cumbria partnership nhs foundation trust · 2019. 9. 25. · cumbria partnership nhs foundation...

Cumbria Partnership NHS Foundation

Trust

Evidence appendix

Trust Headquarters Voreda House, Portland Place Penrith Cumbria CA11 7BF

Tel: 01228602000

www.cumbriapartnership.nhs.uk

Date of inspection visit:

21 May 2019 to 25 June 2019

Date of publication:

25 September 2019

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.

Facts and data about this trust Cumbria Partnership NHS Foundation Trust became a foundation trust in 2007. The trust provides mental health, learning disability services across Cumbria and community physical health service to North Cumbria to a population of approximately half a million people. The trust also provides health care services into HMP Haverigg. The trust employs 3,579 staff to deliver its services (4,254 including bank staff). Cumbria is rural county, which is sparsely populated in some areas. Cumbria has an older population than the national average with 27% of residents aged over 60 compared to a national average of 22%. The proportion of those residents over 60 in Cumbria has risen faster than the national average of 11%. In the last 10 years, the population over age 60 has increased by 16% and is forecast to continue to rise. Children and young people under 20 years of age make up 21% of the population. Infant and child mortality rates in Cumbria are similar to the national average. The level of child poverty in Cumbria is better than the national average with 14% of children under 16 years of age living in poverty. Rates of family homelessness are also rated better than the national average.

The trust operates within a complex commissioning environment, with recent changes to clinical commissioning group structures. The Cumbria clinical commissioning group was dissolved, and two locality clinical commissioning groups established – North Cumbria clinical commissioning group and Morecombe Bay clinical commissioning group. Services are commissioned by: • NHS England – Offender Health, and Dental Services. • North Cumbria clinical commissioning group and Morecombe Bay clinical commissioning

group – General Community, Mental Health, Learning Disability, and Children’s Services. • Cumbria County Council – Sexual Health, Health Visiting, Public Health and Wellbeing

Nurses. At the time of the inspection the trust were making plans to merge with North Cumbria University Hospitals NHS Trust. The two organisations had joint management and governance structures in place and Stephen Eames was the joint Chief Executive for both this trust and North Cumbria University Hospitals NHS Trust. The mental health services in the north of the trust were due to be transferred to Northumberland Tyne and Wear NHS Foundation Trust and the mental health services in the south of the trust were due to be transferred to Lancashire Care NHS Foundation Trust. The changes were planned to take place on the 1 October 2019. Stephen Eames was also the chief executive of the North Cumbria Integrated Health and Care System. The trust is registered to provide the following activities: Regulated Activity: Assessment or medical treatment for persons detained under the Mental Health Act 1983. Regulated Activity: Diagnostic and screening procedures. Regulated Activity: Family planning. Regulated Activity: Surgical procedures. Regulated Activity: Treatment of disease, disorder or injury. The trust had 16 locations registered with the CQC (on 18 April 2019).

Registered location Code Local authority

Brampton War Memorial Hospital RNNBF Cumbria

Cockermouth Hospital RNNCB Cumbria

Dova Unit RNNFG Cumbria

Haverigg Prison RNNHV Cumbria

Kentmere Ward RNNWG Cumbria

Mary Hewetson Cottage Hospital RNNCJ Cumbria

Penrith Community Hospital RNNBE Cumbria

Ramsey Unit RNNFH Cumbria

Ruth Lancaster James Community Hospital RNNRJ Cumbria

The Carleton Clinic RNNBJ Cumbria

The Copeland Unit RNNCL Cumbria

Victoria Cottage Hospital RNNCA Cumbria

Voreda RNNDJ Cumbria

Wigton Community Hospital RNNWT Cumbria

Workington Community Hospital RNN42 Cumbria

Yewdale Unit RNNBX Cumbria

The trust provides the following community health core services; • Community Health inpatient services • Community health services for adults • Community health services for children, young people and families • End of life care • Community dental services • Community sexual health services • Community urgent care services The trust provides the following mental health core services: • Acute wards for adults of working age and psychiatric intensive care units • Community mental health services for people with learning disabilities or autism • Community based mental health services for older people. • Long stay/rehabilitation mental health wards for working age adults • Mental health crisis services and health based places of safety • Specialist community mental health services for children and young people • Wards for older people with mental health problems • Wards for people with learning disability or autism The trust provides primary healthcare services into HMP Haverigg. This includes immunisation and screening programs, wound care, venepuncture and blood-borne virus testing, chronic disease clinics for conditions such as diabetes, asthma, COPD and cardiac risk assessments clinics to inmates. There is also a physiotherapist, an optician, a podiatrist and GUM service on site. The trust had 238 inpatient beds across 15 wards. The trust also had 80 acute outpatient clinics,

572 community mental health clinics and 478 community physical health clinics per week.

Total number of inpatient beds 238

Total number of inpatient wards 15

Total number of day case beds 8

Total number of children's beds (MH setting) 0

Total number of children's beds (CHS setting) 0

Total number of acute outpatient clinics per week 80

Total number of community mental health clinics per week 572

Total number of community physical health clinics per week 478

The methodology of CQC provider information requests has changed, so some data from different time periods is not always comparable. We only compare data where information has been recorded consistently.

Is this organisation well-led?

Leadership

The trust board had the appropriate range of skills, knowledge and experience to perform its role. The board comprised of nine executive members including the chief executive who all had career experience in a healthcare setting and relevant qualifications as appropriate for their roles. There were seven non-executive members including the chair of the trust who brought experience and

knowledge of working within clinical, finance and business, and strategic roles. There was appropriate challenge at board meetings, these were accepted and responded to in a positive way by the executive team. Members of the executive team are also members of the joint executive team with North Cumbria University Hospitals NHS Trust. The joint transitional executive management team structure has been in place since August 2018. At the time of the inspection transitional arrangements were expected to be in place until 31 October 2019. The executive team had taken action to strengthen their position by the appointments of new executives with the skills, competence, experience and motivation to take forward the vision and strategy and deliver the merger. The chief executive of Cumbria Partnership NHS Foundation Trust was also the chief executive of the North Cumbria Integrated Health and Care System. The executive board had one (6%) black and minority ethnic (BME) members the non-executive board had no (0%) BME members. The executive board had four women (25% of the board) and two female non-executive directors ( 35% women on the board). The executive team were passionate and motivated to lead the work that needed to be done to move the organisation forward. There was an acknowledgement that although some progress had been made there was a lot of work to do especially with the merge of the organisations. Capacity below these roles was an issue and interviews for deputies were taking place at the time of the inspection. The board were clear that they needed to have the right people in these roles in order to deliver. The trust board and senior leadership team displayed integrity on an ongoing basis. NHS improvement looked at the financial governance of Cumbria Partnership NHS Foundation Trust and informed us that the trust had a long-standing experienced director of finance who took on the additional role of the director of finance for North Cumbria Acute Hospitals in April 2018. The trust had a well-established project management office structure which was fully embedded into the trust and worked closely with the finance department. NHS improvement had no concerns regarding the capability and capacity of the board. The trust had a lead for child and adolescent mental health, learning disability and autism. As part of the early work to prepare for transfer of mental health services and to provide a dedicated voice at the board for mental health, learning disabilities and CAMHS services, the director for mental health and learning disabilities was the chief operating officer from a neighbouring trust and worked in Cumbria for two days per week. This was an improvement on previous years where mental health had not had dedicated senior leadership at board level. The chief executives in both organisations reviewed capacity on a regular basis with the director and there have been no issues raised. However, the inspection team had some concerns about capacity of this role due to the vast amount of work that needed to be done in terms of the transfer of services and the day to day issues. Personnel files for the board contained most of the necessary information and checks required. The trust was able to demonstrate that appointments of existing directors (and new directors) had been secured through robust and thorough appointments processes. However, the trust did not have an appropriate systems or process in place to ensure that all existing directors continue to be fit and do not meet any of the unfitness criteria set out in Schedule 4 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The trust had not updated its practice in line with the most recent guidance and was not carrying out regular checks of board members. Providers must take proper steps to ensure that their directors, or equivalent, are fit and proper for the role. Directors, or equivalent, must be of good character, physically and mentally fit (in line with the Equality Act 2010), have the necessary qualifications, skills and experience for the role, and be able to supply certain information (including, where appropriate, a disclosure and barring service check and a full employment history). When senior leadership vacancies arose the recruitment team reviewed capacity and capability needs. The trust has taken action to strengthen the position of the board. There had been some

new appointments of executives who had the skills, competence, experience and motivation to take forward the vision and strategy and deliver on the merger. The trust reviewed leadership capacity and capability on an ongoing basis. The trust was restructuring the support under board level to enable the executive team to deliver their work and were clear about getting the right people with right skills in post to carry out the work. The trust leadership team had a comprehensive knowledge of current priorities and challenges and took action to address them. The executive team were able to identify the challenges the trust faced across all of their services, the plans in place to meet those challenges and the current strategic direction for the trust within the wider healthcare system in Cumbria. However, some of the governance systems at service level were ineffective in assessing, monitoring and improving care and treatment. Some systems and audits had failed to identify issues such as patient observation following restrictive physical interventions, medicines management, mandatory training compliance, clear oversight of supervision, bed management, issue with staff experience and skill mix, care records or staff support following incidents. Mental health issues were the sole responsibility of the director for mental health and learning disability who worked at the trust two days per week. Concerns, such as a patient with learning disability in long term seclusion, and estates issues were not known by the chief operating officer. There was a programme of board visits to services. There was also a programme of visits by Non-Executive Directors and Governors. Clinical directors had become more visible and visits to front line teams were taking place. Visits from other members were taking place but due to capacity they were less visible. The chief operating officer visited services monthly but acknowledged that more work needed to be done. We heard that visits were less frequent in the mental health services, but within community health services there was greater visibility. There were mixed views regarding the visibility of leaders in the core services. While most staff said the service leads were visible, few had seen or spoken with the senior managers of the trust. Some staff thought this was because of the geography which at times made them feel isolated. Staff said when trust officials did visit, the short period of time they spent there was not long enough get an understanding of issues. Leadership development opportunities were available, including opportunities for staff below team manager level. The trust had a collective leadership approach to ensure that all staff had access to development through the Cumbria learning and improvement collaborative. This delivered a 'leading sustainable change' and medical leaders programme as well as a bite size leadership skills programme. There was an established programme of executive and board development and a monthly forum for senior leaders to come together across health providers in Cumbria hosted by the chief executive. Staff who had attended leadership courses are connected through an alumni for continuous development and had access to a hub of internal coaches from health and social care. The trust had built a strong relationship with the north east leadership academy and had accessed both regional and national courses. A number of senior managers had attended high level programmes such as Nye Bevan and the queens executive nurse leadership programme. The trust had a number of staff equality networks and board members had had unconscious bias training from the employer’s network for equality and inclusion and were supporting a nurse colleague on the national 'Windrush' programme. Following the development of the Integrated Health & Social Care Submission (IHCS) People Plan the trust were developing a leadership plan with the aim of developing leaders based on assessment of competence and culture. In 2019-20 the trust plan to introduce succession planning and talent conversations starting with the chief executive and executive team. Although unsuccessful in recent years in attracting graduate management trainees the trust were supporting the facilitation of the NHS graduate management training scheme action learning sets.

The clinical director of pharmacy services was appointed in September 2018 and had refreshed the trust medicines optimisation plan 2017- 2019 focussing on medicines safety, system working, workforce and finance. Progress against key milestones was monitored quarterly. A separate digital strategy outlined plans for electronic prescribing and medicine administration. Risks associated with the planned trust merger with North Cumbria University Hospital NHS Trust were included on the merger risk register. Pharmacy workforce (recruitment and retention) and medicines supply were identified as high risk (16+) impacting upon the merged trust’s ability to ensure the safe supply of medicines and to provide clinical pharmacy services. A new pharmacy management structure had been agreed (Clinical Management Group May 2019) allowing the recruitment to senior posts to begin. However, a complete business case for pharmacy and medicines optimisation operational roles was still in development.

Vision and strategy

The trusts vision and values were: Kindness – We know that kindness and compassion cost nothing, yet accomplish a great deal Respect – We are respectful to everyone and are open, honest and fair Ambition – We set ourselves ambitious goals to achieve the best for our patients, our teams, our organisation and our partners Collaboration – We are always stronger and better working together with and for our patients The trust had a clear vision and set of values with quality and sustainability as the top priorities. The values were launched in March 2019 and were joint with Cumbria Partnership NHS Foundation Trust and North Cumbria University Hospitals NHS Trust. The trust developed these with a wide range of staff building on the existing values. The trust’s new visions and values were displayed throughout the wards, on computer screen savers and included on the trust intranet. The strategy for achieving trust priorities and developing good quality, sustainable care was in the development stage and engagement with staff and communities was taking place during the inspection period in accordance with the national process for the NHS Long Term Plan. The director of strategy was leading the engagement process and working closely with partners. The Strategy was focussed on building a new integrated health and care system across North Cumbria. The trust's clinical strategy is the current clinical strategy of the West, North and East Cumbria sustainability and transformation partnership (STP) which was developed in 2016/17 to address three key priorities; population health & wellbeing, service quality and sustainability. Staff, patients, carers and external partners had the opportunity to contribute to discussions about the strategy, with some areas having a real focus on co-production with communities especially where there were plans to change services. Local providers and people who use services had been involved in developing the strategy. The director for strategy was engaging with staff and community groups about the new strategy, questionnaires and focus groups were taking place in June 2019 – September 2019 with a view to having the strategy in place for the Autumn. The clinical strategy was developed as part of the success regime sustainability and transformation partnership submission and was subject to a public consultation "The Future of Healthcare in West, North and East Cumbria" as well as through engagement and consultation with community stakeholder groups and with system partners. Most staff knew and understood the trust’s vision, values and strategy and how achievement of these applied to the work of their team. In acute wards for adults of working age and psychiatric intensive care units’ staff were unsure of the new values but were aware of how the previous values applied to their work. In wards for older people with mental health problems the services were currently in the process of being transferred to new mental health trusts. Services in the south had started discussion with the new provider and felt confident about the move. The provider in the north of the county had just started to lead joint work between the two

organisations. The senior leadership team had not successfully communicated the provider’s vision and values to all of the frontline staff in this service. Staff in most of the services felt supported and informed about the upcoming transfer in care services we inspected. However, staff in mental health crisis services and health-based place of safety told us they did not feel able to contribute to service developments or the strategy for their service. Staff did not know what the changes would mean for them going forward. Staff in the east of the service had received little or no information regarding the changes. The trust was embedding its vision, values and strategy in corporate information received by staff. The trust had a range of communication media that included its vision values and strategy. This included a newsletter ‘Trust Talk Magazine’, twitter feed, Facebook and you tube.

The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders. The trust worked closely with local authority public health colleagues. There were good links with health and well-being strategy. The trust worked with partners to align strategies and plans for the system rather than individual organisations. The trust had planned services to take into account the needs of the local population. The plans took account of aging population, higher rates of cardiovascular disease and cancer survival. The leadership team regularly monitored and reviewed progress on delivering the strategy and local plans. Progress was monitored by the trust board and through the leadership board. Senior responsible officers had been designated to lead on delivery workstreams through the system executive team. Monthly senior responsible officers’ meetings took place to report on and oversee progress. A key enabler to the clinical strategy was the formation of integrated care communities, these had been established and were in their early stages of implementation. NHS improvement looked at the financial governance of Cumbria Partnership NHS Foundation Trust and informed us that the trusts annual financial plan for 2017/2018 was predicated on delivery of an £9.9m efficiency programme against which the trust delivered £5.5m. The trusts annual financial plan for 2018/19 was predicated on delivery of an £6.4m efficiency programme against which the trust is overdelivered by £1.5m. The trust has a one month reporting cycle from Floor to Board ensuring that the most up to date positions are presented and discussed at trust board and that timely action can be taken. The trust is part of an early adopter Shadow Integrated Care System (ICS) and works in partnership with North Cumbria University Hospitals NHS Trust and North Cumbria clinical commissioning group. The clinical director of pharmacy had a strategic role supporting the integration of pharmacy and medicines optimisation within North Cumbria. However, development of this role was dependent on recruitment to the senior pharmacy management posts at the trust. The trust was planning to increase the number of non-medical prescribers in community teams as recommended in the Carter Review Operational productivity: unwarranted variations in mental health services and community health services, May 2018. The four largest ethnic minorities within the trust’s catchment population are: White other (1.7%),

White Irish (0.3%), Other Asian (0.2%) and Chinese (0.2%).

Culture

Most staff felt respected, supported and valued. There was a mixed response from the staff

survey. The impact of change was reflected in the results of the survey which showed a decrease

in the enablers of 'clarity' and 'work relationships' over the past 12 months, deteriorating

engagement scores had been identified in support services that have been going through

reorganisation to integrate teams across Cumbria Partnership Foundation Trust and North

Cumbria University Hospital. Mental health staff reported not feeling heard or valued. However,

there had been some improvements with the appointment of the director for mental health and

learning disability. Themes from the surveys had been triangulated with those from the freedom to

speak up guardian and exit interviews. These were identified as cultural behaviours, staff

involvement in decision making and communication, the trust planned to use these themes to

inform the organisational development plans going forward. In two of the core services we visited

staff described mixed views regarding managers support, staff said some managers were more

supportive than others. In the other two cores services staff found the management supportive and

they felt valued.

Staff generally felt positive and proud about working for the trust and their team. Most teams reported good morale, although acknowledged this could fluctuate in changing circumstances. The coming changes to the trust and merger had led to some low moral from staff in some services. Staff generally said they were proud to work in the trust but there were some mixed feeling and anxieties expressed about the merger and changes to services this may bring. The trust recognised staff success by staff awards and through feedback. Staff awards and recognition were taking place. The trust was aware of the need to support and encourage staff through the changes. Over the past two years the trust had increased its focus on staff recognition introducing Glimpse of Brilliance, weekly staff recognition, staff awards and offering leaders training in appreciative leadership. The trust worked appropriately with trade unions. The union chair had monthly meetings with the chief executive to discuss hot spots in the county and any areas of specific concern. This made a clearer route to progress issues to the board and the staff representatives felt the board listened to the concerns from staff and took action to address these. Managers addressed poor staff performance where needed. The provider had a performance management system which included guidance for managers on how to effectively and promptly address poor staff performance. Dependent on the issues, they would seek to identify whether the staff member had any additional training needs or required extra support. This could be addressed through supervision. Where cases required disciplinary action, the trust had a capability policy and processes, to manage staff performance effectively. Additional support was available when required, from the human resources department. We reviewed 3 disciplinaries, all of which adhered to the trusts policy and procedure. Investigations were thorough and described outcomes in a letter. The trust had appointed a freedom to speak up guardian and provided them with sufficient resources and support to help staff to raise concerns. The guardian had regular meetings with the chief executive and provided regular board reports were produced by the guardian to provide activity details, assurance and oversight. They were also engaged in local and national network forums. The guardian role in Cumbria Partnership Foundation Trust had recently been extended to three days a week from one to fulfil the role. However, there was little evidence of the staff in the core services having knowledge of who the freedom to speak up guardian was or what their role was. We also heard that some staff did not feel comfortable raising concerns with the guardian and would use other routes such as staff representatives.

The handling of concerns raised by staff always met with best practice. The most recent staff survey found that staff reflect a working environment where they feel confident to report concerns and can contribute to improvements at work. Staff at ward level told us they could escalate concerns when required.

