• Organisation
  • SERVICE PROVIDER

Essex Partnership University NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider
Important: We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

All Inspections

22 November 2022, 23 November 2022, 24 November 2022, 4 January 2023, 5 January 2023, 6 January 2023, 17 January 2023, 18 January 2023, 19 January 2023

During a routine inspection

We inspected Essex Partnership University NHS Foundation Trust (EPUT) because we received information and had concerns about the safety and quality of services.

We carried out an unannounced comprehensive inspection of 6 core services:

  • Wards for people with a learning disability or autism
  • Acute wards for adults of working age and psychiatric intensive care units
  • Mental health crisis services and health-based places of safety
  • Wards for older people with mental health problems
  • Substance misuse services
  • Community-based mental health services for adults of working age

We also inspected the well-led key question for the trust overall.

We chose to inspect acute wards for adults of working age and psychiatric intensive care units to see how many improvements had been made following our inspection in October 2022 where we rated the safe domain as inadequate and issued a warning notice. We chose to inspect 3 core services based on their ratings at comprehensive inspections in 2018 and 2019 to see if the trust had made improvements to quality and safety. We chose 2 core services that were rated as good in 2018 to check if the trust had sustained the quality of care delivered.

The trust provides the following mental health services, which we did not inspect this time:

  • Child and adolescent mental health wards
  • Community mental health services for people with learning disabilities or autism
  • Community-based mental health services for older people
  • Forensic / secure wards
  • Long stay/rehabilitation mental health wards for working age adults
  • The trust provides community health services, which we did not inspect this time:
  • The trust delivers the following community health services:
  • End of life care
  • Children and young people’s services
  • Inpatient services
  • Adult services

Our rating of services ​went down​. We rated them as ​requires improvement​ because:

  • We rated safe, effective, responsive and well-led as requires improvement. We reduced the overall rating for caring from outstanding to good because this is a more accurate reflection of how the trust are currently performing overall. Our overall rating considered the current ratings of the 5 mental health core services and 4 community health core services we did not inspect at this time.
  • The governance and safety culture of the trust did not always support the delivery of high quality, person centred care. Issues with timeliness in responding to lessons and inaccurate data impacted staff's ability to support people appropriately. Three core services had declined in their quality. Wards for people with a learning disability or autism and community based mental health services for adults of working age went from good to requires improvement and acute wards for adults of working age and psychiatric intensive care units went from requires improvement to inadequate. Two core services – wards for older people with mental health problems and mental health crisis services and health based places of safety had remained requires improvement overall. One of the 6 core services we inspected had improved from requires improvement to good overall: substance misuse services. The trust had plans or had recently launched new strategies to address key safety concerns for example around staffing vacancies and patient safety observation, but many were very new and not yet embedded.
  • Across the 6 core services we rated 30 domains associated with the key questions. In 9 examples there was an overall reduction from good to requires improvement. In one example there was a reduction from requires improvement to inadequate. In 1 examples ratings remained the same. In 3 examples domains had improved from requires improvement to good and in 1 example the safe domain improved from inadequate to requires improvement.
  • The most concerning ratings were for acute wards of adults of working age and psychiatric intensive care units. We rated safe and well led as inadequate, the other domains as requires improvement which means this service is still inadequate overall. The trust failed to ensure that all the concerns highlighted in the warning notice issued in October 2022 had been achieved consistently across all wards. For example, on some wards staff still applied blanket restrictions. Examples included searching all patients returning to wards and preventing patients from accessing fresh air freely.
  • There remained ongoing challenges with staffing wards consistently and we identified problems with staff completing patient observations safely and in line with trust policies. The rating for safe had remained inadequate, the same rating applied during the inspection in October 2022. CQC recognised Trust wide plans to address issues such as staffing. However, several aspects of these plans were not fully implemented embedded to impact care on all the wards yet.
  • We also saw a reduction in the quality of care staff provided in wards for people with a learning disability or autism and community based mental health services for adults of working age. Both services overall ratings had reduced from good to requires improvement.
  • Whilst there were still improvements required across a number of core services and leadership did not always support the delivery of improvement at pace, the trust recognised this and were in the early stages of implementing various programmes and processes which would drive the quality of care up. The leadership team had been increased to support executives in driving quality improvement. The CQC reflected the need to ensure pace and priority for this work and the trust agreed and committed to this.

Our inspection identified the following areas where further improvement was needed:

  • The arrangements for governance, assurance and performance management did not operate effectively. The CQC recognised the timing of the inspection meant there were multiple examples of new strategies, systems, roles and approaches that were in the early stages of implementation. Examples included the trust safety strategy, the appointment of directors of quality and safety and the implementation of ‘Time to Care’ and safety dashboards. All of these required further embedding to directly impact the quality of care people received. The pace of change remained a concern along with ongoing and repeated breaches of regulation identified in services that had been highlighted to the trust during previous inspections dating back to 2019.
  • The approach to service delivery and improvement was reactive and the trust were in the early stages of implementing more robust assurance arrangements to support a proactive response to improvement. There remained work to be done to ensure quality improvement initiatives were present in services and making an impact on the services people received.
  • Staffing remained a challenge. Bank and agency use was higher than the trust targets. Managers described ways they attempted to book staff familiar with the wards and patients, but staff and patients told us unfamiliar staff were an issue, especially during evenings and weekends. Sickness was rated as ‘amber’ on the trust risk register at 6%. There were challenges in recruiting to roles, vacancy rates for qualified staff were 21%. We continued to find issues with how staff observed patients, with examples of staff sleeping and not interacting in a therapeutic way. However, it was recognised there were some early programmes of work which may have a positive impact in the future, such as the recruitment programme for internationally trained nurses.
  • Data quality affected the trust’s ability to monitor and mitigate against poor performance, risk and poor quality. Data provided about key elements of service performance from executive level did not match with information we found at ward level. An example that supports this can be found in the report for acute wards for adults of working age and psychiatric intensive care units relating to supervision and appraisal data. There was a lack of pace relating to over 10 items reflected on the board assurance framework. From October 2022 – January 2023 there were 7 strategic and 8 corporate risk items that had shown no movement is their score. We identified issues with quality audits not highlighting gaps in the quality of care being provided, an example of this related to governance systems providing false assurance to the board about the quality of patient observations being delivered on wards. There were issues with inpatient services having low bed occupancy despite community teams having increased caseloads and waiting lists. An example of this was seen in acute wards for adults of working age and psychiatric intensive care units and community home treatment teams, this had not been robustly addressed by the trust.
  • The trust were due to launch their new data strategy following the inspection to build on their digital strategy. This would provide focus on how best to utilise data to provide robust intelligence and information to improve patient outcomes. Electronic systems and data quality required attention and pace. The trust have been using 7 different electronic patient record systems since the merger in 2017 and 6 years later are in a position of having funding approved to develop and implement a single system for the trust. In August 2019 we highlighted to the trust issues with training data, performance data and staff difficulties with multiple electronic recording systems. However, the health information exchange (HIE) remained in place to support record sharing between teams.
  • Medicines optimisation and management across the trust required improvement. Pharmacy workforce challenges affected the quality and sustainability of medicines services. Pharmacy teams operated with a 45% vacancy rate overall. Organisational restructures and reporting lines meant Pharmacy teams felt removed from operational decision making. There were issues with medicines management on wards and the capacity of Pharmacy teams to audit and offer support was compromised by staffing challenges. The trust continued to advertise Pharmacy roles but had trouble in recruiting.
  • Leaders did not always support staff effectively. Supervision and appraisal rates did not consistently achieve the trusts target meaning not all staff had regular access to this support. Meetings and opportunities to share learning did not take place consistently and regularly. This applied at all levels in the trust and minimised lessons and learning influencing strategy and practice. Feedback from staff about their engagement with the trust varied greatly, some staffing groups felt disconnected and that leaders did not listen to or recognise their concerns, whilst other groups were mainly positive. Forty two percent of the focus groups expressed some level of concern regarding their ability to express concerns and engagement with the organisation.
  • Long standing complaints required attention to ensure complainants received responses in good time and knew what was happening with their case. One example showed a complaint being made in August 2021, not resolved and the most recent contact recorded as April 2022. Whilst recognising the very recent implementation of a new complaints process, we were not assured that there was enough focus on resolving long standing complaints.

Our inspection identified a number of areas where improvements had taken place:

  • There was a full recognition by the trust of the need to continually improve the culture of the organisation. The freedom to speak up guardian, although in an interim post, had worked hard to increase their visibility and share the importance of speaking up. Many of the staff we met during the inspection talked about the improvements in the workforce culture, although there were still pockets of poor morale, mainly due to staffing challenges and some issues identified via an internal inquiry following a television broadcast. The trust board displayed positive role modelling behaviours which they demonstrated throughout the well led review. The trust made sure learning featured at different levels in the organisation from the executive level learning sub- committee group through to learning newsletters displayed on wards and in services. Executives made themselves available to staff via ‘grills’ where staff could directly challenge leaders about their concerns or any issues. The trust appointed 500 engagement champions who could access the CEO directly, however there remained challenges with capturing the voice of staff working on inpatient wards. The trust set expectations about staff behaviour and developed a behaviour framework to outline clear boundaries about unacceptable behaviour and consequences for those behaviours. This was initially driven by the need to support staff who experienced racial abuse (identified at the CQC inspection in November 2022) but was not limited to this issue.
  • The trust was actively involved work across the systems relevant to Essex. Three members of the executive team served 3 integrated care boards (ICB’s) relevant to the trust’s portfolio. The trust was part of four integrated care systems and were involved in 6 place based alliances. The trust also engaged with 3 local authorities which served different areas to those associated with the ICB’s. Trust leaders understood the need to design, plan and develop effective services to meet the needs of the local population. A priority for the board was to ensure that the trust faced outwards and developed a reputation of transparency and openness. The trust opened their committees to governors to increase challenge and accountability and support the work of the non-executive directors. Feedback from people was integral to planning and reviewing services. The patient experience team developed multiple ways for people to provide feedback on their experiences by working with local teams to understand what fitted their demographic. This included the use of text messages, quick response (QR) codes, paper ballot boxes and forms. The work on creating a variety of feedback methods contributed to an 800% increase in feedback from August 2022 – January 2023. Work was ongoing to ensure that patients and people who use service featured as a key stakeholder. The ‘your voice’ community provided challenge and feedback to the board and the trust launched ‘I want great care’ in January 2022. The patient experience annual review from November 2022 demonstrated positive results for involvement including 92% growth in the recruitment of volunteers (from 126 in 2021 to 243 in 2022) and a 720% growth in recruitment to the lived experience team (from 10 in 2021 to 82 in 2022).
  • The trust participated in the early adoption of the patient safety incident response framework (PSIRF). This sets out the NHS’s approach to developing and maintain effective systems and processes for responding to patient safety incidents. The purpose is to develop a culture of learning to improve patient safety. The patient safety team engaged regularly with the national team to support the re-design of materials to improve their quality. The trust made a commitment to PSIRF despite the fact it was promoted as a cost neutral programme but has needed investment. Responses to patient safety incidents demonstrated compassion and answered all questions and concerns put forward by families and carers.
  • The trust was the lead provider for the COVID-19 vaccination programme and was integral to ensuring people of Essex had access to this. They set up multiple vaccination sites quickly, delivered 1.6 million vaccinations and worked with local systems and partners to offer vaccinations to hard to reach and marginalised groups. The trust used creative ways to increase vaccination uptake such as vaccination busses and home visits.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about each of the core services.

During the inspection visits, we:

  • Visited 29 wards, 17 teams and 4 health based places of safety
  • Spoke to 224 staff performing a wide range of roles
  • Spoke to 104 patients and 17 relatives or carers
  • Looked at 182 individual patient records
  • Looked at over 116 medication records
  • Attended 29 meetings including staff handovers, multidisciplinary meetings and patient community meetings. We observed 5 examples of patient care by sitting and watching from patient areas.
  • Attended 4 home visits
  • Held 12 focus groups with staff of all grades on a variety of topics
  • Looked at records, policies and procedures involved in the day to day operation of the services.

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.

What people who use the service say

We spoke to 104 patients and 17 relatives and carers across the services we inspected. Patients and carers gave largely positive feedback about the way staff treated them and the support they offered. Patients and carers gave examples of staff treating them as individuals and involving them in their care.

