care quality commission - outstanding … · 2019. 9. 28. · locationsinspected locationid...

Locations inspected

Location ID Name of CQC registeredlocation

Name of service (e.g. ward/unit/team)

Postcodeofservice(ward/unit/team)

RRPXX Trust Headquarters Enfield Older Adult CommunityMental Health Team EN2 8JL

RRPXX Trust Headquarters Enfield Memory Service EN2 8JL

RRPXX Trust Headquarters Haringey Older Adult CommunityMental Health Team N15 3TH

RRPXX Trust Headquarters Haringey Memory Service N15 3TH

RRPXX Trust Headquarters Barnet Older Adult CommunityMental Health Team EN5 3DJ

Barnet, Enfield and Haringey Mental Health NHSTrust

Community-bCommunity-basedased mentmentalalhehealthalth serservicviceses fforor olderolderpeoplepeopleQuality Report

Trust HeadquartersSt Ann’s HospitalSt Ann’s RoadLondonN15 3THTel: 020 8702 3000Website: www.beh-mht.nhs.uk

Date of inspection visit: 25 -28 September 2017Date of publication: 12/01/2018

Outstanding –

1 Community-based mental health services for older people Quality Report 12/01/2018

RRPXX Trust Headquarters Barnet Memory Service EN5 3DJ

This report describes our judgement of the quality of care provided within this core service by Barnet, Enfield andHaringey Mental Health NHS trust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘IntelligentMonitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by Barnet, Enfield and Haringey Mental Health NHStrust and these are brought together to inform our overall judgement of Barnet, Enfield and Haringey Mental Health NHStrust.

Summary of findings


RatingsWe are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings willalways be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring dataand local information from the provider and other organisations. We will award them on a four-point scale: outstanding;good; requires improvement; or inadequate.

Overall rating for the service Outstanding –

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Outstanding –

Are services responsive? Outstanding –

Are services well-led? Good –––

Mental Health Act responsibilities and MentalCapacity Act / Deprivation of Liberty SafeguardsWe include our assessment of the provider’s compliancewith the Mental Health Act and Mental Capacity Act in ouroverall inspection of the core service.

We do not give a rating for Mental Health Act or MentalCapacity Act; however we do use our findings todetermine the overall rating for the service.

Further information about findings in relation to theMental Health Act and Mental Capacity Act can be foundlater in this report.

Summary of findings


Contents

PageSummary of this inspectionOverall summary 5

The five questions we ask about the service and what we found 6

Information about the service 11

Our inspection team 11

Why we carried out this inspection 11

How we carried out this inspection 11

What people who use the provider's services say 12

Good practice 12

Areas for improvement 13

Detailed findings from this inspectionLocations inspected 14

Mental Health Act responsibilities 14

Mental Capacity Act and Deprivation of Liberty Safeguards 14

Findings by our five questions 16

Summary of findings


Overall summaryWe rated community-based mental health services forolder people as outstanding because:

• There was a truly holistic approach to assessing,planning and delivering care and treatment topatients. Staff were responsive to individual patients’needs and actively engaged in assessing andmanaging risk. Patients could access acomprehensive range of treatments and therapies.

• Staff empowered patients and carers to be partnersin their care and treatment. Staff developed positiverelationships with patients and carers to ensure theirneeds and individual preferences were reflected inplanning their care. Patients and carers reported thatstaff went the extra mile and exceeded theirexpectations.

• The services were flexible, provided choice andpatients could access them at times that suitedthem. Staff responded promptly and appropriatelyto heightened patient risk. Carers were provided withextensive support and opportunities to gain skills tohelp them with their caring responsibilities. Forexample, carers programmes featured guestspeakers who shared tips and experiences, eventswere held with community organisations to giveadvice about how to care for loved ones safely in thecommunity, and carers were trained to continuepracticing cognitive behavioural therapy with theirloved one at home.

• Staff were fully engaged with developing services.They took individual responsibility for completingquality improvement projects and quality audits.Staff supported each other through regular clinicaldiscussions in groups and as part of one to onesupervision sessions. This ensured they wereproviding the most appropriate support possible topatients on their caseload.

• Staff worked hard to keep waiting times as short aspossible. They had collaborated with stakeholderssuch as GPs and other healthcare providers to helpimprove the flow of patients through services andthe timeliness of diagnoses.

• Staff met the individual and diverse needs ofpatients, and the facilities were appropriate for thepatient group they served. Staff took time to makelinks with local organisations that could helppromote the wellbeing of patients and carers. Forexample, staff had developed links with a Greek carehome, which could be accessed to offer respite careto Greek patients, and with an LGBT support charity,which provided a community for older LGBT people.

• Staff were well supported by their managers, andwere given opportunities to have a say about howthe services were run. Staff had access to careerdevelopment opportunities, specialist training, andregularly discussed career progression plans withtheir supervisors.

Summary of findings


The five questions we ask about the service and what we found

Are services safe?We rated safe as good because:

• Detailed, up to date risk assessments and management planswere in place for all patients. Staff proactively responded tochanges in patients’ risk.

• Staff followed safe medication management practices,including safe storage, transportation and disposal ofmedicines.

• Staff in all teams followed robust lone working practices.• All facilities and clinical equipment was visibly clean and in

working order. Staff completed records to indicate they hadcleaned clinical equipment.

• Teams had safeguarding tracker systems in place and wereproactively monitoring the progress of safeguardinginvestigations. Staff put in place measures to ensure patientswere safe whilst any safeguarding concerns were investigated.

Good –––

Are services effective?We rated effective as good because:

• The services promoted the wellbeing and social inclusion ofpatients. Patients had goals as part of their care plans to helpintegrate them into their community.

• There was a holistic approach to assessing, planning anddelivering care and treatment to people who used the services.Care plans were person centred and covered all aspects of thepatients’ needs. Patients and carers collaborated with staff inproducing care plans that included advance directives.

• Staff followed professional guidance when prescribingmedications. When they prescribed antipsychotic medicationfor patients with a functional mental illness, staff completedregular physical health checks for patients. Patients’ physicalhealth was closely monitored and advice was given to supporta healthy lifestyle.

• Patients could access a wide range of treatments and therapiesled by different professional disciplines. Psychologicaltherapies were delivered in line with best practice guidance.

• The teams worked closely with external services, including thirdsector providers to meet the needs of the patients and carers.

Good –––

Summary of findings


Specialist dementia navigators supported patients and carersin Haringey following initial diagnosis of dementia andsignposted them to local services that offered support such asdementia cafes and activity groups.

• Staff proactively supported patients with social needs such asaccessing housing benefit. In Haringey, staff had successfullyincreased the uptake of carers’ assessments in the borough bysupporting carers through the process.

• Evidence based techniques were used to support the deliveryof high quality care. Dementia service practitioners workedclosely with local care homes to enable their staff to managepatients with dementia better, reducing referrals to the olderadult community and inpatient services.

• The teams worked well with other services provided by thetrust. Staff from all teams routinely attended bed managementmeetings at older adult inpatient mental health wards. Thishelped to share essential information about each patient’sindividual needs.

However:

• The Haringey older adult CMHT needed to continue their workwith GPs to improve the completion of physical health checksfor patients using the service.

Are services caring?We rated caring as outstanding because:

• Patients and carers were very positive about the support theyreceived from staff, across all the teams we visited. They told usthat staff were very caring and the service they receivedexceeded their expectations.

• Staff respected and empowered patients and carers. Staffdescribed colleagues as highly committed and caring. All staffspoke enthusiastically about their work.