Staff knew how to use the whistle-blowing process. A register of whistleblowing incidence was kept and maintained by the company secretary. The log of open cases were reported to the quality and safety committee. All previous whistleblowing incidents had been investigated to the satisfaction of the quality and safety committee and had been closed. There had been no whistleblowing incidents in the last 12 months and there are no open cases ongoing. Staff in the cores services we inspected felt able to raise concerns without fear of retribution. The trust applied duty of candour appropriately. At our last inspection in 2016 we found the trust were not fully applying the duty of candour requirement. At this inspection staff in the core services had a good understanding of duty of candour. Incidents meeting the duty of candour requirement contained an apology to the appropriate person. There was a joint Cumbria Partnership NHS Foundation Trust and North Cumbria University Hospitals NHS Trust being open and duty of candour policy in place and in date. Duty of candour was managed by each of the care groups within Cumbria Partnership NHS Foundation Trust. All care group quality and safety leads review all incidents to ensure that they have been correctly graded and that, were required, duty of candour had been applied for patient safety incidents which were graded as moderate and above. The trusts electronic risk management system (Ulysses) was the primary method for storing information linked with duty of candour. All serious incident investigation reports were reviewed and signed off at the trust patient safety panel. The trust had quarterly duty of candour audits in place. The trust had webinar sessions available for the system aspect of recording information on Ulysses which relates to duty of candour. Learning lessons leads had conducted 'ad hoc' duty of candour training across the county. The trust had developed a joint duty of candour e learning package which they planned to be mandatory for all staff with a 3-yearly refresher. The trust had an effective guardian of safe working hours. The guardian was passionate about his role and improving the lives of junior doctors. There was a junior doctors forum established although the attendance sometimes was not as good as expected. The most recent forum had 13 members attended. The trust was developing creative ways to access the junior doctors including attending the trainees teaching session, joining WhatsApp groups and use technology to facilitate attendance such as four-way video conferencing. The guardian was working on increasing exception reporting within Cumbria Partnership NHS Foundation Trust, an example of this was that junior doctors were not reporting travel time to secondary sites. The guardian was very active within seeking resolutions to issues raised by junior doctors such as addressing, with consultants, the issue of North Cumbria University Hospitals NHS Trust sending patients back to mental health wards with intravenous drips. The guardian had a good working relationship with the board who were receptive. However, the guardian felt there wasn’t enough allocated time to undertake the guardian role. All staff had the opportunity to discuss their learning and career development needs at appraisal. This included agency and locum staff and volunteers. Staff across the core services we inspected said they had an annual appraisal and had the opportunity to discuss their work performance and progression. The overall percentage for appraisal compliance for the trust was 72.15% in June 2019. Staff had access to support for their own physical and emotional health needs through occupational health. The trust had a range of programmes to support staff’s physical and emotional health needs. The trust provided access to complimentary therapies, counselling and stress management services occupational health service. The trust also provided a multi-faith service to meet the spiritual and religious needs of staff. One member of staff we spoke with told us that the trust supported dragon software (speech recognition software) as a reasonable adjustment for their individual needs. The trust had developed a menopause policy for staff and this had been given high profile in the organisation. A staff representative was the lead for this and

spoke passionately about supporting female colleagues and ensuring managers had the support and knowledge to support staff. Sickness and absence figures were not outliers with rest of the NHS. The latest figures released by NHS Digital show that for February 2019 NHS staff sickness absence was 4.51 per cent. The trust average was 4 per cent. However, between January 2018 and December 2018, medical and dental staff took 5.1% of working days as sick leave, which was much worse than the national average of 2.3%. Staff felt equality and diversity were promoted in their day to day work and when looking at opportunities for career progression. Workforce race equality standard data shows that there is a difference of 12% between the percentage of staff believing the trust provides equal opportunities for career progression or promotion in between black minority ethnic (75.9%) and white staff (88.1%). Staff networks were in place promoting the diversity of staff. The trust had four staff networks that meet quarterly and they have an executive board sponsor. The groups were; armed forces, LGBT+, accessibility/disability and cultural diversity and all of these have terms of reference and action plans in place. Some staff attend more than one of these. The groups meet quarterly, some staff preferred to physically meet and some preferred other ways of communication such as feeding in via email. Meetings are held over lunchtime at Cumberland infirmary to make it easier for people to attend, there are also drop in session held and the teams rotate. The trust hosts an annual development day and people were starting to become more aware of the networks. The trust promotes diversity through the trust website, intranet and social media. Rainbow lanyards have been distributed across the trust. The trust had developed a champions programme for all staff and governors as well as patients. There were 200 champions in total who meet bi-monthly. Where any issues arise, these are taken to workforce / organisational development steering group which reports to quality and safety committee. Most teams had positive relationships, worked well together and addressed any conflict appropriately. Teams in the core services worked well together and staff felt respected, supported and valued. However, the trust did not ensure that all staff working on Rowanwood ward felt supported, valued and respected following serious incidents or assured that there were measures in place, protected them from reoccurrence.

The following illustration shows how this provider compares with other similar providers on ten key themes from the 2018 NHS Staff Survey. Possible scores range from zero to ten – a higher score indicates a better result.

The trust’s 2018 scores for the following themes were significantly lower (worse) when compared to the 2017 NHS Staff Survey:

• Equality, diversity and inclusion

• Health and wellbeing

• Quality of care

• Staff engagement

The Workforce Race Equality Standard (WRES) became compulsory for all NHS trusts in April

2015. Trusts must show progress against nine measures of equality in the workforce. There was

senior manager and board commitment to equality and diversity, the chair was very committed to

the inclusion agenda. There was an equality board champion and equality champions programme

in place. Staff networks had been developed and were supported by the trust. All of the staff

networks had executive level sponsors. However, WRES indicators 2,3 and 4 needed to be

calculated correctly; there was no equality, diversity and Inclusion strategy but this was being

developed to cover Cumbria Partnership Foundation Trust and North Cumbria University Hospitals

NHS Trust at the time of the inspection; the WRES data not published by banding.

1 The percentages of White and BME staff in each of the Agenda for Change (AfC) pay bands 1 to 9, and at Very Senior Manager (VSM) level (including executive board members), compared with the percentage of staff in the overall workforce:

“The trusts employ 48 BME staff on AFC 1-9 and VSM grades (8 in non-clinical roles and 43 in

clinical roles). This figure has increased from last year which was 45 BME staff, and, the

percentage of BME staff to white staff has increased this year to 1.8%. EDS2 Equality objectives

include:

Develop and implement staff networks across Cumbria Partnership Foundation Trust and North

Cumbria University Hospitals NHS Trust.

Work with BME community groups to understand barriers to recruitment and promote

opportunities for attraction and employment of people from diverse ethnic backgrounds”

2 Relative likelihood of staff being appointed from shortlisting across all posts:

Reporting year: BME – 6.5%, White – 9.9%. Previous year: BME – 11%, White – 16%.

"NHS Jobs reporting will only return data up to 12 months from the date of the report, therefore, the recruitment data considered is dated 28/07/2017 to 27/07/2018. Applications are shortlisted with EO forms and identifiable data removed, the gap has decreased between BME and White shortlist percentages. As can be seen there has been a 27.7% decrease in all staff appointments with the gap closing to 3.4% difference from previous year.

As the BME demographic is low within Cumbria it makes targeted recruitment promotion challenging. However, the Trust is keen to promote and encourage applications from all different protected characteristics and under-represented groups, therefore, run focused recruitment campaigns.

We are working with AWAZ (Organisation providing support to BME people across Cumbria) to understand how we can better reach BME communities, to increase the likelihood of BME people applying, being shortlisted and successfully appointed. This is included in EDS2 as one of the Trust’s Equality Objectives.”

3 Relative likelihood of staff entering the formal disciplinary process, as measured by entry into a

formal disciplinary investigation. This indicator will be based on data from a two-year rolling average of the current year and the previous year:

Reporting year: BME – 1.4%, White – 0.5%. Previous year: BME – 0%, White – 1%.

“There has been one disciplinary case this year for BME staff. This has shown as a more significant increase to previous year due to the low number of BME staff within the workforce.

The Trust is a member of the Cumbria EDI Partners Group which is chaired by AWAZ.

The implementation of our staff networks including the Cultural Diversity network will hopefully increase confidence and provide a forum to bring and report issues.”

4 Relative likelihood of staff accessing non-mandatory training and CPD

Reporting year: BME staff are 4.4% more likely to access non- mandatory training than white staff. (BME: 68.5%; White: 64.1%) Previous year: BME staff are 5.8% more likely to access non- mandatory training than white staff (BME: 62.5%; White: 56.7%) “Although the gap has decreased from the previous year there is a 4.4% increase in the likelihood of BME staff accessing non-mandatory training compared to white staff. The Trust is developing inclusive career pathways to indicate at varying levels what training and opportunities are available, to progress careers within the Trust and wider Health and Care Sector.

The Trust is currently promoting the Leadership Academy “Ready Now” programme and the HEE Windrush Leadership Development Programme with 1 member of staff from Cumbria Partnership Foundation Trust and 1 from North Cumbria University Hospitals Nhs Trust applying for the latter.” 5 The percentage of BME staff on the board was 0% compared with 1.8% BME staff in the

overall workforce. The percentage difference between the board voting membership and

overall workforce was 1.8%.

The Patient friends and family test asks patients whether they would recommend the services they

have used based on their experiences of care and treatment.

The trust scored between 88% and 98% between February 2017 and January 2019.

The Staff Friends and Family Test asks staff members whether they would recommend the trust

as a place to receive care and as a place to work.

The percentage of staff that would recommend this trust as a place to work in Q2 2018/2019

stayed about the same when compared to the same time last year.

The percentage of staff that would recommend this trust as a place to receive care in Q2

2018/2019 stayed about the same when compared to the same time last year.

The trust had seen an improvement in nurse vacancy rates (to 11% from 17%), staff recognition,

review of mandatory training, digital programme to support the way staff work, recognition of stress

and impact on staff of organisational change, improved focus on staff well-being services and

launches of initiatives using values as a starting point (clinical supervision, mandatory training and

appraisal). The trust had developed a people plan which had been approved by the Board of

Directors in March 2019. The plan aimed to support organisational change. New roles and a

recruitment drive was in place with the trust looking at how they could turn attention to retention.

The below chart shows the breakdown of staff in post WTE in this core service from 1 January 2018

to 31 December 2018.

Annual staffing metrics

Core service annual staffing metrics

(1 January 2018 – 31 December 2018)

Staff group Annual average

establishment

Annual

vacancy

rate

Annual

turnover

rate

Annual

sickness

rate

Annual

bank

hours (%

of

available

hours)

Annual

agency

hours

(% of

available

hours)

Annual

“unfilled”

hours

(% of

available

hours)

All staff 4039.2 7% 12% 5.1%

Qualified

nurses 1307.1 7% 13% 5.5%

74907

(13%)

17161

(3%)

16993

(3%)

Nursing

assistants 662.6 2% 11% 6.9%

243025

(27%)

91026

(10%)

36717

(4%)

Medical staff 200.1 17% 12% 2.0% 2106 (1%) 22181

(8%)

69595

(26%)

Allied Health

Professionals 387.4 4% 16% 3.1%

The average sickness rate for ‘Additional Clinical Services’ staff and ‘Allied Health Professionals’ was in the lowest 25% when compared to other similar trusts nationally. The average sickness rate for ‘Medical and Dental’ staff was in the highest 25% when compared to other similar trusts nationally. The average vacancy rate for ‘all staff’, ‘Nursing and Midwifery’ staff and ‘Additional Clinical Services’ staff was in the lowest 25% when compared to other similar trusts nationally. The average vacancy rate for ‘Medical and Dental’ staff was in the highest 25% when compared to other similar trusts nationally. The average turnover rate for ‘Nursing and Midwifery’ staff was in the highest 25% when compared to other similar trusts nationally. The average turnover rate for ‘Additional Clinical Services’ and Allied Health Professionals was in the lowest 25% when compared to other similar trusts nationally. Please refer to the Data Glossary at the end of this document, for further details on what data has

been reviewed and how. Ward/team level RPIR figures can be found via the run chart tool linked in

the footnote (see ‘safe staffing’ subheading).

These indications of assurance, risk, improvement and deterioration are highlighted for further

investigation and may be used to support judgements if confirmed by evidence found on site (they

are not to be used in isolation).

Monthly 'vacancy rates' over the last 12 months for all staff shows a shift from July 2018 to December

2018. This could be an indicator of change

Monthly 'turnover rates' over the last 12 months for all staff shows a downward trend from August

2018 to December 2018. This could be an early indicator of improvement. This merits investigation

to find out if this trend has continued and to learn about the cause, impact and possible actions

taken by the provider to maintain the improvement.

Monthly 'sickness rates' over the last 12 months for all staff shows a shift from July 2018 to

December 2018. This could be an indicator of change. This merits investigation to find out the

causes and impacts of the possible change, what has worked and how learning was shared more

widely.

Monthly 'bank hours' over the last 12 months for all staff shows an upward trend from April 2018 to

August 2018. This could be an early indicator of deterioration. This merits investigation to find out if

this trend has continued and to learn about the cause, impact and possible actions undertaken by

the provider to reverse the deterioration.

Monthly 'turnover rates' over the last 12 months for qualified nurses, health visitors and midwives

show an upward trend from April 2018 to August 2018. This could be an early indicator of

deterioration. This merits investigation to find out if this trend has continued and to learn about the

cause, impact and possible actions undertaken by the provider to reverse the deterioration.

Monthly 'sickness rates' over the last 12 months for qualified nurses, health visitors and midwives

show a shift from July 2018 to December 2018. This could be an indicator of change. This merits

investigation to find out the causes and impacts of the possible change, what has worked and how

learning was shared more widely.

Monthly 'vacancy rates' over the last 12 months for nursing assistants shows a shift from July

2018 to December 2018. This could be an indicator of change. This merits investigation to find out

the causes and impacts of the possible change, what has worked and how learning was shared

more widely.

Monthly 'bank hours' over the last 12 months for nursing assistants shows a shift from July 2018 to

December 2018. This could be an indicator of change. This merits investigation to find out the

causes and impacts of the possible change, what has worked and how learning was shared more

widely.

Monthly 'sickness rates' over the last 12 months for medical staff shows an upward trend from July

2018 to November 2018. This could be an early indicator of deterioration. This merits investigation

to find out if this trend has continued and to learn about the cause, impact and possible actions

undertaken by the provider to reverse the deterioration.

Monthly 'sickness rates' over the last 12 months for allied health professionals shows an upward

trend from August 2018 to December 2018. This could be an early indicator of deterioration. This

merits investigation to find out if this trend has continued and to learn about the cause, impact and

possible actions undertaken by the provider to reverse the deterioration.

The compliance for mandatory and statutory training courses at 31 December 2018 was 75%. Of

the training courses listed, 18 failed to achieve the trust target and of those, eight failed to score

above 75%.

The trust set a target of 85% for completion of mandatory and statutory training and 95% for

Information Governance training. Prevent Radicalisation L1&2 had a target of 80%.

The trust has stated that training is reported on a rolling month on month basis and the following courses were not offered before April 2018: Health, Safety and Welfare, Preventing Radicalisation Level 1 & 2, Preventing Radicalisation Level 3,4&5, Safeguarding Children Level 1 and Resuscitation Level 1

Key:

Met trust target

✓

Not met trust

target

Higher

No change

➔

Lower

Training Module

Number of

eligible

staff

Number of

staff trained

YTD

Compliance

(%)

Trust

Target

Met

Compliance

change

when

compared to

previous

year

Corporate Induction 3541 3439 97% ✓

Manual Handling - Object 3541 3182 90% ✓

Fire Safety 2 years 3541 3123 88% ✓ ➔

Local Induction 3541 3099 88% ✓

Training Module

Number of

eligible

staff

Number of

staff trained

YTD

Compliance

(%)

Trust

Target

Met

Compliance

change

when

compared to

previous

year

Infection Prevention (Level 1) 3540 2965 84%

Equality and Diversity 3541 2898 82%

Safeguarding Children (Level 2) 2604 2134 82%

Information Governance 3541 2860 81%

Mental Capacity Act Level 1 1343 1068 80% ➔

Safeguarding Adults (Level 1) 3537 2776 78%


Medicine management training 209 161 77%

Adult Basic Life Support 2193 1672 76%

Manual Handling - People 1017 774 76%

Safeguarding Children (Level 1) 3540 2513 71%patient

experience N/A

Prevent Radicalisation L1&2 3540 2395 68% N/A

Health and Safety (Slips, Trips and Falls) 3540 2389 67% N/A

Mental Health Act 493 286 58%



Prevent Radicalisation L3,4&6 1373 687 50% N/A

Resuscitation 3666 1655 45%

Total 57965 43665 75%

The trust’s target rate for appraisal compliance is 90%. At the end of last year (1 April 2017 to 31

March 2018), the overall appraisal rate for non-medical staff was 79%. This year so far, the overall

appraisal rate was 83% (as at 31 December 2018).

Three of the core services achieved the trust’s appraisal target. The services with the lowest

compliance were ‘Mental health crisis services and health-based places of safety’ with 54%,

‘Wards for people with learning disabilities or autism’ with 65% and ‘Community Dental’ with 73%.

Core Service

Total number of

permanent non-

medical staff

requiring an

appraisal

Total number of

permanent non-

medical staff

who have had an

appraisal

% appraisals

(as at 31

December 2018)

% appraisals

(1 April 2017 – 31

March 2018)

CHS - Sexual Health 30 29 97% 75%

CHS - End of Life Care 31 29 94% 87%

Core Service

Total number of

permanent non-

medical staff

requiring an

appraisal

Total number of

permanent non-

medical staff

who have had an

appraisal

% appraisals

(as at 31

December 2018)

% appraisals

(1 April 2017 – 31

March 2018)

MH - Long stay/rehabilitation

mental health wards for

working age adults

22 20 91% 88%

CHS - Children, Young People

and Families 274 243 89% 86%

CHS - Community Inpatients 162 144 89% 92%

MH - Community-based mental

health services for adults of

working age

160 141 88% 70%

CHS - Adults Community 942 816 87% 81%


health services for older people 177 152 86% 66%

MH - Wards for older people

with mental health problems 102 88 86% 80%

Other 241 193 80% 84%

MH - Acute wards for adults of

working age and psychiatric

intensive care units

148 119 80% 73%

MH - Community mental health

services for people with a

learning disability or autism

68 52 76% 59%

Provider wide 565 430 76% 81%

MH - Specialist community

mental health services for

children and young people

56 42 75% 47%

CHS - Community Dental 77 56 73% 81%

MH - Wards for people with

learning disabilities or autism 20 13 65% 76%

MH - Mental health crisis

services and health-based

places of safety

85 46 54% 78%

Total 3160 2613 83% 79%


March 2018), the overall appraisal rate for non-medical staff was 67%. This year so far, the overall

appraisal rate was 60% (as at 31 December 2018).

Core Service

Total number of

permanent

medical staff

requiring an

appraisal

Total number of

permanent

medical staff

who have had an

appraisal

% appraisals

(as at 31

December 2018)

% appraisals

(1 April 2017 – 31

March 2018)

Provider wide 1 1 100% 100%

MH - Specialist community

mental health services for

children and young people

1 1 100% N/A


health services for adults of

working age

1 1 100% 0%


with mental health problems 2 0 0% 100%

Total 5 3 60% 67%

The trust’s target of clinical supervision for non-medical staff was not provided.

Between 1 February 2018 and 31 January 2019, the average rate across all core services across

the trust (where data was provided) was 69%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different

ways, so it’s important to understand the data they provide.

Core service Clinical supervision

sessions required

Clinical supervision

delivered

Clinical

supervision rate

(%)

MH - Long stay/rehabilitation mental

health wards for working age adults 48 39 81%

Other 3296 2565 78%

MH - Community mental health services

for people with a learning disability or

autism

260 200 77%

MH - Community-based mental health

services for older people 1311 992 76%

MH - Community-based mental health

services for adults of working age 1320 910 69%

MH - Specialist community mental health

services for children and young people 512 235 46%

MH - Acute wards for adults of working

age and psychiatric intensive care units 304 98 32%

MH - Mental health crisis services and

health-based places of safety 296 63 21%

MH - Wards for people with learning

disabilities or autism 97 19 20%

Trust Total 7444 5121 69%

The trust’s target of clinical supervision for medical staff was not provided.