On acute wards for adults of working age and psychiatric intensive care units, most patients told us staff working day shifts treated them with kindness and helped them to be independent. Patients liked the choice of food and the fact they could have snacks and drinks throughout the day. On wards for people with a learning disabilities and/or autism people told us staff treated them with kindness and that staff provided activities that they enjoyed such as cycling and colouring. Staff supported carers to attend the ward for visits and clinical meetings and involved them in planning the care and discharge of their loved one. On the wards for older people with mental health problems patients told us that staff listened and helped them to understand their care. Patients felt safe, valued and respected.

In the community-based mental health services for adults of working age, patients and carers praised the staff for making sure everyone was involved in care decisions and that staff looked at physical and social needs alongside their mental health. They felt the service responded to their needs quickly and involved other services which could help. Patients liked the frequency of their appointments and the fact that there was a team approach so they could be seen by others if their worker was on leave or absent and didn’t have to repeat their care story. In the mental health crisis services and health-based places of safety, patients said staff treated them kindly and offered flexible appointments to meet their needs. Patients felt staff offered them opportunities to be involved in their care and did everything they could to provide care in the community and help people stay out of hospital. In substance misuse services, people felt staff had an excellent knowledge of substance misuse and this helped them feel supported. They described staff as being available when they needed them and making every effort to involve people in their care.

There were however some areas for improvement identified by people who used the services. On the acute wards for adults of working age and psychiatric intensive care units’ patients and carers described issues with staff working nights. This included 5 patients describing staff falling asleep at night, 3 patients told us that staff talked in different languages during night shifts and were ‘uncaring’. Four patients told us that staff observing them did not engage with them. One patient described issues with the food portions and 11 patients told us that the coffee was decaffeinated so staff could support them with good sleep hygiene. On wards for people with a learning disabilities and/or autism there had been an issue with a walk being cancelled due to staffing shortages and not all carers had a copy of their relative’s care plan.

In the community-based mental health services for adults of working age, some people told us they would like more definite goals and to see the Doctor more often for reviews.

05 and 06 October 2022

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

Essex Partnership University NHS Foundation Trust provide community health, mental health and learning disability services for a population of approximately 1.3 million people across Essex, Bedfordshire, Suffolk and Luton. Essex Partnership University NHS Foundation Trust provides acute wards for adults of working age and psychiatric intensive care across fifteen wards on five sites. The acute wards are part of the mental health services delivered by Essex Partnership University NHS Foundation Trust. These wards provide assessment and treatment in an inpatient care setting for adults either admitted on an informal basis and/or patient detained under the Mental Health Act 1983.

The Care Quality Commission (CQC) have registered this service for the following regulated activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983.
  • Treatment of disease, disorder or injury.

Following the inspection visits on 5 and 6 October 2022, the CQC sent a Letter of Intent to the Trust. A Letter of Intent means CQC considered using potential urgent enforcement action. We asked the Trust to respond and submit an action plan as to how they would improve the quality and safety of care, by 11 October 2022. The Trust submitted their action plan within the required timeframe.

Following review of the action plan the CQC was not fully assured. On 31 October 2022 CQC issued a Warning Notice under Section 29 of the Health and Social Care Act, asking the Trust to make significant improvements by 18 November 2022 regarding:

  • Patient observations
  • Sufficient numbers of regular staff
  • Patient consent
  • Blanket restrictions
  • Incident reporting
  • Ligature cutters

See our website for more information about Section 29 Warning Notices:

https://www.cqc.org.uk/guidance-providers/regulations-enforcement/enforcement-policy

What we found:

  • Staff did not always follow Trust policies and procedures, despite systems being in place which provided them with training and induction.
  • Staff did not always follow the Trusts’ policies and procedures with regards to patient observations.
  • Staff did not always follow the Trusts’ policies and procedures with regards to recording and reporting of incidents.
  • There were very high levels of vacancies and sickness amongst nursing and support staff across both wards. This meant that there were many different temporary staff working on the wards that were not familiar with the patients.
  • High use of bank and agency staff meant that not all staff knew the patient's individual needs, despite the trust systems to record patient risk and care plans.
  • The Trust had not ensured that work was completed to address the inability of staff to observe patients from all areas (blind spots).
  • The Trust had not ensured that all aspects of care and treatment of patients was provided with the consent of the relevant person.
  • The Trust had a policy in place to manage restrictive practices which allowed staff to restrict access to certain areas within the ward based on risk. However, this meant that all patients on the ward were restricted from areas such as the gardens, bedrooms, bathrooms and toilets.
  • The Trust did not ensure ligature cutters were consistently accessible for staff.

However

  • Staff were kept up to date with mandatory training.
  • Staff received regular supervision and appraisals.
  • Staff felt well supported by their leaders.
  • Staff assessed patients’ physical health on admission and during their time on the ward.

Background to the inspection

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services. CQC were informed by Essex Partnership University NHS Foundation Trust of a scheduled broadcast on Channel 4 in October 2022.

We visited two of the Trust's fifteen acute and PICU wards, these were the two wards identified in the Channel 4 television programme.

We suspended this trust’s rating for Acute wards for adults of working age and psychiatric intensive care units as a result of concerns about this service.

How we carried out the inspection

Due to the focused nature of this inspection we looked at four key questions; safe, effective, caring, and well led. We did not inspect all key lines of enquiry across every key question. Because of its limited scope, we did not set out to rate at this inspection. However, during this inspection we identified breaches of regulations. This means the rating linked to the domain the breach sits under will normally be limited to 'inadequate'.

During the inspection we:

  • visited 2 wards and observed how staff cared for patients;
  • viewed extracts of CCTV and body camera footage;
  • toured the clinical environments;
  • spoke with 9 patients who were using the service;
  • interviewed 10 staff members and ward managers;
  • spoke with 7 carers;
  • reviewed 7 patient records;
  • reviewed 11 prescription charts;
  • reviewed 10 patient observation charts;
  • reviewed policies and procedures, data and documents relevant to the running of the service.

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

What people who use the service say

We spoke with 9 patients who were using the service and 7 carers.

Patients told us:

  • Staff were mostly nice, kind and helpful, especially the day-time staff.
  • One to one therapeutic time with a named nurse didn’t always happen.
  • There was not always enough staff and at times there were lots of different staff working on the ward.
  • Escorted leave was sometimes cancelled.
  • They cannot easily access the bathrooms and gardens.
  • Three patients told us night-time staff were sometimes less understanding, compassionate and helpful than day-time staff.
  • Three patients told us that they had seen staff sleeping on duty.

Carers told us:

  • Staff were caring, respectful and polite.
  • They knew how to make a complaint or raise a concern should they need to.
  • Most carers told us they felt informed and were kept up to date. However, one carer told us communication was poor and another told us it was mixed.
  • Sometimes the wards were short-staffed.

1 March, 17 March, 28 April, 29 April

During an inspection of Child and adolescent mental health wards

Essex Partnership University NHS Foundation Trust provide community health, mental health and learning disability services for a population of approximately 1.3 million people across Bedfordshire, Essex, Suffolk and Luton.

Essex Partnership University NHS Foundation Trust provides child and adolescent mental health inpatient services to young people and their families living across the country where a community setting would not be a safe or appropriate place for children and young people’s treatment. The child and adolescent mental health inpatient service consists of three wards located across two sites at the St Aubyn Centre, Colchester and Rochford Hospital.

We carried out this unannounced focused inspection to follow up on the conditions placed on the Trust’s registration after our previous inspection. The conditions included restricting the service from admitting any new children and young people without the prior written agreement of the Care Quality Commission and a condition to ensure all three wards are staffed with the required numbers of suitably skilled staff to meet the new children and young people’s needs and to undertake children and young people’s observations as prescribed.

During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. As result of this, the imposed conditions have now been removed.

At this inspection, we inspected all three wards of the child and adolescent mental health service; Larkwood ward, Longview ward and Poplar adolescent unit.

The St Aubyn Centre accommodates Larkwood ward and Longview ward. Larkwood ward is a ten bedded, mixed sex, locked psychiatric intensive care unit. It provides acute and intensive psychiatric care and treatment for young people between the ages of 13 and 18, who are experiencing acute, complex and / or severe mental health problems.

Longview ward is a 15 bedded, general psychiatric mixed sex ward, providing inpatient assessment and treatment for young people aged 13 to 18 years.

Rochford Hospital accommodates Poplar adolescent unit, a 13 bedded general psychiatric, mixed sex ward providing inpatient assessment and treatment for young people aged 13 to 18 years.

All three wards had education facilities on site, providing education and vocational opportunities in line with the national curriculum.

The Care Quality Commission have registered this service for the following regulated activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983.
  • Treatment of disease, disorder or injury.

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

  • The service did not manage the disposal of medicines and sharps safely. The service did not dispose of out of date stock items as required.
  • Staff did not always follow the Trusts’ policies and procedures with regards to the use of mobile phones and wearing personal protective equipment.
  • The service did not ensure children and young people had access to snacks at all times without being dependant on staff.
  • Not all staff respected children and young peoples’ privacy and confidentiality. Staff did not give carers information on how to find the carer’s assessment.

However

  • The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well and followed good practice with respect of safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the children and young people and in line with national guidance about best practice.
  • The ward teams included or had access to the full range of specialists required to meet the needs of children and young people on the wards. Managers ensured these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.

How we carried out the inspection

For this inspection we reviewed all the key lines of enquiry; safe, effective, caring, responsive and well led.

The inspection team visited all three wards between 1 March and 29 April 2022 and completed off-site inspection activity during this time. We returned to Poplar adolescent unit twice during this time following concerns raised during the inspection. During the inspection we:

  • Visited the service and observed how staff cared for children and young people
  • Visited the Poplar adolescent unit at night and observed how staff cared for children and young people
  • Viewed eight extracts of CCTV from Poplar adolescent unit
  • Viewed five pieces of body camera footage from Poplar adolescent unit
  • Toured the clinical environment
  • Spoke with nine children and young people who were using the service
  • Interviewed 23 staff members and managers
  • Spoke with five carers
  • Observed one community meeting
  • Reviewed 11 children and young people care records
  • Reviewed 15 prescription charts
  • Reviewed policies and procedures relevant to the running of the service.

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

What people who use the service say

We spoke with nine children and young people across all three wards.

One young person told us not all staff knock on their door before entering.

One young person told us some staff ignore them and don’t engage with them. Four children and young people told us they do not always know the night staff, they were always different, and this makes them feel uncomfortable.

Two children and young people told us they never meet with their named nurse.

Three children and young people from either Longview ward or Larkwood ward, told us their leave had been cancelled due to the wards being short staffed.

Two children and young people told us there is a lot of restraint on the wards and one young person told us they feel non-regular staff panic and don’t de-escalate incidents as often as they should. One young person told us they felt they were restrained more than they should have been.

One young person told us some staff talk about other children and young people in front of them.

Five children and young people from Larkwood ward or Longview ward told us snacks are on a timetable and they cannot access fruit or snacks when they want.

Five children and young people told us they did not like the food and the quality of the food is poor. Two children and young people told us the level of choice was limited.

Three children and young people told us staff were nice, kind, respectful and felt like they cared.

Two children and young people told us they knew all about their medications and side effects.

Two children and young people told us education was good and had helped them.

We spoke to five children and young peoples’ carers. Two carers told us they were not involved in their relatives’ care and it is left to the young person to phone them to inform them what is happening.

Three of the carers we spoke to had not been asked to give feedback on the service.

Three carers told us they had not been informed about the carer’s assessment.

11 May 2021, 12 May 2021, 19 May 2021, 25 May 2021, 27 May 2021 and 07 June 2021

During an inspection of Child and adolescent mental health wards

We carried out this unannounced focused inspection following the notification of a serious incident on one of the wards and we received information of concern about the safety and quality of the services.

We inspected all three wards of the children and adolescent mental health service; Larkwood ward, Longview ward and Poplar unit.

Due to the serious nature of the concerns we found during this inspection, we used our powers under section 31 of the Health and Social Care Act 2008 to take urgent enforcement action and imposed conditions on the provider’s registration. This included a condition to restrict the provider from admitting any new patients without the prior written agreement of the Care Quality Commission and a condition to staff all three wards with the required numbers of suitably skilled staff to meet the patient’s needs and to undertake patient observations as prescribed.

