• Organisation
  • SERVICE PROVIDER

Cornwall Partnership 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

All Inspections

1st,2nd 3rd March 2022

During a routine inspection

We carried out this short notice announced comprehensive inspection of acute wards for adults of working age and psychiatric intensive care unit (PICU), community-based mental health services for adults of working age, specialist community mental health services for children and young people and child and adolescent inpatient wards of this trust as part of our continual checks on the safety and quality of healthcare services. At our last inspection we rated the provider as good.

We also inspected the well-led key question for the trust overall. We inspected four services and rated one as good (child and adolescent inpatient wards) and three as requires improvement (acute wards for adults of working age and psychiatric intensive care unit (PICU), community-based mental health services for adults of working age and specialist community mental health services for children services). Overall, we rated safe, effective, responsive and well led as requires improvement. We rated caring as outstanding.

We also inspected the trust's urgent and emergency care services in February 2022 as part of our urgent and emergency care programme. The service was rated good. This report is published separately on our website.

Cornwall Partnership NHS Foundation Trust delivers community health, mental health and learning disability services to people living in Cornwall and the Isles of Scilly. Cornwall and the Isles of Scilly have a population of 545,000 with a higher than average aging population. This increases by an average of 300,000 during the summer holidays with a total of 41 million visitors per year. The trust runs over 80 services in 130 sites across Cornwall and the Isles of Scilly. The trust has over 4,300 inpatient admissions annually across the 12 community health hospital sites and over 550 inpatient admissions to the mental health wards. The trust operates ten minor injury units with over 93,000 attendances per year. The trust employs over 4,100 staff.

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 rated one of the trust’s services as good. This was the child and adolescent mental health ward (which had not previously been inspected). We rated acute wards for adults of working age and psychiatric intensive care unit as requires improvement overall, with an inadequate rating in the safe domain. This had gone down from the rating of good given at our inspection in February 2018. We rated community-based mental health services for adults of working age as requires improvement. This had gone down from the good rating given at our last inspection in April 2019. We rated specialist community mental health services for children and young people as requires improvement, with an inadequate rating in safe. This had improved from the overall inadequate rating given following our inspection in April 2019. In rating the trust overall, we included the existing ratings of the nine previously inspected services.
  • We found environments at a number of the locations we visited to be in poor condition and not fit for purpose. This was a safety risk for patients using these services. On the acute wards for adults of working age and psychiatric intensive care unit the ward environments were not well maintained which caused staff difficulties in safely managing patients within the environments. For example, we found a ligature risk assessment on one ward that was not up to date and on two of the wards there were blindspots. On each ward there were areas of the environment that were not safe or were unfit for purpose and posed risks to the safety of the patients. All the wards we visited needed updating and maintenance work completed to make them more safe, therapeutic and comfortable for patients. For example windows on two of the wards were damaged and had been requiring repair for some months. In the specialist community mental health services for children and young people not all of the premises where young people were seen were safe, clean, well equipped, well maintained and furnished and fit for purpose. Only half of the services visited had environmental risk assessments. In one location there were ligature points such as screws protruding from the walls. In the same location furniture was not compliant with fire regulations. In the community-based mental health services for adults of working age not all of the locations we inspected were fit for purpose and required maintenance work to be undertaken. Three of the six teams inspected were located in premises that required maintenance works to be completed for issues such as damp, poor décor and damaged walls.
  • The trust’s estates issues were a key risk to the organisation. The trust was experiencing significant challenges arranging maintenance works across the service. The trust only owned 16% of their estate and in some locations were reliant on external contracts. There were ongoing issues in the management of external contacts to ensure appropriate repairs were carried out in a timely fashion. Some locations were operated through PFI providers. The trust had been experiencing significant difficulties in getting the PFI provider to complete maintenance in a timely manner. The trust informed us that they believe PFI’s were performing at a standard that was considerably below the standard expected in all areas. The trust had engaged NHSE/I, DHSC and the Cabinet office to support rectification of this situation. The estates team were working through these issues and in the process of developing a strategy.
  • The trust were facing workforce issues and a number of the teams we visited did not have enough staff and high vacancy rates. In the community-based mental health teams for adults of working age teams had only between 40% and 60% of the staff they should have. As a consequence, there were long waiting lists for patients to be seen and long waits for a range of therapies due to a lack of clinical psychologists and occupational therapists. The specialist community mental health services for children and young people had similar issues with staffing and the teams were not always able to provide treatments as the teams did not have access to the full range of specialist staff. Young people on the external waiting lists were not always monitored to detect, and respond to, increases in their level of risk. The acute wards for adults of working age and psychiatric intensive care unit had high vacancy rates for registered nurses and healthcare assistants. The services had to use high numbers of agency staff to ensure shifts were filled. Patients’ escorted leave or activities were often delayed or cancelled as there weren’t enough staff to facilitate these. In addition, the wards could not always provide patients with timely access to the full range of treatment and therapy options due to a lack of clinical psychologist.
  • As part of a governance review it had been identified there were issues in the way the trust was managing and investigating complaints. The trust was not classifying complaints and concerns accurately with a risk of complaints not being reviewed and investigated in line with requirements. The trust had 254 complaints open, 176 of these were outside the trust target of 60 days.
  • The trust did not have a current strategy which clearly defined objectives and deliverables aligned to trust and partner strategies. The trust also had a number of strategies which were out of date at the time of the inspection, this included the estates strategy and financial strategy.

However:

  • We rated the caring domain as outstanding.
  • Since our last comprehensive inspection of the trust in March 2019 there had been significant changes to the trust board and a number of new appointments, including a new chair, chief executive, chief operating officer, chief medical officer, chief information officer, chief nursing officer, executive director of finance and an executive director of corporate affairs and assurance. Several members of the executive board were undertaking their first executive appointments. These board members had been offered a mentor and undertook leadership training.
  • The trust executive board had a range of skills and knowledge to perform its role and deliver community health services and mental health services. The trust leadership demonstrated awareness of the priorities and challenges facing the trust and had acted at pace during the pandemic. The trust had been in a critical incident for a prolonged period of time and had been working to manage this situation.
  • The trust had reviewed governance arrangements and developed a Governance Improvement Plan (GIP). The work around governance identified a number of areas that required improvement. This work had been on going and a significant number of areas related to governance had been incorporated into the GIP. Improvements were on going and were in the process of being embedded to support the overall governance structure of the organisation.
  • The director of governance had identified areas of improvement required around risk management within the trust. An internal audit had validated these findings. The trust had taken steps to address this and developed a new risk management strategy which incorporated policy requirements. The implementation of the policy trust wide was early in its adoption and the trust were in the process of embedding a new risk management structure. There was a positive change in the risk culture apparent in the trust. Risk management had been a key focus for the trust and it was evident this work was gathering pace.
  • The trust had responded positively to previous inspection findings in 2019. For example, we saw improvements in the way the specialist community mental health services for children and young people age monitored patients on the internal waiting lists to keep them safe and respond to changing risks. This service had been rated inadequate in our previous inspection.
  • The trust leadership team had actively engaged with staff following negative staff survey results. The chair had commenced a culture review when new in post and recognised the need for this work with staff. The review had given staff the chance to share their views with the leadership team and make suggestions about improvements they would like to see being made. The leadership in the organisation had developed a plan to address the views and concerns of staff following the findings of the review in the form of a ‘You said, We did’ action plan.
  • The trust had introduced a Patient Leader programme. The programme had recruited and trained a number of patient volunteer leaders to ensure the patient and public voice was well represented in all aspects of service design and delivery. Patient leaders supported and co-produced quality improvement projects, review of services and participated in staff recruitment.
  • The board were committed to quality and inclusion. There was an active focus on equality, diversity and inclusion represented at board level. There were several staff networks who met regularly.

How we carried out the inspection

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic including on site and remote interviews by phone or online.

We visited six of the trust’s community-based mental health teams for adults of working age, we visited the West, Central and North East locality teams for the specialist community mental health services for children and young people, we visited the child and adolescent mental health ward and four acute wards for adults of working age and psychiatric intensive care unit (PICU).

During the community--based mental health teams inspection, the inspection team:

  • visited six ICMHTs (integrated community mental health team) over three days visiting the Team bases and speaking with multidisciplinary team members within each of the teams
  • spoke to all managers leading each of the teams
  • spoke to the overall teams community matron for service
  • interviewed six nurses
  • reviewed the quality of the environments
  • conducted three staff focus groups with 17 staff members including, employment coordinators, clinical lead occupational therapy, occupational therapy student, nurses, administrative staff, social workers, preceptorship mental health nurse and clinical psychologists
  • reviewed six clinic rooms
  • spoke to six patients
  • reviewed 34 care and treatment records including risk assessments.
  • reviewed two team meeting minutes
  • attended two multidisciplinary team meetings
  • looked at a range of policies and procedures.

During the specialist community mental health services for children and young people inspection, the inspection team:

  • visited the West, Central and North East locality teams. We also interviewed staff from the eating disorder service, the learning disability team, the intensive support team and the access team
  • interviewed the manager for each team and the overall service managers
  • reviewed 18 care records
  • spoke with three young people and seven parents or carers
  • spoke with 26 staff from all the teams
  • reviewed a number of policies, meeting minutes and assessments related to the running of the services
  • observed two therapy sessions
  • observed several staff members in two multidisciplinary team meetings

During the child and adolescent mental health ward inspection, the inspection team:

  • visited the site and looked at the quality of the ward environments and observed how staff were caring for young people
  • spoke with six young people who used the service and six parents and carers
  • reviewed five electronic and paper copies of care and treatment records
  • spoke with 11 members of staff including a specialist paediatric pharmacist, the operational lead for inpatient CAMHS (child and adolescent mental health services) and urgent care pathway, a speciality doctor, a family therapist and family liaison officer. We also spoke to healthcare assistants and nurses
  • reviewed a range of documents relating to the running of the service
  • looked at medicines management, including medicines charts and electronic systems.

During the acute wards for adults of working age and psychiatric intensive care unit (PICU) inspection, the inspection team:

  • visited four inpatient wards: Carbis and Perran ward at Longreach House and Fletcher and Harvest ward at Bodmin Hospital. We were unable to enter Cove ward due to an outbreak of COVID-19 on the ward
  • spoke with 17 members of nursing staff including registered nurses, health care assistants, agency nursing staff and student nurses
  • spoke with seven multidisciplinary team members including occupational therapists, social inclusion officers, pharmacists, and a clinical psychologist
  • spoke with leaders of services, including modern matrons, clinical and quality leads, ward managers, a nurse consultant and members of the estates team
  • completed a focus groups with mental health advocates that visited the ward
  • spoke to members of the estates team
  • interviewed 16 patients and five relatives of patients
  • reviewed 18 patients’ care and treatment records
  • carried out a specific check relating to medication management on the wards and reviewed medicines administration records for 19 patients
  • looked at a range of policies, procedures and other documents relating to the running of each service.

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.

01 February, 02 February, 03 February 2022

During an inspection of Community urgent care services

Cornwall Partnership NHS Foundation Trust provides urgent care at 10 minor injury units located across the county. Minor injury units (MIUs) provide treatment and advice on a range of minor injuries and illnesses not serious enough to require accident and emergency department treatment.

Our inspection was a short notice announced inspection so we could check if all sites were accessible on the day of inspection. We had a focus on the urgent and emergency care pathway for patients across the integrated care system in Cornwall. We carried out a comprehensive inspection of this service so we could provide a rating of the service.

A summary of CQC findings on urgent and emergency care services in Cornwall

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Cornwall below:

Cornwall

The health and care system in this area is under extreme pressure and struggling to meet people’s needs in a safe and timely way. We have identified a high level of risk to people’s health when trying to access urgent and emergency care in Cornwall. Provision of urgent and emergency care in Cornwall is supported by services, stakeholders, commissioners and the local authority and stakeholders were aware of the challenges across Cornwall; however, performance has remained poor, and people are unable to access the right urgent and emergency care, in the right place, at the right time.

We found significant delays to people’s treatment across primary care, urgent care, 999 and acute services which put people at risk of harm. Staff reported feeling very tired due to the on-going pressures which were exacerbated by high levels of staff sickness and staff leaving health and social care. All sectors were struggling to recruit to vacant posts. We found a particularly high level of staff absence across social care resulting in long delays for people waiting to leave hospital to receive social care either in their own home or in a care setting.