Between 1 February 2018 and 31 January 2019, the average was 82%. Please note that data was

provided for Specialist community mental health services for children and young people only.



Core service Clinical supervision

sessions required


delivered

Clinical

supervision rate

(%)

MH - Specialist community mental health

services for children and young people 50 41 82%


Although the board had some oversight of supervision they did not have a robust system to

provide clear oversight of both quantity and quality of supervision. At our last inspection in 2016

we told the trust they must ensure that regular supervision was provided to in line with policy and

that this is monitored to provide assurance of compliance to the senior management team. At this

inspection supervision had been a focus for the care groups and each network has focused on

improving supervision which has led to an increase in supervision across the networks. The trust

had ensured that staff have received training on the use of formulation which provided group

supervision for staff with the current caseload. The introduction of formulation training and the use

of formulation supervision had seen a significant decrease on readmissions across the inpatient

units of 66 % based on the previous 12 months. The trust were undertaking piece of work within

Cumbria Partnership NHS Foundation Trust covering all staff with a task and finish group jointly

with North Cumbria University Hospitals NHS Trust. A task and finish group was established and

was working towards the recording of clinical supervision within electronic staff record (ESR). The

trust were also developing a joint trust combined supervision policy. The trust had undertaken a

recent audit of supervision across the care groups in Cumbria Partnership NHS Foundation Trust

which was commissioned by the task and finish group. A survey monkey questionnaire had also

been sent to all staff across Cumbria Partnership NHS Foundation Trust and North Cumbria

University Hospitals NHS Trust. There was local monitoring in place in all care groups to record

and monitor supervision was taking place, this was to continue to be audited on a quarterly basis

and reported to the board. There was local monitoring in place in all care groups to record and

monitor supervision was taking place, this was to continue to be audited on a quarterly basis and

reported to the board.

Governance

The trust had effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees, team meetings and senior managers. Leaders regularly reviewed these structures. A meetings structure was in place with formal committees reporting direct to the board. These committees were; audit and risk; charitable funds; renumeration; finance, investment and performance; quality improvement and safety; mental health legislation. Each of the committees had a comprehensive meeting structure below which supported its function. The Mental Health Act governance system had recently been reviewed and there had been a mental health legislation committee formed, this was led by the director for mental health and learning disability. The mental health and learning disability care group had also been amended to include learning disability and child and adolescent mental

health services. Some of the governance systems at service level were ineffective in assessing, monitoring and improving care and treatment. Some systems and audits had failed to identify issues such as patient observation following restrictive physical interventions, medicines management, mandatory training compliance, clear oversight of supervision, bed management, issue with staff experience and skill mix, care records or staff support following incidents. Papers for board meetings and other committees were of a good standard and contained appropriate information. We attended both the public and private board meetings. A patient experience presentation was also delivered at the board meeting we attended. Non-executive and executive directors were clear about their areas of responsibility. The coming merger of the organisation had meant some non-executive directors were joint appointed and some still with the current organisations. There was tension at board level due to the recruitment process of non-executive directors. The process for appointment was determined by Cumbria Partnership Foundation Trust governors through the nominations committee in line with NHSI Guidance. Phase 1 of the process involved recruitment of up to four non-executive directors from within the existing non-executive team at Cumbria Partnership Trust and North Cumbria University Hospitals Trust. Four non-executives were appointed but three existing Cumbria Partnership Foundation Trust were not which required the individuals to terminate the term of office. This termination of the term of office had resulted in some tensions. Appropriate governance arrangements were not in place in relation to Mental Health Act administration and compliance. The trust had identified that the current structure of governance for the Mental Health Act was not effective and there were plans to address this with the formation of a mental health legislation committee which would replace the Mental Health Act and associate managers committee and report directly to the board. The current structure was not effective as there was inconsistency of information being passed to the board and no direct escalation structure. There were examples of repeated issues identified by Mental Health Act reviewers and too much responsibility for the Mental Health Act had sat with the (associate) hospital managers. The first meeting of the mental health legislation committee was due to take place the week after our inspection. This meeting intended to identify which partners would be invited to be members of this committee. There was currently no representation from partners (approved mental health act professionals, local authority, independent mental health advocates, police, ambulance) on the Mental Health Act and associate managers committee. Approved mental health professions described a good relationship with the trust and they said they had good lines of communication and interface with the police. They described good communication with the Cumbria Partnership Foundation Trust bed managers, but this stopped out of hours and was transferred to the crisis teams. There were issues with availability of section12 doctors to attend Mental Health Act assessments. The executive director of mental health was now the lead for Mental Health Act, prior to their appointment, there was no executive director for the Mental Health Act. The non-executive Mental Health Act lead was the chair of the board and had been in the role for 18 months and was employed by Cumbria Partnership Foundation Trust. The Mental Health Act lead had been in the role for 10 days at the time of our visit. They were also employed by Northumberland Tyne and Wear NHS FT and worked within Cumbria Partnership Foundation Trust on a part-time basis. This was not an executive or non-executive post, they line managed the Mental Health Act administration team and reported to the executive lead for management and the non-executive for board matters. The six Mental Health Act related polices we reviewed were up to date and complied with the Mental Health Act Code of Practice 2015. There were associate hospital mangers in place that met regularly and received regular training. There was a Mental Health Act administration team in place with sufficient resources available, however, it had been identified that these were not being used in the most efficient way

geographically. There had also been a gap in the line management from April 2019 till June 2019 when the new manager came into post. In the April Mental Health Act and associate managers committee minutes it was reported that a staff contract was due to end in August 2019 and if not renewed there would be no Mental Health Act administration in South Cumbria. NHS improvement looked at the financial governance of Cumbria Partnership NHS Foundation Trust and informed us that the trust had a strong track record of control total delivery until 2018/19. In 2017/18 the trust reported a favourable variance of £0.1m against its control total target of £4.9m deficit resulting in an outturn excluding sustainability and transformation fund of £4.8m. For 2018/19 the trust reported in its draft accounts an adverse variance of £2.4m against its control total of £4.4m deficit resulting in a deficit outturn excluding sustainability and transformation fund of £6.8m. For 2019/20 the trust has signed up to its cost target of a £4m deficit (excluding. financial recovery fund (FRF) / provider sustainability fund (PSF) and this is predicated on the delivery of £10m efficiency plan (5.9%) NHS improvement were not aware of any regulatory issues or adverse external audit reports for the trust. A clear framework set out the structure of ward/service team, division and senior trust meetings. Managers used meetings to share essential information such as learning from incidents and complaints and to take action as needed. Issues were discussed at ward/team/service level and fed up to the board through the care group quality and safety groups, care management group, system operational delivery group and the system leadership board. Within the core services there was a clear framework of what must be discussed during team meetings to ensure essential information was shared and discussed. Standing agenda items included incidents, complaints, safeguarding and the five key questions covered during Care Quality Commission inspections. The chief operating officer was in the process of reviewing this process as it was felt that there were too many managers above front-line staff before they were heard at board level. However, we found some audits and governance systems were ineffective in some areas of the core services. In acute wards for adults of a working age and psychiatric intensive care units, issues had not been addressed in relation to blanket restrictions, the environment at Dova ward, concerns regarding bed management, a significant number of patients being placed out of area, support for staff and providing suitably qualified and experienced staff on shifts. The trust was developing and embedding the structure for medicines governance. The new audit, decision-making process and governance arrangements were detailed in the first biannual medicines management report to the quality and safety committee in December 2018. There was now a combined medicines optimisation committee and a joint Safe Medicines Practice Group across both trusts. Work was ongoing to establish these groups and to facilitate the discussion of medicine optimisation and learning from incidents both across the trust footprint and wider North Cumbria Health and Care System. Following review, a single new prescription chart was implemented (April 2019) for use across the trust footprint. The trust’s medicines incident dashboard gave easy oversight of trust wide medicines incidents by number, type and care group. However, there was recognition of the need to increase pharmacy representation within the care group governance meetings, to develop shared ownership of medicines safety issues. The required controlled drugs quarterly reports were submitted to the Local Intelligence Network by the trust’s controlled drugs accountable officer. Pharmacy was not routinely involved in junior doctor training and was looking at how pharmacist could support junior doctors in safe prescribing as stated in Supporting safe prescribing, Royal College of Physicians 2017. Additionally, the compliance board in December 2018, noted that medicines management had been removed from trust Induction. There was no provision for face-to-face medicine management training to community teams.

In February 2019, the trust was categorised as being ‘offered 'targeted support' by the NHS

Improvement Single Oversight Framework.

The trust was asked to comment on their targets for responding to complaints and current

performance against these targets for the last 12 months.

In Days Current

Performance

What is your internal target for responding to* complaints? 3 100%

What is your target for completing a complaint? 35 50%

If you have a slightly longer target for complex complaints please indicate

what that is here Not provided Not provided

* Responding to defined as initial contact made, not necessarily resolving issue but more than a confirmation of

receipt

**Completing defined as closing the complaint, having been resolved or decided no further action can be taken

Total Date range

Number of complaints resolved without formal process*** in the last 12

months 191 1 Feb 2018 – 31 Jan 2019

Number of complaints referred to the ombudsmen (PHSO) in the last 12

months 1 1 Feb 2018 – 31 Jan 2019

**Without formal process defined as a complaint that has been resolved without a formal complaint being made. For

example PALS resolved or via mediation/meetings/other actions

This trust received 1518 compliments during the last 12 months from 1 February 2018 to 31

January 2019. ‘CHS Sexual Health’ had the highest number of compliments with 415 (27%)

followed by ‘CHS Adults Community’ with 265 (17%).

Cumbria Partnership NHS Foundation Trust has submitted details of four external reviews

commenced or published in the last 12 months (1 February 2018 to 31 January 2019).

1. CCG Safeguarding Review of Ruskin and Yewdale Units1

2. CCG Edenwood Assurance visit (Report in P118 is in draft form, the trust is awaiting the final

report)2

3. CCG Safeguarding Review of Strengthening Families Workington3

4. CCG Safeguarding Review of Strengthening Families Ulverston4

Management of risk, issues and performance

The trust had systems in place to identify learning from incidents, complaints and safeguarding alerts and make improvements. The governance team regularly reviewed the systems. The trust had a safeguarding improvement plan for 2018/19 which was robust and clear and actions related to the four published safeguarding adults reviews and identified the 13 themes from these. However, some sections were not complete so there was difficult to see where actions were in

1 Yewdale CCG Assurance Visit Ruskin CCG Assurance Visit 2 Edenwood Quality Visit Jan 2019 3 Workington Safeguarding 4 Ulverston Safeguarding

terms of service improvements. The safeguarding team engaged with services directly through their line management and had developed routine safeguarding supervision. The safeguarding team were open and had a good awareness of current safeguarding issues and local issues relating to safeguarding. They were professionally accountable and responsive to national agendas and local issues and were committed to the delivery of face to face training for staff and links with multi agency forums and meetings. Senior management committees and the board reviewed performance reports. Leaders regularly reviewed and improved the processes to manage current and future performance. The trust provided assurance in relation to safety and quality by the production of heat maps within performance and quality and safety dashboards. The performance reports are produced monthly based on key safety and quality metrics. Quality and safety dashboards were available at team, service, network, care group and corporate level and are populated in relative 'real time' based on data held within a range of information systems such as the incident reporting system and the electronic staff record. The information obtained is shared with each clinical area as well as the divisional teams. The heat maps provide an overview and/or assurance as well as identifying KPIs where improvements are required. The heat maps and dashboards are reviewed by the ward and departmental and care group clinical and managerial teams. They are also routinely reviewed at the trust wide clinical governance group and performance & delivery group, Clinical management group, 6-weekly performance reviews, board level committees and at board level. Care group clinical governance meetings report into the trust wide quality and safety meetings for assurance and/or escalation or key issues relating to patient safety, quality or experience. At the last inspection we told the trust they must ensure that the risk register is effectively reviewed and managed in line with trust policy and that there is evidence of a clear link between the register and the board assurance framework. The trust had made progress on this however, there was still some duplication of risks, for example risks around child and adolescent mental health service waiting times; risks to workforce recruitment, retention and availability of registered staff and mental health risks such as ligature points. The link between the risk register and board assurance framework had improved but there was still work to do to ensure that there was a clear leadership approach from the board of directors to ensuring that all board members and members of staff understand the process of escalating risks to the board through the board assurance framework. Staff in the core services maintained and had access to the risk register at ward/service or directorate level. Staff at ward/service level could escalate concerns when required. Each ward/service had identified local risks which were specific to their ward. Staff concerns matched those on the risk register. The corporate risk register was reported to care management group and separately at each meeting of the audit and risk committee in line with the policy to ensure line of sight by board members. The information is also contained within the report to the board on a quarterly basis. The board was mostly sighted on risks. However, this was more focused on the providers acute services rather than mental health services. Where significant risk were identified, such a patient in seclusion in the psychiatric intensive care unit, these were often dealt with at an operational level. Staff had access to the risk register either at a team or division level and were able to effectively escalate concerns as needed. The trust risk register contained 70 risks. Those risks rated 15 or more on risk rating scale were reported through to the board. NHS improvement looked at the financial governance of Cumbria Partnership NHS Foundation Trust and informed us that the trust had managed cash well and had not had to apply for interim financing due to working capital issues. They had submitted reporting and review meeting discussions with NHS Improvement that had evidenced that financial risks are actively identified and mitigated/managed by the trust. The deputy director of finance post in place was transitioning to a joint deputy post as the two Trust’s merge. A recruitment to a successor joint deputy director role was taking place at the time of the inspection and following the inspection has been successfully appointed to.

Pharmacy capacity was identified as a factor impacting on arrangements for monitoring the safe use of medicines. The home care service provided to neurology patients had not been audited to ensure compliance with the Professional Standards for Homecare Services, Royal College of Psychiatrists 2018. The trust standard for medicines reconciliation was not in line with current Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes as detailed in the National Institute for Health and Care Excellence NG5 2015 guidance. Limited pharmacy support was provided to community teams. Peer review in October 2018 identified ‘insufficient evidence that high dose antipsychotic prescribing is identified and managed’. Additionally, the trust identified an ‘urgent need for a community Medicines Optimisation Clinic embedded in primary care on an Integrated Care Community footprint’. Following the peer review the trust had provided medicines management training to the access and liaison integration service and had focused on providing training regarding high dose antipsychotic prescribing in community mental health teams. A complete business case for pharmacy and medicines optimisation operational roles was in development. The trust had participated in the Prescribing Observatory for Mental Health Rapid Tranquilisation audit. The trust performed better than average regarding the use of oral medication and in updating the patient’s care plan to acknowledge patient wishes with respect to the management of episodes of disturbed behaviour. However, this remained low at 35%. The audit also recorded that the required recent electrocardiogram (ECG) was only present in 20% of cases where Haloperidol was administered. An action plan was in place to review policy and share learning at a clinical teaching session, with plans for re-audit in 2021. Arrangements had been agreed for wards to complete any prescribing, administration and monitoring of medicines for patients in a section136 suite (Health based place of safety) ,but a policy was not in place for this. The trust advised that this would be discussed at the July 2019 Medicines Optimisation Committee. Where cost improvements were taking place there were arrangements to consider the impact on

patient care. Managers monitored changes for potential impact on quality and sustainability. The

board considered cost improvement plans as secondary to improving quality and safety. The focus

for the trust for cost improvement was productivity and efficiency with the belief that the cost

improvements will fall out of getting it right first time hence ‘Keeping it safe, keeping it good’.

Historical data Projections

Financial Metrics

Previous financial

year (2 years ago)

(1 April 2016 – 31

March 2017)

Last financial

year (1 April 2017

– 31 March 2018)

This financial

year (1 April 2018

– 31 March 2019)

Next financial

year (1 April 2019

– 31 March 2020)

Actual income £180,297 £180,157 £161,112 £166,618

Actual surplus (deficit) -£5,529 -£1,630 -£2,090 £0

Actual costs/expenditure -

full -£186,044 -£181,775 -£163,202 -£166,618

Planned budget or (deficit) -£4,525 -£3,204 -£2,090 £0

The trust has submitted details of 18 serious case reviews commenced or published in the last 12

months.

Reference Number

Team/Ward/Unit Recommendations Actions Taken Outstanding Actions

BE All robust risk assessments

development of new risk assessment guidance

to fully implement across the care group

BE All improved info sharing between GP/HV

ongoing discussion between GP and HV team lead

BE All consideration to the impact of learning disability in respect of parenting capacity

training package to be developed for staff as well as a 7-minute briefing

BE All use of genograms when working with families

guidance has been developed for staff on the sue of genograms

to fully implement across the care group

BF All importance of recording families members on the records, specifically fathers.

guidance and updates have been shared with all staff

to further audit this work

BF All need to link all family members within the records.

guidance has been developed as well as an audit has been undertaken to establish current practice

BF All all injuries to non-mobile babies to be escalated to children social care

There is LSCB guidance as well as internal guidance. 7-minute briefings have been developed for staff to share at team meetings.

Y All Improve referral processes and reviewing and decision making

PFT has updated the safeguarding policy and developed a policy which advises staff how to make a referral to adult social care if they have a concern relating to a vulnerable adult. This is also highlighted in training. Cumbria Partnership Foundation Trust safeguarding team provide representation on the multi-agency T&F group

Y All Assessment and planning needs to be robust and standard practice

The organisation needs to ensure that discharge planning is part of the MDT process Cumbria Partnership Foundation Trust staff to ensure referrals are followed up and appropriate challenge is given when referrals are not to the required standard, this has been re-enforced in training and learning events that have been held. Cumbria Partnership Foundation Trust safeguarding team have a duty safeguarding number where staff are expected to raise concerns following discussion with their line manager.

Reference Number


Mr and Mrs Z, JB

All staff must have clear access to services including communication and information sharing.

Cumbria Partnership Foundation Trust's guidance on what to do if you are concerned about an adult, and how to make a referral to Adult social care has been updated, and Making safeguarding personal is a priority of the organisation. The importance of information sharing in the interests of safeguarding is re-enforced in training and supervision. Cumbria Partnership Foundation Trust have a information sharing policy in place.

Mr and Mrs Z, JB

adult Y

All The need to improve appropriate and consistent application of MCA/DoLs and understanding of the MCA

Staff have access to MCA and Dols training within the organisation. The policy for self-neglect also includes consideration of MCA. There is a new template which has been developed which will be added to EMIS around the assessment of capacity, bespoke training sessions have been scheduled to support staff in how to assess capacity and future training needs analysis is taking place.

Cumbria Partnership Foundation Trust Safeguarding team will further embed the MCA in future face to face training

Y All Medication reviews in hospital settings to be reviewed

Cumbria Partnership Foundation Trust have reviewed medication policies in line with NICE guidance. Cumbria Partnership Foundation Trust's pharmacy team perform medicines reconciliation on each patients medicines on admission to our units. The Medicines Management committee has approved the STOPP/START tool in the trust which support the optimising of medicines for older people

SAR BE All There is a need for a strong culture of openness and practice improvement

Cumbria Partnership Foundation Trust has incorporated learning from BE in to level 1 and Level 2 learning. Learning from SAR's and the links to the publications have been uploaded on to Cumbria Partnership Foundation Trust safeguarding Intranet page.

Cumbria Partnership Foundation Trust will continue to develop SAR internal processes including the cascading of lessons learned. This will be done in the form of training/ supervision/ safeguarding

Reference Number


JB All Practitioners must ensure that they have access to information about a person’s care at an early stage and use this information to support individuals and make reasonable adjustments

Cumbria Partnership Foundation Trust utilise the NWAS flagging system to alert them to specific needs our clients may have. Cumbria Partnership Foundation Trust staff provide information to acute trusts when a person with a LD is admitted to hospital. The LD service has a vulnerable client list which would be responsive as part of business continuity plan. LD team have actively lobbied for Hospital LD Liaison Nurses, these are now in place throughout Cumbria with excellent links and joint working with LD community teams.