We did not rate all key questions of this core service, however, our ratings of safe, caring and well-led went down because:

  • The service did not have enough nursing and support staff to keep patients safe. Staffing establishments were not regularly reviewed in response to current patient need. Managers did not accurately calculate and review the number and grade of nurses and healthcare assistants for each shift. The service did not have enough staff on each shift to carry out any physical interventions (for example, restraint) safely and complete patient observations.
  • Bank and agency staff use was high, and managers were not assured as to the skills and experience of agency staff. The lack of regular and familiar staff impacted on the quality of patient care. Staff did not always understand the needs of the patients. We saw evidence where unfamiliar staff did not always understand the needs of the patients they were caring for.
  • Staff missed opportunities to prevent or minimise harm and did not always act to prevent or reduce risks. Staff did not always follow the trust policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk of harm to themselves or others.
  • Staff did not always have the correct items of clothing to respond to risks posed by patients on Larkwood ward and Longview ward.
  • Staff were not always responsive to patient needs. There was a lack of suitable tear proof clothing on both Larkwood ward and Longview ward.
  • Staff did not always report incidents clearly and in line with trust policy. Lessons learned were not always completed in incident forms or shared effectively across wards.
  • Not all leaders had the skills, knowledge and experience to perform their roles. Not all ward leaders had a good understanding of the services they managed. Governance processes did not operate effectively at team level and that risks were not always managed well. Managers were reactive in responding to risk.

However:

  • Ward areas were clean, well maintained and well furnished. Staff knew about any potential ligature anchor points and mitigated the risks. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff reviewed risk assessments and positive behaviour support plans; where patients had them, regularly. Staff involved patients and gave them access to their care planning and risk assessments. Staff made sure patients understood their care and treatment. Staff involved patients in decisions about the service, when appropriate
  • Patients had access to areas such as de-escalation and chill out rooms.

We undertook a focused inspection of this service. For this inspection, we reviewed all of the safe, caring and well led key questions and parts of the effective and responsive key questions.

Essex Partnership University NHS Foundation Trust provide community health, mental health and learning disability services for a population of approximately 1.3 million people across Bedfordshire, Essex, Suffolk and Luton.

Essex Partnership University NHS Foundation Trust provides child and adolescent mental health in patient services to young people and their families living across the country where a community setting would not be a safe or appropriate place for the young person’s treatment. The child and adolescent mental health inpatient service consists of three wards located across two sites at the St Aubyn Centre, Colchester and Rochford Hospital.

The St Aubyn Centre accommodates Larkwood ward and Longview ward. Larkwood ward is a ten bedded, mixed sex, locked psychiatric intensive care unit. It provides acute and intensive psychiatric care and treatment for young people between the ages of 13 and 18, who are experiencing acute, complex and / or severe mental health problems.

At the time of inspection there were seven patients on the ward, all the patients were detained under the Mental Health Act.

Longview ward is a 15 bedded, general psychiatric mixed sex ward, providing inpatient assessment and treatment for young people aged 13 to 18 years. At the time of our inspection there were 13 patients on the ward, seven of whom were detained under the Mental Health Act.

Rochford Hospital accommodates Poplar ward, a 13 bedded general psychiatric, mixed sex ward providing inpatient assessment and treatment for young people aged 11 to 18 years. At the time of our inspection there were 12 patients. All three wards had education facilities on site, providing education and vocational opportunities in line with the national curriculum.

CQC have registered this service for the following regulated activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983.
  • Treatment of disease, disorder or injury.

The inspection team visited all three wards between 11 May and 19 May 2021 and completed further off-site inspection activity until 07 June 2021. During the inspection we:

  • Visited the service and observed how staff cared for patients
  • Toured the clinical environment
  • Spoke with four patients that were using the service
  • Interviewed 21 staff and managers
  • Spoke with five carers
  • Observed two multidisciplinary meetings, one care programme approach meeting and two community meetings
  • Reviewed 14 patient care records relating to physical health
  • Reviewed 21 prescription charts
  • Reviewed policies and procedures relevant to the running of the service.

What people who use the service say

All patients we spoke with told us they felt uncomfortable with unfamiliar staff and it made it hard to build therapeutic relationships.

A patient told us they felt exposed as they were not wearing appropriately sized tear proof clothing.

Patients told us there was not enough activities after school. Patients told us they would ask staff for items such as the television or computer remote control, but staff would tell them to wait and then staff forget.

Carers told us that incidents often happen due to the bank and agency staff not having sufficient knowledge of the patient’s and their risks and whilst the patient was being observed on enhanced observations. Carers told us staff do not always understand the patients complex needs.

Carers told us that their relative had had their activities and escorted leave cancelled due to staffing issues.

Not all carers felt staff kept them informed of their relatives care. However, carers stated that their relative was involved in their review meetings and that they got to share their views on their care and treatment.

However, all carers stated that their relative was involved in their review meetings and that they got to share their views on their care and treatment.

Carers told us their relative had a positive behaviour support plan that staff should follow when their relative was in crisis.

Patients, relatives and carers knew how to complain or raise concerns. All carers we spoke with said that they had not had to make a formal complaint. Two carers said that they had made informal complaints to nursing staff and that these were dealt with appropriately.

29 July to 22 August 2019

During an inspection of Wards for older people with mental health problems

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

The summary for this service appears in the Overall Summary of this report.

29 July to 22 August 2019

During an inspection of Community end of life care

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

The summary for this service appears in the overall summary of this report.

29 July to 22 August 2019

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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

The summary for this service appears in the Overall Summary of this report.

29 July to 22 August 2019

During an inspection of Child and adolescent mental health wards

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

The summary for this service appears in the Overall Summary of this report.

29 July to 22 August 2019

During an inspection of Long stay or rehabilitation mental health wards for working age adults

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

The summary for this service appears in the overall summary of this report.

29 July to 22 August 2019

During an inspection of Substance misuse services

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

The summary for this service appears in the Overall Summary of this report.

29 July to 22 August 2019

During a routine inspection

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

  • We rated effective, responsive and well led as good. We rated caring as outstanding and safe as requires improvement. In rating the trust, we took into account the previous ratings of the nine services not inspected this time. We rated the trust overall for well led as good. At this inspection, we rated two core services as outstanding, one as good and three as requires improvement. Therefore, three of the trust’s 15 services are rated requires improvement, ten out of 15 rated as good and two out of 15 rated as outstanding.
  • The trust addressed many of the issues identified at the last inspection in May 2018. This included increasing the oversight, monitoring and recruiting leaders in service such as end of life care and substance misuse. Staff confidently described knowledge of risk areas in services such as acute mental health wards, they described areas of risk and how they mitigated it to increase patient safety. The trust made improvements to medicines management processes and resolved issues with stock rotation. Staff ensured that they applied for deprivation of liberty safeguard applications in good time and assessed patient’s mental capacity where appropriate.
  • Leadership in the trust was strong and had a clear sense of direction. The board prioritised visibility. In 12 months, members of the board undertook a total of 349 service visits, including unannounced night visits. Staff felt engaged with their leaders and described the introduction of distributed leadership, increasing autonomy and accountability. The board were unitary. Non-executive directors challenged the board positively to improve the performance of the trust. The trust ensured engagement with the wider mental health and social care system to offer support and specialist knowledge. Leaders and staff knew the values of the organisation and this wasutilise incorporated into recruitment processes and appraisals.
  • The trust took opportunities to improve services and provide better care and outcomes for people using services. This included identifying capital to eliminate dormitory accommodation and making significant reductions to the number of local people receiving treatment outside of Essex. During the well led inspection, the number of local people receiving treatment out of area was four. We heard about and saw many examples of innovative practice throughout the trust, this included the trial of a rapid paramedic intervention service for end of life care and the variety of therapy offered to young people on child and adolescent mental health wards. The trust provided space for learning and innovation through a ‘hub’ on the trust intranet.
  • The trust had a clear and robust governance structure to oversee performance, quality and risk. The governance structures of the organisation were in place from the point of merger and the trust reviewed their efficacy on an annual basis, the last review being in quarter three of 2018. Eight governance committees reported directly to the board, with several sub-committees reporting below. Governance spanned the entire organisation, with local managers discussing issues at service level in team meetings. We saw a variety of minutes and papers from meetings during the inspection which demonstrated staff reviewed risk, quality and performance. Local managers knew the reporting structure for sharing information and escalating concerns and could describe the ward to board governance structure.
  • Leaders prioritised culture following the merger in 2017 and continued to see this as a priority. Senior leaders described the ‘command and control’ approach taken immediately post merger to ensure the trust met its immediate objectives bringing two organisations together. Leaders described a shift in approach and a focus on distributed leadership to increase the autonomy of local leaders and increase accountability for their services. The trust freedom to speak up guardian (elected by staff in 2017) worked to encourage staff to raise concerns. Twenty local guardians supported their work. Senior leaders described work relating to embedding a ‘just culture’. A just culture ensures staff involved in incidents relating to patient safety are treated fairly. Just culture promotes a culture of openness to maximise the opportunities to learn from mistakes. Duty of Candour continued to be upheld appropriately
  • The trust used a variety of tools to monitor and assess risk. The trust had a corporate risk register and a directorate risk register. The corporate risk register identified 22 risks and the board reviewed every three months. Directorate risk registers captured service specific risks. The trust had a programme of internal audits to review and monitor aspects of their services, linked to the risks identified on the board assurance framework. Frameworks and action plans set out the ways the trust intended to reduce risks identified.

However

  • The trust did not ensure staff learned lessons from previous incidents and worked in a different way to reduce re-occurrence. Despite a variety of ways in which lessons could be shared, there continued to be repetitive themes identified as recommendations and learning. Examples included: communication with external agencies, record keeping and the administration of emergency treatment. There had been recent difficulties within specific teams tasked with monitoring the implementation of action plans following incidents, which the trust was in the process of addressing.
  • We were not assured the trust was working with pace to reduce the use of prone restraint and to address blanket restrictions. There was no monitoring system for blanket restrictions across the organisation, information about restrictions was held at ward level only. Staff continued to use prone restraint to administer intra-muscular (IM) medication to patients, despite being policy supporting staff to inject in other sites. From March 2019 to August 2019 staff recorded 183 incidents involving prone restraint. Eighty five percent (156) of those incidents occurred to administer IM medication.
  • The trust had challenges with the quality of its data. Staff described difficulties with the electronic record keeping system, the training data and data produced in performance reports. Senior leaders described data as incorrect and the need to provide extra narrative to performance reports to accurately reflect the performance of the service.
  • Engagement with equality and diversity networks and equality and diversity issues required improvement. The trust had increased the number of networks that staff had access to, however had missed opportunities to engage. An example of this was a lack of executive attendance at the equality and diversity conference. Many examples of equality and diversity work described during the inspection focused on the protected characteristic of race only.

3rd and 11th April 2019

During an inspection looking at part of the service

We did not rate this service because this was a focussed inspection.

  • Staff had not embedded lessons learned from a serious incident, into practice despite managers sharing learning. This led to another serious incident, with similar circumstances, occurring at the Basildon Mental Health Unit. There were also inconsistences with staff knowledge of general risks on Thorpe ward, where staff had no knowledge of previous incidents relating to ceiling tiles.
  • All wards had periods of understaffing. Between 01 January 2019 and 31 March 2019 the provider failed to fill 98 nursing shifts and 110 health care worker shifts. Both staff and patients felt wards were understaffed particularly at the Basildon Mental Health Unit.
  • The trust used two different databases across the north and the south locality but despite the trust having a platform to share patient information across both areas, not all staff used this effectively and told us of problems with accessibility
  • The trust made several improvements with regards to patient safety, however there were still issues with the environment. Managers had not identified all potential ligature anchor points in ligature risk assessments. Managers had not completed mitigating action plans for some ligature anchor points on Grangewaters ward and Thorpe ward. Staff we spoke to on all three wards at the Basildon Mental Health Unit had a lack of awareness of some of the anchor points present in the environment.

