatient areas, or were not well co-ordinated with on-call community services. This had led to inappropriate arrangements of care, and possible readmission of these patients. There were long waiting times for assessment and treatment in community mental health teams.

The integrated nature of services helped to support the care of vulnerable people, for example, people living with dementia, and people with a learning disability. The specialist liaison was described as effective by staff. However, there were delays where staff had limited capacity, such as with the support that could be provided by the community psychiatric nurses in A&E to do timely assessments for people with a mental health condition. There was good access to advocacy services for people with a mental health condition.

There was a palliative care team to support patients who were coming to the end of their life. However, patients were not always being identified as being on an end of life care pathway in a timely manner, and did not always receive the care and support they required.

Complaints processes were understood by staff, patients and service users, and in many areas concerns and complaints were being used to improve services. The trust only responded to 44/93 (47%) of complaints (October 2013 to March 2014) within the 25 days target, or within agreed extended timescales.

The trust was developing IT systems towards an electronic records scheme. Where this was working well, it had a great impact, such as in A&E with GP practices. There was an ongoing programme to improve access and use IT across community services, and connectivity issues were a known challenge. Where implemented, the IT system was still not fully functional in community services, and incomplete electronic records created a risk. There were disjointed IT systems in mental health and learning disability services, and this caused delays to care and treatment. In some areas there were fewer computer stations, and staff were often waiting to use the system.

The trust had a statement of vision and values, and many staff were aware of this, but not in all areas. There was a five-year strategy to develop integrated services across the Island, working across health and social care, and to develop sustainable quality care. This would mean expanding community-based services, the centralisation of some services, and developing clinical networks where specialist expertise was in the interest of patients and the prevailing economics of providing a service.

Many staff were not aware of the trust strategy, but could verbalise the strategic direction of their own service; but in many areas these were not devised or written, or considered in alignment with the trust strategy. Mental health services, for example, had little knowledge of why the trust had a clinical network with Hertfordshire. There was a trust strategic overview of the integration of services, but there was less operational support and direction to cope with service demands, resource needs, and manage effective integration within and across the divisions.

The trust had comprehensive corporate governance processes: there was a committee structure, reporting and review processes to monitor key performance indicators, incident, complaints and business risks, at trust level, and across the three divisions of acute care, planned care and community care. However, the trust needed better clinical governance and assurance system to have an overview of the actual quality and delivery of services and practice. There were examples of risks, clinical audit, reporting and learning from incidents, and use of national and evidence-based guidelines that did not happen appropriately, or at all.

The Island had a slow pace of life, and this was the culture within the trust. Some of the issues faced by the trust are as they were in the wider NHS a few years ago. Pressures in terms of bed capacity were not high comparatively, but were recent issues for the trust. The responsiveness of services needed to be better prepared for the service demands and pressures that, with an older population on the Island, will increasingly be experienced by the trust.

Staff engagement did not happen effectively. The trust leadership team and senior managers were changing services and policies, but these were not effectively implemented. Communication came down from the trust leadership, but change happened without effective consultation or discussion. Staff at all levels and in all parts of the organisation told us that they were not being listened to, and there were predictable problems because of this. There were many examples where implementation of change did not happen effectively, and was not monitored appropriately, and this was increasing the risk to patients. There was low morale in the pathology services where service reorganisation and work pressures were affecting staff, and they felt that they had little knowledge, communication or ability to influence decisions.

Many staff in ambulance, community and mental health services described a disconnection with the trust, and considered they had a low profile compared to the acute service. They felt like it was an acute trust with satellite services, and the leadership of the trust did not reflect the complexity and integrated nature of its services.

There were several issues where we were concerned enough to ask the trust to take immediate action.

The paediatric emergency admission pathway required a single agreed point of entry for paediatric admissions. The current criteria of medical / surgical patients to the paediatric ward, trauma patients to A&E, and babies under 14 weeks to the neonatal unit, was confusing (and had caused confusion) for hospital and ambulance staff. There had been two serious incidents prior to this, with ambulances being redirect with children who required emergency care. During our unannounced visit, we found that the trust had implemented a single point of entry, and all children now had emergency care in the A&E. The proposals had previously been discussed with the paediatric team but the immediate change had not been done in consultation with paediatric teams; it did not take account of children who had previously had direct access to the children’s ward and staffing levels on the paediatric wards. The risks in terms of delays to treatment still remained for some children.