Mr and Mrs Z, JB

adult Y

All Care co-ordination must meet complex needs including the improvement of complex case management.

Two learning events have taken place in relation to complex case management. Staff can access the Safeguarding team for support with complex case management and this has been evidenced by the safeguarding teams involvement. Cumbria Partnership Foundation Trust ahs guidance to support CLDT staff in their role as care-coordinators

JB All Improvement in addressing and meeting health needs

Current safeguarding training supports staff to feel empowered to raise and escalate matters of concern. Contingency planning is part of care planning on our electronic record system

JB All The personalisation and role of carers needs clarification

Safeguarding training encourages staff to listen closely to carers when individuals do not verbally communicate, and also the importance of capturing information in other ways. The community LD teams liaise regularly with other clinical teams to highlight the importance of listening to and respecting the views of families and carers.

Develop an escalation protocol that covers both carers and professionals

Reference Number


Mr and Mrs Z

All There is a need to develop multi-agency practice in relation to self-neglect

There is guidance on the safeguarding intranet in relation to self-neglect including care Act guidance and a Cumbria Partnership Foundation Trust policy chapter. The safeguarding duty line has audited a high proportion of calls in relation to self-neglect, identifying staff are seeking support and guidance around the appropriate action to take.

We analysed data about safety incidents from three sources: incidents reported by the trust to the

National Reporting and Learning System (NRLS) and to the Strategic Executive Information

System (STEIS) and serious incidents reported by staff to the trust’s own incident reporting

system. These three sources are not directly comparable because they use different definitions of

severity and type and not all incidents are reported to all sources. For example, the NRLS does

not collect information about staff incidents, health and safety incidents or security incidents.

Between 1 February 2018 and 31 January 2019, the trust reported 53 serious incidents. The most

common type of incident was ‘Apparent/actual/suspected self-inflicted harm’ with 26. Eleven of

these incidents occurred in ‘Community-based mental health services for adults of working age’

and nine in ‘Mental health crisis services and health-based places of safety’.

We reviewed the serious incidents reported by the trust to the Strategic Executive Information

System (STEIS) over the same reporting period. The number of the most severe incidents recorded

by the trust incident reporting system was comparable with STEIS with 53 reported.

Never events are serious incidents that are entirely preventable as guidance, or safety

recommendations providing strong systematic protective barriers, are available at a national level,

and should have been implemented by all healthcare providers. The trust reported no never events

during this reporting period.

Type of incident reported

Com

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Apparent/actual/suspected self-inflicted harm

11 9 1 1 1 2 1 26


Com

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To

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Environmental incident 1 3 1 5

Pressure ulcer 3 3

Medication incident 1 2 3

Abuse/alleged abuse of child patient by third party

3 3

Failure to obtain appropriate bed for child who needed it

2 1 3

Disruptive/ aggressive/ violent behaviour

1 1 2

Confidential information leak/information governance breach

1 1 2

Slips/trips/falls 1 1

HCAI/Infection control incident 1 1

Surgical/invasive procedure incident 1 1

Unexpected Death 1 1

Adverse media coverage or public concern about the organisation or the wider NHS

1 1

Diagnostic incident including delay (including failure to act on test results)

1 1 1 1

Total 13 10 7 6 5 5 3 2 1 1 53

Providers are encouraged to report patient safety incidents to the National Reporting and Learning System (NRLS) at least once a month. The average time taken for the trust to report incidents to NRLS was 29 days5 which means that it is considered to be a consistent reporter. The highest reporting categories of incidents reported to the NRLS for this trust for the period 1 January 2018 to December 2018 were ‘Implementation of care and ongoing monitoring / review’, ‘Patient accident’ and ‘Medication. These three categories accounted for 4909 (75%) of the 6525 incidents reported. ‘Other’ accounted for 31 of the 36 deaths reported. Ninety four percent of the total incidents reported were classed as no harm (36%) or low harm (58%).

5 Insight Report

Incident type No harm Low harm Moderate Severe Death Total

Implementation of care and

ongoing monitoring / review 134 2343 147 2 2626

Patient accident 907 803 45 8 2 1765

Medication 375 132 10 1 518

Disruptive, aggressive

behaviour (includes patient-to-

patient) 265 129 18 1 413

Self-harming behaviour 140 125 40 6 311

Treatment, procedure 139 102 22 1 1 265

Access, admission, transfer,

discharge (including missing

patient) 177 51 14 3 2 247

Other 34 46 8 2 31 121

Clinical assessment (including

diagnosis, scans, tests,

assessments) 38 13 12 63

Infection Control Incident 18 35 6 59

Patient abuse (by staff / third

party) 32 9 2 43

Consent, communication,

confidentiality 31 8 3 42

Documentation (including

electronic & paper records,

identification and drug charts) 25 1 26

Medical device / equipment 11 4 15

Infrastructure (including

staffing, facilities, environment) 7 2 2 11

Total 2333 3803 329 24 36 6525

Organisations that report more incidents usually have a better and more effective safety culture than trusts that report fewer incidents. A trust performing well would report a greater number of incidents over time but fewer of them would be higher severity incidents (those involving moderate or severe harm or death). Cumbria Partnership NHS Foundation Trust reported more incidents from January 2018 to December 2018 compared with the previous 12 months.

Level of harm Jan 2017 – Dec 2017 Jan 2018 – Dec 2018 (most recent)

No harm 1427 2333

Low 1689 3803

Moderate 282 329

Severe 17 24

Death 49 36

Level of harm Jan 2017 – Dec 2017 Jan 2018 – Dec 2018 (most recent)

Total incidents 3464 6525

Between December 2017 and November 2018, 65.2% of patient safety incidents reported to the National Reporting and Learning System were harmful, which was worse than the national average of 34.8%. The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there have been three ‘prevention of future death’ reports sent to Cumbria Partnership NHS Foundation Trust. Details of which can be found below: Date of report: 16 April 2018 A person died as a result of hanging. The Coroner’s concerns were: The provision of mental health services for children and young people in Cumbria is underfunded. There are long delays in getting treatment. Failure to provide for these young people means they risk entering adulthood with unresolved mental health issues. Lives are lost and damaged; including the effect on families as a whole. The financial cost to the state of such deaths is huge; 4 paramedics attended as did out of hours doctor; at least 11 police staff; hospital staff; A&E consultant; Local Safeguarding processes; costs of inquest and Trusts legal representatives etc all of which would be better spent on prevention. It is likely that any of these problems are replicated across the country hence the reference to the Secretary of State. Date of report: 16 November 2017 The Coroner’s concerns were: The recording of medical records was such that entries made by particular clinicians were un-attributable to the author. The basic observations were not performed before the administration of opioid analgesics. That basic observations were not performed when clinically indicated, were not performed prior to the administration of intravenous fluids and were not performed prior to the administration of opioid analgesics. In evidence the nurse explained that this practice still continued. The audit performed of the adequacy of note keeping was inadequate, only assessing 30 cases in 2 ½ years. The letter to staff encouraging remedial action is unlikely to have had any effect whatsoever and should have been supplemented by appropriate training That IV fluids were commenced without a fluid balance chart. It is also a matter for the Trust and the clinicians involved to ascertain whether or not the standard of clinical notes and records regarding observations complies with their professional requirements under the GMC and NMC. Date of report: 29 May 2018 A person died as a result of suicide. The Coroner’s concerns were: The ability and ease with which vulnerable individuals can access and receive urgent care for acute mental health problems in Barrow-in-Furness has been highlighted by this case. In particular: Was it correct that a friend; colleague and trained health professional could not make a valid referral for an individual to receive acute mental health assessment in such circumstances?

Is the trust satisfied that there is adequate liaison on such matters between themselves; emergency services (such as the Police in this case) and GP practices? The trust may consider a review of its policies and procedures may be appropriate given the findings in this case.

Information Management

The trust had a digital strategy which identified the aims of the trust from 2017 to 2021 and aligned to both NHS England initiatives and local strategies. The strategy was underpinned by five key themes: digital care records, infrastructure, technology enabled care and information management and governance. The strategy also proposed creating a digital care board that would report to the trust board. This digital care board would monitor progress against the strategy and agree investment priorities. Team managers had access to a range of information to support them with their management role. This included information on the performance of the service, staffing and patient care. Staff across the organisation had access to an electronic dashboard which provided performance data in a timely and accessible format. The dashboard provided details of current staff training and current risks. The dashboard provided a high-level overview but allowed access to more detailed information at individual, team or core group level to assist with the management of the service. The board received holistic information on service quality and sustainability. Each care group had an improvement plan and meet with the executive team monthly to monitor this. Leaders submitted notifications to external bodies as required. The trust had a data quality team who carried out a monthly audit assurance programme where a number of trust indicators were reported both internally and externally these were audited along with patient demographics. The data quality team also looked at a number of datasets assessing the completeness, timeliness, validity and accuracy of the trust’s information. Issues highlighted from the recorded information were fed back to the services through various senior management and network meetings. Trust indicators audited: • 7 day follow up • Crisis gatekeeping • Delayed transfers of care • Early intervention psychosis The trust used internal and external auditors to audit information annually, this usually occurs in March and November, issues highlighted from these audits were mitigated through training workshops, short videos and working with key individuals. The head of information governance with the support of the head of information management and performance had taken steps to progress; a review of the data definition hand book; a review and update of reporting tools; a collaborative approach to data quality issues across the trust; and collective working with e-health teams for a more coordinated approach on resolving issues. The board and senior staff expressed confidence in the quality of the data and welcomed challenge. Data quality was monitored with reports outside of the systems using data extracts. Examples of this were the patient tracking list used to monitor referral to pathway quality and performance and the caseload report recently developed for mental health services. Information governance systems were in place including confidentiality of patient records. The trust operated an electronic record system for all services which provided access to the latest information about patients. Reporting tools provided the functionality for clinical and administrative staff to access and run reports to monitor their own data. Staff in the cores services had access to

the information technology equipment and systems needed to do their work. The information technology system worked well and helped staff to improve the quality of care. However, in mental health crisis services and health-based place of safety staff did not always have the time to ensure all records were completed and up to date. The trust had received funding to support the implementation of electronic prescribing and medicines administration in mental health services and was awaiting the outcome of a bid for NHS Improvement electronic prescribing and medicines administration funding to facilitate roll out across the merged trusts. The trust’s electronic discharge project was on hold due to the merger. This was included on the trust risk register (Moderate) with identified increased risks of prescribing errors on discharge. The trust had completed an investigation of a serious discharge medicines incident (Q3 2018/19). Processes had been reviewed to include additional checks at the point of discharge, an alert had also been shared across the trust and learning shared with pharmacists in the wider North Cumbria healthcare system. When a patient is detained under the Mental Health Act in hospital, the provider is required to

submit a record to the Mental Health Services Data Set each month until the detention ends.

Between November 2017 and October 2018, the trust only provided end dates for 87.4% of Mental

Health Act episodes for detentions, which had ended. This gives an incomplete picture about the

provider’s use of the Mental Health Act and indicates there may be problems with recording or

sharing data externally.

When a patient is admitted to hospital, the provider is required to submit a record to the Mental

Health Services Data Set each month until their inpatient admission ends. Between November

2017 and October 2018, the trust only provided end dates for 76.8% of inpatient episodes, which

had ended. This gives an incomplete picture about discharges from hospital and patients length of

stay and indicates there may be problems with recording or sharing data externally.

Engagement

The trust had a structured and systematic approach to engaging with people who use services, those close to them and their representatives. The patient experience team were available to gain feedback and manage concerns and complaints. Consultation on the strategy was taking place and local groups, staff and patients were involved. This was ongoing at the time of the inspection. The trust were working with an organisation called Meridian to develop systems that would capture patient feedback on the website. Health watch were developing an E-portal so that members of the public can use the portal. The trust sought to actively engage with people and staff in a range of equality groups. They had good links with external organisations including AWAZ Cumbria (The Voice of Black and Minority Ethnic (BME) People and Communities in Cumbria), black, Asian and minority ethnic groups, refugee groups and LGBT groups. They engage stakeholders from a wide range of equality groups for their EDS 2 grading events and have good links with transgender organisation who have recently delivered training to staff which led to a gender identity policy being developed. The trust has presence at Cumbria PRIDE and patients are also part of the equality champions group who feedback their experience. Communication systems such as the intranet and weekly newsletters were in place to ensure staff, patients and carers had access to up to date information about the work of the trust and the services they used.

Patients, carers and staff had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patients and carers could provide feedback about the service through the Family and Friends Test, complaints process, the provider’s quality and safety team, during multidisciplinary meetings, and anonymous questionnaires. Patients and carers were also contacted by a member of the team to provide feedback in some core services. The trust offered public Governors training on appointment. They were actively involved in the operation of the trust. Governors were provided with appropriate information and training. The trust has a programme of training and development sessions with Governors throughout the year and five half day sessions allocated on an annual basis together with any ad-hoc or external training. Information sharing was good. Governors feel the group had a good skill mix and there was normally someone there who had a good understanding of current issues. There was a clear outline detailing the statutory duties of the governors, this has been reviewed and updated recently. This also outlines the training available and who was able to provide this. There had been some training and development sessions around specific concerns. Need to be able to dedicate the time to training which is sometimes difficult. Healthcare Financial Management Association training was completed online. The trust had a structured and systematic approach to staff engagement. Engagement around the organisational changes had only recently begun and staff had not been involved at the early stages. The trust invited staff to discuss changes at quarterly 'This is Us' sessions held across Cumbria with the chief executive. Information was made available electronically through a weekly chief executive blog and trust website and printed 'Trust Talk' magazine. Leaders were invited to attend a monthly forum where they were able to inform decisions and were expected to cascade information to their teams. Staff were involved in decision making about changes to the trust services. The trust had a strong draft engagement strategy and a good engagement plan was in place. There had been improvements in staff engagement and executive visibility within teams. Most staff in the core services said they were involved and felt informed and involved about planned changes to the trust. However, in mental health crisis services and health-based place of safety, the staff in the east of the trust did not feel managers had kept them informed or involved in the changes. The trust was actively engaged in collaborative work with external partners, such as involvement with sustainability and transformation plans. North Cumbria were one of 14 areas recognised as working as an integrated care system this meant they were working closer together through the development of integrated care communities to improve both physical health and mental health of local people and ensure people were treated in the best place for their needs. The trust gave examples where this had provided a positive impact on patient care. Fledgling programmes were shaping the way community mental health was delivered as a package of care. For example, there was the Copeland integrated care communities multi-disciplinary team meetings that consider patients with complex needs in more depth. Involvement of stakeholders is designed to improve the escalation of concerns and put joint support in place much quicker. In the learning disability pilot across Keswick and Solway integrated care communities, coordinating a response means less duplication and improved decision making than they would have been in the past. There is a dementia pilot within the Eden integrated care community, this has been evaluated and described by GPs as outstanding. This assisted by the clinical commissioning group integrating into the care group leadership and the development of the in-house advice and guidance communication system between primary and secondary care. Leaders engaged with external stakeholders such as Healthwatch, Commissioners, police, local authorities and other hospitals at a local level.

The trust pharmacy team had worked with primary care to develop a pathway for valproate reduction and to ensure safe assessment for women of childbearing age who are prescribed valproate. To support work to develop the pharmacy workforce in line with the NHS Long Term plan, the clinical director for pharmacy services was engaged in pharmacy workforce analysis within the wider North Cumbria Health and Care System. They were also in discussion with neighbouring trusts and Health Education England regarding the development of a rotational pharmacist foundation programme.

Learning, continuous improvement and innovation

Staff were encouraged to make suggestions for improvement and gave examples of ideas which had been implemented. There were examples of improvements in the core services. In mental health wards for older people with mental health problems staff from Ruskin had given presentations across the North East and to senior managers on the impact of psychological input in older people’s settings. The work had demonstrated a positive impact on patients in reducing levels of violence and aggression and a positive impact on staff in terms of stress levels and sickness. Managers from the service facilitated monthly quality improvement days. Staff from each discipline were given time to meet and share good practice for dissemination across the wards. The trust was introducing a memory nurse advisor in older people’s services following completion of a successful pilot. The approach aimed to integrate services at primary care levels to enable delivery of seamless memory assessment and diagnosis within primary care, while also reducing reliance on GPs for annual dementia reviews. The nurse also worked into the inpatient setting. In mental health acute wards for adults of working age and psychiatric intensive care units the patient review meeting process had been changed from multidisciplinary meetings weekly to a more in-depth daily meeting to ensure patients care and treatment was more consistently monitored, and progress checks were more frequent to ensure appropriate and timely discharge. There had been improvement work with care planning which included clinics for staff to attend together with patients and a representative from a local mental health charity. There was also ongoing training for staff in carer awareness, each ward had a champion and there were role play video scenarios for staff to learn from. There were organisational systems to support improvement and innovation work. The trust were working in partnership with organisations across North Cumbria through the Cumbria learning and improvement collaborative (CLIC) and had adopted a common approach to continuous improvement called the Cumbria production system. A common toolkit of lean based improvement tools is available on the Cumbria learning and improvement collaborative website and cross organisational training was available through Cumbria learning and improvement collaborative. Whilst 95 staff had attended Cumbria learning and improvement collaborative face to face training in improvement over the past two years the focus for development had been on supporting work-based learning. Engaging for improvement was a 20-week programme which takes a six-step process to support staff to identify ideas for change and engage with a wide range of stakeholders to implement successful improvements. A programme of rapid process improvement workshops were in place, these facilitated workshop aimed to accelerate improvements in processes and practice making them more reliable, efficient, patient driven. The trust had a number of staff who were Q fellows and worked closely the North East Academic Health Science Networks (AHSN) and Advancing Quality Alliance (AQuA). Effective systems were in place to identify and learn from unanticipated deaths. The trust had a policy for the investigation of deaths. All deaths were reported using the trusts electronic incident reporting system. Incidents were reviewed by senior members of staff dependent on the notification rules set against the types and severity of incidents reported. These were reviewed by quality and safety managers and / or associate directors of nursing in care groups. Following a review of the information and the circumstances a decision was taken whether to investigate further. Reporters of incidents were provided with feedback from those incidents reported through

the trusts incident reporting system, any immediate learning was implemented and shared with staff. Unexpected deaths were declared as a serious incident requiring investigation (SIRI) and were reported to commissioning bodies through the Strategic Executive Information System (StEIS) reporting system. Investigation officers were allocated to progress through the investigation process, which included a review of patient records, holding learning reviews with staff teams, meeting families and carers and maintaining ongoing contact, and meeting with other individuals as necessary. Findings from the investigation were put into a report format which included recommendations and areas for learning. Recommendations and actions relating to the SIRI and an action plan were presented at the care group or director level patient safety panel. SIRI's were a standard agenda item on care group and trust wide level clinical governance meetings and were also captured in the quality and safety dashboards from teams that were presented to the meetings. Care groups also completed thematic reviews around SIRI's and had developed learning lessons bulletins to share within and across the care groups. The trust implemented a patient safety panel towards the end of 2018 this replaced the previous SIRI panels that took place both centrally and within the care groups. One of the key functions of the panel was to provide check and challenge to final investigation reports and to support and promote learning from incidents. A mortality review group continues to be developed and aims to have the final oversight of deaths within the trust. In the community health care group, the nature of the care group work meant that many patients requiring services were at the natural end of life stage. Many of these deaths were therefore expected natural deaths. For any unexpected deaths the trust carried out further investigation and where indicated a full mortality review was conducted. Quarterly the trust reviewed 5 -10 random deaths as mortality reviews using the structured judgment approach. Learning such as development of incident reporting, care planning in the last stages of life was identified. External organisations had recognised the trust’s improvement work. Individual staff and teams received awards for improvements made and shared learning. The Carlisle Clozapine clinic won the Health Services Journal Patient Safety Awards 2018 for Improving Safety in Medicines Management. A multi-disciplinary approach including patients and carers was used to support improvements in the process for Clozapine repeat prescribing. Implementing the project found improvements in prescription accuracy and in recording of patients’ physical observations. All clinic patients were now invited to an annual physical health check. The trust had not yet extended this model to other areas. Peer review at Workington Community Treatment Team found a lack of recorded physical health checks for patients prescribed clozapine. Staff used data to drive improvement. The trust had developed performance, quality and safety dashboards. Performance reports are produced monthly based on key safety and quality metrics. Quality and safety dashboards were available at team, service, network, care group and corporate level and were populated in relative 'real time' based on data held within a range of information systems such as incident reporting system and the electronic staff record. The information obtained was shared with each clinical area as well as the divisional teams and identified key performance indicators where improvements were required. The dashboards were reviewed by the ward, departmental and care group and managerial teams. They were also routinely reviewed at the trust wide clinical governance group and performance & delivery group, clinical management group, 6-weekly performance reviews, board level committees and at board level. NHS improvement looked at the financial governance of Cumbria Partnership NHS Foundation Trust and informed us that the trust had regular meetings with the NHS Improvement senior management team and the trust Executive Team. The trust was working collaboratively with commissioners and the local health system to investigate innovative methods to bridge the overall financial gap alongside streamlining pathways of care.