• Staff gave essential and useful information to patients andcarers in an accessible format, in line with their assessed needs.Dementia navigators at the Haringey memory servicesupported patients and carers and visited them at homefollowing the initial diagnosis. They went through detailedinformation about the diagnosis and the support available topatients and families; at a pace that suited them and reinforcedthe initial information, they had been given in the clinic.

Outstanding –

Summary of findings


• The teams had a strong person centred-culture. Staff placed theviews of patients and their carers at the centre of care planningand actively involved patients and carers in making decisionsabout their care and treatment. Staff enabled patients to leadtheir own care programme approach meetings where possible.

• Staff recognised and understood the wider individual needs ofpatients and carers, including their personal, social and culturalneeds. Dementia navigators identified where patients needed akey safe or pendant alarm and helped them to obtain these.Staff sign posted patients and carers to other agencies thatcould meet their needs, such as voluntary sector providers andmade referrals to the fire service for the provision ofappropriate safety equipment. The Haringey speech andlanguage therapist carried out assessments in patients’ homesso that they could better understand the context in whichpatients lived and tailor interventions accordingly. All staff wereaware of the diversity of the local population and developedcare and treatment strategies that matched people’s culturaland religious needs.

• Staff provided carers with extensive support to help them copewith their caring responsibilities. The number of carers havingcarer assessments had increased because of staff interventions.Staff offered and supported peer support programmes whereguest speakers gave presentations to carers and ‘mini dementiasessions’ in which local stakeholders provided advice andinformation about local community support. Carers had accessto psychological therapies to support them to copeemotionally.

• The Haringey memory service had recruited volunteers, whowere about to undergo training, to provide a welcome and peersupport to patients and carers attending appointments at theservice. This intervention aimed to empower patients to have avoice and to realise their potential.

Are services responsive to people's needs?We rated responsive as outstanding because:

• Staff took innovative approaches to providing integrated,person centred pathways by involving other organisations. Staffwere alert to the specific needs of patients, such as language,culture and sexuality, and they always strove to supportpatients’ diverse needs.

• The services actively reviewed complaints to identify anylearning. They made improvements following feedback. Staff

Outstanding –

Summary of findings


collected feedback in different ways to help bring aboutimprovements to services. For example, staff had improved thelevel of detail they recorded in patients’ notes in response to acomplaint regarding a meeting with a patient.

• All teams met the 13 week overall referral to treatment/diagnosis targets. There were no waiting lists for access to theolder adult CMHTs. The memory services met the six weekreferral to assessment targets and most patients received adiagnosis on the day of their assessment.

• Staff at the memory services worked with local GPs to ensurethey only made appropriate referrals, which reduced waitingtimes for memory assessments. Staff had also worked with theorganisation that provided head scans to reduce waiting times,meaning that patients received a diagnosis quicker and couldstart treatments to slow the progression of dementia sooner.

• People could access services in a way and at a time that suitedthem. Waiting times for access to services were low and staffresponded quicker to patients who displayed high or increasedlevels of risk.

• Staff in Enfield had developed psychological support groups forpatients whilst they waited for individual therapy.

• The facilities were welcoming and appropriate to the needs ofthe patient group. Staff displayed information that was easy toread and made use of colours and diagrams. They displayedimportant information in languages that were prominent in thelocal community. They provided information in waiting areas tohelp patients orientate themselves.

Are services well-led?We rated well-led as good because:

• Staff across the teams told us they felt well supported by theirmanagers. Team managers also felt well supported and couldaccess leadership development opportunities.

• All staff had a good understanding of the trust’s vision andvalues and they demonstrated these values in their day to daywork.

• Monthly quality assurance audits were completed and theresults were acted upon. Individual staff were givenresponsibility for completing specific audits and all staffensured follow up actions were progressed.

Good –––

Summary of findings


• Staff were given the time and support to consider opportunitiesfor quality improvement and innovation. Staff met regularly todiscuss the progress of quality improvement projects for whichthey had responsibility.

However:

• Communication between the teams across the three boroughswas poor. There were no routine mechanisms in place forsharing of information, such as learning from incidents orsuccess with local improvement initiatives, between them. Anycommunication that did take place between the boroughs wasad-hoc and informal.

Summary of findings


Information about the serviceWe inspected three older adult community mental healthteams and memory services in Barnet, Enfield andHaringey. Teams included psychiatrists, communitypsychiatric nurses, occupational therapists,psychologists, admiral nurses (who were specificallytrained to work with carers) and administrators. Socialworkers, who were employed by the local authorities,also worked within the teams.

The teams provided specialist assessment, diagnosis,treatment and support to older adults living withprogressive memory problems, such as dementia. Somepatients had functional mental health conditions, such asdepression, anxiety and psychosis. The majority ofpatients seen by the teams were living with dementia.

The teams worked closely with social services, GPs, localcare homes and voluntary organisations to ensureeveryone received a holistic, comprehensive plan oftreatment and care. Patients were either visited by staff athome, or attended appointments at clinics.

We previously inspected the community-based mentalhealth services for older people’s teams in December2015. We found the teams to be fully compliant at thattime, but did identify the following area the providershould improve:

The provider should review the arrangements for theprovision of the Haringey memory service in order toreduce the length of time patients have to wait betweenassessment and diagnosis.

Our inspection teamThe team that inspected this core service comprised alead CQC inspector, two other CQC inspectors, two nurse

specialist advisors with a background working in olderpeople’s mental health services and an expert byexperience, who had lived experience of caring for arelative who used similar services.

Why we carried out this inspectionWe plan our inspections based on everything we knowabout services, including whether they appear to begetting better or worse.

We undertook this announced comprehensive inspectionin September 2017 to find out whether Barnet, Enfieldand Haringey Mental Health NHS Trust had madeimprovements to community-based mental healthservices for older people since our last comprehensiveinspection of the trust in December 2015.

At our last comprehensive inspection of the trust, inDecember 2015, we rated community-based mentalhealth services for older people as good overall and asgood for all five key questions.

After the inspection, we made no requirement notices butwe did recommend some areas where the service couldimprove.

How we carried out this inspectionTo fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

Summary of findings


Before the inspection visit, the inspection team:

• Requested information from the trust and reviewedthe information we received

• Asked a range of other organisations for informationincluding NHS improvement, NHS England, clinicalcommissioning groups and other professionalbodies and user and carer groups

• Received information from patients, carers and othergroups.

During the inspection visit, the inspection team:

• visited the older adult community mental healthteams and memory services in each of the threeboroughs

• spoke with six team managers and team leaders

• toured the premises at each site, including checks ofclinic rooms

• spoke with 16 patients and nine relatives and carers

• spoke with 24 staff members including nurses,doctors, social workers, occupational therapists,psychologists, administrators, speech and languagetherapists, dementia navigators and associatemental health workers

• attended a quality improvement meeting

• attended a support group for patients and carers

• looked at 18 patient care and treatment records

• looked at a range of policies, procedures and otherdocuments relating to the running of the services

• attended and observed four home visits and clinicappointments

What people who use the provider's services sayThe patients and carers we spoke with were very positiveabout their experience of using the service. We receivedpositive feedback about the support that staff gavepatients and carers and patients told us that staff had agood, positive attitude and were very polite.

Patients felt involved in their care and had theopportunity to discuss their medication and treatmentswith staff. They told us that staff had given theminformation about their conditions, their medications

and additional support that was available to them.Patients told us they were comfortable giving feedbackabout the service and knew how they would raise acomplaint if they wanted to.

Carers told us they felt involved in their loved ones careand staff were supportive and asked them how they weremanaging. Carers had copies of their loved ones’ careplans and were given information about how to accesssupport groups and charities.