However:

  • Staff worked in collaboration with patients to plan their discharge and started discharge planning at the right time. We saw examples robust and detailed discharge plans. The trust employed staff specifically to support patients moving on from hospital and we saw evidence of staff supporting patients with visits to the community in relation to their housing.
  • Staff showed openness and transparency when things went wrong. Staff knew what incidents to report and how to report them. Staff felt supported after incidents and received a full debrief from managers. Senior management conducted thorough investigations and shared lessons learned with all staff through bulletins, emails and monthly team meetings.
  • Staff assessed, monitored and reviewed risks to patients regularly. Staff completed detailed and individualised risk assessments and care plans with patients and patients were involved in creating ‘my care, my recovery’ plans to manage their own risks.
  • The provider conducted the appropriate checks when using bank and agency staff. The provider used a staff bank that worked with agencies that complied with pre-employment checks such as Disclosure and Barring Service, right to work, mandatory training etc. The provider also used a system to ensure staff did not work more than 60 hours per week within the trust.

30 April to 16 May 2018

During an inspection of Community mental health services with learning disabilities or autism

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

  • Staff completed comprehensive assessments of risk that they updated when risk to patients changed. Staff ensured that if a patient suffered a crisis, there was a plan in place for the patient and carers to follow to reduce risk. Staff monitored patients on waiting lists and allocated patients according to priority of risk.
  • Staff completed mandatory training and teams met the trust target for this. Managers provided regular supervision and yearly appraisals of staff’s performance. Staff had access to a trust wide leadership and development programme to increase their skills and support career development.
  • Staff knew how to report incidents and what to report. Staff were trained in safeguarding and knew how to make a safeguarding referral.
  • Care records were personalised. There was evidence that patients were given pictorial and easy read care plans. Staff made records of physical health assessments in the patient notes and kept GPs informed of care plans.
  • We saw evidence of mental capacity assessments and best interest meetings had been held where necessary.
  • Staff were caring and passionate about the care they provided. Patients we spoke with told us they were pleased with the service that they received. Carers told us the team went above and beyond to support their relative. Staff were inclusive of patients’ needs and those in the children’s service involved parents and children in the care planning and risk assessment process.
  • Staff provided a rapid response to support patients who experienced sudden to deterioration in physical or mental health. Carers told us that if they called the adult’s community learning disability team, they would get a response back the same day.
  • There was evidence of parents evaluating the children’s learning disability service provision at the exit interview when children were discharged.
  • Staff received feedback from complaints at team meetings and supervision.
  • Manager’s had an open-door policy and aside from this there was a two hour protected time slot twice per month where staff could meet with the associate director and raise any issues.
  • Service users were involved in recruitment.

However:

  • There was no medical cover outside the hours of 9am to 5pm for this core service. Patients care plans instructed them to telephone the police or attend local accident and emergency departments if their safety was in danger.
  • There continued to be long waits for psychology and Asperger’s assessment and treatment.

30 April to 16 May 2018

During a routine inspection

We rated it as good because:

  • The trust had addressed numerous issues highlighted to them from an inspection of inpatient services in November 2017. The trust had increased the pace of their work to improve patients safety and experience.
  • We were impressed by the extent that the values of the trust have been embraced by everyone and were shown and modelled by all the staff we met. This was particularly important following the merger of the trust in April 2017. The trust values were embedded in the services we visited. Staff described the trust’s vision and values. Staff showed the values in their day-to-day work, showed kindness, respect and a caring attitude towards patients, carers, visitors and each other.
  • Managers discussed the values with staff in supervision and appraisal and based their team objectives on these values. The trust had worked at pace to harmonise policies and procedures to support staff following the merger. Interviews for new staff were values based and there was a culture within the trust to challenge those directly who did not demonstrate the values.
  • Senior staff saw leadership as fundamental to their role and we saw the trust embrace leadership values as being important at all levels of the organisation. Senior managers were very visible in core services and many members of staff told us that the board members were approachable, had visited their services and were willing to hear comments. Team leaders were visible and approachable. The trust supported team leaders to develop their leadership skills. Leadership training was available for all staff at all levels, irrespective of their job role. The trust provided staff with opportunities for career progression. The trust recognised staff success through individual staff and team awards. Managers, at all levels, encouraged and supported staff to develop and attend training for their roles.
  • The trust had a robust governance framework and structure. Service managers attended local monthly clinical governance meetings, which fed into the trust wider governance meetings. Local governance meetings discussed ward issues, such as incidents, safeguarding, staffing concerns, and identified and shared learning from incidents. Managers fed this learning back to front line staff and patients through team meetings, supervision and learning lesson bulletins.
  • Staff maintained a risk register at ward level. Staff could escalate concerns and submit items to the trust risk register. Senior trust staff reviewed the trust risk register and non-executive directors openly challenged issues, which the board welcomed. The trust has taken significant steps to improve patient experience following previous CQC inspections. The trust ensured that actions had been prioritised based on risk and we saw significant work had been undertaken in the children and adolescent inpatient services and the wards for people with a learning disability. This had dramatically improved the environments for patients.
  • Leaders had oversight of safeguarding and incident reporting and shared lessons learnt. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Each service fed into the trusts governance meetings, which then led into board meetings.
  • Compliance with mandatory training, supervision and appraisal was good. Managers supported all levels of staff to attend training relevant to their roles and develop their skills and knowledge and progress in their careers. Leaders encouraged staff to share learning and we saw numerous examples of in house teaching where staff shared knowledge and experience.
  • Managers proactively engaged patients and carers at various forums and in service developments. The trust encouraged staff to submit ideas for service development and quality improvement.
  • Despite some challenging geography, much had been done to ensure that trust leaders were visible and supported staff everywhere. The trust used technology to ensure teams based furthest away from the centre could take part in meetings and to keep up to date with developments. An example of this, was the use of video conferencing.
  • Staff and leaders cared for and supported each other. The executive team worked well together and adopted a ‘no blame’ culture when things went wrong or there was a need for investigations to take place. Leaders at a local level ensured staff felt supported at all times. Local leaders provided debriefs and support to staff through supervision. Staff felt listened to and supported.
  • Engagement and joint planning between departments was well developed. For example, the information management and technology department, and finance team brought projects to fruition. They ensured this worked directly for patient care by involving clinicians working directly with the patient groups.
  • We heard about and saw many examples of innovative practice throughout the trust. This included the use of personalised activity boxes for patients, strong links with community services to support patients back into employment, virtual dementia tours for families and carers and media applications for young people to ask difficult questions. Staff were enabled to take actions to improve services and to make a difference. Leaders promoted an environment where staff felt able to suggest improvements and ways to better care for patients.
  • The trust supported staff to work innovatively. Staff participated in working groups to improve services. We saw this within the work of the reducing restrictive interventions group. Staff and patients contributed to this work so people using services could experience the least restrictive environment whilst receiving care.

However:

  • We were concerned by the lack of oversight and leadership in some services. This included end of life care and substance misuse services. We identified issues with governance systems and were not assured that the trust monitored services effectively. End of life services did not provide opportunities for patients, families and carers to provide feedback and did not give patients information about the service. Substance misuse services did not monitor unexpected deaths and did not ensure people were seen for medication reviews.
  • The trust’s pace for implementing equality and diversity initiatives across the organisation needed improvement. This was particularly relevant to protected characteristics other than race. The trust supported a BAME network (black and minority ethnic) however, there were no other formal networks available.
  • The trust’s system for the management of medicines was inconsistent. There were various examples of poor practice in relation to the rotation of stock, across the organisation.
  • There remained inconsistencies in the assessment of environmental risks at some locations. This included the identification and mitigation of ligatures. However, it was evident that the trust had taken significant steps to address this issue. This included the removal of ligature anchor points and the introduction of ligature heat maps.
  • Training compliance for services based in Luton and Bedford was poor. This was not helped by the recent closure of training facilities local to the service. Staff expressed concern at the distance and time to travel to training facilities in Essex.
  • The implementation of positive behavioural support for patients with a learning disability lacked pace in Bedford services.
  • Older adult wards deprived people of their liberty without the appropriate safeguards in place. There were delays in deprivation of liberty applications, best interest decision assessments and capacity assessments.

30 April to 16 May 2018

During an inspection of Child and adolescent mental health wards

We rated child and adolescent mental health wards as good because:

  • On all wards, staff followed hand hygiene practices. Clinic rooms were clean, tidy and well managed. Staff followed prescribing practises which met national guidance and best practise. Staff completed thorough and detailed physical healthcare risk assessments of patients
  • Wards had minimal vacancies and staff retention was good. At the time of inspection supervision rates for non-medical staff were, Larkwood ward 100%, Longview ward 88%, and Poplar ward 100%. Appraisal rates were: Larkwood ward 82%, Longview ward 94%, and Poplar ward 98%.
  • There were clear procedures for patient risk assessment and management plans to address behaviour that challenges. Staff completed robust risk assessments and management plans and updated them regularly. Staff anticipated patients heightened emotions and used de-escalation before patients got too distressed. The wards were working towards reducing restrictive practice.
  • The multidisciplinary team provided a holistic approach to assessing, planning and delivering care and treatment. Care plans demonstrated how occupational therapy, psychology, medical and physical healthcare assessments were complimentary and supported each other. Staff designed structured and individualised therapeutic programmes, comprising of a mixture of group work activities, exercise, education and individual sessions, to encourage self-management of health conditions, self-awareness and adaptive coping strategies.
  • Staff used outcome measures to evaluate programme effectiveness and treatment interventions. Staff actively engaged in activities to monitor and improve the quality of the service and outcomes for patients. This included a range of clinical audits and benchmarking relevant to their area of work. Staff acted on clinical audits and made changes accordingly.
  • Feedback from patients was positive about the way staff communicated with them and treated their relatives. We observed staff treating patients with dignity, respect and kindness during all interactions. Staff and patients had a positive relationship.
  • Staff supported patients to be partners in their care and decision making. Patients formulated their own needs plans, coping plans and goals. Patients had been involved in designing and redecorating the ‘chill out’ room, and were involved in recruitment interviews. There was a comprehensive parents and carers workbook to help support families and carers while their relatives were in hospital.
  • The service was well integrated with the community and local resources. On Poplar ward patients went off the unit for field trips and staff invited speakers to come onto the unit to discuss specialist subjects such healthy eating and nutrition, benefits (where applicable), supported work and training opportunities.
  • Leadership was strong across all wards, and staff we spoke with said they respected their managers and what they had achieved since the trusts merger in April 2017. Staff felt managers had guided the merger well, kept them informed along the way and overall the CAMHS wards had benefitted from the merger.

However:

  • Two issues on Larkwood ward presented an infection control risk. We found black mould on the ceiling in the ensuite showers, and storage boxes used to store patients’ clothes and belongings showed signs of damp on the inside, meaning that items stored in the boxes could be getting damp, or damaged by mould.
  • On Poplar ward there was potential for patients’ privacy and dignity to be affected throughout any period of seclusion or segregation.
  • On Poplar ward, we found some of the diagnostic testing consumables, including dip sticks, blood bottles and drug tests, were out of date. We informed the manager who took immediate action to correct this before we left.
  • Staff had not protected the privacy of patients using activity rooms on Poplar ward. At the time of the inspection, staff had removed the curtains as a temporary risk management strategy, but had not replaced the curtains with any other screening. This meant that patients using these rooms could be observed by people in overlooking buildings. The manager told us she would address this situation at the earliest opportunity.
  • Staff did not give firm timelines for the implementation of positive behavioural support plans for appropriate patients.

30 April to 16 May 2018

During an inspection of Community-based mental health services for older people

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

  • Overall, staffing levels were good. The trust determined staffing levels across the service and the number and grade of members of the multidisciplinary team required at each service. Overall, staffing levels were sufficient to meet the needs of the patients. Repeat appointments were held at appropriate intervals and were rarely cancelled.
  • Staff could get access to psychiatrists for patients if urgently required. Staff responded promptly if they identified deterioration in a patient’s health and staff could refer to dementia review support teams, or to dementia intensive/crisis support teams.
  • Staff monitored patients on waiting lists to detect and respond to increases in levels of risk. Staff used a red, amber and green traffic light system to highlight patient’s risk levels.
  • Staff provided a range of care and treatments to patients. Staff held wellbeing groups for carers and patients. Kingswood Centre held a weekly dementia café in the community for patients, carers and members of the public interested to learn more about dementia. Patients were provided with information and support with employment, housing, benefits and interventions that enable patients to acquire living skills.
  • We observed effective working relationships with other teams in the organisations. A newly funded role for care liaison looked to diagnose patients in care homes with dementia, and to support hospitals to prevent unnecessary admission to inpatient wards.
  • Staff involved patients in care planning and risk assessment. At Brentwood and Basildon teams staff used ‘my care and my support’ plans with patients to gain the patient’s view of their needs. Examples of patient and carer involvement across the services included inviting patients and carers to care plan approach reviews. Staff knew patients’ needs and responded in a timely way.
  • The buildings that accommodated the teams were clean, except one for one area that was dusty. They had good furnishings and were generally well maintained throughout. The trust had systems for cleaning, and adhered to control of substances hazardous to health guidelines. Staff followed infection control principles, including hand washing.
  • Managers completed environmental risk assessments, including ligature risk assessments, except one. Patients were not left unattended in any of the rooms at all services. Staff had access to alarms when using interview rooms and staff were on site to respond to alarms.