NHS trusts can take part in accreditation schemes that recognise services’ compliance with standards of best practice. Accreditation usually lasts for a fixed time, after which the service must be reviewed. The table below shows services across the trust awarded an accreditation and the relevant dates (if provided).

Accreditation scheme Core service Service accredited Comments and Date of

accreditation / review

CCABI -SMART assessor

accreditation, Coaching Level 6

accreditation, Advanced

Counselling accreditation and

NVQ assessor accreditation,

Dysphagia Assessment and

Therapy Accreditation and the

HCPC and the BPS (British

Psychological Society)

accreditation, Association for

Cognitive Analytic Therapy

(ACAT) accreditation.

MH - Other Specialist Services

SSCG - ABI team N/A

Stage 1 Accreditation Baby

Friendly initiative with UNICEF N/A C&F Care Group N/A

Mental health services

MH – Acute wards for adults of working age and psychiatric intensive care units

Facts and data about this service

The methodology of CQC provider information requests has changed, so some data from different

time periods is not always comparable. We only compare data where information has been

recorded consistently.

Location site name Ward name Number of beds Patient group (male,

female, mixed)

Carleton Clinic, Carlisle Rowanwood (Psychiatric

Intensive Care Unit)

10 Mixed

Carleton Clinic, Carlisle Hadrian Unit 22 Mixed

West Cumberland

Hospital, Whitehaven Yewdale Unit

16 Mixed

Dane Garth, Barrow in

Furness Dova Unit

20 Mixed

Westmorland General

Hospital, Kendal Kentmere Ward

10+1 Mixed

Cumbria Partnership NHS Foundation Trust provide four acute mental health wards for adults of

working age. The wards are based across four locations in Whitehaven, Barrow in Furness,

Kendal and Carlisle. All wards provide care for patients aged 18-65 who require hospital

admission in an acute phase of their mental health illness either for assessment or treatment, or

under the Mental Health Act.

Cumbria Partnership NHS Foundation Trust also have one psychiatric intensive care unit called

Rowanwood, for patients aged 18-65. This unit provides services for the most unwell patients who

present higher risks and require increased levels of observation and support;

All five wards admit both males and females.

We previously inspected acute wards for adults of working age and psychiatric intensive care units

between 13 February and 17 February 2017. The inspection report was published 20 July 2017

and we found some areas for improvement. At that inspection, we rated the services as requires

improvement overall. We rated the service as ‘requires improvement’ in three key questions safe,

effective and well led and rated the service as ‘good’ in caring and responsive.

Is the service safe?

Safe and clean care environments

Safety of the ward layout

Staff did regular risk assessments of the care environment. This included an assessment of ligature risks with an action plan about how to manage potential ligature points. A ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. A copy of the assessment was available on each ward and managers reviewed these annually or sooner, if necessary. All wards had areas of risk from ligatures which staff managed via clinical practice and individual patient observations. Ligature cutters were available on all wards. There were ligature risks on five wards within this service. All five wards have had a ligature risk

assessment in the last 12 months.

Ward / unit

name

Briefly describe risk - one

sentence preferred

High level of risk?

Yes/ No Summary of actions taken

Hadrian Unit Only relatively low risks

remain in the ward following

annual risk assessments and

agreed action plans to

reduce the risk over the past

12 years.

No An action plan has been

agreed and all identified

risks being addressed.

Dova Unit Only relatively low risks


annual risk assessments,

agreed action plans and a

major refurbishment /

extension to reduce the risk

over the past 12 years.




Kentmere Ward Relatively high risk items are

still present i.e. windows, IPS

Panels etc - these have not

been addressed due to high

cost and Trust's ambition to

close the ward.

Yes An action plan has been

agreed and capital funding

being sought.

Rowanwood Only relatively low risks


annual risk assessments and

agreed action plans to

reduce the risk over the past

12 years.




Ward / unit

name

Briefly describe risk - one

sentence preferred

High level of risk?


Yewdale Unit Only relatively low risks


re-provision of the ward in

2011. Annual risk

assessments and agreed

action plans to reduce the

risk have been carried out

since the new unit opened.




Since our last inspection the trust had undertaken refurbishment work to help reduce ligature risks and continued to look at further improvements to reduce risk. Staff also completed

environmental checks of patient areas each shift, documenting and sharing any found with the

team to keep risks to a minimum for patients.

Staff could observe all parts of the ward with the use of mirrors and the positioning of staff to

mitigate blind spots. All wards had CCTV to improve observations.

Not all wards complied with national guidance on eliminating mixed-sex accommodation. All

wards were mixed sex wards. On Dova Unit, Yewdale Unit and Rowanwood wards, all bedrooms

were ensuite with the sleeping areas separated. On Kentmere Ward, there were separated male

and female dormitories with direct access to washrooms within the dormitory area. There was also

one single room, which was not ensuite and access to the wash room was via the main ward

corridor. Hadrian Unit patient’s had single rooms some of which were ensuite and located in

designated male and female corridors. Over the 12-month period, from 1 January 2017 to 31

December 2017, there were no mixed sex accommodation breaches within this core service.

However, at the time of our inspection there was a male and female patient occupying single

rooms in a separate area at the end of the main ward corridor which had been declared a breach.

Neither patient had to go past each other’s room to access washrooms, however, the female

patient had to walk along the main communal ward corridor to access one. The female patient was

provided with an alarm to call staff if required, and observations were increased whilst the patient

remained in the room. We were assured staff had taken sufficient actions to mitigate the risks in

this case. The provider had firm plans place to eliminate mixed sex accommodation in future. All

wards had a lounge area for females only.

Nurse call alarms were available in patient bedrooms or sleeping areas and communal areas on

all wards. In Hadrian unit staff assessed patient risk and presentation and when necessary,

provided patients with portable alarms to alert staff when required. All staff on Hadrian Unit carried

personal alarms.

Maintenance, cleanliness and infection control

All ward areas were clean, had good furnishings and were generally well-maintained. However,

there was an ongoing issue with water leaks from the ceiling on Dova Unit, in several areas

including a patient bedroom. Several attempts to fix the issue had not been successful. The

bedroom had been used whilst this was ongoing but following our inspection the bedroom was

decommissioned awaiting a full repair.

Each ward had a cleaning roster and dedicated domestic support staff. Cleaning records were up

to date and demonstrated that wards were being cleaned regularly. There were effective

processes in place to reduce the risk and spread of infection, including handwashing, with signage

in appropriate areas and antibacterial hand gel dispensers placed around the ward areas.

PLACE assessments aim to provide a clear message from patients on how the care environment

may be improved. They are undertaken by teams of local people alongside healthcare staff and

assess privacy and dignity, food, cleanliness, building maintenance and the suitability of the

environment for people with disabilities and dementia.

The sites which deliver acute wards for adults of working age and psychiatric intensive care units

within Cumbria Partnership NHS Foundation Trust were compared to other sites of the same type

and the scores they received for ‘cleanliness’ were found to be about the same with the except of

Kentmere Ward which was found to be worse. During our inspection the ward appeared clean and

the manager confirmed their score was usually higher and in line with other wards. The scores for

‘condition, appearance, and maintenance’ were found to be about the same as the England

average

Site name Core service(s) Cleanliness Condition appearance

and maintenance

Carleton Clinic

MH - Acute wards for adults

of working age and

psychiatric intensive care

units


with mental health

problem


learning disabilities or

autism



working age adults

99.6% 94.2%

Yewdale Unit


of working age and


units

99.4% 90.0%

Dova Unit


of working age and


units

99.4% 88.6%

Kentmere Ward


of working age and


units

90.8% 90.4%


and maintenance

Trust overall 99.3% 91.6%

England average

(Mental health

and learning

disabilities)

98.4% 95.4%

Seclusion room

There was a seclusion room on Rowanwood which was in the psychiatric intensive care unit. The

seclusion room allowed clear observation and had a two-way communication system in place.

Patients had access to toilet and washing facilities and a clock was visible from inside the room.

The room had access to natural light. However, the seclusion room was in use at the time of our

inspection and had been for two months. This was the only seclusion room in Cumbria and

therefore, when two further patients required seclusion this occurred in other parts of the ward.

This was not in line with trust policy, which required that only the dedicated seclusion room was

used for seclusion.

Clinic room and equipment

Clinic rooms were fully equipped with accessible resuscitation equipment which included a

defibrillator, grab bag, oxygen and drugs for use in an emergency. There was also examination

couches and the necessary equipment to carry out physical health checks for patients. Staff

regularly cleaned and maintained all equipment to ensure it was safe and ready for use. This

included monitoring fridge and clinic room temperatures on a daily basis, which were all within

recommended safe ranges.

Safe staffing6

Most staff on the wards felt staffing levels were safe and managed appropriately, although at times

some said they felt more vulnerable due to the remoteness of their ward. They also acknowledged

that acuity and unwell patients caused an increase in demand on staffing levels. This was

particularly an issue for wards which also had a Section 136 suite namely, the Yewdale Unit,

Kentmere Ward and Dova Unit. When the Section 136 was in use it was staffed by the existing

ward staff. Staff felt supported by their colleagues locally and were aware of actions by managers

and the trust to address vacancy levels.

Staffing recruitment and retention were on the trust risk register for the service and it was

recognised that vacancies had led to a reliance on bank and agency staff. The trust had

recruitment initiatives underway to improve the situation.

The below chart shows the breakdown of staff in post Wole Time equivalent (WTE) in this core

service from January 2018 to December 2018.

The below table covers staff fill rates for registered nurses and care staff during October, November

and December 2018.

Key:

> 125% < 90%

Day Night Day Night Day Night

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

October 2018 November 2018 December 2018

6 Staffing Data Safer Staffing Oct to Dec 2018

0

20

40

60

80

100

120

140

160

Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018

Nu

mb

er

of

sub

stan

tive

WTE

(w

ho

le t

erm

eq

uiv

ale

nt)

Substantive WTE - comparing staff groups

qualified nurses, health visitors and midwives nursing assistants

medical staff allied health professionals

Hadrian Unit 108.9 101.3 101.6 103.4 125.0 91.2 101.7 97.8 135.5 94.0 100.0 84.7

Rowanwood 100.0 125.8 66.1 132.8 90.0 127.7 93.8 135.8 107.9 116.4 100.0 132.3

Yewdale

Unit 98.4 101.9 100.0 103.0 104.2 99.3 98.3 100.0 96.0 101.9 98.4 103.2

Dova Unit 100.0 103.9 100.0 100.0 100.0 120.0 100.0 100.0 100.0 120.0 100.0 100.0

Kentmere 93.5 117.3 129.0 110.5 100.0 112.5 128.3 110.8 104.3 109.3 106.5 121.8

Managers calculated the number and grade of nurses and healthcare assistants required in line

with the national safer nursing staffing tool, based on patient levels of acuity and dependency.

Rotas were overseen by the Acute Network Manager on an ongoing basis. All wards had a three

shift pattern with a requirement of two registered nurses on duty during the day and night except

Dova Unit and Kentmere Ward which reduced to one registered nurse on duty at night. However,

more recently we were told Rowanwood at times during the day, did not have full cover of the

second nurse as did Kentmere Ward at times over weekends due to the availability of registered

nurses.

Ward managers could adjust the staffing levels to respond to increases in ward acuity and activity.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing

levels to ensure safe care and treatment.




Staff group

Annual

average

establish

ment

Annual

vaca

ncy

rate

Annual

turno

ver

rate

Annual

sickn

ess

rate

Annual

bank

hours

(% of

availa

ble

hours

)

Annual

agenc

y

hours

(% of

availa

ble

hours

)

Annual

“unfill

ed”

hours

(% of

availa

ble

hours)

All staff 374.4 8% 12% 6.6% N/A N/A N/A

Registered

nurses 153.2 11% 14% 5.4%

26352

(13%)

7955

(4%) 9925 (5%)

Nursing

assistant

s

135.0 1% 10% 8.8% 83098

(27%)

41626

(14%)

16649

(6%)

Medical staff 24.1 15% 7% 0.1% 0 (0%) 0 (0%) 0 (0%)

Allied Health

Professio

nals

43.2 12% 21% 2.8% N/A N/A N/A

Annual sickness, total vacancy and turnover rates were about the same as the average when

compared to similar core services nationally.

When bank staff and agency staff were used, they received training and an induction. Bank staff

had the same training as permanent staff and agency staff had minimum training requirements,

before being permitted to work on the wards. If agency staff were employed for longer periods,

they were provided with the trust mandatory training, which then allowed them access to the

computerised patient record system. Most bank staff and agency staff used, were on a regular

basis which meant they were familiar with the environment and patients. When new agency staff

were used, they familiarised themselves with the ward and patients with the support of a

registered nurse and by attending handovers.

Staffing levels allowed patients to have regular one-to-one time with their named nurse, however

staff shortages occasionally resulted in staff cancelling escorted leave for patients

There were enough staff to carry out physical interventions for example, observations, restraint

and seclusion safely and staff had been trained to do so.

Most staff on the wards felt staffing levels were safe and managed appropriately, although at times

some said they felt more vulnerable due to the location of their ward. They also acknowledged that

acuity and unwell patients caused an increase in demand on staffing levels. This was particularly

an issue for wards which also had a Section 136 suite as this was staffed by the existing ward staff

when in use. These were on Yewdale unit, Kentmere ward and Dova Unit. Staff felt supported by

their colleagues locally.

Annual vacancy rates for registered nurses, nursing assistants, allied health professionals were in

the lowest 25% when compared to similar core services nationally.

Monthly 'vacancy rates' over the last 12 months for all staff showed an upward trend from April 2018

to August 2018. However, this stabilised with the intake of newly registered staff around September

2018.

Managers and staff reported an increase in registered nurse vacancies since January 2019. This

was acknowledged not only as a national issue but also a local issue. Staffing recruitment and

retention were on the trust risk register for the service and it was recognised that vacancies had

led to a reliance on bank and agency staff. The trust had recruitment initiates underway to improve

the situation.

Monthly 'vacancy rates' over the last 12 months for allied health professionals shows a shift from

April 2018 to September 2018. However, the data shows the vacancy rate reduced following that

period.

Medical staff

An on call consultant psychiatrist provided psychiatric medical cover out of hours and at weekends.

Psychiatric medical cover was provided up to 5pm weekdays on Dova Unit, Kentmere Ward and

Yewdale Unit and up to 12 midnight, seven days a week on Hadrian Unit and Rowanwood. Physical

screening examinations for admissions were conducted by nursing staff with the requirement for a

full physical examination to be completed within 24 hours during core working hours or when the

patient consented. Cumbria Health on Call Limited were contacted for medical emergencies.

However, any other physical health patients would need to wait until core hours.

The on call consultant psychiatrist was available for staff to refer to or to attend wards out of hours.

Where response times were longer due to the distance, and emergency medication was required

prior to the consultant’s arrival, this was prescribed by phone in the presence of two registered

nurses and followed up by an email confirmation.

The medical out of hours cover, to attend wards in the event of an emergency was reviewed by the

trust since our last inspection, when a requirement notice was served. The trust acknowledged the

concerns raised around out of hours response times and some work had been completed to reduce

risks out of hours, for example, Carleton clinic triaging all new referrals after 8pm for all wards,

however, response times for medical cover remained on the trusts risk register.

Mandatory training

The compliance for mandatory and statutory courses at 31 December 2018 was 79%. Of the

training courses listed, 15 failed to achieve the trust target and of those, nine failed to score above

75% as shown below.


Information Governance training.

Following our inspection, the trust updated their training data and for this core service the

compliance had increased to 85% and the additional rate for information governance was also

achieved.

The trust has stated that training was reported on a rolling month on month basis and the following

courses were not offered pre- April 2018: Health, Safety and Welfare, Preventing Radicalisation

Level 1 & 2, Preventing Radicalisation Level 3,4&5, Safeguarding Children Level 1 and

Resuscitation Level 1.

Key:

Below 75% Met trust target

✓

Not met trust target

Higher

No change

➔

Lower

Training Module

Number

of

eligibl

e staff

Number

of

staff

traine

d

YTD

Comp

liance

(%)

Trust

Targ

et

Met

Complianc

e

change

when

compar

ed to

previou

s year



Safeguarding Adults (Level 1) 158 145 92% ✓

Equality and Diversity 158 142 90% ✓

Local Indiction 158 140 89%

Safeguarding Children (Level 2) 151 131 87% ✓

Fire Safety 2 years 158 133 84%

Other (Please specify in next column) 544 452 83%



Mental Capacity Act Level 1 151 117 77%

Prevent Radicalisation L1 & 2 158 121 77% N/A


Health and Safety (Slips, Trips and

Falls)

158 116 73%






Training Module

Number

of

eligibl

e staff

Number

of

staff

traine

d

YTD

Comp

liance

(%)

Trust

Targ

et

Met

Complianc

e

change

when

compar

ed to

previou

s year



Prevent Radicalisation L3, 4 & 6 70 37 53% N/A


Total 3009 2366 79%

Of the training courses listed above whereby 15 failed to achieve the trust target and of those, nine

failed to score above 75%, the position changed with the updated figures. There was 8 which failed

to reach the trust target of 85% and only the Mental Health Act course failed to reach 75%, although

it had improved to 56.1% compliance.

Staff said they were able to access training when needed and had time to attend training. Training

was provided through a combination of e-learning, internal classroom sessions and external

courses. Training completion was monitored by managers and staff received automated monthly

emails to inform them of any training courses due to expire.

Assessing and managing risk to patients and staff

Assessment of patient risk

During the inspection we reviewed 21 care records. The trust used the Galatean Risk and Safety

Tool (GRIST), which is a recognised risk assessment tool to support clinical risk management.

Staff did a risk assessment of every patient on admission. We found 18 care records with completed

and up to date risk assessments although the remaining three risk assessments had not been

updated for more than one month. Risk assessments were generally updated in response to

changes or following an incident however, on one occasion this was not the case. All records we

saw contained a current risk assessment for the patient.

Management of patient risk

There was information to help staff manage and mitigate patient risk. Each patient had an

associated risk management plan with details about what support patients needed to help reduce

their risks. If patients had specific risk issues, such as risk of falls or pressure areas, then staff

included this as part of the risk assessment.

Staff followed good policies and procedures for use of observation, including to minimise risk from

potential ligature points and for searching patients or their bedrooms. Staff attended handovers

prior to their shifts in which they discussed patients’ presentation and required levels of

observation. There were three levels of observation, namely eyesight, 15 minute observations or

hourly observations. Staff comprehensively discussed patient risks in daily multidisciplinary

meetings and responded to changing risks in patients where these were identified. For example,

we saw instances of patient’s observations levels changing in accordance with their risk level and

presentation.

The trust had a policy for the searching of patients and their rooms. Staff searched patients on the

basis of individual risk assessment and they would be asked to consent.