Good practice• The teams offered programmes of cognitive

stimulation therapy, which helped improveoutcomes for patients. Staff tailored these sessionsto ensure they suited the needs of the group. AtHaringey and Barnet memory services, carers wereinvited to a maintenance therapy group so theycould continue to practice cognitive stimulationtherapy with their loved one at home in future.

• Staff worked with other organisations to ensurepatients received the most appropriate care andtreatment and to improve waiting times atcommunity services.For example, staff worked

closely with local GP practices to ensure they onlymade appropriate referrals to memory services. Staffhad also worked with the organisation that providedhead scans to reduce waiting times, meaning thatpatients received a diagnosis quicker and could starttreatments to slow the progression of dementiasooner.

• Dementia service practitioners worked closely withlocal care homes to develop staff skills in caring forpeople living with dementia, reducing hospitaladmissions.

Summary of findings


• Dementia navigators at Haringey memory servicegave extensive support to carers and helped them toaccess carers’ assessments. Staff also set up anenablement project to help find the activities thatpatients liked to do and then link them in withrelevant local community groups.

• Staff established close links with local communityorganisations to provide patients with personalisedsupport. Staff had developed links with a local Greekcare home in Enfield and had links with a local LGBTsupport charity in Barnet.

Areas for improvementAction the provider SHOULD take to improve

• The provider should implement a governancesystem for sharing information and learning acrossthe community older adult services in differentboroughs.

• The provider should continue its work to improve thecompletion of physical health checks by GPs forpatients using Haringey older adult CMHT.

Summary of findings


Locations inspected

Name of service (e.g. ward/unit/team) Name of CQC registered location

Enfield older adult community mental health teamEnfield memory serviceHaringey older adult community mental health teamHaringey memory serviceBarnet older adult community mental health teamBarnet memory service

Trust headquarters

Mental Health Act responsibilitiesWe do not rate responsibilities under the Mental Health Act1983 (MHA). We use our findings as a determiner inreaching an overall judgement about the Provider.

Mental Health Act (MHA) training was not mandatory, butstaff demonstrated a good understanding of the MentalHealth Act and Community Treatment Orders (CTO).

Staff could contact MHA professionals within the trust ifthey had queries about the application of the MHA. Policiesand procedures regarding the MHA were accessible for allstaff to refer to.

During our inspection, one patient was subject to aCommunity Treatment Order at Barnet older adult CMHT.The patient’s understanding of their rights was clearlyrecorded and they were able to access an advocate ifneeded.

Multidisciplinary team members frequently discussed themental health act and ensured that the communitytreatment order was being followed correctly for thispatient.

Barnet, Enfield and Haringey Mental Health NHSTrust

Community-bCommunity-basedased mentmentalalhehealthalth serservicviceses fforor olderolderpeoplepeopleDetailed findings


Mental Capacity Act and Deprivation of Liberty SafeguardsMental Capacity Act 2005 (MCA) training was notmandatory, but staff demonstrated a good understandingof capacity. Staff were aware of the trust’s MCA policy andknew how to access it.

Staff completed detailed assessments of patients’ capacitythat showed clearly how staff had determined whether thepatient had capacity to make a specific decision.

For patients with impaired capacity to make specificdecisions, staff made best interest decisions thatrecognised the importance of the person’s wishes, feelings,culture and history.

The trust target was that 90% of all patients seen shouldhave an assessment of their capacity to consent totreatment completed. This data was collected as part of themonthly quality assurance audits and was generally met.However, at Enfield older adult CMHT compliance haddropped below 90% on eight occasions during the yearprior to our inspection.

Detailed findings


* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatoryabuse

Our findingsSafe and clean environment

• Staff completed regular risk assessments of the clinicenvironments where they saw patients’ and carers. Anyareas that needed attention were reported and progresswas monitored by staff using the team risk register.

• All interview rooms were fitted with alarms so that staffcould call for assistance if needed. Display panels werein place at all buildings to alert staff to the locationwhere an alarm had been activated.

• Clinic rooms were suitably equipped to enable staff tocarry out physical examinations. All equipment wasregularly serviced and calibrated to ensure it was fit foruse. Staff checked defibrillators each day. Barnetcommunity mental health team (CMHT) accessed aclinic room managed by the day hospital, which waslocated in the same building.

• All areas were clean and well maintained. During ourlast inspection in December 2015, the provider did notkeep records to show that staff had cleaned clinicalequipment. During this inspection, we found that thishad improved and staff now completed records to showthey had cleaned clinical equipment.

• Staff adhered to infection control principles. Informationabout the correct procedure for safe hand washing tominimise the risk of cross infection was prominentlydisplayed at all the services we inspected.

Safe staffing

• Safe staffing levels were maintained. The provider useda tool to work out how many staff were needed. Agencystaff covered vacant posts and caseloads weremanageable.

• A variety of professional disciplines made up each team.Each of the older adult CMHTs consisted of nurses,occupational therapists and social workers. In Enfieldand Haringey, all of these staff acted as carecoordinators, but in Barnet, only nurses acted as carecoordinators. Each memory service consisted of a team

leader, nurses, an admiral nurse and occupationaltherapists. All patients could readily access psychology ifneeded. Staff at Haringey memory service were alsosupported by an associate mental health worker andtwo dementia navigators.

• The service manager post at the Haringey communityolder adult services and the team leader post at Barnetmemory service were vacant during the time of ourinspection. Interim staff had covered both roles and theteams were functioning well. At the time of ourinspection, the trust had frozen recruitment to anoccupational therapy vacancy at Enfield older adultCMHT. However, an occupational therapist was workingin the team filling a nurse vacancy and was available tooffer advice.

• Both Barnet and Enfield memory services had one nursevacancy. One psychiatrist post was vacant across theHaringey older adult community services. However,recruitment was taking place for this post and was beingfilled by a locum psychiatrist in the meantime.Appropriate arrangements were in place to manage staffabsences.

• Duty systems were in place at each older adult CMHT.Patients whose appointments were cancelled due tostaff sickness or leave, or whose health haddeteriorated, could be seen by duty staff if their carecoordinator was unable to see them. Care co-ordinatorswere normally able to see high-risk patients on thesame day.

• Across all teams, it was very rare for appointments to becancelled due to short staffing.

• Staff at all teams reported that psychiatrists could beaccessed easily at short notice when needed.

• Staff reported that their caseloads were manageable.The average caseload for staff working in the older adultCMHTs was between 14 and 25. No patients wereawaiting allocation of a care co-ordinator during thetime of our inspection. Staff routinely reviewedcaseloads every week in Enfield and every month inHaringey. In Barnet, staff discussed caseloads atindividual supervision sessions and fed into a twice-weekly allocation meeting.

Are services safe?By safe, we mean that people are protected from abuse* and avoidable harm

Good –––


• The admiral nurse at Barnet memory service had acaseload of 77 carers and consequently felt under a lotof pressure at work. Managers were trying to secureadditional funding to recruit an additional admiral nurseto the team, so the service could continue to provide anappropriate amount of support to carers.

• Most staff across the services were up to date withmandatory training requirements. The trust target formandatory training was 90% compliance for all courses,except for information governance, which was 95%. Theservices were generally performing well against thistarget.

• However, less than 75% of staff had completedmandatory training courses in breakaway at Barnet andHaringey memory services, resuscitation basic lifesupport at Barnet and Enfield memory services andolder adults CMHTs, and care programme approachtraining at Enfield older adult CMHT. Fifty six per cent ofstaff working in the western section of Barnet olderadult CMHT had completed moving and handlingtraining. There had been some issues around accessingbreakaway and resuscitation basic life support, andmoving and handling training had only recently beenmade mandatory, but all staff who needed to be trainedwere booked and were due to complete the trainingsoon.