Staffing levels on the stroke rehabilitation and general rehabilitation wards were unsafe, and the stroke unit was a concern. There were inappropriate numbers of medical and nursing staff, and stroke patients received inconsistent care, and risks were not being managed appropriately. The ward also had medical and surgical outliers, and staff did not have the appropriate numbers, experience and skills to also care for acutely ill patients. There were patients requiring rehabilitation on other wards in the hospital who should have been on this ward. The admissions to the ward were not organised. The trust informed us that they had stopped medical outlier admissions to the ward, and were reviewing staffing levels. During our unannounced visit, we found that the trust had restricted medical outliers to the general rehabilitation ward, but outliers still remained on the stroke rehabilitation ward. Staff were still under pressure and had not had breaks. They could struggle to cope when a patient required one-to one-care, and an elderly patient was being wheeled around in a chair, as this was the only way nurses could observe them.

In adult community services, district nurses worked as lone workers from 8pm to 8am, and were at risk in terms of protection and security. This issue has been highlighted as a risk, but no action had been taken. The nurses were also identified as recently qualified or inexperienced (Band 5) nurses, who did not have the appropriate experience and skills for the decisions that they were being asked to make, such as to triage patients, and determine appropriate levels of care. The trust informed us that they had introduced an on-call senior district nurse and hospital at night team support for the district nurse on-call. During our unannounced inspection, we found that there was no district nurse on-call, and ambulance staff had only been informed at 8pm that night. There was no senior nurse on call, and the hospital at night team were not aware of the support they should be providing to the district nurse service. Patients who could be treated in the community, had delays to treatment and had to attend A&E.

The medicines kept in the ambulance station were kept at an inappropriate temperature. The temperature in the room was above 29 degree Celsius (and could get higher because of the radiator and computer equipment in the room). The drugs should be kept at 25 degrees Celsius or below; one drug should have been refrigerated. The ambulance station did not have a system for stock control, so even though drugs were within their expiratory date, the drugs stored the longest were not always the first to be used. The heat degradation would mean that the efficacy of the medication would be reduced. The trust told us that they had put an air conditioner in the ambulance station room, to keep the medicines cool. During our unannounced visit we found that medicines were appropriately stored at the correct temperature, and the stock had been reduced. However, we found that records of the temperature in the room were not kept, and there had not been a risk assessment done for the movement of IV fluids to another storage area.

The A&E had a non-clinical screener for patient attenders. The receptionist in A&E was determining where patients went for assessment. Triage was not undertaken by a nurse or doctor. The trust told us that this practice had ceased, and assessment and triage was now undertaken by a trained nurse. During our unannounced inspection we found that triage was being undertaken by a nurse, but patients were waiting over an hour to be assessed and triaged. Patients were being assessed in order of attendance, and there had been no triage of patients in terms of priority.

We have served a warning notice under Regulation 10 (Assessing and monitoring the quality of service provision), because there was a lack of effective implementation and monitoring of quality and risks in services.

We saw several areas of outstanding practice including:

Trust-wide

The Integrated Care Hub was an excellent example of efficient multidisciplinary teams working closely together to ensure the best outcomes for patients. This integrated call centre opened in 2013 and provided access to the 999 emergency calls service, the NHS 111 service, the GP out-of-hours service, district nursing, adult social care, tele-care services, non-emergency patient transport services, and mental health services. The Integrated Care Hub co-ordinated access to emergency, urgent and unscheduled care for the Isle of Wight. There were 64 staff located at the Integrated Care Hub, including switchboard, call handlers, dispatchers, clinical advisors, and operational and clinical managers. Key services were accessed out of hours through the Hub. The Hub was effective in ensuring that patients had timely access to appropriate services, avoiding unnecessary admissions to hospital, and delivering better outcomes for patients.

The pharmacy service was operational seven days a week. The service was innovative, and worked effectively within multidisciplinary teams to improve patient care. For example, electronic prescribing had reduced medication errors, and was being used to ensure that venous thromboembolism risk assessments occurred. The service offered an advice line, and was involved in the pre-admissions initiation of antibiotics with ambulance services.

The trust was developing integrated information systems, and was working towards electronic patient records. There was connection between the A&E and ambulance services, and local GPs.