All wards had blanket restrictions. A blanket restriction is a rule or policy that is routinely applied to

all patients on a ward without individual risk assessments to justify their application. The trust did

not have a blanket restriction policy and blanket restrictions were in place without these being

individually risk assessed for patients, reviewed regularly or subject to local accountability and

governance arrangements as is required by the Mental Health Act Code of Practice (8.9). For

example, aerosols, razors and glass/mirrors were all stored in a locked cupboard on the ward

which patients could access through staff. All mobile phone chargers for patients were held in the

staff office and phones were charged there except for on Dova Unit where patients used very short

cables on chargers which did not present a ligature risk. On all wards, except Rowanwood,

patients did not have a key to their bedrooms. On Rowanwood, patients had their bedroom keys if

appropriate, following a risk assessment and also had a lockable cupboard for possessions inside

of their room. On Dova Unit, Rowanwood and Hadrian Unit, all patients used plastic cups and

plates without being individually risk assessed which the trust confirmed was historic and agreed

as part of their catering provision. Since our inspection, the trust have been in the process of

agreeing a blanket restriction policy, to be introduced shortly.

Staff offered smoking cessation support to patients and the trust was due to be smoke free in line

with best practice guidance by 1 October 2019.

Staff advised informal patients they could leave at will and we saw evidence of signage on wards.

We spoke to a number of informal patients, who told us they were aware that they could leave the

ward.

Use of restrictive interventions

Managers told us that the trust had a restrictive interventions reduction program called ‘Restrain

Yourself’. This included each ward having key staff designated as champions for others to refer to

and an increased level of training in the prevention and management of violence for staff. The

training team were also available to visit wards as required.

This service had 312 incidences of restraint (177 different service users), these were the highest in

Rowanwood and Yewdale Unit. This was an increase in overall restraint from 248 restraints in the

previous 12 months. There were also 24 incidences of seclusion between 1 February 2018 and 31

January 2019, all on Rowanwood.

The below table focuses on the last 12 months’ worth of data: 1 February 2018 to 31 January 2019.

Ward name Seclusions Restraints

Patients

restrain

ed

Of restraints,

incidents of

prone

restraint

Of restraints,

incidences of

rapid

tranquilisation

Hadrian Unit 0 68 47 2 (3%) 40 (59%)

Rowanwood 24 110 46 6 (5%) 18 (16%)

Dova Unit 0 20 16 0 (0%) 2 (10%)

Kentmere Ward 0 35 24 2 (6%) 2 (6%)

Yewdale Unit 0 79 44 1 (1%) 4 (5%)

Core service

total 24 312 177 11 (4%) 66 (21%)

There were 11 incidences of prone restraint, which accounted for 4% of the restraint incidents. Over

the 12 months, incidences of prone restraint ranged from none to three per month. The number of

incidences (11) had decreased from the previous 12-month period (46).

All staff received training in the prevention of management of violence and aggression. Staff told us

they used restraint only if other de-escalation techniques had not been successful and were taught

to avoid the use of prone restraint whenever possible. They said restraint was always used a last

resort and for the shortest amount of time possible. However, we reviewed three episodes of recent

restraints that had taken place on the wards. None included information about what strategies staff

had employed prior to using restraint. In each case it was not evidenced whether staff used de-

escalation prior to the restraint. In the instance where a patient refused oral medication, it was

unclear if they were offered this more than once before the restraint. Following two out of three

restraints it was unclear if staff and patients had had a debrief.

There were 66 incidences of rapid tranquilisation over the reporting period. Incidences resulting in

rapid tranquilisation for this service ranged from one to 12 per month for the 12-month period. The

number of incidences (66) had increased from the previous 12-month period (59).

Staff did not always follow best practice and national guidance where patients had been

administered rapid tranquilisation. In three instances of rapid tranquilisation, we found no evidence

that any post monitoring had taken place or been completed in line with the trust policy or as

recommended by The National Institute for Health and Care Excellence [NG10 Violence and

aggression: short-term management in mental health, health and community settings]. This states

‘People with a mental health problem who are given rapid tranquillisation have side effects, vital

signs, hydration level and consciousness monitored after the intervention’. Therefore, staff did not

have full information to review the patient’s rapid tranquilisation. This included the patient’s condition

and progress following rapid tranquilisation, its effectiveness and any adverse effects observed or

reported by the patient.

There have been zero instances of mechanical restraint over the reporting period. The number of

incidences (0) had reduced from the previous 12-month period (1).

There have been 24 instances of seclusion over the reporting period, all on Rowanwood. Over the

12 months, incidences of seclusion ranged from none to five per month. The number of incidences

(24) had decreased from the previous 12-month period (33).

We viewed the latest records of a seclusion episode on the psychiatric intensive care unit and

information was not all present and complete. The trust had a seclusion and long term segregation

policy which outlined how often and by whom a patient should be reviewed, which was not followed

consistently. The policy also stated that seclusion takes place in a designated and approved

seclusion room or suite of rooms which serves no other function to the ward. Staff told us, and we

saw incident reports, which confirmed two patient seclusions had occurred on Rowanwood in the

visitor’s room and in the extra care area. This was not in accordance with policy, but there was no

other option, due to bed availability elsewhere. This was not the case at the time of our inspection,

however, staff were concerned that this may occur again in future, when the existing seclusion room

was in use.

There have been two instances of long-term segregation over the 12-month reporting period. The

number of incidences (2) had decreased from the previous 12-month period (3), which were all on

Rowanwood.

Safeguarding

A safeguarding referral is a request from a member of the public or a professional to the local

authority or the police to intervene to support or protect a child or vulnerable adult from abuse.

Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and

institutional.

Each authority has their own guidelines as to how to investigate and progress a safeguarding

referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will

work to ensure the safety of the person and an assessment of the concerns will also be conducted

to determine whether an external referral to Children’s Services, Adult Services or the police

should take place.

The trust provided adult safeguarding referrals data for the whole trust, so we are unable to

determine how many of these were for this core service.

Number of referrals

Core service Adults Children Total referrals

Acute wards for adults of working age and

psychiatric intensive care units Not known 0 Not known

Staff undertook mandatory safeguarding training and were confident about identifying and reporting

safeguarding concerns. The combined adults and children’s safeguarding training compliance data

for this core service, at the time of our inspection was 86%.

The trust had a safeguarding lead in place; staff were familiar with who this was and how to

contact them. Staff were confident in the process of raising a safeguarding alert and did this when

appropriate. Staff were able to give examples of how they would protect patients and how to

identify any patients that were at risk of harm. They had close working relationships with local

safeguarding teams and were able to easily access them when needed.

The trust did not have a policy regarding the arrangements for children and young people who visit

patients in hospital. This was not in line with the Mental Health Act Code of Practice (11.3).

Managers said each child visit was individually risk assessed. Patients at Dova Unit and Yewdale

Unit had access to the family rooms on the ward, but if acuity was too high, alternatives were

sought off the ward. At Kentmere, all children visiting was off the ward and at Hadrian Unit and

Rowanwood the family room was located within the secure entrance but before entering further

doors onto the ward, therefore this was within a secure area for visitors and patients.


months (1 February 2018 and 31 January 2019), none of which relate to this service.

Staff access to essential information

Patient information was mainly stored electronically, and some was recorded in paper format. Staff

completed care plans and risk assessments using the electronic patient record system. Physical

health monitoring was in paper form and scanned onto electronic records by staff subsequently.

Staff felt they were able to access information when needed; this included when patients moved

between teams and they understood how the dual systems worked.

Information to deliver patient care was not accessible to agency staff employed without the

assistance of a permanent member of staff. However, if the agency appointment was for a

planned longer period for example to cover Maternity cover, the agency staff member completed

the trust mandatory training and gained access to the system.

Medicines management

Acute Wards:

Staff generally followed good practice in medicines management in line with national guidance. A

clinical pharmacist visited the wards at least twice weekly to check the prescription charts and

make interventions to support medicines optimisation. The prescription charts were clearly

maintained and where people were detained under the Mental Health Act, the appropriate legal

authorities were generally in place for medicines to be administered. However, we saw three

instances where documents for urgent treatment (Section 62) did not include a complete list of the

medicines prescribed. We raised this with the pharmacist in order that this could be promptly

addressed. We also found that one prescription chart showed an informal patient had been

prescribed medicines to be given by injection for rapid tranquilisation. These had not been

administered and we raised this with the doctor, who agreed that they should be removed from the

prescription chart.

Staff generally reviewed and documented the effects of medication on patients’ physical health

regularly, although there were three instances where this was not recorded correctly to confirm

this had occurred. One patient had received rapid tranquilisation on two occasions. The patient

regularly refused physical observations, this was recorded on the first occasion, but not

documented for as long as stated in policy on the second occasion. With the second patient there

was no physical health recording evident following rapid tranquilisation and for the third patient

monitoring was incomplete. Additionally, incident reports had not been completed for three out of

the four episodes of rapid tranquilisation. Staff told us the incident reports should be written and

recorded within 48 hours of the incident therefore potentially due to the timing of our inspection of

the documents, only one out of the four incident reports were not completed in line with trust

policy.

The trust had dedicated paperwork in place to help ensure that patients starting Clozapine were

monitored appropriately. This was generally, well completed, although there were occasional

omissions in recording the patient’s physical observations when the medicine was given. We saw

that where needed, therapeutic drug monitoring was carried out and recorded. A self-reporting

questionnaire was used to help identify if patients were experiencing side effects of antipsychotic

medication.

Psychiatric Intensive Care Unit:

Staff generally followed good practice in medicines management in line with national guidance. A

specialist mental health pharmacist provided clinical support to the ward, reviewed prescription

charts and supported medicines optimisation. The prescription charts were up-to-date and clearly

presented to show the treatment people had received. The relevant legal authorities for treatment

were generally in place and checked by nurses when administering medicines. However, one

authority did not list all the medicines currently prescribed for one patient and an urgent treatment

form was not in place. We raised this with the pharmacist in order that this could be promptly

addressed.

Patients were supported to use formal side-effect rating tools for reporting and monitoring side

effects in order that these could be managed effectively. Therapeutic drug monitoring was carried

out and recorded when needed.

Staff generally reviewed the effects of medication on patients’ physical health regularly and in line

with National Institute for Health and Care Excellence guidance, especially when the patient was

prescribed a high dose of antipsychotic medication. However, we found records showed that one

patient had been administered medication for rapid tranquilisation and physical health monitoring

post rapid tranquilisation had not been completed to ensure the patient’s health and well-being.

On both the acute wards and the psychiatric intensive care unit, as recommended by The National

Institute for Health and Care Excellence [NG10 Violence and aggression: short-term management

in mental health, health and community settings] a multidisciplinary team reviewed the use of rapid

tranquilisation. We saw that the use of ‘when required’ medicines was reviewed weekly, but

patients did not have individualised plans about the use of medication, as part of a strategy for

managing the risk of violence and aggression.

Track record on safety

Between 1 February 2018 and 31 January 2019 there were two serious incidents reported by this

service. Both incidents were categorised as ‘Apparent/actual/suspected self-inflicted harm’.



by the trust incident reporting system was comparable with STEIS with two reported. However, in

STEIS this incident is categorised as ‘pending review’.

At the time of the inspection the incident ‘pending review’ had been closed following the coroners

report. The incident related to a patient death on the ward which was fully investigated. Lessons

were learned regarding observations of patients and an area was structurally altered to prevent

further incidents. The trust had a policy on learning from deaths and these were discussed by the

senior management team and any learning was fed down to ward staff.

Number of incidents reported


(SIRI) Apparent/actual/suspected self-inflicted harm Total

Rowanwood 1 1

Hadrian Unit 1 1

Total 2 2

A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the

available preventative measures are in place. This service reported zero never events during this

reporting period.

Reporting incidents and learning from when things go wrong

The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all

contain a summary of Schedule 5 recommendations, which had been made, by the local coroners

with the intention of learning lessons from the cause of death and preventing deaths.

In the last two years, there have been five ‘prevention of future death’ reports sent to Cumbria

Partnership NHS Foundation Trust. None related to this core service.

All staff knew what incidents to report and how to report these via the trust’s electronic incident

reporting system. These were submitted to ward managers who could review the reports to

determine whether any further action was necessary. Senior managers also had access to view all

incidents reported.

Staff understood the duty of candour. They were open and transparent and gave patients and

families a full explanation if and when things went wrong.

Learning from incidents was a standard agenda item for team meetings across all wards, where

feedback from investigations and learning from incidents was shared. The teams across all wards

also held de-brief sessions after serious incidents and shared information through one-to-one’s

and daily ward handover meetings. Staff felt supported by their immediate managers and

colleagues however, on Rowanwood, when the nature of the incident was grave they felt

unsupported by more senior managers within the organisation.

Staff were made aware of external incidents at other organisations through regular emails sent to

all staff at the trust, which included learning from the incidents.

There was evidence that changes had been made as a result of feedback from serious incidents.

For example, there was an incident whereby a patient obtained obsolete medication. The

investigation for the safe storage of these was undertaken and changes made both internally on the

ward regarding the layout to the entrance of the clinic room and throughout the trust regarding the

safe storage of such medication.

Is the service effective?

Assessment of needs and planning of care

During the inspection we reviewed 21 care records. Staff had completed a full comprehensive

assessment of the patients in a timely manner at or soon after, admission. All patients received a

physical health assessment as part of the admissions process.

Staff developed care plans which met the needs identified during the comprehensive assessment.

All patients received an initial care plan which was designed to meet basic needs for the first 72

hours of admission. Thereafter, patients and carers were invited to a ’72-hour meeting’ which

included members of the multidisciplinary team as well as the consultant and nursing staff. The

meeting allowed a more detailed goal-orientated care plan to be produced in conjunction with

patients and families or carers. The meeting also allowed staff to start planning for the patient’s

eventual discharge.

We attended three morning meetings which were referred to by the services as the ‘Acute Admission

Pathway’ meeting and attended by a full range of the multidisciplinary team. Discussions were

positive, patient focused, and discharge orientated. Staff were knowledgeable and familiar about

patients’ needs.

Care plans were holistic, individualised and detailed. There was evidence plans had been written

with the patient, quoting their needs and aspirations and using simple language which they could

understand. Staff reviewed, and updated care plans regularly and when necessary.

Physical health monitoring had improved since our last inspection. However, on Hadrian unit there

was an instance where this had not been completed as required. This related to a patient where the

Doctor specified daily physical health monitoring due to an ongoing health condition. In an eight day

period this only occurred on three days. There were also other instances following rapid

tranquilisation, whereby physical health observations had not been completed in line with the trust

policy as highlighted previously in this report. Where there were inconsistencies and omissions of

physical health monitoring, there was a risk staff may not have been able to identify concerns in a

timely manner and ensure patients received necessary treatment.

Best practice in treatment and care

Staff provided a range of care and treatment interventions suitable for the patient group. The

interventions were those recommended by, and were delivered in line with, guidance from the

National Institute for Health and Care Excellence. This was led by doctors on the wards.

Psychology input was limited on the wards, most input was for patient review meetings and support

for the staff. There was little availability to undertake one to one work with patients on the wards. At

the time of our inspection a psychologist was present on all five wards for a maximum of two days

per week.

Occupational therapy input was available on all wards. The service also employed activities

coordinators to deliver a range of activities for patients. Activities were run seven days a week, at

all times of the day, with a good range of choices to include patients. The activities encouraged

engagement and patients clearly valued the activities coordinators input and enthusiasm. When the

coordinators were not present, activities were run by the health care support workers.

Patient care records showed input from other professionals and specialists in relation to their health

needs. Where patients had ongoing, complex pre-existing physical health conditions there was

evidence of patients receiving appropriate care and support and discussions between staff at the

service and other specialists. However, in two patient care records, issues were noted regarding

patient weights, however, they had not been referred to a dietician.

Staff supported patients to live healthier lives. The ward activities programs encouraged exercise

and information about healthy living and support available, was displayed around the wards.

Smoking cessation advice was offered with trust smoking ban due to be imposed on 1 October

2019.

Staff used recognised rating scales to assess and record severity and outcomes. These included

health of the nation outcome scales, national early warning score, mental health clustering tool,

malnutrition universal screening tool and the Glasgow antipsychotic side-effect scale.

This service participated in four clinical audits as part of their clinical audit programme 2018 -

2019.

Audit name Audit scope Audit

type

Date

completed

Key actions following the

audit

Yewdale

documentation/care

plan audit for

current patient files

(SUAC topic)

Yewdale Unit Clinical 26/02/2018 Ward manager fed back

the audit findings, and

those of the previous

audit, to ward staff by

email and in the team

meeting. Ward

manager clarified with

Pharmacy what side

effects monitoring tool

should be used for

drugs other than

antipsychotics and

determination was

made to use GASS

for all side effect

monitoring.

Development 1/2

days were delivered

by ward manager in

which key criteria

were particularly

emphasised. Deputy

ward manager/OT

Lead will deliver carer

and family

involvement training

to staff. The audit

question covering

signed care plan has

been amended to

Audit name Audit scope Audit

type

Date

completed

Key actions following the

audit

reflect the new Rio

procedure.

Re-audit of

Rowanwood

documentation/care

plan audit for


(SUAC topic)

Rowanwood Clinical 29/05/2018 Side effects tool has

been clarified with

Pharmacy. The audit

question covering

signed care plan has

been amended to

reflect the new Rio

procedure.

Re-audit of Dova

documentation/care

plan audit for


(SUAC topic)

Dova Unit Clinical 16/05/2018 Action taken:

implementation of a

new, quality

standards based audit

tool for care planning

along with a launch

day to discuss these

changes and support

staff in improving care

planning. Side effects

tool has been clarified

with Pharmacy. The

audit question

covering signed care

plan has been

amended to reflect

the new Rio

procedure.

The suitability of

seclusion areas in

Rowanwood

Rowanwood Clinical 23/05/2018 Action taken: managers

will facilitate/authorise

urgent funds to

transfer patients who

are secluded in an

inappropriate room to

another hospital, with

the aim of reducing

time spent in these

areas.

Skilled staff to deliver care

On all wards, the multidisciplinary team included a full range of specialists required to meet the

needs of patients. This included consultant psychiatrists, junior doctors, psychologists, nurses,

nursing assistants, occupational therapists and occupational therapy assistants. Psychology input

was primarily for patient reviews and to support staff, rather specific sessions for patients.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of the

patient group. However, on Rowanwood ward staff were less experienced as many staff had

worked on the ward for less than two years. All new trust employed staff including bank staff were

required to undertake the trust’s corporate induction as well as a local ward-based induction

process and all mandatory training. Agency staff had completed in life support and Prevention of

Management and Aggression training, prior to working on wards. New members of staff shadowed

existing staff before working alone.


March 2018), the overall appraisal rate for non-medical staff within this service was 73%. This year

so far, the overall appraisal rates was 80% (as at 31 December 2018). The wards with the lowest

appraisal rate at 31 December 2018 were Rowanwood with an appraisal rate of 41% and Dova

Unit with an appraisal rate of 71%. Managers confirmed that this had since improved with one

ward at the time of our inspection reporting 100% compliance.

Ward name Total number of

permanent

non-medical

staff requiring

an appraisal

Total number of

permanent

non-medical

staff who have

had an

appraisal

% appraisals

(as at 31

December

2018)

% appraisals

(1 April 2017

– 31

March

2018)

Kentmere Ward 25 25 100% 100%

Hadrian Unit 34 33 97% 61%

Yewdale Unit 29 28 97% 97%

Dova Unit 28 20 71% 43%

Rowanwood 32 13 41% 73%

Core service total 148 119 80% 73%

Trust wide 3167 2618 83% 79%

This service does not have any medical staff to report on.

Managers provided staff with supervision (meetings to discuss case management, to reflect on

and learn from practice, and for personal support and professional development) and appraisal of

their work performance. Staff told us they felt supported in their role, had annual appraisals,

regular one-to-one time and could approach managers when needed although the data does not

reflect this fully.