Assessing and managing risk to patients and staff

Assessing patient risk

• Detailed, up to date risk assessments were in place in allof the 18 patient records we reviewed. Risk assessmentswere completed at all initial assessments. Staffdiscussed risk at referral meetings and triaged referralsaccordingly.

• Risk assessments were completed using a standardisedtool and were routinely reviewed every six months ormore frequently if there was change in the patientscircumstances.

• Crisis plans were in place for patients. These wereindividualised and outlined coping strategies and usefulcontacts if patients experienced a mental health crisis.

Management of risk

• There were no waiting lists for access to older adultCMHTs. Staff were alert to the need to maintain contactwith and triage patients if waiting lists did develop infuture.

• At the time of our inspection, average waiting times forreferral to assessment across the memory services wasbetween four and nine weeks. Patients received contactinformation on their initial referral confirmation letter.Staff at the memory services responded to changes inrisk if the patient or a carer contacted them during thistime. Staff could book an appointment at the nearestolder adult CMHT, where the duty worker would see thepatient.

• Staff followed robust lone working practices. Staff whovisited patients on their own had a ‘buddy’ who tookresponsibility for ensuring the lone worker had eitherreturned to the office safely after a visit or had contactedthem once they had left the patient’s home. Loneworkers also carried a telephone and would use a codeword if they required assistance. Staff always visited newpatients or patients with elevated risks in pairs and staffhad a good understanding of the lone workingprocedures.

Safeguarding

• All staff had a good understanding of safeguardingissues and knew how to make a safeguarding referral.Training in both safeguarding adults and children wasdelivered to all staff, and all staff in Enfield had beentrained in how to undertake a safeguardinginvestigation.

• At Barnet and Enfield, in-house safeguardinginvestigations normally took place, except for referralsthat concerned staff members working in the services,which staff escalated to the trust safeguarding lead. InHaringey, staff referred all safeguarding incidents to thelocal authority safeguarding team to investigate. Eachteam had a designated safeguarding lead, who staffcould approach for advice.

• Staff worked in partnership with other agencies whencompleting safeguarding investigations, such as socialservices. Staff used safeguarding trackers to monitor theprogress and outcome of investigations.

• Staff at the Haringey older adult community servicestold us that safeguarding investigations by the local


Good –––


authority sometimes took a long time to complete. Staffcompleted incident reports when they were not keptupdated about safeguarding referrals in a timelymanner. The teams safeguarding champion wasworking on a quality improvement project to identifyhow this could be improved.

Staff access to essential information

• Teams used electronic patient records, which all staff,including bank and agency, could access. Teams couldeasily access archived paper patient records if theyneeded to, for example, when an existing patients werere-referred.

• All information used to deliver patient care wasaccessible by agency staff and other teams in the trustin case patients were transferred to other services.

Medicines management

• Staff followed good medicine management practices.Monthly pharmacy audits were completed to ensuremedicines were managed safely and regular stockchecks were completed.

• Staff recorded prescribed medicines appropriately onmedication charts and transported medicines in anappropriate lockable case.

• Appropriate arrangements were in place for medicinesand clinical waste disposal. Staff checked thetemperature of clinic rooms daily to ensure the efficacyof medicines was not affected.

Track record on safety

• There were three serious incidents reported over thelast 12 months within this core service. These incidentshad been subject to investigation, one of which wasongoing at the time of our inspection.

• Staff received a debrief following serious incidents andcould access external counselling if they needed it.

Reporting incidents and learning from when thingsgo wrong

• Staff who we spoke with knew what incidents theyshould report and how to do this.

• Staff discussed feedback and learning from incidents atmonthly service improvement meetings, which werespecific to each team and changes were made to theway in which services operated to prevent similarincidents happening in future. For example, at Haringeyolder adult CMHT there was a cluster of incidentsinvolving patient’s transport not turning up, resulting inmissed appointments. The team changed the processfor booking transport to a ‘pool’ system, which wasmore efficient and had resolved the issue.

• Staff had also made changes to improve the safety ofthe services. For example, at Barnet older adult CMHT, apatient visited the hospital pharmacy to collect theirown medication when an agreement was in place thatstated that this patient should not collect their ownmedication because of their level of risk. The servicelearned to work collaboratively with the pharmacy on-site to ensure they were aware of patients who were notable to collect their own medications to prevent asimilar incident re-occurring.

• During our last inspection in December 2015, we foundthat there was a lack of systems to share learning acrossthe three boroughs. During this inspection, we foundthat key messages, for example, following seriousincidents, could be shared across the trust. However,there was still no formal mechanism for routine shareddiscussions about governance, including learning fromincidents, between the older adult community teams inthe three boroughs.

• Staff understood the duty of candour, being open andtransparent with people when things go wrong. Aflowchart was displayed at the Haringey older adultcommunity services to reminded staff to exercise theirduty of candour when necessary.


Good –––


Our findingsAssessment of needs and planning of care

• There was a holistic approach to assessing, planningand delivering care and treatment to people who usedservices. We reviewed 18 care records and found thatstaff had completed comprehensive assessments for allpatients. These assessments included level offunctioning, social and family histories and physicalhealthcare. Patients and their families or carers wereinvolved in these assessments and staff recorded theirviews in care plans.

• Care plans were person-centred and holistic. Theyincluded the patient and carer views and addressed theneeds identified during assessment. Staff updated themregularly and included information about physicalhealth conditions. Patients’ GPs completed routinephysical health checks at the time of referral and thesewere repeated routinely afterwards. Staff documentedthese physical health checks in patients’ records.

• Care plans included constructive goals that patientsworked towards, which promoted their health andwellbeing. For example, one patient’s goal was toprogress from walking short distances near their hometo visiting a local shop each day, to improve theirphysical health and their social inclusion.

• Staff updated care plans with patients on a regularbasis. In Haringey, staff worked with patients and carersto develop advance directives for patients living withdementia. This meant that patients could be supportedin line with their wishes as their condition progressed.Staff gave patients leaflets that explained advancedirectives and the benefit of completing them.

Best practice in treatment and care

• Patients could access a range of care and treatmentinterventions to promote their health and wellbeing.Staff delivered these in line with national institute forhealth and care excellence guidance. All services hadinput from occupational therapists, who had clinicappointments or visited patients at home to enablethem to maintain their daily living skills.

• Patients at all locations were referred for psychologicalinterventions when necessary. At Haringey older adultCMHT, psychologists ran a tree of life group, based onthe idea of using the tree as a metaphor to tell storiesabout individuals’ lives.

• The speech and language therapist at the Haringeyservices provided communication training for carersand families to increase their understanding of patients’difficulties so they could better support them. Staffreferred patients to specialist services where swallowingdifficulties were identified.

• Staff offered patients support with housing and benefits.Staff also supported carers with issues such as power ofattorney and accessing carers’ assessments. At Haringeymemory service, two dementia navigators worked toprovide this support to carers and they had increasedthe uptake of carers’ assessments in the borough.

• All teams offered cognitive stimulation therapy (CST)groups, which provided post-diagnostic therapeuticinterventions for patients with dementia. At Haringey,staff invited relatives and carers to attend these groupstowards the end of the programme. Staff collectedfeedback about the group to measure outcomes forpatients. Staff also used this opportunity to pass skillson to carers so they could continue to follow theprinciples of CST at home.