GP practices reported concerns about the availability of urgent and emergency responses, often resulting in significant delays in 999 responses for patients who were seriously unwell and GPs needing to provide emergency treatment or extended care whilst waiting for an ambulance. GPs also reported a lack of capacity in mental health services which resulted in people’s needs not being appropriately met, as well as a shortage of District Nurses in Cornwall.

A lack of dental and mental health support also presented significant challenges to the NHS111 service who were actively managing their own performance but needed additional resources available in the community to avoid signposting people to acute services. The NHS111 service in Cornwall worked to deliver timely access to people in this area, whilst performance was below national targets it was better than other areas in England.

Urgent care services were available in the community, including urgent treatment centres and minor illness and injury units and these services were promoted across Cornwall. These services adapted where possible to the change in pressures across Cornwall. When services experienced staffing issues, some units would be closed. When a decision was made to close a minor injury unit (MIU) the trust diverted patients to the nearest alternative MIU and updated the systems directory of services to reflect this. However, this carried a potential risk of increased waiting times in other minor injury units and of more people attending emergency departments to access treatment. This had been highlighted on the trust’s risk register.

Due to the increased pressures in health and social care across Cornwall, we found some patients presented or were taken to urgent care services who were acutely unwell or who required dental or mental health care which wasn’t available elsewhere. Staff working in these services treated those patients to the best of their ability; however, patients were not always receiving the right care in the right place.

Delays in ambulance response times in Cornwall are extremely concerning and pose a high level of risk to patient safety. Ambulance handover delays at hospitals in the region were some of the highest recorded in England. This resulted in people being treated in the ambulances outside of the hospital, it also meant a significant reduction in the number of ambulances available to respond to 999 calls. These delays impacted on the safe care and treatment people received and posed a high risk to people awaiting a 999 response. At the time of our inspection, the ambulance service in Cornwall escalated safety concerns to NHS England and NHS Improvement.

Staff working in the ambulance service reported significant difficulties in accessing alternative pathways to Emergency Departments (ED). When trying to access acute assessment units, staff reported being bounced back and forth between services and resorting to ED as they were unable to get their patient accepted. Many other alternative pathways were only available in specific geographical areas and within specific times, making it challenging for front line ambulance crews to know what services they could access and when. In addition, ambulance staff were not always empowered to make referrals to alternative services. The complexity of these pathways often resulted in patients being conveyed to the ED.

Hospital wards were frequently being adapted to meet changes in demand and due to the impact of COVID-19. There was a significant number of people who were medically fit for discharge but remaining in the hospital impacting on the care delivered to other patients. The hospital had created additional space to accommodate patients who were fit for discharge but were awaiting care packages in the community; however, staff were stretched to care for these patients.

Delays in discharge from acute medical care impacted on patient flow across urgent and emergency care pathways. This also resulted in delays in handovers from ambulance crews, prolonged waits and overcrowding in the Emergency Department due to the lack of bed capacity. We found that care and treatment was not always provided in the ED in a timely way due to overcrowding, staffing issues and additional pressure on those working in the department. These delays in care and treatment put people at risk of harm.

In response to COVID-19, community assessment and treatment units (CATUs) had been established in Cornwall. These wards were designed to support patient flow, avoid admission into acute hospitals and provide timely diagnostic tests and assessments. However, these wards were full and unable to admit patients and experienced delayed discharges due to a lack of onward care provision in the community.

Community nursing teams had been recently established to support admissions avoidance and improved discharge. This work spanned across health and social care; however, at the time of our inspections it was in its infancy so we could not assess the impact.

The reasons for delayed discharge are complex and we found that discharge processes should be improved to prevent delays where possible. However, we recognise that patient flow across the Urgent and Emergency Care pathway in Cornwall is significantly impacted on by a shortage of staffed capacity in social care services. Staff shortages in social care across Cornwall, especially for nursing staff, are some of the highest seen in England. This staffing crisis is resulting in a shortage of domiciliary care packages and care home capacity meaning many people cannot be safely discharged from hospital. A care hotel has been established in Cornwall providing very short-term care for people with very low levels of care needs; this is working well for those who meet the criteria for staying in the hotel, however this is a relatively small number of people.

Without significant improvement in patient flow and better collaborative working between health and social care, it is unlikely that patient safety and performance across urgent and emergency care will improve. Whilst we have seen some pilots and community services adapted to meet changes in demand, additional focus on health promotion and preventative healthcare is needed to support people to manage their own health needs. People trying to access urgent and emergency care in Cornwall experience significant challenges and delays and do not always receive timely, appropriate care to meet their needs and people are at increased risk of harm.

Summary of Cornwall Partnership NHS Foundation Trust urgent care service

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

  • Staff had training in key skills and had completed the required mandatory training, they understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records.
  • Staff triaged patients within national target times and the prioritisation system was clear. The clinical need of the patient dictated the priority in which they were seen. The service had access to mental health liaison and specialist mental health support.
  • Staff within the service managed medicines well. They managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment and gave patients pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • The service had enough nursing and support staff to keep patients safe.
  • The trust had robust arrangements in place if a minor injury unit had to close due to staffing issues. Patients would be redirected to another minor injury unit to be seen quickly. The trust had highlighted this on the risk register and monitored the impact on patients and on whether it impacted on increased pressure on Emergency Department attendances.
  • The minor injury units occasionally stayed open past their commissioned hours in order to support an increase of patients within the system.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Outcomes for patients were positive, consistent and met expectations, such as national standards.
  • Staff met daily with ambulance crews, doctors, GPs, clinical specialists and emergency nurse practitioners to discuss patient care and ensure any issues facing any party could be addressed speedily.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. Managers made sure staff received regular wellbeing checks during the Covid 19 pandemic. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Blood pressure machines at Camborne Redruth minor injury unit required safety checks – we found these had not been recalibrated when required in September 2021.
  • Staff did not always label medicines supplied to take home with the hospital address.
  • We saw that’s some healthcare assistants (HCAs) were not supervised when carrying out certain assessments that required direct supervision by a senior practitioner, for example, when carrying out assessment of head injuries
  • Staff working in minor injury units did not have access to the trust’s main shared electronic patient record which caused frustration for staff when trying to access information about a patient who had used other services within the trust.
  • Staff working at St Austell minor injury unit were following an out of date printed standard operating procedure for minor injury units.
  • Not all staff were receiving regular supervision and appraisals, completion of these had been affected by Covid 19 although managers made sure that staff received regular well being checks
  • Community assessment and treatment units had been set up specifically to care for older people which MIU teams could request admission to for local, rapid assessments and treatment. However, these units were full and patients experienced delays to their discharge due to a lack of onward care provision in the community.
  • Some staff were not always using approved translators to communicate with patients who required this service.
  • The trusts patient advice and liaison service (PALS) did not always respond to patients and families who made complaints about the service in a timely manner.

How we carried out this inspection

We visited six out of the 10 minor injury units at Camborne and Redruth, Helston, Liskeard, St Austell, Bodmin and Newquay. The minor injury units were nurse-led and provided advice and treatment for minor injuries. The full range of services on offer varied greatly, including the treatment of minor illness depending on the staff available and the setting the service was provided in. Primary care medical support was available from a General Practitioner at one minor injury unit, Camborne and Redruth. Patients who needed to access the service were advised to contact NHS 111 by phone or online to find out where they should go and when. These patients were then offered appointments at the most suitable unit. However, patients who turned up without an appointment were still seen and prioritised according to clinical need.

Services were provided in most units seven days a week from 8am to 10pm (Helston 8am to 8pm). Each unit was staffed by registered nurses and/or paramedic practitioners, healthcare assistants and a receptionist. The MIUs employed band six and seven nurses, with band five nurse development posts. Not all units had access to a health care assistant and a receptionist outside of normal working hours and at weekends. Of the 10 minor injury units, nine locations provided X-ray departments. Attendances at the minor injury and illness units fluctuated, with an increased demand during holiday seasons.

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

  • Is it safe?
  • Is it effective?
  • Is it caring?
  • Is it responsive to people’s needs?
  • Is it well-led?

During the inspection visit, the inspection team:

  • visited six of the 10 minor injury units and looked at the quality of the environment and observed how staff were caring for patients;
  • spoke with 42 members of staff across the units including: registered nurses, health care support workers, paramedics, administrators and a consultant nurse;
  • spoke with 25 patients and one carer;
  • looked at 45 patient records;
  • looked at the medicines storage and medicines administration records at all sites;
  • reviewed local policies, procedures and audits at all sites.
  • held a staff focus group for those staff unable to contribute during the inspection.

02 October 2019

During an inspection of Specialist community mental health services for children and young people

This inspection was a focussed inspection so therefore did not provide a rating. The purpose of the inspection was to see if the provider had made significant improvements to the service following the issuing of a section 29 warning notice in April 2019.

  • The trust had recruited to all but two of their vacancies. The trust had employed more than 30 additional clinical associate psychologists to support assessments and an additional quality lead to provide oversight and assurance for team leaders to make the required improvements following the section 29a warning notice. The trust had developed and implemented an escalation plan for managers to use should staffing incidents pose a threat to the safe running of the service. This was being implemented effectively at the time of our inspection. Staff morale was much improved with increased engagement and development opportunities being provided by the trust.
  • Since our inspection in March 2019, every young person on the waiting list had been contacted and their risk reviewed. Urgent and emergency cases were being followed up by the CAMHS crisis team or early intervention in psychosis team as required. The crisis team undertook a thorough assessment including an assessment of risk after the first appointment. Urgent cases were seen within 48 hours. Young people on the waiting list were being contacted regularly to ensure staff were aware of any change in presentation or risk.
  • The trust had developed and implemented new electronic caseloads, with reporting functions, to ensure appropriate management of waiting lists within teams. Waiting times in the mid teams had reduced significantly and were improving in the east teams. The trust had developed an operational plan to address the long waits for a first assessment.
  • Individual staff caseloads were now much lower due to the increase in staffing and transparency in viewing caseloads on the new electronic system. New managers no longer held a clinical role and therefore did not hold the large caseloads we saw during our last inspection.
  • The trust had developed processes which meant they had complete oversight of the key issues raised in the warning notice. Operational managers and other senior members of staff monitored and audited a live waiting list to ensure wait times were reducing and high risk young people were being seen. Staffing issues were now known to the senior management team via a new escalation process and incident reporting and complaints were being monitored through operational governance meetings.
  • All staff had received training and ongoing support in incident reporting, processing complaints and learning from adverse events. Incidents and complaints were now a standing agenda item during team meetings.

However:

  • At the time of our inspection, 73% of young people in the east teams had breached the trust’s target of being seen within 28 days for an initial assessment. Current wait times for a first assessment was 117 days (17 weeks) in the east teams. There were 47 young people waiting for treatment in the east teams who had been waiting for an average of 37 weeks. 54% of young people had breached the trust’s target of 84 days of being seen for treatment following their assessment.
  • The manager for the east teams had several overdue incident reports to review.
  • Some staff in the east teams were not keeping the wait list up to date.

05 Mar to 03 Apr 2019

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

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

  • All staff demonstrated a strong, visible, person-centred culture. Staff were highly motivated and inspired to offer care that was kind, compassionate and promoted patients’ dignity. This was reflected in the way staff interacted with patients, patients care records and during multidisciplinary meetings.
  • Patients were active partners in their care. Staff were fully committed to working in partnership with patients and supported patients to make decisions about their care for themselves. They understood the trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity appropriately and clearly. Feedback from all carers was positive and all felt staff went the extra mile.
  • Patients had comprehensive assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. Staff developed holistic care plans informed by a comprehensive assessment.
  • Patients’ individual preferences and needs were always reflected in how care was delivered. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. The expected outcomes were identified and care and treatment were regularly reviewed and updated. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Staff actively and holistically focussed on the safe and supportive discharge of patients. Despite considerable difficulty in finding placements for patients following discharge staff worked together as a team and with other agencies to support the patients’ safe and timely discharge wherever possible.
  • Staff supported patients with family relationships. Families were encouraged to visit their relatives on the ward, there were no restrictions around visiting times. Patients were supported to visit their families at home as appropriate.
  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk thoroughly. Staff managed medicines safely and followed good practice with respect to safeguarding adults at risk.
  • The ward teams included, or had access to, the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

05 Mar to 03 Apr 2019

During an inspection of Community urgent care services

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

  • Staff in the minor injury units had received training to ensure they could keep patients safe. The staff team followed the correct procedures to keep the MIUs clean and reduce the spread of infection. Staff made sure all equipment was correctly maintained so it was ready for use. Staff recorded patient care and incidents following trust processes. Staff shared learning and apologised for mistakes.
  • All the MIUs worked to the same policies and procedures. Staff assessed pain and gave effective pain relief promptly. The trust collected information from across the MIUs and used it to improve services. The teams worked well together and with other services. Staff considered patients’ capacity before giving care.
  • Staff treated all patients with dignity. Staff were professional when giving care. Staff had made reasonable adjustments to ensure all patients were involved in their care.
  • The staff worked across the MIUs to ensure services were available where needed. Staff worked to meet the needs of all patients. Staff followed procedures so that if patients’ needs changed they recognised this and met them. The trust had addressed the delays in acutely ill patients being transferred by ambulance from the MIUs to the local general hospitals. Patients were advised how to raise complaints with the trust and learning was shared.
  • Staff felt supported by leaders at all levels in the trust. There was a vision for the MIUs and the trust was reviewing the services to ensure it met the community’s needs.