The trust’s target of clinical supervision for non-medical staff was not provided. However, during

the inspection staff and managers confirmed the trust requirement is six sessions of clinical

supervision a year. Between 1 February 2018 and 31January 2019 the average rate across all five

wards in this service was 32% as shown in the table below. Managers reported that there had

been an issue with inputting data into the system prior to January 2019 and this may explain the

low figures. There was also a shortage of trained clinical supervisors available to provide sessions

to staff which was being addressed by the service. Staff told us they had opportunities for

supervision. There was an open door policy on wards so staff had other discussions, albeit, at

times outside of formal sessions, which were not recorded. As such, there was no overview of the

of the full supervision system at organisational level.



Team name Clinical supervision

sessions required


delivered


rate (%)

Dova Unit 64 11 17%

Hadrian Unit 80 45 56%

Kentmere Ward 44 18 41%

Rowanwood 52 17 33%

Yewdale Unit 64 7 11%

Core service total 304 98 32%


This service does not have any medical staff to report on.

Managers identified the learning needs of staff and provided them with opportunities to develop

their skills and knowledge. There was access to specialist training across the wards and recent

courses undertaken included the care certificate, venepuncture, therapeutic talking and wound

care.

Managers were able to deal with poor staff performance when necessary. Dependent on the

issues, they would seek to identify whether the staff member had any additional training needs or

required extra support. Where cases required disciplinary action, the trust had a capability policy

and processes, to manage staff performance effectively. Additional support was available when

required, from the human resources department.

Multi-disciplinary and interagency team work

Staff on all wards held regular and effective multidisciplinary team meetings. In place of a weekly

ward round, staff held daily ‘Acute Admission Pathway’ reviews to discuss and inform the needs of

patients receiving support at the service. We observed three separate meetings on Yewdale Unit,

Kentmere Ward and Hadrian Unit which were well attended and well led. Staff were warm, respectful

and knowledgeable about patients’ care needs. The discussions were comprehensive, and recovery

focused with the least restrictive options considered.

The wards had a system for handover of patient information to help ensure effective care. All

wards had a three shift structure of early, late and night shifts. Staff handovers occurred at each

shift change where staff relayed information about patients’ care needs. There were three

handovers per day on all wards. Staff discussed a range of useful information. This included

patient risk, incidents, patients’ observation levels, activity levels, medication changes, food and

fluids, and discharge plans.

Staff across the wards had good working relationships with teams internally and externally to the

organisation. The staff we spoke to felt they had close links with community mental health teams,

crisis teams, care coordinators, GP’s and local authorities.

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

Practice

As of 31 December 2018, 49% of the workforce in this service had received training in the Mental

Health Act. The trust stated that this training was mandatory for all services for inpatient and

community staff and renewed every year. At the time of our inspection compliance had improved

to 56%, however this was still below the trusts own training compliance target of 85%. Despite this

figure we found staff had a good understanding of the Mental Health Act, the Code of Practice and

the guiding principles.

Staff had access to administrative support and legal advice from the trust’s Mental Health Act

administration office. Staff knew who the administrators were and how to make contact with them.

There were copies of the Mental Health Act Code of Practice on wards and staff could also access

this electronically, via the trust intranet.

Patients had access to information about advocacy support available to them. Information was

displayed around the wards about how to contact the service and advocates attended the wards

regularly. Staff referred all patients detained under the Mental Health Act to an advocate.

Staff explained detained patients’ rights to them in accordance with the provisions of the Mental

Health Act, in a way they could understand. There was evidence of staff making repeat attempts

where a patient did not understand their rights and patients told us they were aware of their rights.

However, records showed patients were not always informed of their legal rights under section

132, at the frequency required.

We reviewed 21 care records during our visit in relation to the appropriate documentation of Mental

Health Act records. We found staff stored patient’s detention papers and associated records

correctly and they were easily accessible to staff. This included documentation on section 17 leave

(permission for patients to leave hospital) which were in order.

Staff requested an opinion from a second opinion appointed doctor when necessary. We saw

evidence of doctors making requests for this service where required.

The service displayed a notice to tell informal patients that they could leave the ward freely.

Care plans referred to identified Section 117 aftercare services to be provided for those who had

been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment.

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there

was evidence of learning from those audits.

The Mental Health Act audit process for the Mental Health Act documentation comprised of weekly

checks on the ward by registered staff and then ad hoc audits by the Mental Health Act teams.

Both audits checked the Mental Health Act was being applied correctly and if not, established

whether there was any learning. Managers told us that any results and actions would be fed back

for them to review and act upon.

Good practice in applying the Mental Capacity Act

As of 31 December 2018, 77% of the workforce in this service had received training in the Mental

Capacity Act. At the time of our inspection this had increased to 83%. The trust stated that this

training was mandatory for all services for inpatient and all community staff and is a ‘one off’

training course. However, during the inspection staff told us that the training was a mandatory

course to be completed annually, online.

The majority of staff we interviewed had a good understanding of the Mental Capacity Act

including the guiding principles. Staff told us that they assumed capacity unless they had a reason

to doubt it and were able to give examples of how they would respond in situations where a

patient’s capacity was questioned.

The trust had an up to date policy on the Mental Capacity Act, including Deprivation of Liberty

Safeguard. Staff were aware of the policy and they could access it through the intranet. Staff were

aware of who to contact if they needed advice regarding the Mental Capacity Act and told us that

the Mental Health Act office assisted them when needed.

Mental capacity assessments were recorded appropriately. Staff took all practical steps to enable

patients to make their own decisions. For patients who might have impaired mental capacity, staff

assessed and recorded capacity to consent appropriately. They did this on a decision-specific

basis, with regard to significant decisions and recognised the patient’s wishes, feelings, culture

and history. Staff described this as an inclusive process which included the patient’s family,

advocate and community mental health team.

Staff made Deprivation of Liberty Safeguard applications when required, however, it was very

rare that these applications were made for patients using this service.

The trust told us that there were no Deprivation of Liberty Safeguard applications were made to the

Local Authority for this service, between 1 February 2018 and 31 January 2019, to protect people

without capacity to make decisions about their own care.

Is the service caring?

Kindness, privacy, dignity, respect, compassion and support

For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018), Dova Unit

and Kentmere Ward scored worse than the average for mental health and learning disabilities for

privacy, dignity and wellbeing. The scores for the other sites were found to be about the same as

the England average when compared to sites of a similar type.

Site name Core service(s) provided Privacy, dignity

and wellbeing

Yewdale Unit MH - Acute wards for adults of working age and

psychiatric intensive care units 85.5%

Carleton Clinic

MH - Acute wards for adults of working age and

psychiatric intensive care units

MH - Wards for older people with mental health

problem

MH - Wards for people with learning disabilities or

autism

MH - Long stay/rehabilitation mental health wards

for working age adults

79.5%

Kentmere Ward MH - Acute wards for adults of working age and


Dova Unit MH - Acute wards for adults of working age and


Trust overall 82.0%

England average (mental

health and learning

disabilities) 91.0%

Staff attitudes and behaviours when interacting with patients showed that they were discreet,

respectful and responsive, providing patients with help, emotional support and advice at the time

they needed it. The feedback we received from most patients was positive. We observed a

community meeting and saw patients’ thoughts and views were actively sought, considered and

addressed. Patients were then provided with suggestions and practical solutions to improve or

resolve the issue or concern.

Staff supported patients to understand and manage their care, treatment or condition. They

directed patients to other services when appropriate and, if required, supported them to access

those services. For example, staff could help signpost patients to activity groups within the trust

and external specialist services with the patient’s consent and where it was felt beneficial.

We spoke with 18 patients, the majority of whom spoke highly about the staff that supported them.

They said staff treated them well and behaved appropriately towards them. Many told us staff

were really nice, caring, polite, wonderful, can’t do enough, human, and that staff listen to them.

One patient disliked the registered staff although liked the healthcare assistants.

Staff understood the individual needs of patients including their cultural, social and religious

needs, which was evident from discussions with staff. Staff were able to raise concerns about

disrespectful and discriminatory behaviour towards patients and were open about doing so.

Staff respected patients’ privacy and dignity. They demonstrated this by actions such as knocking

on bedroom doors before entering. Staff did not discuss personal information about patients where

this could be overheard by others. This helped to maintain and protect patient confidentiality.

Involvement in care

Involvement of patients

Staff used the admission process to inform and orientate patients to the ward and to the service.

Most patients told us that staff showed them around the ward and gave them information about

what to expect. This included information leaflets about the ward.

Staff involved patients in care planning and risk assessments. Where there was no input, staff

documented that the patient did not wish to participate. Patients were offered a copy of their care

plan and although some we spoke to confirmed they had copies others said they had refused it or

were too unwell at the time they were admitted to remember. Patients were involved in their 72

hour formulation meeting together with carers or family members and if appropriate their advocate.

Staff communicated with patients so that they understood their care and treatment, including

finding effective ways to communicate with patients with communication difficulties. Several care

plans reviewed were written in easy to understand language. Another example was using a

computer application to help a foreign speaking patient understand. Interpreters were also

available for patients whose first language was not English.

Patient meetings were held across all wards either daily or weekly to ensure the patient’s view was

heard. Patients commented that their concerns were listened too, and changes were made as a

result of their feedback. There were no patient surveys in place as a means of receiving feedback

around the time of our inspection.

Staff ensured that patients could access the independent mental health advocacy service. Staff

referred patients they felt would benefit from having input from an advocate. The advocate visited

the wards on a regular basis and some patients we spoke with confirmed they had one.

Involvement of families and carers

Staff involved carers and families in patients care where appropriate. This included attending

meetings to review the patients care and progress. Carers felt able to contact wards for updates

about how their relative had been, some said this worked well. However, one carer of a patient in

Hadrian ward, mentioned that they had no confidence in calling the ward as the phone was often

left unanswered.

Wards had a notice board with carers information, such as local carers support groups, carers

assessments, patient diagnosis and medication. On Hadrian ward, there was a weekly family clinic

to encourage involvement.

Staff enabled families and carers to give feedback on the service they received for example the

friends and family test. Carers told us they knew how to complain or would contact a nurse directly

first and were confident raising concerns if they felt they needed to. The patient experience team

provided feedback to wards monthly regarding issues raised directly through them.

Is the service responsive? Access and discharge

Bed management

A bed was not always available in the psychiatric intensive care unit or acute wards when needed,

so some patients were placed out of area which made it difficult for the person to maintain contact

with family and friends. The trust recognised this as an increasing issue and was putting measures

in place to improve the situation.

Patient beds were not always available when patients returned from leave. There were instances

where a bed was held for a patients’ return. However, this was usually if it was the patients first

period of leave. Generally, when a patient was on Section 17 leave, the bed was highlighted as

available on the computer system for another patients’ use. Staff told us that this had an impact on

patients not wanting to take leave for fear of losing their bed and also affected clinicians positive

risk-taking regarding patient leave. Patients were not moved between wards during an admission

episode unless it was justified on clinical grounds and was in the interests of the patient. When

patients were moved or discharged, this happened at an appropriate time of day, whenever possible.

The trust provided information regarding average bed occupancies for all five wards in this service

between 1 February 2018 and 31 January 2019.

All of the wards within this service reported average bed occupancies ranging above the minimum

benchmark of 85% over this period. Where the occupancy was in excess of 100% managers said

this was where patients were on leave and the ward used the bed for another patient.

Ward name Average bed occupancy range (1 February 2018 – 31 January 2019)

(current inspection)

Hadrian Unit 94% - 113%

Rowanwood 89% - 101%

Dova Unit 95% - 100%

Kentmere Ward 95% - 100%

Yewdale Unit 93% - 99%

The trust provided information for average length of stay for the period 1 February 2018 to 31

January 2019.

Ward name Average length of stay range (1 February 2018 – 31 January 2019)


Rowanwood 49 - 93

Kentmere Ward 20 - 67

Dova Unit 36 – 65

Hadrian Unit 34 – 57

Yewdale Unit 22 - 52

This service reported two out area placements between 1 February 2018 and 31 January 2019. As

of 4 February 2019, this service did not have any ongoing out of area placements. There were no

placements that lasted less than one day and the placement that lasted the longest amounted to 18

days.

Both of the out of area placements were due to capacity issues.

On the last day of our inspection we were provided with updated out of area placement figures with

a total for psychiatric intensive care of 5 patients and acute wards 13 patients. The trust held bed

meetings twice daily with ward managers to address the situation and review patients. They had

recently employed a Band 5 nurse who visited all wards and assisted, when discharges were

delayed. The service recognised there were concerns with the numbers of people being placed out

of area.

Number of out of

area

placements

Number due to

specialist

needs

Number due to

capacity

Range of lengths

(completed

placements)

Number of

ongoing

placements

2 0 2 16 – 18 0

This service reported 36 readmissions within 28 days between 1 February 2018 and 31 January

2019. Nineteen of the readmissions (53%) were readmissions to the same ward as discharge. The

average of days between discharge and readmission was 12 days. There were no instances

whereby patients were readmitted on the same day as being discharged but there were three where

patients were readmitted the day after being discharged, one on Hadrian unit and two on Dova Unit.

Ward

name

Number of

readmissio

ns (to any

ward) within

28 days

Number of

readmissio

ns (to the

same ward)

within 28

days

%

readmissio

ns to the

same ward

Range of days

between

discharge

and

readmissio

n

Average days

between

discharge

and

readmissio

n

Hadrian 13 4 31% 1 – 27 17

Kentmere 4 1 25% 3 – 22 13

Yewdale 8 4 50% 3 – 21 12

Rowanwood

2 2 100% 7 – 9 8

Dova 9 8 89% 1 - 28 7

Discharge and transfers of care

Staff planned for patients’ discharge and liaised with appropriate individuals. This included the

patient’s care co-ordinator, community teams and other support networks. Each patient’s care plan

included a section on their discharge information. In some records, this was not as detailed,

although we saw further evidence of discharge planning through patient’s case notes and team

discussions.

Between 1 January 2018 and 31 December 2018 there were 715 discharges within this service.

This amounts to 25% of the total discharges from the trust overall (2911). For this core service, 9%

of the discharges were delayed.

Delayed discharges across the 12-month period ranged from two to 10 per month from the acute

wards and psychiatric intensive care unit. The main causes were difficulties finding suitable housing,

the lack of availability of community placements or funding issues and delays. At times, discharge

from the psychiatric intensive care unit was due to the lack of an available bed in a forensic or acute

ward.

Facilities that promote comfort, dignity and privacy

Patients had their own bedrooms on four out of the five wards, some of which were ensuite. On

Kentmere ward there were dormitories with partitions between each bed and a curtain at the end of

the cubicle. The provider had plans in place to eliminate this type of accommodation.

Patients could personalise their bedrooms or bed area of the dormitory and had somewhere

secure to store their possessions. In Yewdale, Kentmere and Rowanwood patients had lockers

with direct access and patients on Dova and Hadrian units gained access by asking a member of

staff.

Staff and patients had access to the full range of rooms and equipment to support treatment and

care. This included clinic rooms to examine patients, activity rooms and female only lounges. All

wards had direct access to a courtyard except for Kentmere Ward. Patients had access to the

garden area through the main hospital on site, this was accessed by others. For detained patients,

who were not able to have unescorted leave from the ward, a staff member accompanied them to

the garden area.

There were quiet areas on wards and a room where patients could meet visitors. Some patients

preferred to use their own bedrooms for a quiet area which they had access to at all times.

Patients could keep their own mobile phones with them on the ward. If there were any concerns

with this arrangement for individual patients, staff would risk assess this. The wards had a phone

that patients were also able to use if they required. Patients could make a phone call in private.

All five wards had activities programs seven day a week which were compiled by activities

coordinators on the wards with input from occupational therapy. The coordinators ran the program

with support from the healthcare assistants in their absence. Activities included baking, djembe

drums, pamper sessions, film nights, newspaper discussions, sports evenings, breakfast clubs,

pet dog visits, Tai Chi, gardening, walking and a variety of trips. Patients said the activities were

good and we saw some patients on each ward we visited, participating and enjoying them.

The sites which deliver acute wards for adults of working age and psychiatric intensive care units

within Cumbria Partnership NHS Foundation Trust were compared to other sites of the same type

and the scores they received for ‘ward food’ were found to be about the same as the England

average.

Patients’ engagement with the wider community

When appropriate, staff took into account patient’s needs in relation to education and work

opportunities. As the wards were for acutely unwell patients, the main focus was on their current

treatment. Staff provided opportunities for patients to access activities in the community where

possible, for example football sessions at the Carlisle stadium.

Staff supported patients to maintain contact with families and carers. Carers were able to visit

patients on the wards and patients also went on periods of home leave to spend time with their

family and friends.

Meeting the needs of all people who use the service

The service made adjustments for patients with disabilities and specific communication needs.

Each ward was accessible to wheelchair users and had accessible bedrooms and bathrooms

available. Where patients required additional adjustments or equipment, staff had accommodated

these.

Staff ensured patients could obtain key information they needed on all aspects of care, treatment

and support. Notice boards on the wards and around the sites included a good level of information

about local services, patients’ rights, how to complain and advocacy services. Staff told us they

would be able to provide such information in alternative formats if necessary. For example, if

patients required easy read information, there were resources within the trust to accommodate

this. Staff were also able to access materials in other languages and a translation service for

patients whose first language was not English.

Patients had a choice of food to meet dietary requirements of religious and ethnic groups. Staff

also ensured that patients had access to appropriate spiritual support. A chaplain visited all wards

regularly and patients could access spiritual support including services in the community.

The sites which deliver adults of working age and psychiatric intensive care units within Cumbria

Partnership NHS Foundation Trust were compared to other sites of the same type and the scores

they received for ‘disability’ and ‘dementia friendliness’ were found to be about the same as the

England average.

Site name Core service(s) provided Dementia friendly Disability

Dova Unit


age and psychiatric intensive care

units

- 90.1%

Yewdale Unit



units

80.5% 89.8%

Kentmere Ward



units

77.5% 84.5%

Carleton Clinic



units

MH - Wards for older people with

mental health problem


disabilities or autism


health wards for working age

adults

68.6% 78.4%


England average

(Mental health and 88.3% 87.7%

learning

disabilities)

Listening to and learning from concerns and complaints

This service received 33 complaints between 1 February 2018 and 31 January 2019. Six of these

were upheld, eight were partially upheld and 11 were not upheld. Five were under investigation

and three were categorised as ‘Other’.

Ward name

To

tal C

om

pla

ints

Fu

lly u

ph

eld

Pa

rtia

lly u

ph

eld

No

t u

ph

eld

Oth

er

Un

de

r

Inve

sti

gati

on

Wit

hd

raw

n

Re

ferr

ed

to

Om

bu

dsm

an

Yewdale 10 5 3 0 1 1 - -

Hadrian 9 0 4 2 0 3 - -

Rowanwood 6 0 0 5 1 0 - -

Dova 5 1 0 2 1 1 - 1

Kentmere 3 0 1 2 0 0 - -

Total 33 6 8 11 3 5 - -

Patients knew how to complain and raise concerns. There was information on display around the

wards about how to make complaints, including contacting the Care Quality Commission where

patients were detained. Most said they would speak to staff and felt comfortable in raising any

issues. Others said, they would raise issues through patient community meetings held on the

wards. Carers told us they would raise issues with staff in the first instance, and were happy to do

so, although the need had not arisen.

We saw evidence of staff acting upon patient complaints and concerns investigated, this included

training for staff in working with people with personality disorder and further work on patient

discharge planning. Complaints and community meeting issues were standard items on the team

meeting agenda for discussion amongst staff. Patients told us staff tried to resolve any concerns

locally and would support patients to make formal complaints if required.

This service received 64 compliments during the last 12 months from 1 February 2018 to 31

January 2019 which accounted for 4% of all compliments received by the trust as a whole.