• In line with best practice, staff referred younger patientswith cognitive impairments to other specialist servicesfor a diagnosis to rule out other potential diagnosesbefore commencing treatment at the older adultCMHTs. Staff at Haringey older adult CMHT ran a CSTgroup for patients living with early onset dementia,which people from across London attended.

• The teams had other groups to support carers. Admiralnurses at each of the memory services ran groupsoffering carers support and facilitated peer support forcarers. We attended ‘Tom’s club’ in Haringey, which wasa support group for both patients and carers. Differentcoping strategies were discussed during sessions andpatients’ participated in group exercises to help improvetheir physical health.

• A psychologist and another staff member ran theHaringey older people’s enablement group (HOPE). This

Are services effective?By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.

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group aimed to find the activities that patients liked todo and then link them in with local community groupsso that they could continue the activities on a regularbasis.

• Staff at all three CMHTs held case presentationmeetings, where one staff member presented a complexcase or challenging situation and colleagues offeredsuggestions about how best to manage the situation.

• Patients who had a mental illness were prescribed highdose antipsychotic or lithium medication receivedregular physical health monitoring. Staff followed theMaudsley prescribing guidelines on administeringantipsychotic medication to older people. Monitoringcharts were available to prompt clinicians to completephysical health monitoring for these patients. AtHaringey older adult CMHT, staff provided a well-beingclinic once a month where they carried out physicalhealth checks for patients, including those prescribedanti-psychotic medicines. The clinic was ‘mobile’ and itvisited some patients at home.

• GPs completed physical health checks on referral to theservices and at least annually thereafter. At Enfield andHaringey, the older adult CMHTs had facilities forphysical health examinations to take place on site. AtHaringey older adult CMHT, 75% of patients had up-to-date physical examinations by GPs at the time of theinspection. Staff were working to follow these cases up.

• Staff were responsive to changes in patients’ physicalhealth. For example, staff had altered medications andreferred patients for further physical healthinvestigations when their physical health changed.

• Staff routinely offered patients support to improve theirlifestyles. For example, staff gave patients who smokedinformation about how to access smoking cessation.Staff also supported patients to improve their physicalactivity and diet.

• Staff used health of the nation outcome scales (HoNOS)to measure outcomes for patients.

• Staff completed detailed discharge summaries for othercare providers to refer to, which complied with the NHSEngland transfer of care standards.

• All staff took responsibility for completing monthlyaudits, which fed in to team ‘heat maps’. Recent auditsincluded identifying whether patients smoked, whetherthey had capacity to consent to treatment and theirmarital and accommodation status.

• Team managers presented routine audit and monitoringinformation at quarterly ‘deep dive’ meetings, whichtook place with other service managers within theirborough. Managers talked through their results anddiscussed the challenges there were around meetingtargets during the deep dive.

Skilled staff to deliver care

• Teams consisted of a range of disciplines includingnurses, doctors, occupational therapists, occupationaltherapy assistants, psychologists, psychology assistants,social workers, speech and language therapists,associate mental health workers and admiral nurses inthe memory services. The Haringey memory service alsohad dementia navigators.

• Occupational therapists helped patients to accessspecialist equipment to support them at home and helpthem maintain their independence.

• Admiral nurses provided long-term practical andemotional support, primarily to carers of patients withdementia. They gave this support through both groupsupport sessions and one to one appointments.

• Some nurses had undertaken training to becomespecialist dementia service practitioners. They gaveadvice to carers about how to manage behaviours thatchallenge at home. They also supported other staffthrough training and could be consulted regarding careand discharge planning.

• New staff and agency staff received a comprehensiveinduction when they started working at the service. Thisincluded access to training and a detailed orientation tothe service.

• The continuing development of staff skills, competenceand knowledge was recognised as being integral toensuring high quality care. The trust proactivelysupported staff to acquire new skills and share bestpractice. Staff could access specialist training. Forexample, an administrator at Barnet older adult CMHT


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had recently completed training in computer spreadsheets and speed typing. Dementia service practitionershad shared their knowledge of caring for people withdementia during training sessions for all staff.

• Supervision sessions took place at least every six weeksfor all staff, and staff had completed annual appraisals.Staff received supervision from staff members with thesame professional background supervised. During ourlast inspection in December 2015, we found thatoccupational therapists at Barnet older adult CMHTreceived managerial supervision only. During thisinspection, we saw that this had improved. This staffgroup now received monthly group clinical supervisionin addition to individual management supervision.

• Staff held clinical discussions regarding their patientsduring supervision and supervisors gave clinical advice.Staff also discussed mandatory training compliance,other professional development opportunities andinvolvement in service improvement initiatives. Stafftold us that they found these sessions supportive andhelpful. Managers discussed career progression andrecognised good performance during annual appraisals.

• Managers dealt with poor staff performance promptlyand effectively. We identified examples where managerssupported staff following episodes of poor performanceto access additional training and change aspects ofpractice to help improve their performance.

• Haringey memory had developed a new carer volunteerscheme to provide additional peer support to carers,which it planned to launch shortly after the inspection.Members of the public were keen to volunteer at Barnetolder adult CMHT and staff were in the process ofestablishing what their responsibilities would be.

Multi-disciplinary and inter-agency team work

• Regular business meetings took place at each team.Staff discussed operational issues and held discussionsabout learning from incidents and ways to improve theservice.

• Case presentation meetings took place across theservices. For example, in Enfield a psychologist ran amonthly case discussion group for all staff. Staffdiscussed complex cases and provided professionalsupport and advice to each other.

• Handovers took place between individual staffmembers when they were going on planned leave.Managers planned handover periods when new staffcame into post, so they could learn the skills needed todo their new job from the existing staff member.

• Staff from all older adult CMHTs kept in close contactwith inpatient services. Care co-ordinators attendedward rounds when patients on their caseload wereadmitted to hospital. Detailed handovers also tookplace between teams when patients admitted ordischarged from wards. Staff from all three older adultCMHTs also attended delayed transfer of care meetingsat inpatient services to ensure timely and smoothtransition between services.

• Staff kept in close contact with GPs and maintained on-going contact when there was a change in patients’physical health needs. Following care programmeapproach meetings, staff sent detailed update letters toGPs.

• Dementia service practitioners worked closely with localcare homes. They provided advice to staff, which helpedto develop their skills in supporting their residents livingwith dementia and minimised the need to admitindividuals to hospital.

• The memory services had a target to diagnose at least80% of their patients with dementia, in a bid toencourage them not to accept inappropriate referrals.Staff worked closely with local GPs to ensure they onlymade appropriate referrals to the memory services. Thiswork had also led to a decrease in waiting times inBarnet and Haringey.

Adherence to the Mental Health Act and the MentalHealth Act Code of Practice

• Mental Health Act (MHA) training was not mandatory,but staff demonstrated a good understanding of theMental Health Act and Community Treatment Orders(CTO).

• Staff could contact MHA professionals within the trust ifthey had queries about the application of the MHA andpolicies and procedures regarding the MHA wereaccessible.

• During our inspection, one patient was subject to aCommunity Treatment Order at Barnet older adult


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CMHT. Staff clearly recorded that they had explained topatients their rights under the MHA and patients couldaccess an advocate if needed. Multidisciplinary teammembers frequently discussed the mental health actand ensured that they followed the communitytreatment order correctly for this patient.

Good practice in applying the Mental Capacity Act

• Mental Capacity Act 2005 (MCA) training was notmandatory, but staff demonstrated a goodunderstanding of capacity. Staff were aware of the trustsMCA policy and knew how to access it.

• Staff completed detailed assessments of patients’capacity that showed clearly how staff had determinedwhether the patient had capacity to make a specificdecision.