However:

  • There was a lack of oversight by managers and the wider trust in the managing of medicines and equipment on the older people’s mental health community services. Staff at the Basildon team had not checked and disposed of out of date medication. We found that four types of medication had expired, including four depot injections. This posed a risk that medication would not be effective for patients.
  • We found some equipment had passed its use-by date in teams posing a risk that it would not be effective if staff used it with patients. For example, at the Harland team there were electrocardiogram pads which had expired in 2008. At Thurrock the blood pressure cuff and blood glucose strips had expired. The blood glucometer had no calibration date.
  • Staff had not assessed ligature risks at Brentwood, which meant risks to patients had not been identified or mitigated.
  • Across teams, patient care records were limited in information and detail. Three patient records reviewed had no care plan.
  • Staff across teams did not have a consistent approach for completing physical health annual reviews and checks and records were difficult to find.

30 April to 16 May 2018

During an inspection of Forensic inpatient or secure wards

Our inspection was announced (staff knew we were coming) to ensure that everyone we needed to talk to was available. Before the inspection visit we reviewed information that we held about these services and information requested from the trust.

Between 1 and 3 May 2018 the inspection team visited all seven forensic wards in Essex. We inspected the two forensic wards in Bedfordshire on 15 and 16 May. During both visits the inspection team:

  • visited all nine wards and looked at the quality of the ward environment and observed how staff were caring for patients
  • spoke with 51 patients who were using the service
  • spoke with seven carers of people who were using the service
  • interviewed the managers for each of the wards and one senior manager
  • spoke with 62 staff members; including nurses, doctors and an occupational therapist
  • attended and observed two handover meetings and five multidisciplinary clinical meetings
  • looked at 46 care and treatment records of patients
  • carried out a specific check of 110 medication charts
  • Looked at a range of policies, procedures and other documents relating to the running of the service.

We rated Forensic inpatient or secure wards as good because:

  • Staff completed individual patient risk assessments. They only searched patients who they had assessed as posing a high risk. Staff locked some rooms when not in use and maintained a presence in patient areas.
  • Ward areas were visibly clean, had good furnishings and were well maintained. Staff had access to protective personal equipment, such as gloves and aprons in accordance with infection control practice. Posters advising staff of the principles of effective handwashing techniques were on display on all wards. Wards had fully equipped clinic rooms with examination couches and accessible resuscitation equipment, which staff checked regularly. Staff maintained equipment; stickers were in place specifying when it had been cleaned.
  • Managers calculated the number of staff required to cover shifts, the staffing rotas showed there was the appropriate number of staff on each shift. Ward managers reported that they could adjust staffing levels to take account of increased clinical need. The number of nurses and healthcare assistants matched this number on all shifts. The ward manager could adjust staffing levels daily to take account of case mix.
  • Staff identified and managed specific risk issues and gave examples where they provided specialist equipment to meet the needs of a patient who was terminally ill to prevent pressure sores. Staff identified and recorded changing risks on the risk assessment form in the electronic care record. Staff had access to ligature cutters in all areas in the event of an emergency occurring.
  • Staff followed National Institute for Health and Care Excellence guidelines in relation to practice and when prescribing medications. These included regular reviews and physical health monitoring. Staff described applicable NICE guidelines and how they used these with patients. Psychologists used a variety of treatments including offence based therapy and an offending behaviour groups.
  • Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw staff responding to patient's needs in a discreet and respectful manner. Staff treated patients with dignity and supported them to engage in a variety of meaningful activities, including education and employment. Staff interacted with patients in a timely way and at a level that was appropriate to individual needs.
  • Patients had their own bedrooms, they could personalise these, for example with artwork and photographs. Patients stored their possessions in lockers adjacent to their bedroom. Wards had sufficient rooms for patients to access 1-1 time with nursing staff, to receive visitors or to participate in ward based activities.
  • Wards had information boards detailing the staff on duty and staffing levels. These informed patients of the staff available for care and treatment for that day. Managers and staff facilitated weekly community meetings, these allowed patients to raise concerns and provide feedback about the wards. The minutes of the meetings showed that actions taken following the meetings, for example purchasing games and equipment for patients to use. Patients told us they had met with senior leaders when they visited the wards.

However:

  • The kitchen fridge on Dune and Alpine wards and at Edward House contained open items of food. However, labels were not in place indicating when the food had been opened and when it should have been consumed by.
  • Staff told us that one patient on Alpine ward was being cared for under the trust long term segregation policy and at times the patient also required periods of seclusion. We reviewed the records and found staff had not implemented the appropriate trust documentation when seclusion commenced. Staff had not completed the checks required for secluded patients under the Mental Health Act Code of Practice.
  • We reviewed two seclusion records at the Robin Pinto unit. We found gaps in the recording of two hourly nursing and four hourly medical reviews. We also found that one patient had not had a medical review for 11 hours which is not in line with the Mental Health Act Code of Practice.

30 April to 16 May 2018

During an inspection of Wards for older people with mental health problems

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

  • The multidisciplinary team completed thorough risk assessments on admission which included individualised risk assessments and patient historic risks. Risk assessments were updated regularly and after incidents. All patients had care plans in place suitable for their needs. There was evidence of patient and family involvement in developing individualised care plans.
  • Ward managers participated in safe staffing phone calls twice per day. During the calls ward managers would input their current bed occupancy, patient observation level and current staffing levels. All wards had achieved the safer staffing model at the time of inspection.
  • Wards were clean and well maintained and furnishings were in good repair. Clinic rooms were well stocked and had physical health monitoring equipment that was checked in line with manufacturer’s guidelines.
  • Staff interacted with patients in a positive, kind and respectful manner. Patients told us there was sufficient staff for patients to have escorted leave and for staff to engage with patients during therapeutic and meaningful activities.
  • Staff were able to raise concerns about practice. Staff spoken to were aware of the trust’s whistleblowing policy.

However

  • We reviewed care records on all 11 wards and found nine Mental Capacity Assessments and Best Interest Assessments were not complete in full, on five wards; these were on Bernard, Roding, Kitwood, Topaz and Tower wards. We found gaps ranging from two to 13 days between the dates where patients who were detained under the Mental Health Act became informal and when clinical staff had applied for Deprivation of Liberty Safeguards as the patients lacked the capacity to consent to their care and treatment. This meant that patients were being treated on these wards without a lawful basis to do so.

30 April to 16 May 2018

During an inspection of Substance misuse services

We rated Substance Misuse Services as requires improvement because:

  • Not all patients receiving detoxification or maintenance substitute prescribing had regular medication reviews. The Department of Health guidelines on clinical management of drug misuse and dependence recommend 12 week reviews with a prescriber. Non-medical prescribers did not review medication levels for over six months in most cases and in some cases over a year.
  • Mandatory training levels were low and below the trust target. Of the 26 mandatory training courses, only 7 courses had met the trust target and 14 had below 75% completion. 27% of relevant staff had up to date medicines management training in place and 50% had dual diagnosis training within date.
  • Managers had not addressed the low levels of mandatory training and supervision across the service and there was no plan or process in place to improve these. Appraisal rates had also been low prior to the inspection and managers did not have a clear oversight of staff performance.
  • The trust did not have a clear overview of staff competencies and risk. The trust had implemented an in-house competency framework for non-medical prescribers with no experience or qualification in substance misuse. However, managers and clinicians had different understandings of how the non-medical prescribers would work whilst undertaking the portfolio. This meant that the trust could not be assured that non-medical prescribers were working within their scope of competency.
  • The trust had not conducted any service wide audits. Local managers had completed some audits for their site but these were individual to their locations and not shared across the service. As a result, managers were not aware that medication reviews were not happening within recommended timelines.

However:

  • Staff assessment and monitoring of physical healthcare was thorough and included physical health clinics for patients with additional needs.
  • The service did not have waiting lists for assessment following referral and 97% of patients commenced treatment within three weeks of assessment.
  • Patients spoke highly of the staff and service they had received. Staff were respectful, kind and supportive.

30 April to 16 May 2018

During an inspection of Community health services for children, young people and families

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

  • Staff kept children and young people safe from harm and abuse. Staff understood and followed procedures to protect all children and young people including those that were vulnerable. Staff assessed and monitored individual patient risk.
  • Staff had appropriate skills, knowledge and experience to deliver effective care and treatment. There was effective multidisciplinary working across the service and care was delivered in line with national and best practice guidelines. Staff planned and delivered services to meet individual needs.
  • Staff cared for children, young people and families with compassion, dignity and respect. Staff involved patients and carers in decisions and their care and treatment.
  • There was a strong, visible person-centred culture and staff are highly motivated and inspired to deliver care that is kind and promotes children and young people’s dignity. Parents and children we spoke with valued their relationships with the team and felt that staff often went the ‘extra mile’.
  • Staff supported the children and young people to minimise their distress.
  • Complaints were effectively managed and the outcomes used to improve the quality of the service.
  • The service had governance frameworks, risk management plans and quality monitoring systems in place to improve patient care, safety and outcomes.
  • There was a systematic programme of clinical audits across the service to reassure senior staff of the safety of the service.
  • There was a child friendly patient satisfaction survey to provide feedback.
  • Staff were given opportunities for further learning and development. Several staff members described how they had developed and progressed within the organisation. Managers spoke of succession planning.

30 April to 16 May 2018

During an inspection of Community health inpatient services

We rated community health inpatient as good because:

  • Patient safety was prioritised, which was reflected in the running of the service.
  • Care and treatment was delivered effectively by competent staff.
  • Patients were involved in their care, and were shown compassion by the staff working with them.
  • The service was planned based on the needs of local people, and new initiatives were set up to improve the service.
  • There was an open and transparent culture with engaged and experienced leadership.

30 April to 16 May 2018

During an inspection of Community end of life care

We rated community end of life care as requires improvement because:

  • There was a lack of effective monitoring of patient outcome data. There was no end of life clinical audit plan in place and no qualitative auditing had taken place over the past year. Data that was captured was not used to develop or improve services.
  • We could not be assured that the service was meeting objectives set out in national guidance. This was because the framework in place was new and the implementation of action plans were in the early stages.
  • Staff did not have access to competency training or regular clinical supervision.
  • Governance systems were not well established. There had been no board assurance sought on the quality of end of life services in the past year. Reporting through the governance structure was weak. There were no formalised methods for the service to take account of risks, complaints, incidents, patient feedback or other monitoring data. This meant the service could not adequately assess where improvements were needed.
  • Staff were not supported with polices and guidance. There was no end of life care policy in place nor a policy to describe to staff how they should care for person following their death in the community.
  • The service did not gain patient or family feedback specifically relating to end of life services. Not all patients received written information about the support services that were available for them.

However:

  • The service was safe. There were clear safeguarding, infection control and medicines management practices in place and being adhered to. Equipment and records were well maintained and people were given holistic care assessments to ensure their needs were met.
  • Staff were passionate about the care they provided to patients. There were many examples of how staff had gone above and beyond to support patients at the end of their lives. Patients and their families were involved in developing care plans and given information to help them understand choices available to them.
  • The service was responsive to people’s needs. There were a variety of referral methods and staff were able to see patients at short notice. Vulnerable people had their needs met and there was good access to specialist staff and support services.