Acute and Ambulance Service

There was evidenced based care for orthopaedic patients having hip and knee operations.

A widely shared care network for managing children with the most complex and rare conditions had enabled families to be supported and treated closer to their homes. It also enabled access to the best possible advice for these families. For example, the children’s ward was a Level 1 Paediatric Oncology Shared Care Unit, and could also offer care to visitors to the Island with oncological problems.

Ambulance staff used electronic tablets to enable operational staff to complete their e- learning.

The ambulance service was participating in a trial in early intervention in sepsis, jointly with another ambulance service. The aim was to identify patients who might have sepsis, and to reduce their mortality through early intervention prior to admission to hospital.

The Individual Learning Plan (ILP) had been developed and implemented to support the development of staff competency in the ambulance service. This was introduced in 2014, and staff were given learning objectives and were required to demonstrate learning as part of their continuous professional development.

Community Mental Health Services

The Integrated Sexual Health service provided a good service to wider groups in the community, and improving access to the service for harder to reach patients. The services provided access for the full range of the demographic population of the Island, including young people, the homeless and vulnerable adults.

The staff in the Community Stroke Rehabilitation Team provided an excellent service, by working towards patient-specific rehabilitation goals, facilitating early discharge from hospital, and always putting the patient at the centre of their care.

Innovative practice and collaborative working were identified in the children’s physiotherapy department, with a specialist therapy provider that enabled funds to benefit more children.

A productive series community programme was embedded in the orthotics department. This had demonstrated sustained improvements in the treatment and care of children.

Changes to the local authority safeguarding arrangements in 2013 and resulted in large increases in safeguarding and child protection referrals. These were being managed effectively to reduce risks to children.

The trust had introduced an Alzheimer’s café, and created a garden for dementia patients.

A Parkinson’s care co-ordinator had been created to meet the needs of larger numbers of patients with Parkinson’s disease.

Staff demonstrated a good background knowledge of families and children, as well as areas of higher risk in different localities across the Island.

Effective multidisciplinary working and communication, both within the service and with other health and social care professionals, was evidenced.

Mental Health Services

Primary mental health services teams provided and referred people for a range of evidence-based psychological therapies, on both a group and individual basis.

The service had developed new and innovative services to protect vulnerable people, and reduce the use of the Mental Health Act. One example of this was 'Operation Serenity', where there was joint working with the police, to treat people at home, or in the community. This had reduced the use of the S136 Place of Safety, and decreased the number of people having to be detained under the Act.

The Learning Disability Service was innovative in its use of assistive technology, to help people with communication difficulties, to encourage their choices and preferences.

The Drug and Alcohol Service had introduced a range of health promotion measures, and had integrated its work with GPs. Service outcome measures were used to improve the service.

The outside garden space on Afton Ward for older adults was funded and developed by staff. The garden was gender-specific, and had a quiet and restful area, as well as areas that encouraged activity and learning. It was described as inspirational by people and their families.

On the acute, PICU and Rehabilitation wards (including S136 Place of Safety) there was effective debriefing for staff following incidents, and staff shared lessons learnt in team meetings. Reflective practice was provided to staff through a skilled psychologist.

There was effective use of the wellness recovery action plan (WRAP) for patients on the acute, PICU and Rehabilitation wards (including S136 Place of Safety). Discharge planning started on admission and the discharge tree was used on the PICU. The wards had excellent relationships with housing and employment services.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

Trust-wide

The clinical leadership of services improve, and there must be operational support and co-ordination to cope with service demands and to manage effective integration.

Staff engagement is effective, so that service changes and developments are owned and effectively implemented, to reduce risks to patients and people that use services.

Complaints need to be responded to within 25 days, or agreed timescales.

Acute and Ambulance Services

Staff receive training on the Mental Capacity Act 2005 and the Deprivations of Liberty Safeguards. The principles must then be applied to ensure that where people do not have capacity to consent, the correct procedures are followed.

Staff are competent in how to recognise when a patient is on an end of life journey, so that decisions are made and their care managed appropriately; the trust must ensure that staff have received the appropriate training, and understand the tools available to them. This includes the use of the AMBER care bundle, and the use of syringe drivers.

'Do not attempt cardio pulmonary resuscitation' (DNA CPR) orders must be completed in their entirety, in a timely manner, for all patients where this decision has been made. There must be clear documentation as to how this decision was reached.