However:

  • Staff at the Helston MIU could not observe all patients as they waited in the waiting rooms due to the layout. Not all the units had separate staff teams and staff occasionally had to stop the treatment of one patient to triage another patient who had just come into the MIU to ensure they didn’t need urgent attention. Not all staff had signed the patient medicines group directions to show they had read and understood them.
  • Not all staff in each of the MIUs had received supervision.
  • It was not clear on the trust’s website when GPs were available at the Camborne and Redruth.

05 Mar to 03 Apr 2019

During an inspection of Community health inpatient services

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

  • Staff recorded patient risks and completed comprehensive risk assessments. Staff understood safeguarding processes and knew how to report abuse. Staff reported incidents and learned from them.
  • Staff across all wards followed national guidance when providing care to patients. The ward teams worked well together when planning, assessing and managing patient care.
  • Staff were highly motivated and delivered compassionate care to patients. Staff treated patients with dignity and respect. There were good interactions between staff and patients. Feedback from patients and carers was positive. The trust sought feedback from patients and carers to improve service delivery. Staff were considerate of patients spiritual, cultural and religious beliefs.
  • Each ward had clear admission criteria which staff understood. Patients were able to make choices about their care. Care and treatment were delivered in collaboration with health and social care providers to meet the needs of patients. Patients were able to raise concerns and staff reviewed and acted upon these appropriately
  • Staff felt supported by the leadership within the trust. The trust had a vision and strategy which staff within the services understood and signed up to. The service had a system of governance in place to improve the quality of care provided to patients. The trust engaged well with staff, patients and carers.

However:

  • Cleanliness on four wards at three hospitals was not good enough. There were gaps in cleaning rotas, poor compliance with infection control and unhygienic food standards. Equipment was not always maintained well.
  • Staffing levels on two wards at two hospitals was not always met and shifts were unfilled. This created additional pressure on staff.
  • There were some gaps in the recording of patients’ capacity to consent.
  • Staff found the electronic rostering system frustrating and time consuming to use.

05 Mar to 03 Apr 2019

During an inspection of Community end of life care

  • Staff completed and updated risk assessments for each patient and responded when the patient’s condition deteriorated. Community staff kept detailed records of patients’ care and treatment. The services followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medicines at the right dose at the right time. In the wards and community there was timely access to equipment to support patients at the end of life. Nutrition and pain needs were met. The service adjusted for patients’ religious, cultural and other preferences.
  • The community service had enough nursing and medical staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. Doctors, nurses and other healthcare professionals supported each other to provide good care. Staff worked collaboratively with other health professionals and across healthcare disciplines to ensure continuity of specialist and individualised care for patients.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers monitored the effectiveness of care and treatment and used the findings to improve them. Audits were completed on the wards through the guidance of the end of life care facilitator, and in the community by the specialist palliative care teams.
  • The trust set a target of 85% for completion of mandatory training. The compliance for mandatory training courses at 30 November 2018 was 78%. Of the training courses listed, 15 failed to achieve the trust target. End of life staff confirmed they had completed the mandatory training and found it relevant and helpful. Further specific training was provided to staff to support end of life care. Staff all confirmed they felt supported in their development and had supervision in the last year.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent. Since our last inspection in 2017 a review had taken place of the treatment escalation plan, this is a form for clinical guidance which includes mental capacity and agreed ceilings of care. Audit results showed an improvement in completion.
  • Staff cared for patients with compassion. Patients gave feedback that staff treated them well and with kindness. Throughout our inspection we observed patients being treated with the highest levels of compassion, dignity and respect. Staff provided emotional support to patients to minimise their distress and involved patients and those close to them in decisions about their care and treatment.
  • The trust planned and provided services in a way that met the needs of local people. The service took account of patients’ individual needs. The trust worked with stakeholders, including commissioners and other providers, to promote end of life care across the county.
  • The service treated concerns and complaints seriously, investigated them, learned lessons from the results, and shared these with all staff. Complaints were managed in an effective way.
  • Leaders at ward level and in the community had the right skills and abilities to run a service providing high-quality sustainable care. The trust had a vision for what it wanted to achieve and was working on plans to turn it into action. In Cornwall the work on an end of life strategy was being implemented as part of a whole system approach.
  • End of life leads across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. We found there was a positive culture across the services we visited.
  • The trust used a systematic approach to monitoring and improving the quality of its end of life services.
  • There were systems to ensure end of life services were monitored and appropriate action taken to improve services. The service had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust had recently implemented an end of life risk register.
  • The end of life service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The end of life service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

  • At Camborne Redruth, Newquay, Helston, Bodmin, St. Mary’s and Falmouth hospitals, end of life care plans were not consistently used and the care plans were not as personalised as they could have been.
  • Care and treatment was not always provided in accordance with national guidance. The Gold Standards Framework system was in place across the service but was not used consistently used. At Camborne, Redruth, Newquay, Helston, Bodmin, St. Mary’s and Falmouth hospitals, staff did not fully complete the Gold Standard Framework care plans.
  • The Continuing Health Care Team provided by the trust was only available in part of the county. The trust was only commissioned to provide this service for part of the county. This meant that the team, that covered the middle of the county, could provide a more responsive and accessible service although good care was provided in all areas of the county Training was not consistently provided across all areas of the county. Nurses on the Isles of Scilly required update training for both syringe drivers and verification of death.
  • The trust leadership was not visible to all the end of life care service. Changes were planned following staff feedback, which would see the process being updated.

05 Mar to 03 Apr 2019

During an inspection of Community health services for adults

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

  • There were systems and processes to protect patients from healthcare-associated infections. Staff completed risk assessments and the service mostly had suitable premises and equipment. However, the completion of patient records varied and learning from incidents were not always shared effectively across teams in different areas.
  • The service delivered care based on current national guidance. Many specialist services used outcome measures to evaluate the effectiveness of care and treatment. There was good multidisciplinary working across all localities although it was a challenge to extend specialist services to the Isles of Scilly.
  • Staff were compassionate, and patients told us staff were kind and delivered exemplary care. Staff supported patients’ carers.
  • Staff took account of each individual’s care needs. Referral to treatment times were mostly met and referrals were triaged using effective processes. The service did not receive many complaints about care from patients and their relatives.
  • Leadership and governance structured had strengthened. Managers promoted a positive culture and most staff told us they felt valued.

05 Mar to 03 Apr 2019

During an inspection of Specialist community mental health services for children and young people

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

  • We had serious concerns about the safety of young people in two of the six teams (the mid and the east local teams). The trust did not have clear oversight of the large number of children and young people waiting for treatment, the length of time they had waited nor the level of risks for each of those on the waiting list. The trust was not aware that risks were not being managed appropriately.

  • The trust lacked an understanding of the impact that staff moving from the mid and east teams to newly developing teams was having on the mid and east teams’ ability to deliver a service in a timely manner. Concerns by staff about the level of risk in the service had not been escalated appropriately to the trust senior team due to changes in the way the services were managed. The child and adolescent mental health services (CAMHS) had recently been transferred to the mental health directorate from the children’s directorate but robust governance systems had not been put in place and information that could have identified issues had not been picked up.

  • Some of the services did not provide safe care. The trust did not have enough staff with the right skills in the mid and the east team to see all the children and young people allocated to them for a first assessment following identification that they needed to be seen by the CAMHS. The risks were not being picked up or managed appropriately. Staff told us that they thought the service was unsafe. Local management was unable to provide an accurate record of current staff establishment and vacancies. Staff kept important information relating to patient care in several separate places, including the electronic record system and individual managers own spreadsheets. The electronic records could not be interrogated by the team managers, so they didn’t fully understand which children and young people were allocated solely to them or to other team members (for example, the consultant) or were awaiting allocation for treatment. Following a review of records, we found that a number of children and young people whose mental health had seriously deteriorated and suffered harm because they could not be seen in a timely manner due to insufficient numbers of staff. Staff told us that they thought the service was unsafe. Staff had not ensured that all the premises were safe for the young people. The managers had not all completed ligature and environmental risk assessments on the premises. The waiting area on the Truro site had not been changed since the last inspection. Young people waited in an area that was not observed by reception and was stark and not child friendly.
  • The mid and east CAMHS teams did not have robust governance systems. This meant that there was very little oversight of the quality of services being delivered, how complaints were being managed or whether incidents were being reported, addressed and learnt from. This meant that opportunities to identify issues and make improvements were being missed.

  • Care plans and crisis plans were inconsistent across the sites we visited so did not support all the teams to deliver safe care and treatment to young people.

  • Staff members did not consistently record incidents. Managers in mid and east teams could only see a list of incidents on the reporting system but did not have access to the analysis function to look at trends. Lessons learnt across the trust were not known to the mid and east staff teams as they were to the staff in the west teams. This meant that opportunities to identify issues and make improvements were being missed.

  • The local governance meetings that had taken place when CAMHS was part of the children’s directorate had been dominated by the risks and impact of the transfer of school nursing and health visiting to the local authority. As a result, concerns about CAMHS had not been adequately considered. Information presented to the trust board about CAMHS had not identified the issues in mid and east teams as the information was presented for CAMHS and was not broken down to individual team level; four of the teams were working effectively so this masked the poor performance of the mid and east teams. Following the inspection, the trust commenced governance meetings specifically dedicated to CAMHS to ensure clear oversight of the concerns and ensure all action required was addressed and monitored.

However:

  • Children and young people and their families were positive about the care and treatment from the staff teams. Staff treated children and young people with compassion and dignity. Feedback from young people confirmed that staff treated them well and with kindness.

  • Staff provided an out-of-hours advice service to colleagues in other organisations should they be worried about the mental health of a child or young person. The crisis team had been developed into a large team and had a base at the local hospital and in local teams. They offered a more responsive service as they had extended their hours from a 5pm finish to an 8pm finish; with plans to ultimately have a 10pm finish.

05 Mar to 03 Apr 2019

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

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

  • Staff completed and updated risk assessments for each patient and used these to understand and manage risks appropriately. The service responded well to safeguarding concerns and managed patient safety incidents well.
  • Staff developed individual care plans and updated them when needed. Staff provided a range of treatment and care for patients based on national guidance and best practice.
  • Managers ensured they had staff with a range of skills needed to provide high quality care. They supported staff with opportunities to update and develop their skills.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005, seeking support within the team as needed.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs.
  • Teams had worked to reduce their waiting lists, and developed systems and processes to ensure oversight of all people waiting for allocation or support.
  • Managers had the skills and abilities to run the service, and promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

  • Staff did not follow best practice when dispensing and recording medicines. We found a number of errors and omissions in recording information on patient medication charts. Staff did not always recognise medication errors as patient safety incidents and did not report these appropriately.
  • Physical healthcare checks were not carried out for all patients in line with National Institute for Health and Care Excellence guidelines. Staff only carried out routine physical healthcare checks for high risk patients. The service acknowledged that there were improvements to be made in physical healthcare monitoring and support. There were plans in place and actions being progressed to address this at the time of the inspection.