• For patients with impaired capacity to make specificdecisions, staff made best interest decisions thatrecognised the importance of the person’s wishes,feelings, culture and history.

• The trust target was that 90% of all patients seen shouldhave an assessment of their capacity to consent totreatment completed. This data was collected as part ofthe monthly quality assurance audits. However, atEnfield older adult CMHT compliance had droppedbelow 90% on eight occasions during the year prior toour inspection.


Good –––


Our findingsKindness, dignity, respect and support

• Patients and carers across all teams were positive aboutstaff, saying that they were polite, treated them withcompassion and went the extra mile to help them. Weobserved very positive interactions between staff andpatients, and we saw staff responding in a timelymanner to people who telephoned services for adviceand support.

• Patients found it easy to contact the service. Staffanswered their queries promptly and provided supportwhenever they needed it. Staff were often able to meetpatients on the same day if necessary, and made suresomebody was able to see patients who turned up atthe services unexpectedly.

• Patients and carers said that staff took time to explaintheir condition and treatments and answered anyquestions they had. Staff provided patients with leafletsto which they could refer, including leaflets in Turkish, alanguage spoken widely in the local community. Staffgave patients a choice of treatment options wheneverthis was possible.

• Haringey memory service employed dementianavigators. They supported patients and carers tounderstand their condition and access additionalsupport. Patients who were newly diagnosed receiveddementia packs, which dementia navigators took timeto review with patients and carers. These were tailoredaccording to the type of dementia the patient wasdiagnosed with. They included information about theircondition, details of support organisations for patientsand carers, and information about how carers couldaccess carers’ assessments.

• Staff took time to consider the range of needs thatpatients had, and signposted them as necessary. Forexample, one carer told us they had attended a mobilityand falls prevention course following arecommendation by a staff member. This had helpedthem to safely support their loved one and minimisetheir risk of falls.

• Staff considered personal, cultural, social and religiousneeds when allocating patients to care coordinators.

Staff always worked hard to support and understandthese needs by spoke with patients to establish whichstaff member they might feel most comfortable workingwith.

• Staff understood the individual and diverse needs ofpatients and the diverse communities from which theycame. The speech and language therapist visitedpatients at home so that they could better understandthe context in which patients lived and tailorinterventions to meet the needs of the family as well asthe patient. For example, by understanding the types offood a family ate the speech and language therapist wasable to individualise the advice they gave and make itmore relevant to the patient’s everyday life.

• Staff recognised and understood the social andpractical needs of patients and directed patients andcarers to other services when needed. During homevisits, the dementia navigator identified whetherpatients needed a key safe or pendant alarms andsupported patients and carers to obtain these. They alsomade referrals to the fire brigade for the provision ofsmoke alarms and fire retardant mattresses.

• Staff were able to raise concerns about disrespectful,discriminatory or abusive behaviour or attitudestowards patients. Staff described colleagues as highlycommitted and caring. All staff spoke enthusiasticallyabout their work with older people.

• Staff maintained the confidentiality of informationabout patients. For example, staff referred to patients bytheir initials in the staff office, and patient records werestored securely on an electronic system that onlyauthorised persons could access. Staff stored archivedhistoric paper records securely away from patient areas.

Involvement in care

Involvement of patients

• The teams demonstrated a strong, visible, personcentred culture. Patients and their carers wereempowered as partners in their care. Staff wrote careplans with patients and, if the patient consented, theircarers. The care plans we reviewed contained patients’views and opinions, as well as those of carers. Patientsand carers we spoke with knew about their care plansand kept their own copy if they wanted.

Are services caring?By caring, we mean that staff involve and treat people with compassion,kindness, dignity and respect.

Outstanding –


• Patients were actively involved in care programmeapproach (CPA) meetings. We observed one CPAmeeting, which was led by the patient, enabling them tomake their views and opinions known throughout.

• Staff made time to speak with patients so they couldgain a good understanding of their diagnosis, care andtreatment. Where English was not a patient’s firstlanguage, staff obtained written information in theirpreferred language and interpreters were booked whenneeded. Staff found creative ways to communicate withpatients who had communication difficulties, forexample, using diagrams.

• Barnet memory service had established a userinvolvement group. Initially, staff used this group togather feedback about the service. During the time ofour inspection, staff were considering other ways inwhich these individuals could be involved in decisionsabout the service, such as sitting on staff interviewpanels.

• Staff took people’s individual preferences and needsinto account, and they used this feedback to inform howthey delivered the service. At the end of group sessions,staff asked patients for their feedback, both to improvethe overall service and to make minor adjustments toimprove the groups for the next cohort of patients.

• Patients regularly received surveys about the service.Staff shared positive feedback with the staff memberconcerned. Questionnaires for patients and carers wereavailable in waiting areas. The results were analysedregularly by staff and used to improve services.

• Staff supported patients to complete detailed advancecare plans, which covered issues such as clothing stylesand preferred make up. This helped preserve the dignityof patients should they be unable to express thesepreferences as their condition progressed.

• Staff supported all patients to access advocacy, anddetails about advocacy were displayed at the services.Staff involved advocates in best interest decisions whenthey assessed a patient as lacking capacity.

• Staff planned to involve patients and carers asvolunteers in the memory service. They were to beambassadors for the service, welcome patients andcarers in reception as they came to the service forappointments and provide opportunities for informal

peer support. Three patients and carers had beenrecruited as volunteers and were about to undergotraining before the programme was rolled out inNovember 2017. A patient attends the weekly staffmeeting once a month to provide user feedback.

Involvement of families and carers

• The service provided excellent support for carers andinvolved them in the design and delivery of the service.Carers told us that staff worked in partnership with themand offered them all the support they could. Whereappropriate, staff invited carers to attend appointmentswith their relatives and contribute to care plans and riskassessments. Staff gave carers guidance on how to helptheir relative complete a ‘this is me’ summary to bringalong to their next appointment, allowing them to taketime over it and ensure it was as accurate as possible.Carers also told us staff were available to give advice onimportant topics such as lasting power of attorney.

• The service provided a group psychological interventionprogramme for carers. This lasted for eight weeks, andsupported carers with anxiety and other psychologicalissues.

• Enfield memory service held ‘mini dementia sessions’for carers twice per year to provide them with advice,support and useful information to help them and theirrelative stay safe in the community. The event includeddifferent stalls representing stakeholders such as thepolice, fire brigade, dementia charities and carerssupport charities.

• Staff sought feedback from carers at the end of eachgroup programme and via questionnaires that werepresent in waiting areas. They used this feedback toimprove subsequent support programmes and toimprove the overall service.

• Staff went to great lengths to inform carers and familiesappropriately and enabled them to access a range ofadditional support to meet their needs. For example,staff had received training in the Carers Act andsupported carers to make applications for a carer’sassessment. The dementia navigator referred carers tothe carers’ information and support programme,provided by the Alzheimer’s Society, for support.Information on how to support to a person withdementia was provided in different languages includingTurkish.


Outstanding –


• The service in Haringey ran a carers programme inpartnership with an admiral nurse. The programme ranover eight weeks and covered different topics relevantto carers, such as the diagnosis of dementia, lastingpower of attorney, making a will and information aboutaids available for the home such as falls censors. Theprogramme created a supportive and lasting peer groupfor carers.

• In order to the measure outcomes of CST moreeffectively, the Haringey and Barnet teams hadintroduced an additional session at the end of the

formal CST groups where relatives were invited toattend. As well as receiving feedback from participantsand carers about the outcomes of the therapy, staff tooktime to explain to carers how CST worked, how they ranthe groups and suggestions for carers to continue andfollow up at home with the patient.