Risk assessments in relation to patient care must be completed, and used to inform the patient’s plan of care.

All patients have a named consultant for the duration of their stay, with clear referral and acceptance criteria when there is a change in consultant for clinical needs.

The provision of care is reviewed for patients who have had a stroke, to ensure that the pathway is fully reflective of national guidance.

National guidance is reviewed, gap analysis completed, and improvement plans put in place and monitored where required, to ensure that practices are in line with nationally-recognised guidance.

The trust must ensure there is a lead nurse qualified in the care of children (RN(children)) and sufficient registered (Children) nurses are employed to provide one per shift in emergency departments receiving children as per Standards for Children and Young People in Emergency Care Settings 2012.

There is a single point of access for children in an emergency situation. Short-term measures should be safely implemented while long-terms plans are developed.

The nursing staff provision is reviewed within the Accident and Emergency Department and the Stroke ward, to ensure that they are staffed to the agreed establishment and skill mix, in line with current guidance.

There is an effective and safe procedure for the obtaining, recording, handling, using, safe keeping, and dispensing of medicines used by the ambulance service.

Community Health Services

There are effective operation systems to regularly assess and monitor the quality of the services provided, in order to identify and manage risks. Risks as a result of the implementation of the IT project were not monitored at all times. Staff did not report all risks and near misses, and the trust was not responding to risks and near misses, particularly with regard to the levels of medical, nursing and therapy staff.

There are effective and reliable measures, and support is in place to protect the safety of staff working alone and out of hours in the community.

Community nursing staff receive regular training and updates for Doppler assessments, and ensure that patients with leg ulcers get regular and timely reviews of risk assessments.

There are sufficient qualified and experienced nursing and medical staff on the wards, including out of hours, to meet patients’ needs. This includes the stroke TIA clinic, the needs of patients who are medical outliers, and those placed in the additional four beds used in Rehabilitation. Short-term measures need to be in place whilst longer-term measures are arranged.

There are clear admission policies to community inpatient wards, and adherence to these must be monitored. Patients placed on the stroke rehabilitation and general rehabilitation wards must meet the criteria for admission, so that they can benefit from the services offered.

Staff receive regular supervision and this includes bank staff.

Doctors are offered adequate training, and sufficient staffing needs to be in place to enable medical and nursing staff to attend all teaching and development sessions.

Infection prevention and control measure are followed. The risks from damaged equipment must be removed; local infection control audits must include a review of equipment; yellow clinical waste bins outside the ward must be kept locked at all times; sharps boxes must always be left closed; and patients must be given appropriately handover checks and screening for MRSA on the wards.

There are adequate levels of equipment (including stroke chairs, wheelchairs and other equipment), in good repair to meet patients’ needs; and all equipment must be regularly checked and appropriately maintained.

Trip hazards from electric leads in the ward corridors are eliminated.

Staff have the correct understanding of ‘intentional rounding’ practices and recording on the stroke ward.

Standards for pressure area care are followed. Patients with pressure ulcers must have appropriate and timely reassessment on the stroke ward, action must be taken and recorded in response to patients’ skin changes, and all patients must have use of a pressure-relieving mattress where assessments indicate this is required. The use of inco sheets for pressure ulcer care needs to be reviewed.

Staff request and record patients’ written consent to the display of their details on the computerised screen on the wards.

Wards display a contact point for access to information and complaints regarding the use of CCTV on the wards.

The trust must update the DNA CPR policy, and ensure wards audit their adherence to this policy.

Mental Health Services

Risk management and care planning in people’s records in the Community Mental Health Team must be improved. Records were not reviewed consistently or updated in a timely manner.

The caseload management and line management supervision of caseloads in the Recovery and Rehabilitation Team are regularly undertaken to identify issues that may impact on care delivery and quality.

Professor Sir Mike Richards

Chief Inspector of Hospitals

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

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.

All Inspections

Importantly, the trust must ensure:

In addition the trust should:

Chief Inspector of Hospitals

Professor Sir Mike Richards

Key findings related to the following:

Mental Health Act Responsibilities

Key findings related to the following:

Our key findings were as follows:

Trust-wide

Acute and Ambulance Service

Community Mental Health Services

Mental Health Services

Trust-wide

Acute and Ambulance Services

Community Health Services

Mental Health Services