05 Mar to 03 Apr 2019

During a routine inspection

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

  • We rated the trust as outstanding overall for the key question, 'are services caring' and as good for effective, responsive and well-led. We rated safe as requires improvement overall. At this inspection we rated one of the seven core services that we inspected as outstanding, five as good and one as inadequate. In rating the trust overall, we took into account the current good ratings for the six services not inspected this time.
  • Staff in the trust had worked hard to address the concerns we had raised at our last inspection. Five services that had previously been rated requires improvement at the last inspection were now rated as good. Community health services including community hospitals and minor injury units had all improved, as had community mental health teams.
  • We rated wards for older people with mental health problems as outstanding due to the way that the staff worked with patients and their families and how they ensured patients moved on to appropriate placements despite a challenging environment which had seen over 200 nursing home beds closed locally since 2016. Staff implemented creative solutions so they could get patients discharged home or into a care placement when there were limited placement options. The complex care and dementia nurse consultant who was also the responsible clinician, actively focussed on the discharge of patients through visiting and educating staff in nursing homes about settling patients post discharge. Occupational therapists supported patients on home visits to support the discharge process.
  • Effective leadership in the community health services and community mental health teams had led to improvements in those services. In particular the positive impact of a GP working as primary care director and a nurse consultant overseeing the pathway in the minor injury units. The consultant nurse for MIUs had reviewed the operating policy since the last inspection and had introduced the same one across all MIUs. This covered staffing, training, and scope of practice. The primary care director also worked as a GP and had helped improve links with other health providers.
  • Recent growth of staff in the pharmacy team meant that clinical pharmacy support was more widely available across the trust in both community and mental health services.
  • The trust had developed innovative approaches to improve dementia services for people who identify as LGBT. A specialist nurse had been awarded a Winston Churchill Fellowship and had visited Australia to learn from work completed there.
  • Improvements had been made to how the trust learnt from deaths. A new suicide prevention training program and learning from how the trust engaged with families following deaths and during the investigation had been completed with a parent’s involvement as part of the team.
  • The trust had an experienced stable senior leadership team with the skills, abilities, and commitment to provide high-quality services. The executives and non-executives presented as a strong unified board.
  • The board and senior leadership team had set a clear vision and values that were at the heart of all the work within the organisation. They worked hard to make sure staff at all levels understood them in relation to their daily roles. This was demonstrated by the work to change the culture of the enlarged organisation and bring the trust together as one following the transfer of the community health services contract to the trust in 2016.
  • The culture of the trust had improved and staff morale was high in the majority of services. Staff felt respected, supported and valued by their managers and the trust.
  • Senior leadership in the trust had improved relationships with partner organisations and were engaging positively in the wider health systems.

However:

  • We had serious concerns about the safety of child and adolescent mental health services in the two of the six teams. The trust did not have clear oversight of the large number of children and young people waiting for treatment, the length of time they had waited nor the level of risks for each of those on the waiting list in the two teams. Despite improvements in other child and adolescent mental health teams the trust was not aware of the impact staff moves to newly developing teams had on the mid and east teams’ ability to deliver a service in a timely manner. Concerns by staff about the level of risk in the service had not been escalated appropriately to trust senior team due to changes in the way the services were managed. As a result of the significant concerns identified on the inspection we issued a section 29a warning notice to the trust. The warning notice served to inform the trust that it must take immediate action to address the serious concerns. The trust responded positively and took immediate action to address the concerns and put plans in place to ensure children and young people received a timely, safe service.
  • There were issues with staffing, cleanliness and infection control at three out of the 13 community hospitals. Not all wards had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trust took immediate action to address the concerns at the time of inspection.

25-29 September 2017 3-5 October 2017

During a routine inspection

Following the inspection in September 2017, we have rated Cornwall Partnership NHS Foundation Trust as requires improvement because:

  • At the time of our inspection, three of the trust’s 13 hospitals were subject to an organisation review under Section 42 of the Health and Social Care Act 2014. This related to a number of safeguarding concerns initially raised under organisation abuse by CFT in April 2016 following the transfer of services from PCH on 1 April 2016. The trust had implemented an action plan to address these concerns; this was ongoing.
  • Not all premises were suitable for patient assessment, treatment and maintaining confidentiality. Falmouth, Newquay, Bodmin and Liskeard hospitals stored hazardous substances in unlocked sluices, including bleach tablets, cleaning solutions and nail varnish remover. The physical environments at Bolitho House, Truro Health Park and St Austell required improvements; including some basic maintenance and ensuring safe and age appropriate environment for children and young people. Truro integrated community mental health team had not carried out a health and safety audit since 2013. Staff based at Caradon did not know how to activate the emergency alarms. Within some community health services, lone working systems and processes did not ensure the safety of staff. This left staff working on call vulnerable and posed a risk to their safety.
  • Some community-based services did not have a sufficient number of staff. Five out of the six integrated community mental health teams that we inspected had vacancies. At the time of the inspection there were approximately 114 patients unallocated for treatment and the trust did not have a clear process in place to monitor these patients. In the minor injuries unit’s reception staff did not work out of core hours or at weekends and there was no observation of patients in the waiting room at these times; there was a risk that patients with serious or life-threatening conditions may not be identified promptly. In the specialist community mental health services for children and young people there was not enough provision of service to provide a safe service for the numbers of children and young people need care.
  • Medicines management systems were not robust in all trust clinical settings; not all clinic rooms contained the expected equipment and in some cases where there was medical equipment it was not calibrated or tested in line with the trust policy. None of the six integrated community mental health teams had a robust system in place for the management of medicines. We found out of date medicines and medicines not being stored at the correct temperatures. A fridge in the Bodmin clinic had not had the temperature recorded since November 2016.The cards used to record patient’s depot medicine had essential information missing from a number of cards. In Kerrier, a paliperidone injection box (an anti-psychotic individually prescribed medication), had its patient label removed. Cover provided by pharmacists and pharmacy technicians across the community inpatient service was inconsistent.
  • Compliance with mandatory training was low; data provided by the trust up to May 2017 showed that the training compliance for trust-wide services was 54% against the trust targets of either 85%, or 95%.

However, we found the following areas of good practice:

  • Staff were positive about working for the trust as an employer and said it encouraged individual services to improve and had a ‘no-blame’ culture. Staff knew who senior managers were and generally felt they were visible. Senior managers and executive board members had visited all locations, though staff on the Isles of Scilly felt distant and at times forgotten by the organisation following several cancelled visits. Non-executive directors had a good understanding of the trust’s strategy and presented appropriate challenge to the executive team.
  • There was good assessment and management of risk throughout most services. For example, ligature risk assessments were in place and well managed either by rectifying the issues identified or by actively managing the areas where risk was identified to reduce the risk to patients.
  • Generally, the wards and community environments were clean, bright and well furnished. The trust was committed to refurbishing environments that required it. However, at the Bodmin hospital site there were difficulties with refurbishment and maintenance programmes. The site was managed as part of a private finance initiative and the provider struggled to get the landlord to make changes and improvements as required in a timely manner. The trust had taken legal action against the landlord to get improvements made.
  • The trust had robust infection control policies and procedures and staff adhered to these across almost all environments.
  • Staff delivered care and treatment to patients in a kind, caring manner that respected their dignity. Where concerns had been expressed by patients and carers this had been addressed appropriately and in line with the expectations of duty of candour. Staff described an awareness of the need to be open and apologise to patients when necessary.
  • There was a strong commitment to patient safety, the community team for learning disabilities and autism would routinely follow up service users discharged from their service to identify any changes to their epilepsy. This aimed to reduce cases of sudden death in epilepsy.
  • The majority of the patients that we spoke with on the wards were positive and complimentary about the support they received from staff. Staff interacted with patients positively and respectfully. They demonstrated that they knew the patients well in their interactions with patients and in their responses to them. This was particularly apparent on Fettle ward where there were many opportunities for patients to have their voice heard and staff helped them realise their potential. Staff truly valued patients emotional and social needs and were committed to helping them recover in a meaningful way.
  • Care plans mostly documented patients’ wishes and feelings about their treatment with the exception of the community mental health teams where there was a lack of recording to show that the patient had been involved in developing their care plan. Where it was appropriate carers and family members were involved in the care planning process. Staff referred carers for assessments and advocacy support when needed.
  • The trust had processes in place to identify and report serious incidents. Risks were generally well managed across most services with locally held risk registers that fed into the trust wide risk register. There were robust processes in place to review risks at both local and trust level and plans were agreed at board level to reduce significant risk across the organisation.

25, 26, 27, 28 & 29 September 2017

During an inspection of Community health inpatient services

Overall we rated community inpatient service as requires improvement because:

  • Staffing levels across the service were inconsistent. There were high levels of vacancies, which, despite a high agency and bank staff use, resulted in unfilled shifts.
  • Feedback from incidents was not provided promptly.
  • Storage of medicines was not always safe.
  • Cover provided by pharmacists and pharmacy technicians across the service was inconsistent.
  • The recording of equipment across the service was not always effective which presented safety issues.
  • There were delays in repairing and replacing equipment.
  • Processes for checking resuscitation trollies were not always followed across the service.
  • Safety issues occurred in relation to infection, prevention and control measures as process were not always adhered to.
  • Staff did not always follow policy, guidance and legislation regarding the Mental Capacity Act as documentation was not always completed.
  • Clinical supervision was not formalised or embedded across the service.
  • Managerial supervision was inconsistent.
  • Patients using the community hospital alcohol detoxification service were receiving treatment from staff who had not received the appropriate training.
  • The training offered by the service was not easily accessible to all staff.
  • Confidential patient matters were not always kept private as telephone conversations could be heard when taking place at nurses’ stations.
  • Some patients were left without assistance during mealtimes.
  • The senior management team did not always communicate important information, regarding changes to services at community hospitals, to ward staff.
  • There was limited engagement with ward staff regarding significant decisions regarding the hospitals they worked in.
  • The processes for identifying, managing and mitigating risk were not effective.
  • The vision, strategy and specific values of the community inpatient service were not known by all staff.

However,

  • Incident reporting was encouraged and staff were supported to do so by their supervisors and service leads.
  • The duty of candour was understood by all and applied in all appropriate circumstances.
  • An organisational safeguarding action plan had been implemented and was being followed in response to an increase in alerts regarding staff conduct.
  • Record keeping within the service was of a high standard.
  • Thorough risk assessments were carried out and mitigated at all appropriate times.
  • Assessments were carried out to assess patient’s pain and regularly reviewed to ensure treatment was given to increase comfort.
  • Patient nutritional and hydration needs were regularly assessed and reviewed. Appropriate referrals were made to specialists when required.
  • Communication and cooperation of staff was good which enhanced the multidisciplinary team working within the service.
  • Discharge planning was commenced upon admission and all staff were dedicated to ensuring patients achieved good outcomes.
  • Staff were compassionate, kind and sensitive to patient, relative and visitor’s needs.
  • Staff communicated with patients clearly and kept them updated on their condition, progress and treatment.
  • The service planned and delivered services which met patient needs.
  • Staff showed commitment to ensuring patients accessed the right care and treatment at the right time.
  • There were low levels of complaints within the service but they were investigated thoroughly.
  • There was good local leadership within the community hospitals as leaders were approachable, supportive and visible.
  • Safe care and treatment was central to the culture within the service.
  • Most staff were happy in their roles which contributed to positive morale on most wards.
  • Managers and supervisors addressed any concerns raised by staff.