• Staff also provided support to care home staff caring forolder people with dementia. They offered advice to staffon how to provide high quality care to people withdementia and prevent unnecessary admissions tohospital.


Outstanding –


Our findingsAccess and discharge

Access and waiting times

• Referrals to older adult CMHTs mostly came from GPsand each borough had a single point of access. A dutyworker reviewed, triaged and directed referrals to theappropriate team.

• None of the three older adult CMHTs had waiting lists forallocating patients to care coordinators. Referralmeetings took place at least weekly and staff took thecultural and social needs of the individual into accountwhen allocating care coordinators. Once referred, staffcompleted initial referral assessments quickly. Thetarget time for referral to assessment at older adultCMHTs was thirteen weeks. Staff completed mostassessments between seven and 14 days after receivingthe referral.

• Duty staff at all three older adult CMHTs could seeurgent referrals on the same day and the crisis teampicked up urgent referrals made out of hours.

• Memory services worked towards a six-week referral toassessment target and an overall 13-week referral todiagnosis/treatment target. At Barnet and Haringey,assessments took place between four and six weeksafter referral. More than 70% of patients attendingmemory services received a diagnosis on the day oftheir assessment, which was well within the overall13-week referral to treatment/diagnosis target.

• At the time of our inspection, average waiting time foran assessment at Enfield memory service had recentlyincreased from six to nine weeks, because a qualifiednurse post had recently become vacant. However, 75%of patients received a diagnosis on the day of theirassessment, which was well within the overall 13-weektarget. Staff were confident that the wait for anassessment would reduce back down to six weeks oncea nurse was recruited. Staff were working hard to fit inadditional appointments and prioritise those waiting foran assessment in the meantime.

• During our last inspection in December 2015, we foundthat the provider should review the arrangements forthe provision of the Haringey memory service in order to

reduce the length of time patients had to wait betweenassessment and diagnosis. During this inspection, wefound that 70% of patients using the Haringey memoryservice had received a diagnosis within four weeks oftheir referral.

• Memory services had reduced the time patients had towait between referral and diagnosis since our lastinspection. Staff at Enfield memory service had workedwith the provider that completes magnetic resonanceimaging and computerised tomography scans to ensureneuro-radiologists, rather than general radiologistsinterpreted them. The memory service received scanreports quicker because of this. Consequently, they hadreduced their waiting list and given diagnoses in a moretimely way.

• Staff at Haringey and Barnet memory services hadworked closely with local GPs to explain the referralcriteria to the services. This had led to a reduction ininappropriate referrals and reduced time patients hadto wait for an assessment. Associate mental healthworkers at Haringey memory service also supporteddoctors to interpret psychometric tests, which sped upthe diagnosis process, meaning that doctors could seemore patients each day. Referral criteria did not excludepatients who needed treatment and would benefit fromit.

• The service offered appointments to patients whotelephoned the service or turned up unexpectedly withtheir care coordinator or a duty worker.

• Staff effectively followed up patients who did not attendappointments. Staff telephoned patients to remindthem about their appointments. When patients did notattend appointments staff contacted them to find outwhy they had not attended and considered ways tosupport the patient to attend in future such as arrangingtransport for them.

• People could access services in a way and at a time thatsuited them. Staff arranged subsequent appointmentsat the end of appointments. Patients and carers couldtelephone the service to re-schedule appointments.

• The teams rarely cancelled appointments. If staff calledin sick, staff either re-arranged appointments or patientswere seen by other members of the team or the dutyworkers.

Are services responsive topeople’s needs?By responsive, we mean that services are organised so that they meet people’s needs.

Outstanding –


The facilities promote recovery, comfort, dignityand confidentiality

• The facilities where the services were located had beentailored to meet the needs of the patient group. Clearsignage and contrasting colours were used along withpictures to help patients orientate themselves. Waitingareas were bright, spacious and comfortable. InHaringey, the team clearly displayed the time, date andseason on a board and music was playing in the waitingarea.

• Suitable rooms were available at each service forindividual patient consultations to take place. Theserooms were comfortable and adequately soundproofed.Larger rooms were used for group support and therapysessions.

• Information leaflets on a range of relevant topics wereavailable in waiting areas. This included informationabout carers support, help for men suffering domesticabuse, the ‘ten commandments’ when caring for peopleliving with dementia and patient transport information,which was also displayed in Greek and Turkish inHaringey. Each service had a notice board with picturesof staff members displayed in waiting areas, along withinformation about how to provide feedback about theservice or make a formal complaint.

• Where appropriate, staff spoke with patients under theage of 68 about employment and educationopportunities and they supported them to access these.

Meeting the needs of all people who use theservice

• Staff took a proactive approach to understanding theneeds of different groups of people and delivered carein a way that met their needs and promoted equality.

• All buildings were fully accessible to people whoattended appointments. Staff arranged transport forpatients with mobility issues and they supportedpatients to move around the building if they neededassistance. Walking aids were available for patients touse at each location.

• Staff proactively considered how to meet the needs ofLGBT patients. Following their first known LGBT patientreferral, staff in Barnet older adult CMHT met to discuss

how the service would work to meet the needs of LGBTpatients in future. This meeting included a discussionabout how to identify and support people’s partners orcompanions. Staff could refer LGBT patients to a localcharity that provided an activity group for older adults.This enabled patients to actively participate in a localLGBT community.

• Staff worked with other organisations and the localcommunity to plan patient’s care and ensure they metpatient’s needs. Staff involved GPs, care homes andsupport charities to provide person-centred pathwaysfor patients.

• Staff at Enfield older adult CMHT maintained contactwith a local Greek care home. This benefitted patientswith Greek as a first language who wanted to be in aGreek-speaking environment if their dementiaprogressed.

• Staff referred patients who were socially isolated or whostruggled to maintain their relationships to local dayhospitals in Barnet and Enfield. Staff ran groups forpatients at these services to promote and maintainsocial inclusion.

• All trust leaflets and other information could betranslated into any language. To minimise the wait forthis information to be translated, key information wasavailable on hand already translated into the mostwidely spoken languages in the local area. At Haringeyolder adult CMHT, we found that some informationdisplayed on walls, such as fire safety instructions anddetails about patient transport, in Greek and Turkish.

• To help patients living with dementia to understandinformation leaflets and posters, staff wrote them inplain English and included pictures and bright colours.

• Staff could access interpreters were easily across theservices. Staff could request any language andinterpreters attended appointments and joined staff onhome visits.

Listening to and learning from concerns andcomplaints

• The services had received few formal complaints frompatients and carers. During the 12 months leading up to


Outstanding –


our inspection, the services we inspected had receivedsix formal complaints. Enfield older adult CMHT receivedfour complaints; Haringey and Enfield older adult hadeach received one complaint.

• Patients who we spoke with had a good understandingof how they would make a complaint if they wanted to.The teams had leaflets and posters informing peopleabout how to make a complaint displayed in waitingareas. People could complain in writing, on thetelephone or in person.

• Staff knew how to support patients to make complaints.Staff knew how to protect patients who complainedfrom discrimination. The teams managed informalcomplaints and compliments locally, but ensured theylogged them with the trust’s patient experience team sothey could identify themes and learning.

• The services actively reviewed complaints, includinginformal complaints, to identify any learning and madeimprovements using the feedback. They communicatedfeedback on the outcome of complaints to both thecomplainant and staff. Staff discussed recentcomplaints and learning at monthly clinical governancemeetings, to help prevent similar issues happening inthe future.