30 April to 16 May 2018

During an inspection of Community health services for adults

We rated community health services for adults as good because:

  • The service managed patient safety incidents well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service planned for emergencies and staff understood their roles if one should happen.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • The service provided care and treatment based on national guidance and evidence of effectiveness. The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff of different kinds worked together as a team to benefit patients.
  • Staff understood their roles and responsibilities under the Mental Capacity Act 2005.
  • Staff cared for patients with compassion, involving patients and those close to them in decisions about their care and treatment. Staff provided emotional support to patients to minimise their distress.
  • The trust planned and provided services in a way that met the needs of local people. The service took account of patients’ individual needs. People could access the service when they needed it. Response times and waiting times were monitored and senior staff took action to improve access to the service.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The trust 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.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers across the trust promoted a positive culture that supported and valued staff.
  • The trust had a systematic approach to continually improve quality and safeguard high standards of care and treatment by creating an environment in which excellence in clinical care would flourish.
  • The service had effective systems for identifying risks and planning to eliminate or reduce them. The trust collected, analysed, managed and used information well to support all of its activities, using secure electronic systems with security safeguards.
  • The trust engaged well with patients, staff and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.

However:

  • Staff had not always completed mandatory training provided, to the trust’s target.
  • Equipment was kept on the floors of large storage cupboards, which reduced effective cleaning of these areas to prevent healthcare associated infections.
  • Patient records did not demonstrate that all patients received timely risk assessments such as malnutrition universal screening tool and Waterlow risk assessment.
  • Records provided by the trust showed compliance with staff appraisal did not meet the trust’s target of 90%.

30 April to 16 May 2018

During an inspection of Community-based mental health services for adults of working age

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

  • Staff followed best practice clinical guidelines. They undertook ongoing physical health check clinics and staff were trained to do so. Managers ensured that nursing staff had undertaken training in physical health. This included training in phlebotomy, which enabled staff to take patient blood for testing when required. Staff provided a range of care and treatment interventions suitable for the patient group in line with guidance from the National Institute for Health and Care Excellence. Several innovations were in place across the service.
  • Staff undertook annual audits of the environment to assess for potential ligature points. They had acted to mitigate the identified risks and communicated these actions to staff. Staff had access to lone worker tracking devices and there were appropriate alarms in case of an incident.
  • Staff managed risks to patients well and ensured that patients did not wait too long for assessment and treatment. Patients had risk assessments in place, which had been regularly updated. Most staff dealt with any specific risk issues as they arose. A robust procedure was in place for responding to patients who did not attend planned appointments. There were no waiting lists for psychological therapies once a patient had commenced treatment. Emergency referrals were responded to within one to two days of receipt of referral.
  • The majority of patient care plans were personalised, holistic and recovery-focused. Staff supported patients to understand and manage their care plan, and manage their care and treatment. Staff ensured that patients had access to education and work opportunities. Staff attitudes and behaviours when interacting with patients showed that they were discreet, respectful and responsive. Patients identified several staff who had gone the extra mile. Staff knew how to handle complaints appropriately and there was oversight of complaints and concerns by each team manager.
  • Staff in all teams held regular and effective multidisciplinary meetings and shared information about patients at team meetings. There were some good examples of joint working arrangements with general practitioners.
  • Leaders had the skills, knowledge and experience to perform their roles. Staff told us that their team leaders supported them and that the service was being well managed. Leaders in Brentwood and Basildon had supported clinical staff by allocating staff with protected days for administration.
  • Staff felt respected, supported and valued by their team leaders and felt that they had authority to undertake their role. Staff felt able to raise concerns without fear of retribution. Staff and leaders did not report any examples of bullying or harassment within teams.

However:

  • Risk management plans for five patients in Canvey Island and Basildon, did not contain crisis and contingency plans. Of the forty care plans inspected, five were not personalised, six were not holistic and nine were not recovery focused.
  • Over a third of staff reported that information systems were poor and time consuming. Managers had developed improvement plans which were in place, however the electronic health record remained difficult to navigate.
  • We found a box of medications which were out of date. There was a week’s gap in the recording of medication fridge temperatures in the Linden centre, Chelmsford and the Taylor centre Southend.
  • The level of patient involvement was limited and could be improved.
  • Managers above team level did not visit the clinical areas often. This meant staff did not know them well. Managers did hold meet and greet events which staff could attend. Staff had not had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

30 April to 16 May 2018

During an inspection of Long stay or rehabilitation mental health wards for working age adults

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

  • Resuscitation equipment was available in the clinic but items were missing. Digital scales and the blood pressure machine were broken but still in use. Safe checking systems and processes were not in place. The ward manager took immediate action on the day of inspection.
  • Two patients risk assessments were not up to date or sufficiently detailed.
  • Patients gave mixed feedback about the heating in bedrooms. Staff were unable to control the heating in the unit.
  • There was no staff room within the unit. The ward manager had raised this with managers.
  • Relationships some members of the multidisciplinary team were mixed. Not all staff felt respected, supported and valued. Some staff did not feel able to raise concerns without fear of retribution.There had been a turnover of four managers over four years. Staff found this concerning and affected staff morale and stability of the team.
  • The ward manager did not maintain a complete risk register at ward level.

However:

  • The environment was safe and clean with ligature risks assessed and mitigated. Facilities included rooms for therapies and activities.
  • The unit had an adequate number of staff to provide safe care. Where there were vacancies, managers were actively recruiting new staff. They used suitably skilled bank and agency staff to cover gaps. Staff were up to date with all mandatory training at 90%. There were regular team meetings and supervisions and appraisal.
  • Staff knew how to report incidents and managers monitored these reports to identify and implement any lessons learnt. The ward manager undertook a daily call to senior managers around the management of patient care and risks. Staff managed and administered medication correctly.
  • Staff created a holistic and robust overview of patient care and treatment. Staff used care plans, recovery star and my care, my recovery documents to achieve this with the patients.
  • Staff reviewed paperwork for any detained patients weekly and information about the Mental Health Act was available to patients. Patients had access to an advocacy service, and knew how to make a complaint if they needed to.
  • Patients received regular physical health checks and staff supported patients to live healthier lives. For example, patients were encouraged to participate in smoking cessation schemes. Staff provided breakfast and patients were supported to prepare and cook their own lunch and dinner. Patients had access to a Recovery College where they could develop a wide range of skills to support them in the future.
  • Staff offered carers the opportunity to discuss their needs and create their own care plan (where appropriate).
  • Staff were respectful and caring. We observed positive interactions between patients and staff. Staff understood the individual needs of patients. Patients said staff treated them well. Each patient had an allocated key worker named nurse and healthcare assistant (co-worker).
  • Staff planned for patient’s discharge, including good liaison with care managers/co-ordinators.
  • Patients attended spiritual support in the community. Patients had opportunities to feedback to the service.

30 April to 16 May 2018

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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

  • Managers had not ensured safe environments on six out of 13 wards. We found unidentified ligature points on Grangewaters, Chelmer, Ardleigh and Peter Bruff wards. We found unidentified ligature risks in gardens, kitchens, laundry rooms, bathrooms and bedrooms. Managers had identified ligature risks but not mitigated against them on Hadleigh psychiatric intensive care unit and Gosfield ward. We found unidentified blind spots on Ardleigh and Chelmer wards.
  • The service did not always have beds available when needed. Patients often did not have a bed to return to following leave. Managers and staff spoken with told us that there was pressure to admit new patients to leave beds. Managers told us that patients would also be discharged following leave if no bed was available. We were given examples of patients having to wait to access a bed. There had been a serious incident and complaints relating to beds not being available.
  • Staff had not completed detailed risk assessments for all patients. We reviewed six patients’ records that did not include a detailed risk assessment. On the Mental Health Assessment Unit, we reviewed three patient records. Staff had not completed detailed risk assessments or risk management plans. There was no evidence of ongoing assessment of patients’ mental state. These patients had presented with serious risk issues on admission to the ward. On Ardleigh, Peter Bruff and Cedar wards, we found one patient record on each ward that did not contain an up to date and detailed risk assessment.
  • Staff did not always follow procedures for safe management of medicines. Staff had not labelled all liquid medicines with the date of opening and the medicine fridges were not clean on Peter Bruff unit and Ardleigh ward. There was no adrenaline available on Peter Bruff unit. Staff had not signed in medication on Ardleigh ward. Staff were not checking patients’ vital signs following the administration of oral lorazepam on Chelmer ward.
  • The trust had not ensured learning from incidents was shared. Staff spoken with were not always aware of relevant incidents that had occurred on other wards within the service. We reviewed 25 incidents, of these, 16 did not include any lessons learned and in three, lessons learnt had not been shared.
  • Staff did not always complete care plans to meet patients’ specific physical healthcare needs. On Peter Bruff ward, we found a patient with a physical health condition who did not have a care plan to meet their physical health needs. On Ardleigh ward, a patient with diabetes did not have a clear plan as to how staff should manage their condition and another patient did not have a care plan to address their specific physical healthcare need.

However:

  • The trust had made significant improvements to managing environmental risks across the service. The trust had funded work to remove and reduce ligature risks. On Gosfield ward, high risk areas had been reduced from 20 to eight. Window handles had been removed from wards. Wards had ligature packs with information on environmental risks easily accessible for staff.
  • Wards were clean and well maintained with good quality furnishings. Staff adhered to infection control procedures, for example, handwashing and the application of hand sanitiser. Staff prompted us to apply hand sanitiser before entering the wards.
  • Clinic rooms were fully equipped with accessible resuscitation equipment. We inspected nine clinic rooms at Hadleigh, Chelmer, Stort, Ardleigh, Peter Bruff, Christopher psychiatric intensive care unit, Galleywood, Cedar and the Mental Health Assessment Unit. The CQC medicines team inspected Grangewaters clinic room.
  • Staff had completed up to date, personalised, holistic and recovery focused care plans in 98% of patient records and full physical health assessments in 95% of records reviewed.
  • We observed staff behaving in a kind, respectful and compassionate manner when interacting with patients. Patients told us that staff were respectful, kind, polite, compassionate and fair. Patients told us that staff kept them safe, listened to them and were responsive to their needs.
  • The trust had introduced regular bed management meetings and discharge coordinators supported the service to ensure smooth transfers of care.
  • Staff felt able to raise concerns without fear of retribution and were aware of the trust’s whistleblowing policy. Staff advised that they were able to raise concerns anonymously on the trust’s intranet and told us about the trust’s freedom to speak up guardian.

30 April to 16 May 2018

During an inspection of Wards for people with a learning disability or autism

We rated wards for people with a learning disability or autism it as good because:

  • The trust had refurbished the physical environment of the ward to a high standard. Furniture was sturdy and suitable for patients who had behaviours that challenged. The trust had reduced ligature risks and staff mitigated these by observations. The clinic room was clean and tidy; medicines were well organised and staff prescribing practices were good.
  • The service had reviewed and increased staffing levels to ensure there were enough staff to support patients safely. Staffing in the month prior to the inspection matched these identified levels. Staff had regular one to one time with their nurse and for identified therapies, participated in regular group activities and had regular time away from the ward.
  • Staff received regular training, appraisal and supervision; staff said that managers supported them well and made them feel valued. Managers debriefed staff after incidents, ensured regular team meetings took place to discuss issues, learn lessons from incidents and discuss patients’ treatment. Morale was high and staff were proud of the team and were passionate about providing high quality care.
  • Staff undertook assessments and care plans in a timely manner. Staff completed detailed physical healthcare assessments and staff supported patient’s physical health issues throughout their stay. Staff gave positive behaviour support plans to patients, which were detailed and person centred and identified positive strategies to reduce patients’ challenging behaviours and helped them gain insight and positive coping strategies. Handovers reinforced these plans by repeating positive strategies to ensure staff were familiar with them and knew how best to support patients. Staff used positive behavioural support plans to help reduce physical interventions.
  • Staff involved patients in care planning and asked patients how they wanted staff to support them. Staff encouraged patients to participate in daily ward meetings and monthly patients’ forum meetings. They enabled patients to lead meetings and to take the minutes. Patients used these meetings to request changes and received feedback from previous meetings.
  • Patients undertook a wide variety of activities, including individual and group sessions away from the ward. Patients chose items and activities for their activity box which they accessed at any time to occupy their time and to calm them when they felt distressed.
  • The service worked closely with other agencies. Staff worked with the community learning disability team adjacent to the ward to ensure high quality transition plans were in place for patients moving from children’s to adult services. Staff reviewed positive behaviour support plans on discharge and worked closely with their community colleagues to enable patients to move back into community placements positively.
  • Patients and carers told us that staff were caring, kind and polite. We observed staff speaking to patients in a positive and caring manner.
  • Staff used accessible communication methods with patients. This included one to one discussions, signs, symbols and pictorial resources. Staff had produced documents covering a range of issues in easy read format and made great efforts to aid patient understanding.
  • The ward manager and multidisciplinary team had driven significant changes to the service. Managers ensured systems were in place to monitor the performance of the team and take action when needed. Managers encouraged staff to participate in service development and were well informed about changes. Leadership was strong and the ward manager worked closely with staff to enable them to make changes effectively.