25 to 29 September 2017

During an inspection of Community health services for adults

Overall, we found the community adult service required improvement because:

  • Risk assessments, risk management plans and reviews were not being consistently completed by the community nursing teams. Therefore, assessments were not used to respond positively to patient risk or to minimise harm to patients. We saw examples of serious incidents investigations where risk assessments had not been completed for patients.
  • Monthly audits for the Titration of Diabetes Medicines by Diabetes Specialist Nurses were not being carried out according to trust policy.
  • Learning from incidents was not always shared between the teams. Investigations into serious incidents were insufficient and did not always demonstrate learning had been fully understood. Actions did not demonstrate how learning was to be implemented and embedded into practice. There was little evidence to demonstrate how learning or action was taken to improve safety.
  • Compliance with mandatory training was poor and not meeting the trusts target. Compliance with mandatory training was just 36% for the community adult service.
  • The sepsis screening tool was not fit for purpose, as the nursing staff did not have the tools identified on the chart to monitor patients for sepsis. The community nursing service was not using a national early warning score to identify deteriorating patients and the trusts sepsis policy was not based on the most recent National Institute for Health and Care Excellence guidelines for sepsis (NG51).
  • Staff at the leg clinic were not working in line with the Nursing and Midwifery Council Code Of Conduct: Professional standards of practice and behaviour for nurses and midwives standard 10.4 (2015).
  • Risks were not always accounted for or managed appropriately when planning and delivering services. There was a lack of challenge from senior staff with regards to anticipated patient risk during handovers.
  • The management of pain was inconsistent and did not always include an appropriate assessment and management plan for patients who were, or could be, experiencing pain.
  • There was poor compliance countywide with completion of initial nutrition and hydration assessment for patients.
  • Not all community nurses received any formal supervision sessions.
  • The process of receiving referrals into the service was not clearly defined.
  • Staff were not always compliant with the trust’s consent policy and completion of the consent to sharing information documentation.
  • Not all staff provided us with assurance they understood their role and responsibility around the Mental Capacity Act and best interest decisions.
  • There were mixed feelings about the senior management team and their understanding about caring for patients with physical problems. However, teams spoke highly of the support from their local managers.
  • The governance system needed to be reviewed to ensure processes were standardised and aspects of quality and safety were fully understood.
  • Meeting minutes did not demonstrate any depth or quality as to the content of the meeting. Minutes did not demonstrate how incidents were scrutinised for trends to ensure learning was identified, to improve performance and safety for future patients.
  • Not all risks to the community adult service had been identified and recorded on the risk register.
  • Lone working systems and processes did not ensure the safety of staff. This left staff working on call vulnerable and posed a risk to their safety.
  • There was confusion between the community adult service teams with regards to the introduction of a new electronic records system being introduced in November 2017. At the time of our inspection, staff still had not received any training on the new system being implemented.
  • Specialist nursing teams were concerned about the future sustainability for their services and the need for financial investment.

However

  • Staff understood their role and responsibility to report safeguarding concerns and knew the process to carry this out.
  • Patient group directions used by the community nursing teams and the musculoskeletal service were complete, signed and in date.
  • Infection, prevention and control practice was adhered to by the majority of the staff.
  • Staffing levels, skill mix and caseloads accounted for patient risk and acuity when they were planned and reviewed
  • Care and treatment was based on relevant evidence based practice, national guidance and legislation. Staff were able to demonstrate how they were underpinning national guidance to support their practice.
  • Audit programmes captured positive information about patient outcomes.
  • Teams provided comprehensive training for staff to upskill them in their roles. Staff were competent to carry out their roles effectively.
  • Staff received yearly appraisals to determine their development for the following year.
  • We saw good examples of multidisciplinary working both internally and also with external partners.
  • Patients were consistently positive and complimentary about the care they received. Staff worked hard to empower patients to manage their own health and wellbeing.
  • Staff treated patients with kindness, dignity, compassion and respect, and interacted with patients in a respectful and considerate manner.
  • Staff ensured patients understood the care and treatment they were receiving and understood the importance of involving family members or carers as partners in their care.
  • Patients were given timely support and information to cope emotionally with their condition.
  • Where possible, services were planned to meet the needs of the local population. Staff used information about the local population to support the planning for future service delivery.
  • Team leads in specialist nursing teams demonstrated knowledge about what their services were commissioned to deliver.
  • Services were planned to take into account the needs of individual patients, and staff were non-judgemental in the way they cared for patients.
  • Teams delivered services which took into account the needs of patients with complex needs such as learning difficulties and dementia.
  • Access to the majority of community adult teams on the whole was timely, and where possible, services prioritised care and treatment for patients with urgent needs.
  • Leaders at local level understood the challenges faced by the community adult services and staff felt supported by their leaders at local level.
  • A clear vision and strategy had been set out for the service which staff were on board with and able to discuss.
  • There was a programme of internal and external audit to monitor quality and performance.
  • There was a strong culture of patient centred care.
  • Innovative work was being carried out by the specialist nursing teams.       

25 October 2017

During an inspection of urgent care services

We rated this service as requires improvement overall because:

  • Out of hours and at weekends patients were not always kept safe because reception staff were not scheduled to work. This meant that patients with serious or life-threatening conditions may not have been identified promptly. There was also no observation of patients in the waiting room.

  • Risks associated with out of hours staffing and emergency ambulance transfers had not been highlighted at department level and there was no evidence that safeguards were put in place to mitigate these risks.

  • The trust did not record and monitor how quickly patients were assessed by triage or were seen by a nurse practioner. The recording of the time triage started did not include the time patients waited to be booked in and so did not recognise the risk that a serious or life threatening condition may not have been identified promptly.

  • The practice of when the time triage started was not clear and so did not inform the trust accurately. It was unclear in some MIUs when the ‘clock started’ in order to meet the 15 minute triage target. In some MIUs patient records showed that the triage time started and stopped with the receptionist taking the initial booking information. This would indicate that the receptionist triaged the patient when we saw that the nurse or trained health care assistant did the full triage.

  • There was no auditing of the reasons patients attended the units to identify any themes or trends. There were no risk assessments and reviews of the units which presented specific geographical challenges and how they should be managed.

  • Mandatory training compliance did not meet the trust’s target and not all staff received mandatory training in line with trust policy. Due to the amalgamation of two providers, training records were unclear and the trust was still in the process of reviewing them, despite having had 18 months to have completed this. Training attendance was difficult for the staff at St Mary’s MIU on the Isles of Scilly. No systems had been considered to enable staff to remain updated.

  • Staff did not have consistent knowledge of policies and procedures in place to support them to run the service to within the planned opening hours and so staff were delayed in closing the units. There was no planning consideration for planned public events during the holiday season, other than at St Mary’s Hospital. These events meant a substantial influx of visitors to a small town, without consideration of how this impacted on demand for MIU services.

  • The trust website did not reflect when primary service GPs were not available at Camborne Redruth MIU. This meant that patients were not correctly informed about the medical services available and who would be available to see and treat them.

  • Staffing planning systems did not meet the needs or geographical challenges of the region. The rostering of staff at St Mary’s MIU on the Isles of Scilly did not address the locations specific challenges with regard to access to the islands because of the weather.

  • There was a corporate vision and strategy in place for staff but there was no specific minor injury unit vision or strategy in place.

  • Not all premises were suitable for patient assessment, treatment and maintaining confidentiality. Falmouth, Newquay, Bodmin and Liskeard hospitals stored hazardous substances in unlocked sluices, including bleach tablets, cleaning solutions and nail varnish remover. These substances if ingested would be hazardous to health and should be secured.

However:

  • There were systems in place to report, investigate and learn from incidents.

  • Cleanliness, infection control and hygiene were well managed in most of the minor injury Units.

  • Medicines were managed in a way that kept patients safe. Medicines were stored securely.

  • The management of patients’ pain was established as part of triage and treatment.

  • Systems were in place to ensure patients’ information was kept .safe. Records were stored securely.

  • Policies and procedures were in place to support the safeguarding of vulnerable adults and children. Patients’ consent to care and treatment was sought in line with legislation and guidance. Staff had a clear understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.

  • The trust’s policies and services were developed to reflect best practice and evidence-based guidelines. The trust had in place systems to monitor aspects of the service, which included the minor injury and illness units.

  • Staff treated patients with kindness, dignity, and respect. Staff interacted with patients in a positive, professional, and informative manner. The hospital took account of patients’ specific needs and had access to support services.

  • There was a strong ethos of teamwork and staff felt well supported. There was flexibility and willingness among all the teams and staff. Staff worked well together, and positive working relationships existed to support each other.           

25 -29 September 2017

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

Overall, community health services for children and young people were good. We rated all five domains as good.

Cornwall Partnership NHS Foundation Trust provides community health services for children and young people and families across Cornwall and the Isles of Scilly.

During the inspection, we spoke to 49 staff including managers, nursing staff, allied health professionals and health visitors. We also spoke with people who use the services including eight parents and staff from other organisations who work with the service. We reviewed 15 sets of patient records and observed staff providing care for children, young people and their families in a variety of settings including clinics, schools and homes.

We found

  • There was an open reporting culture which supported staff to learn from incidents and improve services they delivered.

  • Patient records and medications were kept securely and confidentiality was maintained at all times.

  • Staff were busy but had strategies to manage their case loads safely and were supported by their managers to do so.

  • Vulnerable families and safeguarding issues were given priority with safety for patients embedded in practice.

  • Staff followed national guidelines to deliver effective care and worked well with other agencies to provide a seamless service for children and their families.

  • Staff kept the patient at the heart of what they did and understood how they could deliver services to meet children’s needs.

  • Emotional support was offered to patients and their families in a way patients would be able to accept. Staff ensured patients understood their options.

  • Services were planned using information from a variety of sources, to inform their decision making. Where staff identified gaps in services they worked together to provide further access for patients.

  • Managers made difficult decisions to provide these services in times of financial constraint but maintained their vision of retaining staff numbers and working in collaboration with other agencies.

  • Leadership teams provided good informationto staff about challenges and developments about the service although some staff felt this took a long time to filter through to them.

  • Good governance procedures gave senior managers oversight of the service and how well it was performing. Systems were in place which fed this information to the local authority commissioners but was not routinely fed back to staff.

However

  • We witnessed some occasions when handwashing practices were inconsistently carried out be staff.

  • Some of the premises not owned but used by the service were in need of repair or decoration.

25 to 28 September 2017

During an inspection of Community end of life care

Overall, we found that end of life care required improvement because :

  • Not all staff were up to date with the required mandatory training. The recording and monitoring of this training meant accurate up to date figures were not available.

  • There were inconsistencies in the completion of the patient TEP forms (Treatment Escalation Plan) which could mean

  • There was inconsistent understanding on the wards of the GSF (Gold Standards Framework) system being used to monitor and deliver end of life care. We found patients who were coded incorrectly and also staff who did not understand what the various codes related to, in terms of the stages of end of life.

  • There was a lack of personalised information being recorded in the care plans for patients. There was little detail completed about any personal preferences or wishes, which may have been identified through discussion with a patient or their family.

  • There were inconsistencies in the completion of specific end of life training, and also the levels of training undertaken. There was no record of the training provided by the specialist palliative care teams to other staff, nor any formal plan for what was provided. There was a lack of clarity around how this was organised, and what was available to ward and community staff.

  • Staff working for the continuing care at home team were not provided with sufficient training in end of life care.

  • There was a lack of clarity for some staff regarding the role of the specialist palliative care teams.

  • There was inconsistency in the recording of capacity assessments on the TEP forms (Treatment Escalation Plan).

  • There was variable provision for supporting patients in their own homes. The trust ran a continuing care at home team, that was very responsive and could be organised quickly, but this was only commissioned for one locality.

  • There was no trust wide strategy group that focused on the implementing of trust policies and initiatives in relation to end of life care. There were no regular formal meetings which involved representatives from all staff involved in delivering end of life care.

  • There was a fragmented approach to end of life care, due to a variation in service provision and the lack of visibility of the leadership for end of life care. There was lack of clarity about the future use of the GSF (Gold Standards Framework).

  • There was only one end of life care facilitator and they were required to cover a wide geographical area, covering a range of staff teams and different hospitals.

  • The trust did not have had an overarching vision for what it wished to achieve in relation to end of life care.

  • There was not a bespoke risk register for end of life care. There was no assurance that any potential risks to the effective delivery of end of life care were being identified and recorded.

However:

  • The service managed patient safety incidents well. Staff understood how to report incidents and felt confident about reporting them.

  • Staff had training on how to recognise and report abuse, and knew how to apply it. Within the services we inspected in relation to end of life care, including the specialist palliative care team and the continuing care at home team, all were up to date with their mandatory safeguarding training.

  • Patients receiving end of life care were prescribed anticipatory medicines, and these were well managed by staff. Appropriate and up to date guidance was in place.

  • Staff kept appropriate records of patients’ care and treatment. Records were securely stored and patient confidentiality was protected.

  • 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.

  • Audits were completed to monitor the effectiveness of care and treatment, and the findings used to develop improvements.

  • Staff spoke positively about the supervision and support they received from managers. All staff had an annual appraisal, and those requiring clinical supervision were having this completed.

  • We observed compassionate care in the approach from all the staff working in the wards and in the community. Feedback from patients was very positive about the caring and professional approach of staff.