• Team managers provided examples of changes they hadmade to their service in response to complaints. Forexample, following a complaint about poorcommunication from staff at a care programmeapproach meeting, staff learned about the importanceof documenting conversations during meetings on thepatient records system in detail, so that they could beeasily referred back to in future by other staff.


Outstanding –


Our findingsLeadership

• Team managers had the skills, knowledge andexperience to perform their roles. Their immediatemanagers supported them well and most had extensiveexperience of working in management positions in thepast. Leaders had a good understanding of the servicesthey were providing and could explain how the teamswere working to provide high quality care.

• Staff at all teams were comfortable with their managersand felt able to approach them for support. The servicemanager at the Haringey community older adult mentalhealth services was working on an interim basis, but hadbeen in post for almost one year. The team leader atBarnet memory service also worked on an interim basis,but had been in post for 10 months. These teamsfunctioned very well under interim managementarrangements.

• Leadership development opportunities were availablefor staff. Some managers told us they had completedpostgraduate diplomas in leadership, which had beensupported and funded by the trust. Other staff were alsosupported with career development, which wasdiscussed during supervision. Some staff had beengiven the opportunity to act up into more seniorpositions and were supported in their new roles. Existingleaders gradually handed over and explained theirresponsibilities to their successor.

Vision and strategy

• Staff had a good understanding of the trust’s vision andvalues. All staff attended mandatory training in thetrust’s vision and values. Staff were given theopportunity to participate in role play and discuss eachvalue, considering how they demonstrated them in theirroles. The teams also displayed the vision and values forall staff and patients to refer to.

• Staff were given the opportunity to discuss and reflecton the service’s strategy during monthly team meetings.They were able to explain how they were working hardto deliver high quality services within budget

constraints. For example, staff told us about how theywere pulling together to maintain a high standard ofsafe care for patients whilst posts were either frozen ornot planned to be recruited to.

Culture

• Staff who we spoke with said they felt respected,supported and valued by their leaders and by eachother. Staff described a strong sense of team workingand reported that all team members had an equal say.

• Staff felt able to raise concerns without fear ofretribution and were aware of the whistleblowingprocess.

• Managers told us about occasions when they addressedstaff performance issues and how this had led to animprovement in the quality of service delivery.

• Average staff absence was 4% across the older adultcommunity services.

• We reviewed staff appraisal records at Barnet olderadult CMHT. Discussions about specialist training andcareer progression and staff development goals tookplace during appraisals. Staff told us that they discussedtheir career goals with their managers.

Governance

• There were clear governance systems in place thathelped embed continuous improvement in the service.

• Staff completed high standard care plans, riskassessments and risk management plans across all ofthe teams and they delivered high quality care to allpatients and carers. They provided care and treatmentin accordance with national guidance and best practice.Systems were in place to ensure staff regularlydiscussed the safety of individual patients. All of theservices responded quickly when risks to patientsincreased.

• Staff members completed quality-assurance audits on amonthly basis. Managers gave individual team membersresponsibility for completing a specific audit on carerecords to feed in to heat maps. The team leader atBarnet memory service explained that delegating thisresponsibility to team members had improved staffengagement with the audit process. This had driven

Are services well-led?By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.

Good –––


improvements in record keeping. Audits includedquality of care plans, completion of physical healthchecks and presence of crisis plans. This process hadled to improvements where needed.

• Team managers attended quarterly deep dive meetingswith managers from other services within the boroughthey worked in, which the director of nursing chaired. Atthese meetings, staff reviewed the monthly ‘heat map’quality indicators for each service and managers wereheld to account for areas that required improvement.Whilst managers appreciated that these meetingsencouraged them to drive up standards, they also toldus they could be pressurised and stressful.

• The teams used a clear framework at staff meetings toensure they discussed key information. They discussedrecent incidents and complaints and the learning fromthem at business meetings.

• Communication between services across the threeboroughs was poor. The teams did not have a formalprocesses share innovative practice, learning fromincidents and complaints, and any other keygovernance information across the teams. Teammanagers told us that, whilst they were able to contactfellow managers in other boroughs informally for advice,there were no routine occasions where managers cametogether to discuss clinical governance. This meant theteams could miss on good practice and learning madein other teams.

Management of risk, issues and performance

• Staff maintained and had access to team risk registers.Staff could escalate specific risks via the incidentreporting system to directorate level. At directoratelevel, staff could escalate significant risks to the trust riskregister.

• Staff concerns matched those on team risk registers. Forexample, managers knew the risk of staff receivingviolence and aggression and had reduced these risks byensuring staff carried alarms and completed breakawaytraining. Staff summarised any identified environmentalrisks on team risk registers.

• Each location had a business continuity plan in place,which detailed how service delivery would continue inthe event of an emergency such as building failure or

widespread staff sickness. The Barnet older adult CMHTkept a folder that contained all the necessary templatesfor documentation, should the service have to relocateat short notice.

Information management

• The systems used to collect data from the services werenot over burdensome for frontline staff. The trust pulledmost information that fed into monthly heat mapsautomatically from an online system or from routineaudits that staff completed.

• Staff had access to the equipment and informationtechnology needed to do their work. All records systemsrespected the confidentiality of patients. However, somestaff said that the online patient records system workedslowly from time to time.

• Each team manager received a monthly heat map. Thisincluded key information about the performance of theteam and meant that managers could promptly identifyand work on areas that required focussed improvement.A centralised reporting system fed information in to theheat map, such as incidents, complaints and mandatorytraining compliance. A series of monthly qualityassurance audits also fed into the heat map.

• Staff made notifications to external bodies as needed.Staff sent all safeguarding incidents to the relevant localauthority. They reported on the online incidentreporting system and the system was used to identifyinformation that needed to be sent to external bodies.

Engagement

• Staff received regular up-to-date information about thework of the trust through the trust intranet system andnewsletters. The chief executive regularly wrote a blog,which staff could follow.

• Patients and carers had numerous opportunities toprovide feedback about the services. Feedback boxeswere positioned in waiting areas and satisfactionsurveys were often sent. At the end of groupprogrammes, such as carer support groups or cognitivestimulation therapy groups, staff actively soughtfeedback about both the usefulness of the group andthe service overall.


Good –––


• All feedback was referred to the patient experience teamand staff also had access to this feedback so they couldreflect on it.

• At Barnet memory service, staff were considering waysthey could include patients in decisions about theservice, such as including a patient on staff interviewpanels.

Learning, continuous improvement and innovation

• Staff at all services considered opportunities forimprovements. A ‘Kanban’ meeting took place once aweek at each location. In these meetings, staff sharedprogress with quality improvement initiatives, updateson NICE guidance and learning from other sources. Atthe ‘Kanban’ meeting we observed during theinspection, staff fed back learning from a study day andreviewed quality improvement strategies. The wholeteam attended the meeting.

• Staff were innovative and committed to qualityimprovement. They brought back ideas from trainingand conferences, which they tried to develop andintroduce to benefit patients. Managers encouraged allstaff to lead grass roots initiatives aimed at producingsustainable improvements. For example, at theHaringey older adult community services, staff hadrecently made the move to paperless record keeping.

• Local clinical improvement group meetings took placeat each service every month, where all staff discussedthe monthly performance audit and the ways theservice could improve. Team managers used thesemeetings to share learning and ways in which otherteams in the borough were improving.

• All three memory services were accredited by the RoyalCollege of Psychiatrists Memory Service NationalAccreditation Programme. Staff at Enfield older adultCMHT were working towards gaining accreditation fromthe Royal College of Psychiatrists.


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care quality commission - outstanding … · 2019. 9. 28. · locationsinspected locationid...

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