However:

  • There were a number of out-of-date dressings, glucose test strips and sterile tubes and strips in the clinic room. There was also one out-of-date medication in the fridge. Managers had not put a system in place to check these items to ensure that they staff replaced them when they reached their expiry date.
  • The service used the female-only lounge on some occasions to support a male patient who needed a quiet environment.
  • Clinical supervision, where staff could reflect on their practice, took place during supervision with managers. Registered staff did not meet separately with a clinical supervisor of their choosing. This was not required by Trust policy.
  • Patients did not understand the role of the independent advocate.
  • Bed occupancy rates were often in excess of 100%, above the 85% recommended for acute wards by the Royal College of Psychiatrists.

30 April to 16 May 2018

During an inspection of Mental health crisis services and health-based places of safety

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

  • Staffing was sufficient to meet need and managers could bring in additional staff when needed. New staff received a trust induction and a team induction which involved shadowing experienced staff. Staff received mandatory training and compliance was 81%, with some staff on long term leave so not available. Managers monitored training through monthly reports and discussed at team meetings. Staff knew about safeguarding and considered this as part of their multidisciplinary meetings. Staff received supervision and annual appraisals. Staff accessed specific training when needed.
  • The environment for the health based places of safety was safe, clean and ensured clear sight for observation. Staff managed medicines well and kept accurate records of medicines used. Ligature assessments were up to date and accurate, apart from the Lakes.
  • Staff identified and managed risk well using a red amber green rating and zoning for caseload management. Staff were patient focused and respectful whilst managing risk. There was a robust incident reporting system and staff knew how and what to report. Apart from the Linden crisis team, managers shared lessons from incidents in team meetings.
  • Staff kept records up to date and overall the records were detailed and person centred. Staff discussed mental capacity at the multidisciplinary meetings and handover and documented patients’ capacity. There was the expected range of professionals in the team and managers were recruiting to the vacancies in psychology, social work and occupational therapy.
  • Patients and carers said they felt involved in their treatment.
  • The section 136 (health based place of safety) policy had been updated to comply with the Policing and Crime Act 2017.
  • Targets for seeing patients within four hours of referral were met consistently. Staff in the health based place of safety at Rochford demonstrated responsiveness to patients and their family. For example, they provided some clothes to enable a patient to have a shower and they washed the patient’s own clothes to give them as soon as they were dried, they charged the patient’s mobile phone so they could keep in touch with family and facilitated a relative to visit a patient in the health based place of safety.
  • Leadership was strong and staff said they felt supported and could raise any concerns if needed. Managers received monthly reports which they used to monitor the service and staff performance. They acted when required to deal with any issues.

However:

  • At the health based place of safety in the Lakes and Linden Centre there was closed circuit television in place with no signs telling people this was the case. The ligature assessment for the Lakes health based place of safety was incorrect. The hot spot map was of another area. The author of the ligature assessment had described the furniture incorrectly as too heavy to throw when the furniture could be lifted and thrown. There were also electric sockets in the room which had not been identified as a risk. These posed a potential risk to patients and staff.
  • The handover at Linden and the Lakes was not documented.
  • Crisis plans lacked detail about what a patient should do in a crisis. There were gaps in some records at the Linden team. At the Lakes, the records were not scanned onto the system from the health based place of safety.
  • There was an identified need for more approved mental health professionals (AMHPs). The approved mental health professional lead was monitoring access to AMHPs for Mental Health Act assessments and was encouraging more staff to train to fill the gap. Despite the shortage any delay in accessing an AMHP was never more than one or two days, according to staff and the AMHP lead.
  • Caseloads for the teams could reach more than 32 in which case the situation was escalated. The caseload at the Lakes was 47 at the time of our inspection and had been escalated.
  • Teams were unsure of the plans for teams across the area since the merger of the two trusts. They were unsure what the plans were for changing the assessment process, home treatment and whether it would be standardised across the trust. There was little evidence of working across the north and south of the area. There was a crisis response and home treatment steering group which staff from the north had only recently started attending.

6 to 8 November 2017

During an inspection of Wards for people with a learning disability or autism

We found the following issues that the trust needs to improve:

  • The ward layout did not allow staff to observe all areas of the ward. The staff could not view patient living areas from the ward office. Bedrooms were in corridors meaning staff had to be close to patients to allow accurate observation. However, we saw during our inspection that staff were regularly observing patients.
  • Staff could not effectively manage patient behaviour and risk safely. The ward did not have seclusion facilities or a de-escalation area, which meant that staff used de-escalation and restraint in communal areas or patients’ bedrooms. This could compromise patient’s privacy and dignity.
  • Managers provided data during inspection that there had been 80 incidents of restraint during the six months prior to inspection.
  • Staff did not ensure that patients’ care plans and risk assessments were regularly updated.
  • The trust had not addressed some environmental issues identified at the last inspection in July 2017. The trust had not redecorated the communal living area, completed repairs and cleaned radiator covers.
  • The trust did not ensure all patients had safe furniture and furnishings to promote a recovery environment.

  • Managers did not always debrief staff after incidents. This posed a risk of staff not feeling supported and not learning from incidents,
  • Managers did not have sight of any trust targets or key performance indicators to monitor the performance of the team.
  • Staff rotas for the month of October 2017 showed that there was insufficient staff to meet patients’ complex needs on a daily basis.
  • Staff did not complete positive behavioural support plans with all patients. Five patients out of seven did not have positive behavioural support plans. There were plans in progress for other patients but these needed finalising.

However:

  • Some actions from the last inspection were in the process of being addressed. Privacy screens had been applied to patients’ bedroom windows, bedrooms had been redecorated, and specialist furniture for patients’ bedrooms had been identified. Managers showed us a quote for purpose built wardrobes; they were awaiting approval from senior managers to order them.

  • Managers had begun to train staff in positive behavioural support, 50% of staff had attended this training.

  • Ligature risks were being managed effectively. Managers had updated the ward ligature assessment on 29 September 2017, which identified all ligatures points.

  • Managers ensured that staff received regular supervision and appraisals. Staff told us the ward manager was supportive.

  • There was effective multidisciplinary working both on the ward and with teams outside the organisation. Staff communicated regularly to formulate plans for patients that helped patients achieve their goals.

  • We observed staff treated patients with kindness, dignity and respect. Staff were passionate about patient care and wanted to do their best to improve patient’s experience.

  • Patients were involved in writing their care plans and were given copies of them. Patients were involved in decisions about the service and had been involved in the recruitment of staff in the 12 months prior to inspection.

6 to 9 November 2017

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We found the following areas of good practice

  • Ward and clinical areas were visibly clean and comfortable.

  • The clinic room was fully equipped with an emergency response grab bag. We found out of date urine testing strips and some open eye wash with no start date. Staff addressed these concerns immediately. No other concerns were identified in relation to medicines management, dispensing or reconciliation.

  • The ward had a low staff vacancy rate and low sickness and absence.

  • Patients told us that staff rarely cancelled leave due to staffing shortages and that they met regularly with their named nurse.

  • Comprehensive risk assessments were in place. Staff continually reviewed patient risk assessments after incidents, during shift handovers and as part of the weekly multi-disciplinary team meetings.

  • Staff demonstrated a good knowledge and understanding of safeguarding practice and procedures and recognised types of abuse. Staff training compliance was 99% for safeguarding children and adults, this included housekeeping staff.

  • Staff treated patients with dignity, care and respect and were familiar with each patient’s care and support needs and preferences. Staff demonstrated passion for their role and viewed involvement in patient’s treatment progression as a privilege.

  • Staff involved patients in the development of personalised and holistic care plans.

  • The multi-disciplinary team gave careful consideration to discharge planning arrangements, including suitability of follow on housing or placements to prevent readmission.

  • We examined five staff human resources files, these contained evidence of staff receiving regular clinical and managerial supervision. Appraisal completion compliance was 100%.

  • The staffing rota showed there was an adequate level of qualified nurses and senior health care assistants to meet clinical need.

  • There was a low level of complaints received by the service. Patients were encouraged to give feedback during weekly community meetings. Evidence of staff discussing and acting on patient feedback was present in the team meeting minutes examined.

However, we found the following issues that the trust needs to improve:

  • Ward based areas contained multiple ligature points. There was an audit document in place which identified the ligature points (fittings to which patients intent on self-injury might tie something to harm themselves), but this did not have corresponding photographs as a visual source of reference for staff particularly for those who were not familiar with the service.

  • Blind spots were present throughout the ward environments impacting on the ease of monitoring patients, with nothing in place to mitigate risks.

  • We found an outdoor, unlocked shed containing hazardous substances. The shed was accessible from the adjacent public footpath and by patients.

  • Food stored in shared refrigerators did not have labels to indicate when opened or due to expire. Raw meat was stored in open packaging mixed in with dairy products and other food items increasing risk of cross contamination or spread of infection. Food was not stored in line with food hygiene standards.

  • Housekeeping staff left cleaning products on the ward landings making items accessible to patients. Staff did not keep a product list on their trolley.

  • The service did not have up-to-date environmental fire risk assessments or records of evacuation drills completed within the last 12 months.

  • Training data provided by the service showed that no qualified nursing staff were up to date with Mental Capacity Act and Deprivation of Liberty Safeguards training. It also showed no qualified nursing staff had up to date Mental Capacity Act and Deprivation of Liberty Safeguards training. The trust informed us that staff completed Mental Capacity Act training and Deprivation of Liberty Safeguards training as part of safeguarding level three training. Seven out of eight qualified nursing staff were compliant with safeguarding level three training. Enhanced emergency skills training was 14% and immediate life support training was 66% for eligible staff.
  • Patients did not have access to psychology services as part of the rehabilitation treatment programme.

  • The ward manager expressed concern that staff did not have access to up to date policies since the trust merger. This resulted in staff working to out of date policies. This was not a concern identified when we inspected other wards in the trust.

  • Since the trust merger, staff identified services based in the north and south of the trust continued to work on different electronic recording systems. Staff reported this could impact on ease of information sharing and gathering patient information relating to historic risks.

  • There was a lack of private space for staff, with lockers and their fridge positioned in the patient’s dining area. This did not offer staff breaks away from clinical areas.

6 to 9 November 2017

During an inspection of Forensic inpatient or secure wards

We found the following areas of good practice:

  • Clinic rooms were visibly clean and had enough space to prepare medications and undertake physical health observations. Physical health monitoring and emergency equipment had been calibrated and was checked regularly to ensure it was in good working order.

  • The wards were well maintained and clutter free. Cleaning rotas had been completed and the wards were visibly clean and tidy. Furnishings were in good condition, bright and colourful.

  • Staff used restraint techniques as a last resort.Staff used restraint to protect patients from causing serious injury to themselves or others. Quiet rooms and the de-escalation rooms were used prior to patients being moved to the seclusion room. Seclusion was used correctly; we reviewed four seclusion records which were completed appropriately.

  • Staff completed comprehensive risk assessments which they reviewed regularly and after incidents. Staff discussed and recorded updates of potential risks to patients in handover meetings, so all staff on duty were updated.

  • Staff followed National Institute for Health and Care Excellence (NICE) guidelines when prescribing medications. These included regular reviews and physical health monitoring. Staff described applicable NICE guidelines and how they used these with patients. Psychologists used a variety of treatments including offence based therapy and an offending behaviour group.

  • Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw that staff were responsive to patient's needs, discreet and respectful. Staff treated patients with dignity and remained interested when engaging patients in meaningful activities. Staff interacted with patients at a level that was appropriate to individual needs.

  • Patients said food was of a good quality and there is always a vegetarian option and their dietary requirements were always met.