  • Staff ensured that patients and families were involved in their care and understood their treatment and prognosis.

  • Emotional support and information was provided to those close to people who use services, including carers and dependants.

  • The trust worked with other stakeholders, commissioners and providers to promote end of life care across the county. There was a county wide strategy group for end of life care which was chaired by the Director of Primary Care.

  • Relatives were supported to visit and stay in the community hospitals and most wards could provide side rooms for end of life care patients.

  • Ward staff and community teams worked proactively to support patients to achieve their preferred place of care. Audits showed that improvements had been made over the previous 12 months.

  • When care packages were available, the ward staff could organise a rapid discharge and could co-ordinate well with the community teams and local GPs.

  • There was evidence of good local leadership, with staff speaking positively about their managers and the support and direction of the service.

  • Staff were clear about the governance structure within their services, both in the hospitals and in the community teams. There were regular team meetings and opportunities for staff to talk to their managers.

  • We found there was a positive culture across the services we visited. Staff were proud of their work and committed to providing high quality end of life care. Managers promoted a culture that supported and valued staff.

  • The trust engaged effectively with staff to ensure they were kept informed of changes and developments, and also to provide opportunities to give feedback.

26 – 29 September 2017

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

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

  • There were safety procedures and protocols in place that staff followed in relation to personal safety, infection control and medication storage. Each team had access to a full range of experienced health professionals. Caseloads were of a manageable size. There were some staff vacancies and speech and language provision had been placed on the team risk register.
  • Staff completed comprehensive assessments of service users which included physical health needs. Staff reviewed the assessments regularly. Staff and service users could easily access a psychiatrist during office hours. Out of office hours psychiatric help was only available as part of the general psychiatry on call rota. In April 2015, we said that the trust should discuss with commissioners out of hours provision. Team managers we spoke to told us that following the April 2015 inspection they had reviewed learning disability contacts to the out of hours service and found that the impact of not having a learning disability specific psychiatrist on call had a limited impact. There had been two contacts over three months.
  • There were evidence based care pathways in place that led to the development of personalised care plans.
  • In April 2015, we said the trust should continue to improve working relationships with the adult social care service to further develop the model of care in line with current and projected population changes. During this inspection, we found that the teams had effective working relationships with other services. However, staff felt that moving away from the co-location model had not helped maintain these relationships.
  • The team had addressed the risk of over-use of psychotropic medication in learning disabilities, by introducing innovative practice such as the purple book. The purple book was a record that the service user could carry that showed what medication they had been prescribed and why.
  • Service users and carers reported that staff always treated them with respect and that they were involved in their care. The teams showed learning from complaints. Staff had recorded service user involvement in the electronic record. Service users had helped develop the service by being on interview panels and the learning disability advisory group. Staff recorded communication needs on the electronic record as an alert and the teams had trained communication champions across Cornwall.
  • There were no waiting lists and the teams met their targets for referral to treatment times. Staff had made reasonable adjustments to appointments to meet the needs of the service users.
  • During the April 2015 inspection, we told the trust that it should ensure that all staff and team managers have access to well-structured and effective support and supervision through the re-design process, with a clear plan to monitor and undertake impact assessments on staff health and wellbeing. During this inspection, we found that managers gave staff regular structured supervision.
  • Staff reported team morale as good and staff felt they could approach their managers if they needed to raise an issue. Staff felt they had the opportunities to input into service development.
  • Team managers had put plans in place to monitor and review risks to service provision, particularly around staffing.

26 – 29 September 2017

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

We rated Long stay/rehabilitation mental health wards for working age adult as outstanding because:

  • Staff focused on ensuring the safety of patients through assessing the patients, and the environment. These risk assessments were comprehensive and updated regularly to help staff provide safe care. If things did go wrong, staff would give patients a sincere and prompt apology and keep them informed on steps taken to prevent it from happening again.
  • Systems were in place to ensure that the ward had adequate staffing. Staff were skilled and experienced at delivering care in that environment. Although there was some difficulty in obtaining places on training courses, staff demonstrated knowledge that meant patients could receive high quality care.
  • Patients and staff co-created care plans that were holistic and recovery centred. Staff supported patients to set goals to help them reach their objectives, and provided a range of activities and nationally recommended therapies to help them to do this. Staff had continued to use the protocols for patients to self-administer their medicines safely that we had seen on the last inspection. This was still working well in helping patients to become more independent and prepare them for living in the community. They worked to ensure that patients’ wishes about their care were taken into account and were valued.
  • Staff had strong links with local services, and had social inclusion workers that helped patients to access training and activities in the community. We saw examples of patients volunteering, gaining employment and entering higher education.
  • Patients were only transferred from the ward when they needed care that could be better provided in another setting. The ward was full at the time of inspection and there was one person waiting for a bed. Staff would only discharge patients when there was a suitable placement for them and worked hard to find somewhere where patients could move to without their health deteriorating. The average length of stay was 538 days.
  • Throughout our inspection, patients told us that staff were caring and kind and we saw that staff were truly dedicated to giving high quality, person centred care in a respectful way. They had made changes to the ward environment to help protect patients’ privacy, as well as ensuring that the communal areas were well decorated and there were plenty of things for patients to do while they were on the ward.
  • Staff benefitted from stable leadership from the ward manager; staff of all levels said that they felt the team was supportive and cohesive. They had a team vision of recovery and the way the they should deliver care that echoed the values of the trust.

26 and 28 September 2017

During an inspection of Forensic inpatient or secure wards

We rated forensic inpatient/secure wards as good because:

  • The ward provided safe care. Despite a number of ligature point being evident on the ward staff had received training on managing ligature risks and staff were able to tell us where the high-risk ligature anchor points and ligatures were and how these risks were mitigated and managed. There was a good sense of relational security. A low level of restrictive interventions and serious incidents had occurred in the last 12 months. Patients and carers told us the ward felt safe.
  • There was a stable team. There were sufficient skilled and experienced staff to deliver care to a good standard and the staffing rotas indicated that there was always sufficient staff on duty. There were low staff vacancies on the wards.
  • The staff team worked collaboratively with patients. Morale was good; staff appeared motivated and told us they felt well supported.
  • There was a good understanding of and adherence to legal requirements such as the Mental Health Act, Mental Capacity Act and safeguarding.
  • There was an embedded multi-disciplinary approach to patient care. Assessments and care plans were comprehensive and patients were involved in discussions about risk. There was a recovery-focussed approach to care and staff considered and responded to carer’s needs and concerns.
  • There were good incident reporting and monitoring processes. There was learning and changes in practice following incidents.
  • There were good links with other agencies and providers in the southwest.

However:

  • There were challenges in providing free access to fresh air for patients because the garden had not been maintained and the anti-climb rollers on the roof were rusty. As a result, patients could not use the garden unless there were two members of staff with them. The private finance initiative landlord was responsible for this maintenance and despite every effort by the trust the landlord had not made the required improvements in a timely manner. The trust was actively continuing to address this issue.
  • Staff had difficulties accessing some key training.

26 – 28th September 2017

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 as good because:

  • Patients told us that they had been treated with respect and dignity and staff were polite, friendly, and willing to help. Patients told us that staff were nice towards them and were interested in their wellbeing. Staff showed patience and gave encouragement when supporting patients. We observed this consistently throughout the inspection. Patients told us that they were the priority for staff and that their safety was always considered. Patients were involved in their care and all patients had either signed a copy of their care plans or said they did not want to sign the plans. The approach of the staff towards patients was person centred, individualised and recovery orientated. The trust encouraged feedback from patients and satisfaction surveys were available for patients to complete on every ward. On each ward a ‘you said we did’ initiative was advertised on patient information boards and gave examples of staff making changes on the wards in response to patient requests.
  • The wards provided safe care. Staff had received training on managing ligature risks and staff were able to tell us where the high-risk ligature anchor points and ligatures were and how these risks were mitigated and managed. Staff on each of the acute wards had created areas of the ward for particularly vulnerable patients to use, for example, older adults who may be quite frail. There were sufficient staff to deliver care to a good standard and the staffing rotas indicated that there were always sufficient staff on duty. There were low staff vacancies on the wards. Staff practiced relational security to a high standard and staff actively promoted de-escalation techniques to avoid restraints and seclusion where possible. As a result of this approach, the number of seclusion episodes had decreased by 64% compared to the previous year. The number of restraint incidents had decreased by 6% compared to the previous year.
  • Staff shared risks in the daily handover meetings in a written handover to all staff. The handover was recorded on the electronic system. In addition each ward carried out a daily ‘safety huddle’ which is a nationally recognised good practice initiative to reduce patient harm and improve the safety culture on the wards. The meetings involve all available staff to discuss specific patients’ risks and any potential harm that may affect patients.
  • Staff worked together to provide effective care. In all of the 27 care records we reviewed across the four wards, there were detailed and timely assessments for patients. Staff had assessed all patients for their current mental state, previous history and physical healthcare needs. The care plans were recovery focused. Patients told us that they were included in the planning of their care. Staff used National Institute for Health and Care Excellence guidance when prescribing medicines, in relation to options available for patients’ care, their treatment and wellbeing, and in assuring good standards of physical health care delivery. Patients had discharge plans and told us staff helped them to achieve these plans. Well-staffed multidisciplinary teams worked across the wards. Regular and inclusive team meetings took place.
  • The wards were well led. The senior management and clinical teams were visible and staff said that they regularly visited the services. All staff and patients knew who the senior management team were and felt confident in approaching them if they had any concerns. Governance systems were in place with comprehensive clinical quality audits, human resource management data and data on incidents and complaints. The information was summarised and presented monthly, for managers to measure their progress and achievements.

However:

  • There was one blind spot, impairing staff observation, in the garden area of Harvest ward. There was a risk of patients gaining access onto the low roofs, accessible to patients, in all of the four ward gardens, across both hospital sites. There had been one incident, on Perran ward when a patient climbed onto the roof. The patient came down from the roof voluntarily and was transferred to Harvest ward.
  • The trust should consider, highlighting high dose antipsychotic medicine on medication administration charts, to ensure there is a method to easily alert any nurse administering medicines.
  • The privacy windows in the bedroom doors on Harvest ward did not afford patients privacy and dignity. Patients were not able to close the blinds, when they were in their bedrooms. The doors and blinds had been scheduled for replacement in November 2017, soon after our inspection.
  • There was one incident, involving one patient when staff did not carry out physical observations and record these accurately, post rapid tranquilisation, to reduce the risk of adverse effects.
  • Staff did not always complete care records to reflect discussions on decision specific ‘best interests’ assessments when they have taken place.
  • The locality model on the acute wards was difficult to organise because at any one time there could be between six and 16 different doctors looking after their patients on the wards. This put nursing staff under pressure, to organise and hold several clinical meetings at the same time.
  • Occupancy figures and length of stay figures were high on Carbis and Fletcher wards because a number of patients were on extended leave from the ward under Section 17 of the Mental Health Act.

26 – 28 September 2017

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

We rated community based mental health services for adults as requires improvement because;

  • Staffing levels were not safe. Five out of the six integrated community mental health teams that we inspected had vacancies. The vacancies had affected all five integrated community mental health teams as at the time of inspection, there were approximately 114 patients unallocated for treatment and the trust did not have a clear process in place to monitor these patients.
  • The trust had not taken all of the actions to keep staff safe. Truro integrated community mental health team had not carried out a health and safety audit since 2013. Staff based at Caradon did not know how to activate the emergency alarms. The trust did not have an effective process in place to manage risk when staff met with patients that staff had assessed as high risk.
  • The provider did not ensure patients receive physical health checks in line with national guidance. The emergency equipment available in each clinic room varied and some of it was out of date. We found four integrated community mental health teams did not have resuscitation masks. Eight of the masks found were out of date. In three integrated community mental health teams the dates recorded on physical health, monitoring equipment had expired. For example, two tympanic electronic thermometers dates expired in March 2015 and December 2015. However, there was no risk to patients, as staff did not carry out physical health checks.
  • Staff did not work together with GPs to ensure patients had robust health monitoring in place. None of the six integrated community mental health teams had a robust system in place for the management of medicines. We found out of date medicine. Medicines were not being stored at the correct temperatures. One fridge in the Bodmin clinic had not recorded the temperature since November 2016. The cards used to record patient’s depot medicine had essential information missing from a number of cards. In Kerrier, a paliperidone injection box (an anti-psychotic individually prescribed medication), had its patient label remove.
  • Staff recognised that they did not always report incidents. This was because staff had high workloads and did not get the chance to complete the paperwork. In two of the three sites visited, the managers told us they were behind and had outstanding incidents awaiting manager sign off. The September 2017 team brief highlighted there were 203 outstanding incidents.
  • The quality and detail of patient risk assessments was inconsistent. We found risk assessments that were out of date. Staff had not updated risk assessments following significant change/incidents involving patients and in particular, five of the 12 records reviewed had no risk assessment.
  • Care plans varied in quality, style, and content. There was little evidence that patients had been involved in their care planning. At Carrick, integrated community mental health team seven of the 12 care records reviewed did not contain a care plan, and a further three were out of date.
  • Mandatory training attendance was low. Rates across the six locations ranged from 58%-87%, core essential training 66%-77% and other 52%-73%. This included safeguarding training where 52% of staff had attended level two safeguarding training

However;

  • The trust responded to the time it took to carry out an assessment by creating a dedicated assessment team. There were six core members of the team with a further six members of staff rotating from their roles within the integrated community mental health team.
  • Patients found staff to be kind, polite, respectful, supportive, caring, and encouraging.
  • Patients described staff as excellent despite so many organisational changes.

26th to 28th September 2017

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

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

  • Staff were risk aware, and despite a low number of serious incidents, staff demonstrated an understanding of how to report, deal with and learn from incidents.
  • Staffing levels were sufficient to meet the needs of the patients.
  • Staff demonstrated a good understanding of safeguarding.
  • Care plans were completed well and involved the patients and carers in the process, and were made in accordance with National Institute for Health and Care Excellence guidance. Risk assessments and crisis plans were completed comprehensively to ensure safety.
  • Patients were monitored effectively and supported. If their needs changed, staff took appropriate action, utilising the necessary assessment tools to ensure appropriate care was provided.
  • Staff were skilled in their jobs and there were tools in place to ensure professional development.
  • Staff demonstrated that they went over and above the call of duty, for example staying beyond their working hours. They exhibited a passion and enthusiasm for their job in delivering care of the highest standard, and this was supported by testimonials from patients and carers.
  • There was no waiting list at the service due to the efficiency with which referrals were handled.
  • Support was offered to patients in various forms, from providing information, intermittent assessment and treatment, increasing accessibility to premises and a complaints process.
  • The service was well-led with visible management. Performance was monitored and training, supervision and appraisals were all offered to staff.
  • Good governance was displayed through reviewing and learning from incidents, complaints and practice within the service.

However:

  • Some actions from the previous inspection had not been addressed. There was still limited psychology input and there was no formal out of hours support.
  • The environments did not always appear to be well maintained, for example the environment at Penzance appeared tired and in need of updating.

26 September 2017

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

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

  • The provider had addressed the issues found in the April 2015 inspection.
  • The ward staff team was well led and morale was good.
  • Despite the challenges, the team were happy, resilient and supportive of one another.
  • Staffing levels were safe but senior nurses had at times stepped down to ward based roles to provide enough staffing to keep the ward safe when bank or agency staff could not be found.
  • The service had closed two beds in response to the needs of the current patient group and to ensure that the staffing levels were safe to respond to individual patient need.
  • The provider had ensured that mental capacity assessments for cardiopulmonary resuscitation had improved with input from family where the patient had lacked capacity. This was a requirement of the previous inspection. However, one of the cardiopulmonary resuscitation records that we looked at had not been reviewed with the family in a timely way.
  • The provider had ensured that there were lasting arrangements for independent mental health advocate input to Garner ward. This included weekly visits to the ward to support detained patients. This was a requirement of the previous inspection and had been fully addressed. An IMHA service had been in place since April 2015. This was embedded and staff and carers were aware of the advocacy support.
  • Staff were very caring and carers commented very positively about this. Staff told us how well the multidisciplinary team worked together and we observed this during a discharge planning meeting.
  • Carers had been supported to develop a carers group and had also developed a ward information leaflet with hints and tips of what to expect when their relative was admitted to hospital
  • Psychology was embedded on the ward and the psychologist had introduced systems that had reduced incidents and the use of physical restraint. Individual behaviour plans were in place that had demonstrated a positive impact on both patients and ward staff, this had let to a reduction in incidents of restraint.

However:

  • A shortage of band 5 nurses and difficulties with recruitment and retention was a particular issue for this ward and a trust wide risk. The ward was successful in recruiting to band 3 health care assistant posts which were fully staffed.
  • The clinic room was very hot for staff to work in and this was logged as a risk on the health and safety risk register. The ward and pharmacy staff managed this by monitoring the temperature and following guidance to dispose of medicines kept above the recommended temperature within a shortened time period.
  • Psychology support was reducing on the ward to provide community provision as part of a wider planned programme. This left some temporary gaps, such as facilitated reflective practice sessions for staff.
  • Supervision, appraisal and training systems were in place, but staff reported difficulty with the new statutory and mandatory training system and staff did not routinely record one to one supervision.
  • Despite the delays in some discharges due to the limitations of suitable community placements, discharge planning was good and a discharge liaison role supported this.
  • The environment was not dementia friendly in places and many rooms were not personalised.

26-28 September 2017

During an inspection of Specialist community mental health services for children and young people

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

  • The service was not able to respond to the needs of all children and young people who might benefit, because the criteria for access were so high that children and young people had to be seriously ill before they were accepted. There had been a significant increase in the number of referrals over the previous two years but no increase in funding. As such, in discussions with Kernow Clinical Commissioning Group the trust had to raise the criteria for when to accept children and young people into the service.
  • All referrals were triaged through a single hub by members of the CAMHS team. If the child or young person did not meet the criteria for CAMHS, they would then be signposted to a range of other services. Staff, children, young people, and their families all said that the other services, despite being of good quality, could not always meet the needs of children and young people and as such, their mental health would deteriorate. Once their mental health had deteriorated to a level where they met the criteria, they would then be accepted into CAMHS. If a child or young person went into crisis, they would be seen quickly.
  • Waiting times varied across the teams. The longest waiting times were in the east team where one young person had been waiting five months for an initial assessment. The trust did not meet the 28-day referral to assessment set by commissioners. The waiting time across the service was between two and three months.
  • The physical environments at Bolitho House, Truro Health Park and St Austell needed improvements. None of the waiting rooms were child and young person friendly and they offered no age-appropriate books, toys, games or information leaflets. At St Austell 26 staff had to use one toilet in a facility that smelt damp and needed redecoration.
  • Staff members had not ensured that the scales used to weigh children and young people and blood pressure monitors were calibrated in the east or west sites.
  • Children and young people had unsupervised access to knives and other dangerous objects in the staff kitchen in the Truro site.
  • The service did not always provide families with copies of letters or care plans.
  • The trust did not ensure cleaning fluids were always stored safely.

However:

  • Children and young people and their families were extremely positive about the care they received once they had accessed the service. Children and young people in crisis received a prompt service.
  • Teams ensured there were detailed assessments of children and young people’s needs. Care plans reflected the assessed needs and, in the main, were recovery focused.
  • Staff provided an out-of-hours advice service to colleagues in other organisations should they be worried about the mental health of a child or young person. They were commissioned to provide an on-call clinician to provide advice to professionals working with young people out of hours.
  • The staff we met were conscientious, professional and committed to doing the best they could for the children and young people in their care.
  • Senior managers in the service were well aware of the impact that increasing the threshold for access to services was having and had a detailed knowledge of all of the risks in the services. These risks had been escalated to the trust senior leadership team and were high on the trust agenda. The senior leaders and service managers were addressing staffing shortfalls by having an active recruitment programme to fill vacancies. The trust senior leaders were actively working with Kernow Clinical Commissioning group to find a resolution to all of these issues.
  • At the time of the inspection staff felt under pressure due to vacancies of some key disciplines such as clinical psychologists. However, the trust recruited a psychologist in the east team who started work shortly after the inspection. Staff felt this would alleviate some of the pressure they were under.

13 - 16 April 2015

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

We gave an overall rating for the crisis service and place of safety of requires improvement because:

  • There was a lack of physical health assessments in the home treatment teams (HTTs).
  • There were crisis plans missing from some care plans in both HTTs.
  • There was limited integrated multidisciplinary work in the HTTs.
  • There was no permanent management in the HTT west team, since the retirement of the previous manager.
  • There were sometimes delays in transfer from the place of safety / section 136 suite caused by difficulties in finding a placement.
  • There was limited evidence of monitoring, auditing and evaluation of the services being delivered in both the place of safety suite and HTT teams.

13 – 17 April 2015

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

We rated Long stay/rehabilitation mental health wards for working age adults as outstanding because:

  • Medicine management was very good. The ward provided a well-structured support system for people to look after and self-administer their medicines and ensured people understood medicine safety. Detailed risk assessments were undertaken to identify the risks posed to each individual. There was on-going support and assessments of the person at each stage to ensure they were safe to continue on the scheme. Of particular note was the continued support given to a person when they left the service. An outreach system was in place to check that people continued to take their medicines safely at home and any concerns were dealt with immediately to ensure the safety of the person at all times.
  • The ward had a policy for admission to the unit which required all patients to have a risk assessment. We looked at patients’ electronic records and saw updated risk assessments with risk ratings. Incidents relating to individual patients could be accessed from the electronic records. Incidents and risk were discussed each day at the morning business meeting
  • Multi-disciplinary assessments were carried out prior to admission to assess suitability for rehabilitation. On the ward there was a structured assessment process using a variety of standardised assessments. We saw that validated research tools were being used such as Model of Human Occupation (MOHO), Assessment of Motor and Process Skills (AMPS) and REHAB. Physical health care checks were evident in records.
  • There was a team of social inclusion workers whose role was to help patients bridge the gap between hospital and community by using a wide range of services and facilities in the local community. This team was integrated into the ward staff group and provided a graded reintroduction to community involvement for patients. They were involved in quarterly inter-agency network meetings which were attended by a range of community services including; 6 district councils, housing providers, colleges, community centres, specialist employment support, volunteer services, the job centre and citizens advice bureau.
  • Throughout the inspection we observed warm and kind interactions by staff towards patients. Staff demonstrated respect when telling us about the care of people on the ward. We observed lunch and saw lots of friendly chatter and laughter with staff being proactive in talking to quieter patients so that they felt involved. We observed staff being flexible and adapting scheduled activities when a patient requested this.
  • The ward had effective leadership with staff and patients speaking highly of the ward manager.

However:

  • A previous Mental Health Act Review on 31 July 2014 had identified that assessments of capacity were difficult to find at the point of admission and first administration of medication. This had still not been addressed.
  • We found that Mental Health Act section 17 leave of absence (s17 leave) paperwork did not have end dates on it. We were told that s17 leave was reviewed monthly and at the three-monthly Care Programme Approach (CPA) meetings, however it would be best practice to have end dates clearly defined.
  • The ward had been unsuccessful in recruiting to the vacant psychologist post and there was limited availability of psychotherapy for psychosis.

13 – 17 April 2015

During an inspection of Forensic inpatient or secure wards

We rated Bowman Ward, Forensic Secure Ward as good because:

  • The ward showed collaborative working with patients. They adopted a recovery focused approach to care and had comprehensive and up to date information of patients and risks. There was an embedded multi disciplinary approach to patient care.
  • The ward had a range of therapeutic activities and facilities available to support patients recovery.
  • The environment was clean. Soft furnishings were in good condition and the décor light. Paintings by patients were hung on the walls.
  • There was a good sense of relational security and this was observed in the interactions between staff and patients and through the level of knowledge that staff had about the patients on the ward.

13 – 17 April 2015

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

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

  • The ward was clean, fit for purpose and well maintained.
  • There was a good sense of being enough staff on duty to support and observe patients.
  • There was a high rate of incident reporting on the ward, with an open culture to report and learn from incidents.
  • Staff were compliant with management of aggression and violence training and had received additional bespoke training relating to older people.
  • There were high levels of compliance for all staff essential and mandatory training on the ward and staff demonstrated a good understanding of the Mental Capacity Act 2005 (MCA).
  • There was regular liaison with physical care service and records showed that physical health problems were monitored.
  • We saw care records and detailed risk assessments that were up to date and contained family involvement.
  • During our observations we saw that there was consistent warmth and good interactions between patients and their relatives or carers.
  • There were daily activities and a range of equipment to support care with well-equipped outdoor and indoor areas including a ‘pop up’ bar.
  • There was effective leadership and staff felt well supported by their line managers and service managers through supervision, annual appraisal and regular team meetings.