  • Managers supervised staff regularly Compliance rates were 100% for Fuji and Aurora wards and 90% for Edward House. Managers and staff were aware of and demonstrated duty of candour to inform people who use the services of any incident affecting them.

  • Staff had an awareness of the trust’s whistle blowing policy and said they could raise concerns without fear of victimisation.

However, we found the following issues that the trust needs to improve:

  • Staff could not observe patients when using the ensuite bathroom in the seclusion room at Edward House due to blind spots and no viewing panel.
  • Staff had not stored food in ward fridges safely and in line with guidance. We found some items of food in ward fridges that had been opened. However, they did not display a label indicating when they had been opened or when they should be used by.

6 to 9 November 2017

During an inspection of Child and adolescent mental health wards

We found the following issues that the trust needs to improve:

  • All wards had blind spots so staff could not observe all areas of the wards at all times to keep patients safe.

  • The service used high levels of bank and agency staff to maintain safe staffing numbers. There were frequent staffing issues on Larkwood and Longview wards and qualified staff were not visible on the wards. Staff sometimes cancelled activities due to staffing shortages and informal patients could not always to leave the wards when they wished to.

  • The seclusion room on Larkwood ward did not meet the standards laid out in the Mental Health Act Code of Practice.

  • Seclusion paperwork was incomplete and staff did not consistently debrief patients following seclusion.

  • We found gaps in observation records on Larkwood and Longview ward so were not reassured that patients were safe.

  • Two patients had no risk assessment in place after three days of admission.

  • Not all patients felt safe on the ward.

  • There were blanket restrictions across the service.

  • Staff were not routinely documenting if patients had capacity or competence issues on consent paperwork.

  • There were inconsistent practices across the wards for documenting consent to treatment. Capacity paperwork was not fully completed.

  • Care plans were not always holistic, recovery focused or personalised. Two patients on Longview ward did not have any care plans in place after three days of admission.

  • Compliance with mandatory training was below 75% on Larkwood and Longview ward.

  • Compliance with supervision was poor on Larkwood ward and on Longview ward at 41% and 48% respectively.Staff did not consistently change practice following lessons learnt.

  • We identified lapses in management on Larkwood and Longview wards. We were concerned at the lack of management oversight on these wards.

However, we also found the following areas of good practice:

  •   The ward areas were clean and tidy and free from clutter. The clinic rooms were visibly clean, tidy and had enough space to prepare medications. Emergency resuscitation equipment available and staff checked the clinic regularly.
  •   Staff completed routine physical health observations.
  • Consent to treatment forms and current medication forms were kept together so staff could check patients’ consent for medicines.

  • Families and carers were involved with their relatives care and treatment.

  • The advocate visited the wards weekly and patients and staff knew how to access this service.

  • Staff understood the complaint process and how to assist patients should they wish to complain. Most patients told us that they knew how to complain.

  • Staff participated in a variety of clinical audits around medication and care plans.

  • Staff told us that they received feedback following investigation in handovers and team meetings if they attended.

  • Poplar ward was compliant with mandatory training, appraisal and supervision.

6 to 9 November 2017

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We found the following issues that the trust needs to improve:

  • The trust governance systems were not effective since the merger because we found quality and safety risks for patients and others that the trust had not identified. Trust systems were not effective for sharing information with staff, because the trust had not taken action to ensure that staff had easy access to the latest comprehensive ligature risk assessments for their wards. We identified environmental risks such as poor lines of site on wards, which posed risks to patients or others. Ward team meeting minutes did not demonstrate how the trust was sharing information and learning from serious incident investigations and complaints with staff to prevent reoccurrence.
  • The trust had not completed actions for issues highlighted at our 2015 and 2016 inspections of North Essex Partnership University NHS Foundation Trust. For example, the trust had not removed some ligature point risks such as window handles in communal areas on Finchingfield and Galleywood wards. A ligature point is a fixed item to which a person could tie something for the purpose of self-strangulation.
  • The trust had not always ensured sufficient staffing for the wards. The trust had not covered 7,369 hours of nursing staff shifts. All wards reported staffing vacancies, with several wards using a high amount of bank and agency staff across wards (above 40%). Ward staff reported difficulties getting staffing to cover increased observation of patients with higher risks. Eight wards had a staff sickness rate above the national average (4.3%) and the trust target of 4.5%.
  • The trust had not always protected patients’ privacy and dignity because patients on Grangewater and Thorpe wards still shared dormitories. Dormitories cannot always guarantee patients' dignity. The trust had not fully complied with the Department of Health and Mental Health Act 1983 code of practice in relation to the arrangements for eliminating mixed sex accommodation across all wards. For example, the Hadleigh unit did not have an identified female patients lounge.
  • Patients did not always have their own bed to come back to if their community leave was unsuccessful. The trust had challenges managing high bed occupancy levels on acute wards. From April to August 2017, 143 patients were in out of area placements.
  • The trust had not taken adequate action to support two patients with diabetes care at Basildon Mental Health Unit.
  • Staff had not updated eight patients’ care plans and risk assessments.
  • Staff had not fully completed records and checks of patients in seclusion on the Christopher Unit.
  • Staff still carried out restrictive practices, for example, assessment unit patients could not access bedrooms in the morning after 09:30 hours.

However, we found the following areas of good practice:

  • Twenty-four patients spoke positively about the care and support staff gave them. Patients told us staff involved them in their care and treatment.
  • We observed staff interacting with patients in a caring manner treating them with, respect and dignity and giving them time to talk. Staff had a good understanding of patients’ individual needs.
  • Thirty-nine staff had good morale and felt supported by their team and managers. They said the trust had effectively communicated with them about the trusts’ merger.
  • The trust had ensured that ward staff had achieved over 75% compliance with mandatory training. Over 75% of staff had received an appraisal. Eight wards had ensured that 70% or more staff had regular supervision for their role.

6 to 9 November 2017

During an inspection of Wards for older people with mental health problems

We found the following areas the provider needs to improve:

  • Bernard and Tower wards were not safe. Corridors that were identified fire escape routes had items stored along them. This would impede progress of anyone trying to escape in the event of a fire and would hinder any emergency services attempting to gain access. The fire escape route went into a small garden area. The gate out of this area was secured with a key pad and staff did not know the number combination to unlock the gate.
  • Managers had not identified all ligature points on Ruby and Henneage. They were not recorded on the ligature risk assessment. They were, however, in communal areas where patients should be supervised. On Tower, ward managers had highlighted all ligature risks but guidance for staff on management of these risks was not clear.
  • We found a number of medicines management issues. Staff had not listed all medicines given covertly. We found out of date British National Formulary books on five wards. Staff did not follow the correct protocols for a patient on a combination of high dose medications. These included physical health monitoring and indicating the high dose on the patient’s drug chart. Staff had not labelled medicines with the date of opening and we found out of date dressings. There was an oxygen cylinder with no expiry date. Staff had not cleaned two tablet crushers. Three patients went without one of their medications for a day, due to issues with the system for ordering the medication. Another patient had a dose of medication omitted as staff had written the drug chart incorrectly. Two patients did not have allergy information completed on all sections of the drug chart.
  • Bernard and Tower wards did not have enough bathrooms to meet patients’ needs. On Bernard, there was one working bathroom for 14 patients. Tower only had one combined bathroom and shower room for 14 patients.
  • The service often ran below established qualified staffing levels. Between 1 April 2017 and 31 August 2017, there were four months of night shifts that had a qualified fill rate of 50% or less and a further 15 months that had qualified fill rates below 75%.

However, we found the following areas of good practice:

  • The multidisciplinary staff teams completed thorough, holistic and detailed assessments prior to and on admission. They covered aspects of the patient’s history and needs together with an assessment of risk. The plans were personalised and identified patients’ needs and preferences. Staff updated these plans regularly. All patients had risk assessments completed before and during admission. Risk assessments were detailed, clear, used historical information to identify risks and staff updated them regularly.
  • The service had implemented a new falls procedure following high numbers of falls incidents. The trust employed a falls lead who facilitated a monthly falls group to review falls incidents and share learning.
  • Teams carried out twice daily ‘safety huddles’. These ‘huddles’ consisted of all staff on duty meeting and assessing the safety of the wards and ensuring patients’ needs were being met.
  • The ward areas were clean, tidy and well maintained and furnishings were in good condition. The clinic rooms were clean, tidy and well equipped for carrying out physical examinations. Staff ensured equipment was serviced and carried out regular checks.
  • Patients spoken with told us that staff were caring and kind. We observed positive interactions between patients and staff.
  • Managers ensured regular supervisions took place for staff. Managers facilitated monthly team meetings where they discussed incidents and complaints, including learning from other services in the trust.

22 and 23 August 2017

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We found the following issues that the service provider needs to improve:

  • There was a blind spot in the seclusion room on Peter Bruff ward. This issue was reported to senior managers over four months ago by the ward manager who reported that no action had been taken to reduce this risk, however the trust had developed and action plan with date for this work to be undertaken to minimise the risk posed.
  • We reviewed 21 care records. Although each patient had an individualised risk assessment completed on admission, information highlighted on initial risk assessments did not always feature on follow up assessments in 14 records, despite the risk still being present.
  • Staff described how they would identify and make a safeguarding referral. However, we reviewed one particular patient’s care record where safeguarding information had not been fully documented.
  • Staff did not record patient nursing observations on the enhanced observation charts. The nursing observations were in place to maintain patient safety. We found gaps where staff should have signed to indicate they had observed the patient in six out of 15 records we reviewed.
  • Patients’s physical health monitoring was recorded on both electronic and paper forms, however staff had not ensured that all elements of the forms had been completed in seven out of the 15 records we reviewed.
  • We found issues with medication on Peter Bruff ward. Prescription charts were unclear as to the cumulative doses of as required medication. This could have resulted in patients receiving doses above british national formulary limits. Medications had been prescribed and adminstered in breach of the certificate of second opinion (T3). We also found one intra muscular medication had been prescribed for a patient which had not been included on the certificate to consent to treatment form (T2). We brought this to the attention of the consultant psychiatrist and ward manager who said this would rectify this immediately.

However:

  • Vacancy levels across the wards were low. The established level of qualified nurses for the three wards was 30 whole time equivalents (wte). At the time of our inspection, there was one vacancy. The established level of nursing assistants for the three wards was 32 wte. At the time of our inspection, there was one vacancy.
  • Clinic rooms were visibly clean and had enough space to prepare medications and undertake physical health observations. Staff calibrated and checked physical health monitoring equipment weekly to ensure it was in good working order. Staff checked emergency resuscitation equipment daily.
  • Staff knew how to report incidents on the trust’s electronic reporting system.
  • Managers ensured that staff had received an annual appraisal.

27 July 2017

During an inspection of Wards for people with a learning disability or autism

We carried out a focused inspection at Byron Court due to concerns received by the CQC about the environment and the management of patients. We found the following issues that the trust needs to improve:

  • The trust did not have an effective system to identify and respond to risks posed by the ward environment. The wards contained fixtures that patients might have used as ligature anchor points. Also, maintenance work was not always of a high standard. For example, there were exposed screws that might have endangered patients.
  • The ward environment was sparsely decorated, with marks on walls in areas. There was a lack of robust furniture. Some patients did not have curtains or wardrobes in their rooms.
  • Trust audit systems to identify ligature risks for the service were not fully effective as some ligature points were not detailed on them.
  • Staff used a room to seclude patients that did not meet the Mental Health Act Code of Practice standards.
  • Patients did not have identified positive behavioural support plans (or equivalent) as identified in Department of Health policy to assist staff to manage patients with complex behaviours.
  • Trust data showed that the number of times that staff used physical restraint to control patients' behaviour had increased substantially in 2016/17.
  • Carers told us that staff’s communication with them could be improved and they were not always made to feel welcome when they visited.

However:

  • Patients gave examples of how staff helped them, for example with their physical health needs and to manage daily living skills.
  • Staff said there was good team working and they felt supported by their manager. Most staff were passionate about their work.
  • Byron Court was accredited with the ‘Quality Network for Inpatient Learning Disability Services’ with an ‘excellent’ rating.
  • The trust had identified that more nursing staff were needed to meet the current needs of patients. A senior manager had completed a nursing establishment review report July 2017 with a bid to request additional staffing. A new manager had just started in post.
  • Staff were developing a training package for other service staff to increase their awareness of how best to work with patients.