However;

  • The ward was at risk of not fully complying with guidance on same-sex accommodation . There was only one bath which was located at the centre of the ward and one shower was out of use. If several patients required the facilities at the same time then female patients might need to walk through a male only area.
  • Aggression towards staff had increased recently and the behaviour of some patients was severely challenging.
  • The ward had been unsuccessful in recruiting to the vacant psychology post and there were gaps in consultant cover and independent mental health advocacy services.
  • Capacity assessments for Do Not Attempt Resuscitation (DNAR) status records were not always individual and some records of people with DNAR status did not have a capacity assessment.
  • Care plans did not consistently include patients’ views and patients were not given care plans.
  • Patients had frequently stayed longer than needed due to the lack of placements for complex physical needs and challenging behaviour.
  • Some staff thought that the senior management team was not visible enough.

13-17th April 2015

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 as requires improvement because:

  • There were ligature risks that had been identified but with no timescales to reduce.
  • The seclusion rooms did not contain toilet or washing facilities and there were blind spots that restricted views of patients in seclusion.
  • The intercom in one seclusion room did not work making communication between staff and secluded patients difficult.
  • Cleanliness was poor in the kitchen on Harvest ward and the water cooler was dirty.
  • The privacy panels in bedroom doors were locked open which did not protect the privacy and dignity of patients.
  • Rapid tranquilisation was used on Harvest ward but we did not find evidence that staff were following the guidelines on monitoring patients’ physical state. Staff told us they do not use a rapid tranquilisation monitoring form even though the trust’s own policy said they should.
  • Patients experienced delays in discharge from Harvest ward because beds were on available on the acute wards.
  • Patients special dietary needs could not always be met on Harvest ward on admission.

However;

  • Equipment was regularly checked and was accessible to staff in the wards. Staff had been trained in safeguarding people who used the services and there were good arrangements in place for the management and administration of medicines.
  • The needs of patients were assessed and care planning ensured that staff had the information they needed to care for them and to plan for their discharge. Patients were treated with dignity and respect and patients mostly spoke well of how staff treated them.
  • Patients had access to outside spaces and were able to make drinks and snacks throughout the day.
  • When patients spoke English as a second language, interpreters were provided to support them with communication.
  • There was a new governance structure that involved clinicians at different levels in the development of quality services. Staff were very happy with their ward managers.

14-16 April 2015

During an inspection of Specialist community mental health services for children and young people

We rated Cornwall Partnership NHS Foundation NHS Trust Child and Adolescent Mental Health Services as requires improvement because:

  • It was not responsive to the needs of the young people as it did not have safe staffing levels to meet the volume of young people it needed to see.
  • We were concerned with the arrangements for providing crisis care to young people out of hours with no CAMHS consultant cover. We recognise that this is something the trust has to address jointly with its commissioners.
  • The service did not always provide families with copies of letters or care plans.
  • Management supervision was inconsistent , however this appeared to be due to the workload pressure we observed staff to be under, rather than systemic failings.

However;

  • The service was performing remarkably well despite the pressures of the volume of young people who needed its support with the resources it had available. 
  • We found a service that was caring and innovative in the way it delivered mental health services to young people, with  areas of excellent clinical practice. 
  • The service delivered very effective interventions and worked hard to keep young people safe with a dedicated staff team who were valued by the young people and families who used it.

13-17 April 2015

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

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

  • Staffing was sufficient to meet the needs of the population safely. The provider had systems in place to ensure that caseload sizes were monitored and managed.
  • Staff had a good understanding of safeguarding processes and reported incidents. When incidents did occur, there were mechanisms in place for learning.
  • The service had embedded evidence-based practices into the operating models.
  • Staff were well-supported with training and supervision and we saw that there were good systems in place to ensure multi-disciplinary working.
  • People using services and carers were treated with kindness, dignity and respect. The service sought feedback in different ways which were devised to meet the needs of those using the service.
  • Where targets for assessment and treatment were breached, the service developed plans to tackle this.
  • Provision was tailored to meet the needs of a rural community by providing different hubs and they worked with local residential and nursing homes to provide additional support for people to reduce the need for a hospital admission which could be some distance away.
  • The service was well-led as there were robust governance systems in place to ensure that information flowed from the management within the trust to staff at all levels.
  • Staff were positive about working for the trust and generally found their managers supportive.
  • The service was research friendly and some staff actively contributed to research evidence which they brought back into the service.

However:

  • The lack of integration with the local authority had been a challenge in some situations.
  • Some records were not comprehensively completed and did not evidence the work which was carried out by the team.
  • There were no commissioned specialist crisis services for people living with dementia.

14 - 17 April 2015

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

We rated community based services for adults with learning disabilities as good because:

The trust had a system of governance in place, which team managers, and the service manager, used to identify and monitor risks in the services they provided. There was a clear system in place to report incidents. Staff were able to learn from incidents occurring within their locality and were given time to discuss issues in either supervision or team meetings. The teams were well resourced with experienced, skilled and competent staff.

The service had developed clear, evidence based clinical pathways to support effective assessment, treatment and management of varied clinical needs. The teams implemented best practice guidance within their clinical practice. We observed appropriate sharing of information to ensure continuity and safety of care across teams, including involvement of external agencies.

We saw numerous examples of care and service development which reflected the determination and creativity of staff to maximise opportunities for service users. These reflected innovative and person centred best practice.

People using services told us they were treated with kindness, dignity and respect. Clinicians’ knowledge and skills within the teams were highly regarded by all carers and patients we spoke with.

We observed a number of home visits and clinic appointments. We saw staff members were caring and respectful in all their interactions. The staff we met clearly placed the people who use the service at the centre of what they did. The records we reviewed showed evidence of people deciding how they wanted to be supported, and involvement of carers in best interest decisions.

The service had a system in place which ensured all new referrals were made through a single point of triage. The teams worked flexibly to meet individuals needs and promoted social inclusion and community involvement. Services received few complaints from patients and carers, but when they did, we saw examples which reflected that they had responded promptly and implemented learning from complaints.

Staff told us that a service redesign was underway, and this had been a very difficult process and there had been a significant, negative impact on staff morale. Staff were concerned that this was affecting relationships between the professional groups within teams. Some staff did not feel that senior trust management consulted with them, and most staff felt that communication and management of the process had been poor. Some staff felt unable to raise concerns above their team managers, and were not confident that they would be listened to.

14-16 April 2015

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

Overall rating for this core service GOOD

Overall community health services for children and young people were good. We found that services were safe, effective, caring, responsive and well-led.

Cornwall Partnership NHS Foundation Trust provides community health services for children, young people and families across the whole of Cornwall and the Isles of Sicily. As part of this inspection we talked to professionals delivering these services. We also met and spoke with a range of people who were using services. We visited services for children and young people in a range of environments, including clinics and accompanied staff on home visits.

Services were judged to be safe. Risk was managed and incidents were reported and acted upon. Feedback and learning was provided to staff. There was a robust system in place for safeguarding supervision and all staff reported receiving regular supervision of good quality.

Care was effective, evidence based and followed recognised guidance. There was excellent multidisciplinary team working within the trust and with other agencies.

Care and treatment of children and support for their families was delivered in a compassionate, responsive and caring manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their families.

We saw that staff understood the different needs of the children and young people and designed and delivered services which met the specialist needs of children.

There were clear lines of management in place and structures for managing governance and measuring quality. The trust leadership provided good information to the staff about developments, changes and challenges.

13th - 17th April 2015

During a routine inspection

We rated Cornwall Partnership NHS Foundation Trust as Good overall because:

  • Patients were protected from abuse and avoidable harm. There where systems in place to report when things go wrong with lessons learned and improvements made.
  • Some teams were staffed to their complement and where there were vacancies, the trust had contingency plans in place with the use of regular bank and agency staff who received training and supervision.
  • We found across most core services that risk assessments were in place, comprehensive and holistic. Staff understood the local safeguarding procedures, what their responsibilities were and how they could raise concerns.
  • Most services could demonstrate they used evidence based practice and followed national guidance.
  • Teams where multidisciplinary and worked collaboratively to provide care and treatment. There was a high level of adherence to mandatory and statutory training across all the core services.
  • On Fettle ward and across the learning disability community services we found care provided at an outstanding level. We observed staff across all the core services providing skilled interventions in a caring and respectful way.
  • Services were organised so that people’s needs were met. We saw that trust premises were, in the main, accessible for patients. Interpreters were available and staff knew how to access the service if needed. The inspection team noted that information was available to patients and carers in a range of languages.
  • Most teams and services worked within the targets agreed by the trust and there were systems in place to monitor compliance with waiting and response times in most core services.
  • The inspection recognised that the trust was well led with leadership, management and governance systems in place. The trust supports learning and promotes and an open culture.
  • Staff had been involved in the development of the trusts’ vision and values and all teams recognised the values and vision held by the trust
  • There were strong systems of governance in place across most teams which ensured that the senior management had an understanding of the strengths and weaknesses of the service and was able to ensure that information was shared and learnt.
  • We saw a wide range of audits to inform and improve service development. Some of these were being used to inform the redesign.

However;

  • There were notable problems on Harvest ward with ligature risks identified in audits and it was not clear when these risks would be reduced. In the seclusion facility the toilets were not easily accessable, there were blind spots which restricted the observation of patients and the intercom was broken.
  • The cleanliness on Harvest wards was poor and patients privacy and dignity was not protected.
  • In some teams we found there were difficulties in appointing to key staff groups. There was no access to psychological therapies on the Garner ward and no psychology input available across the ward.
  • Across the home treatment teams there was a lack of multi-disciplinary working. There was no psychology or dedicated medical input across this core service. This has resulted in delays for physical health care checks to being undertaken.
  • In Garner ward consent to treatment and information sharing was not consistently recorded and when do not attempt resusitation status was in place individual assessments were not recorded.
  • There was often a shortage of beds for acute admissions in the trust. Patients needing admission were sometimes admitted out of the area. We were unable to judge if patients needed readmission were placed out of area as this information was not available.
  • Adults with learning disabilities, child and adolescent mental health services and older people who experience a mental health crisis outside of office hours had limited access to specialist expertise and support.
  • Support provided to staff in the community learning disabilities teams during the service redesign process was poor.
  • Many of the nurses interviewed reported that they did not feel they had a strong voice and there was confusion about who held the executive lead nurse role.

Throughout this inspection process, we found that patients, their relatives, staff and senior managers all willing to engage in an open and frank way.

13-17 April 2015

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

We rated community based mental health services for adults good because;

  • We found staff understood the local safeguarding procedures, what their responsibilities were and how they could raise concerns.
  • ICMHTs had well established and clear referral routes to the mental health wellbeing services (BeMe team), for patients requiring short term interventions and who would not be referred onto the ICMHT caseload.
  • Staff we observed demonstrated compassion and genuine feeling about the patients who they supported. We saw examples of staff being respectful, empathic and providing emotional support in the ICMHTs and the DRCs at every location we went to.
  • We saw specific projects aimed at improving the services for patients. One example was the development of a new approach to dealing with psychosis called “open dialogue”. This had involved getting a small team from Finland to provide training in the approach for staff. We also saw a supervision session for psychologists via a “Skype” system from London. This enabled them to access specialist supervision which would not have been available locally.

However:

  • Staff within the teams told us their case loads over the last twelve months were between 45-55 and had been in excess of this in some teams. Team managers we met with confirmed this was correct
  • We did not see and the manager was unable to provide any evidence of patient involvement in the evaluation of the DRCs core programme.
  • In the DRCs we noted there was limited room for any disabled patients, no accessible toilets and wheelchair access was very limited throughout. Space was limited in each building with sessions often being run in upstairs rooms with no lift access. Staff told us they would make adjustments to accommodate individual patient’s needs, and we saw a copy of the environmental risk assessments, but we did not see any specific evidence of how the centres were assessed to comply with the Equalities Act 2010

Intelligent Monitoring

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

Mental Health Act Commissioner reports

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

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