Is the service well led? Leadership

Managers had the skills, knowledge and experience to perform their roles. They could explain clearly

how the teams were working to provide high quality care. Staff spoke of their local teams working

well together and supporting each other. Staff were familiar with the service lead but few had seen

or spoken with more senior members of the trust. Some thought this was as a result of the geography

which at times made them feel isolated. Staff said when trust officials did visit, the short period of

time they spent there, was not long enough get an understanding of ward issues.

Leadership development opportunities were available, and staff were encouraged to develop,

including staff below team manager level. The trust provided ward management and leadership

courses for managers which was modular covering all aspects of the role.

Vision and strategy

Staff were unsure of the trust values of kindness, respect, ambition and collaboration as they had

recently been changed to align with the North Cumbria University Hospitals NHS trust. The staff

were aware how the previous values were applied in their work and that of their colleagues. Trust

values had been part of the recruitment and appraisal process for all staff. The trust’s new visions

and values were displayed throughout the wards and included on the trust intranet.

Staff could not recall any recent opportunities to contribute to discussions about the strategy for

their service. The trust was in a process of change with the forthcoming merger which was in

progress.

Managers told us that the service faced financial pressures in common with similar services in

other NHS trusts, however these pressures did not impact on front line staff.

Culture

Staff we spoke to felt respected, supported and valued by their local team. Staff were positive

about working for the trust and spoke highly of their colleagues. Most teams reported good morale,

although acknowledged this could fluctuate in changing circumstances.

Staff felt able to raise concerns without fear of retribution and knew how to use the whistleblowing

process. However, most staff had little knowledge about the role of the freedom to speak up

guardian or who they were. This meant they were not fully aware of all available resources about

how to report concerns.

Managers were able to deal with poor staff performance when necessary. There were processes

and policies in place to support this and the trust had a human resources department which would

be involved where necessary.

Teams worked well together and where there were difficulties staff were confident managers dealt

with them appropriately. Most staff we spoke to felt well supported by their managers and

colleagues in their team.

Staff appraisals included conversations about career development and how it could be supported.

Several staff members we spoke with had progressed up the grades in working in the trust and said

they were supported and encouraged by their superiors with this.

Staff had access to support their own physical and emotional health needs though an occupational

health service. Staff also had access to regular psychological support on the wards. Managers

encouraged staff to seek support when needed.

The provider recognised staff success within the service through the ‘Glimpse of brilliance scheme’.

Nominations could be made by staff for staff or teams where good work had demonstrated the trust

values. The winners were announced in the weekly staff news bulletin. Hadrian Wards staff team

was recently announced as a winner.

Governance

There were systems and processes in place to assess and monitor the quality of care delivery and

the environment. However, we identified several areas of concern from our inspection findings.

There were no trust policies in place for children’s visiting or blanket restrictions. We found a

number of blanket restrictions which were not identified, individually assessed or reviewed

regularly, issues with the premises at Dova ward including a bedroom occupied by a patient,

concerns regarding bed management within the core service which had resulted in a significant

number of patients being placed out of area, physical health monitoring was not always completed

as required, a lack of support for staff in providing suitably qualified and experienced staff on shifts

and to ensure staff had access to regular clinical supervision. On Rowanwood, staff reported a

lack of senior support following very serious incidents together with little assurance that lessons

had been learnt to prevent future reoccurrences.

Staff reported good morale within teams, describing themselves as self-sufficient and resilient.

However, many felt isolated from the trust who they thought had little understanding of the

amount of work and expectations placed on staff on a day to day basis.

There was a clear framework of what must be discussed at a ward, team or directorate level in

team meetings to ensure that essential information, such as learning from incidents and

complaints, was shared and discussed.

Staff participated in local clinical audits. These included reviews of medication documentation,

clinic room and equipment checks, environmental checks, care plans and other areas.


Staff maintained and had access to the risk register at ward level and could escalate concerns

when required. Managers were aware of their ward risks and those which were on the trust risk

register for their service. These included staffing levels and recruitment of registered nurses, the

environment at Kentmere ward being isolated and its dormitory layout, out of hours medical cover

across the services, the isolation of Yewdale Unit and the trust having one seclusion room without

a further alternative. Staff used risk registers to monitor environmental and other risks faced by the

service and any action necessary to reduce or eliminate the risk. Staff concerns matched those on

the risk register.

The service had plans for emergencies – for example, adverse weather or a flu outbreak. Up to

date copies of contingency plans were held on the ward for easy access and were reviewed

regularly.

Information management

The service used systems to collect data from wards that were not over-burdensome for frontline

staff. This helped inform senior managers about the performance of the wards and where

improvements were required. This included information on the performance of the service, staffing

and patient care.

Staff had access to the equipment and information technology needed to do their work. The

information technology infrastructure worked well and helped to improve the quality of care. The

wards were currently working as ‘paper light which meant not all records were online. However, staff

were managing this well and had easy access to records in either form when required.

Information governance systems included confidentiality of patient records. The electronic patient

record system was password protected and we saw paper records were stored securely. Staff were

required to undertake information governance training as part of their induction and as an annual

refresher with a trust compliance target of 90%. At the time of our inspection compliance was above

the trust target at 96%.

Engagement

Staff had access to up-to-date information about the work of the trust through the trust’s intranet as

well as the weekly news bulletin to all staff. Staff received other updates through team meetings.

Staff provided feedback through an annual trust survey as well as supervision, appraisals and team

meetings. All departing staff had an exit meeting to inform the trust of the reasons for leaving.

Patients and carers could access information about the trust through the trust’s website and on the

ward, where noticeboards were up to date. Patients and carers could provide feedback about the

service through the Family and Friends Test. The Family and Friends Test is a national survey tool

which asks people whether they would recommend a service they have used. Patients could also

attend weekly community meetings on the ward, to provide ongoing feedback and raise any issues.

The inpatient service manager had good links and engagement with external stakeholders. This

included meetings with the local clinical commissioning group, links with nearby hospitals and

mental health trusts and working with the local police services.


Staff were given the time and support to consider opportunities for improvements and innovation

and this led to changes within their localities. Such as daily community meetings for patients who

had slept the night before in dormitories and involving patients in the ward refurbishment on

Yewdale ward.

Innovations were taking place in the service. They had changed their patient review meeting

process from multidisciplinary meetings weekly to a more in-depth daily meeting to ensure patients

care and treatment was more consistently monitored, and progress checks were more frequent to

ensure appropriate and timely discharge. There had been improvement work with care planning

which included clinics for staff to attend together with patients and a representative from a local

mental health charity. There was also ongoing training for staff in carer awareness, each ward had

a champion and there were role play video scenarios for staff to learn from.

The service provided data on a monthly basis to the NHS Mental health safety thermometer but

were currently not involved in any further national audits relevant to the service.

NHS trusts are able to participate in a number of accreditation schemes whereby the services they

provide are reviewed and a decision is made whether or not to award the service with an

accreditation. A service will be accredited if they are able to demonstrate that they meet a certain

standard of best practice in the given area. An accreditation usually carries an end date (or review

date) whereby the service will need to be re-assessed to continue to be accredited.

The core service participated in accreditations for example Accreditation for Inpatient Mental

Health Services (AIMS) and Starwards.

MH – Mental health crisis services and health-based places of safety


Cumbria Partnership NHS Foundation Trust provides community health and mental health

services across Cumbria. The trust has four mental health crisis teams and health-based places

of safety based at the following four locations:

Location site name Team name Number of clinics Patient group (male, female, mixed)

Carleton Clinic ALIS & HT Not provided Mixed

West Cumberland Hospital ALIS & HT Not provided Mixed

Dane Garth ALIS & HT Not provided Not provided

Westmorland General Hospital ALIS & HT Not provided Not provided

The mental health crisis services are defined into two pathways, access and liaison and home

treatment.

The methodology of CQC provider information requests has changed, so some data from different time periods is not always comparable. We only compare data where information has been recorded consistently.


Safe and clean environment

All areas were clean and well maintained, including staff and patient interview areas.

There were rooms available for patients to be seen on-site. Staff completed an environmental risk

assessment, including a ligature assessment (a ligature point is anything which could be used to

attach a cord, rope or other material for the purpose of hanging or strangulation). The services

ensured patients did not have unsupervised access to rooms with ligature points.

All clinic rooms had the necessary equipment for patients to have thorough physical examinations.

The clinic rooms were cleaned daily. Staff made sure equipment was well maintained, clean and in

working order.

Staff told us that they carried a personal alarm and radio as the health-based places of safety

could be single staffed. In the event of an alarm being raised through the pinpoint alarm system,

staff from acute wards would attend. However, staff told us that staffing levels on the acute wards

at weekends and through the night meant there was not always a dedicated member of staff who

could assist.

The physical environment of the health-based places of safety did not all meet the requirements of

the Mental Health Act Code of Practice.

The health-based place of safety at Kendal was not a suitable environment to provide safe care

and treatment for those detained under section 136 of the Mental Health Act 1983. The

environment did not meet current standards, according to regulations around the safety and

suitability of premises and guidance on good practice published by the Royal College of

Psychiatrists. This meant that patients who used the service and others were put at risk.

The room at Kendal was an adapted room and was not sufficient in size to comfortably

accommodate people to assess and observe the patient using the required number of staff.

Patients accessing this room were brought through the hospitals main corridor compromising their

privacy and dignity. There were no toilet facilities within the health-based place of safety in Kendal.

Patients used the public toilet in an adjoining corridor. There were ligature points on the taps in the

public toilet. There were no risk assessments in place to consider the safety of patients if they

required to use the external toilets. The external toilets were single person toilets with minimal

space making it difficult for staff to observe patients who had an increased risk. At the Kendal

health-based place of safety, there was a viewing panel in the door to the room, but we noted that

there were blind spots. The trust informed us that they had secured some development money

which had been used to redevelop three of the four sites. Kendal was refurnished with new

furniture and closed-circuit television installed to mitigate the blind spots in the room. The trust

were working with the new provider, prior to transfer, to consider alternatives to the current

provision of where the health based place of safety is situated in Kendal.

The health-based place of safety at Barrow-in-Furness, Whitehaven and Carlisle were mainly

suitable for their purpose as they had been redeveloped. The environment was good and there

were toilet and washing facilities within the health-based place of safety. They connected to a

pinpoint alarm system with the rest of the hospital, so staff could be called in an emergency, but

this relied on there being enough, available staff to respond to the alarm. Patients had access to

outside space for fresh air. There was direct access to the suite from outside so the police could

bring someone to the health-based place of safety safely and discretely.

Safe staffing

The below chart shows the breakdown of staff in post WTE in this core service from January 2018

to December 2018.

The provider had determined staffing levels based on demand. The intensive home treatment

teams had a caseload of approximately 30 which was shared between staff depending on

complexity of cases and capacity within the team. Caseloads and patient complexity were

discussed daily in handover meetings. Regular bank staff were used to cover sickness, vacancies

and if demand for the service increased.

Nursing staff from the inpatient wards staffed and coordinated the assessments of two of the

health-based places of safety and two were staffed by the access and liaison integration service

and home treatment teams who coordinated the assessments. Staffing levels were sufficient 24

hours a day to enable handover of a detained person from the police as soon as possible after

arrival. However, there wasn't always a dedicated member of staff to observe patients in the

health-based places of safety based on the inpatient wards because of the location of the suites

and the availability of staff from the ward. In Whitehaven inpatient ward staff relied on the use of

closed-circuit television from the ward office. In one set of patient notes that we reviewed during

inspection, the notes indicated an eight-hour time frame where staff had to attend to emergencies

on the ward and therefore the patient was observed solely via closed-circuit television cameras.

A member of staff was available for each emergency department throughout the night as part of a

24-hour service. These assessments were carried out by the access and liaison integration

service and home treatment teams.

Medical staff

The services had medical staff within the teams. A consultant psychiatrist worked two days per

week in Whitehaven and in Carlisle two consultants covered four days per week and additional

speciality doctor covered across the week. Medical staff were integrated into the teams.

Managers could use locums when they needed additional support or to cover staff sickness or

absence.




Staff group Annual average

establishment

Annual

vacancy

rate

Annual

turnover

rate

Annual

sickness

rate

Annual bank

hours

(% of

available

hours)

Annual

agency

hours

(% of

available

hours)

Annual

“unfilled”

hours

(% of

available

hours)

All staff 194.7 5% 4% 5.3%

Qualified nurses 151.7 7% 6% 5.6%

Nursing

assistants 17.6 -6% 0% 4.2%

Medical staff 13.0 6% 0% 3.4% 305 (1%) 2613 (8%) 6087 (19%)

Allied Health

Professionals 0.0 34% 1.7%

Annual sickness rates for all staff groups and for registered nurses alone were in the highest 25%

when compared to similar core services nationally.

Annual vacancy and turnover rates were about the same as the average when compared to similar

core services nationally.

The access and liaison integration service and home treatment teams had a total of six nurse

vacancies at the time of our visit. Continuous recruitment had been in place since July 2018 to try

and fill the vacancies. Three nurses had been recruited from within the trust however those nurses

were not being released to the teams until September 2019 due to staffing pressures.

Where necessary agency staff had been used to support the teams and regular agency staff were

used to provide consistency. The South team had an agency worker as a temporary part of the

team provided by winter pressure funds. That contract was due to end in October 2019.

Monthly 'vacancy rates' over the last 12 months for all staff shows a shift from July 2018 to December

2018.

Monthly 'sickness rates' over the last 12 months for all staff shows a shift from July 2018 to

December 2018.

Monthly 'vacancy rates' over the last 12 months for qualified nurses, health visitors and midwives

show a shift from July 2018 to December 2018.

Monthly 'sickness rates' over the last 12 months for qualified nurses, health visitors and midwives

show a shift from July 2018 to December 2018.

Monthly 'sickness rates' over the last 12 months for nursing assistants shows a shift from July 2018

to December 2018.

Mandatory training




the training courses listed, 19 failed to achieve the trust target.

The trust has stated that training is reported on a rolling month on month basis and the following courses were not offered pre- April 2018: Health, Safety and Welfare, Preventing Radicalisation Level 1 & 2, Preventing Radicalisation Level 3,4&5, Safeguarding Children Level 1 and Resuscitation Level 1.

Key:

Met trust target

✓


Higher

No change

➔

Lower

Training Module

Number of

eligible

staff

Number of

staff

trained

YTD

Compli

ance

(%)

Trust

Target

Met

Compliance

change

when

compare

d to

previous

year


Local Induction 90 76 84%



Fire Safety 2 years 90 69 77%





Manual Handling - Object 90 66 73%



Prevent Radicalisation L1&2 90 57 63% N/A


Health and Safety (Slips, Trips and Falls) 90 48 53%


Prevent Radicalisation L3,4&6 64 26 41% N/A




Total 1654 1100 67%

We were told staff sickness and vacancies had impacted on the levels of staff that had completed

the mandatory training. The managers of the service told us that some training had not been

available in their area. The senior managers were aware of the low compliance rates and had an

action plan in place to ensure compliance with the trusts mandatory training target by July 2019.

Post inspection the trust provided refreshed training data for mandatory and statutory training

courses at 30 April 2019 and this was 84%. Of the training courses listed, 8 failed to achieve the

trust target and of those, 2 failed to score above 75% which was adult basic life support and

mental health act training.

Training Module YTD Compliance (%) Trust Target Met

Corporate Induction 97% ✓

Local Induction 87% ✓

Mental Capacity Act Level 1 82%

Safeguarding Adults (Level 1) 91% ✓

Fire Safety 2 years 86% ✓

Safeguarding Children (Level 1) 89% ✓

Information Governance 97% ✓

Safeguarding Children (Level 2) 91% ✓

Equality and Diversity 89% ✓

Manual Handling - Object 92% ✓

Infection Prevention (Level 1) 92% ✓

Safeguarding Children (Level 3) 81%

Prevent Radicalisation L1&2 88% ✓

Adult Basic Life Support 67%

Health and Safety (Slips, Trips and Falls) 86% ✓

Safeguarding Adults (Level 2) 78%

Prevent Radicalisation L3,4&6 77%

Resuscitation 81%

Infection Prevention (Level 2) 77%

Mental Health Act 51%

Total 84%


Staff assessed and managed risks to patients and themselves. They responded promptly to

sudden deterioration in a patient’s health. When necessary, staff working in the mental health

crisis teams worked with patients and their families and carers to develop crisis plans. Staff

followed good personal safety protocols.


Referrals to the access and liaison integration service were taken by the single point of access.

We observed a referral to the team being taken over the telephone and found this to be completed

comprehensively. Basic information and presenting problems were taken including, specific

questions about risk of suicide, physical health, safeguarding and the rationale for referral to home

treatment. A triage risk assessment and threshold assessment grid were both completed and

scored. The information gathered was then passed immediately to a qualified member of staff in

the relevant team. The single point of access worker was situated within the access and liaison

integration service East team and had access to clinical members of staff if required.

Staff completed a risk assessment for each patient when they were admitted and we saw

evidence that this was reviewed however risk assessments were not always updated.

A comprehensive risk assessment using a nationally recognised tool was completed for all

patients. The risk assessments were compiled on the trust’s risk assessment documentation using

a recognised tool called the Galatean Risk Screening tool. It is a structured risk assessment tool

designed to help clinicians assess risk of suicide, self-harm, harm to others, self-neglect and

vulnerability. Risk formulation was based on the ‘5 P’s’ model, which identifies risks based on

looking at presenting needs (current risks), predisposing factors (historical risks), precipitating

factors (triggers), perpetuating factors (those that maintain risk) and protective factors (those that

promote recovery). A multi-disciplinary team decided whether patients needed further assessment

and treatment with the home treatment team. Staff also completed a ‘situation, background

assessment and recommendation’ risk assessment when there was new contact with a patient.

Patient records contained detailed progress notes including information about risk however risk

assessments were not always updated in line with policy. Staff informed us that there was no

protected time for completing documentation, but progress notes would always be completed

including updates relating to risk and actions to be taken. Patient risk was recorded on the patient

board in the office which was available to all staff.

The health-based places of safety had closed-circuit television coverage which are monitored by

staff in the inpatient ward offices.


Patients assessed as high risk were visited on a daily and sometimes on a twice daily basis and

this visit was conducted by a qualified practitioner. Patients assessed as a lower risk were visited

every other day or twice weekly and some of these appointments would be support, time and

recovery worker led. Staff risk assessed the patients at each contact and this helped determine

the level of perceived risk and the level of support required.

Patients were generally seen by the home treatment teams in their own home for ongoing

assessment and treatment. Where there were concerns about risks to patients, staff would visit in

pairs or arrange to see patients in a safer environment, such as the interview rooms available

within the main hospitals where the access and liaison integrated service and home treatment

teams were located.

Staff followed clear personal safety protocols, including for lone working in the community. There

was a clear operating procedure for lone working, whereabouts information was indicated on a

whiteboard in the office which the shift lead monitored. Staff we spoke to told us that they felt safe

with the system in place.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other

agencies to do so. Staff had training on how to recognise and report abuse and they knew how to

apply it.

Safeguarding training is part of the mandatory training for all staff and by April 2019 90% of staff

had completed level one training for both adults and children, 85% had completed level two in

adult and children’s safeguarding, and 81% had completed safeguarding for children at level 3.

Staff could give examples of how to protect patients from harassment and discrimination, including

those with protected characteristics under the Equality Act. Staff gave an example of emotional

abuse between partners and how this would be managed.

Staff knew how to identify adults and children at risk of, or suffering, significant harm, and what

action to take, including working in partnership with other agencies. Where children were admitted

to the health-based places of safety staff checked with the police to ensure a safeguarding referral

had been made. Staff had made two child safeguarding referrals since January 2019 and these

were both as a result of information revealed during an assessment.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff were

aware of the safeguarding lead within the trust and knew how to make an online safeguarding

referral.




institutional.





should take place.

Serious case reviews7 (Internal use only - Remove before publication)


months (1 February 2018 to 31 January 2019), none of which relate to this service.


The trust used an electronic patient record system and all records were stored securely on this

system, however staff working for the mental health crisis teams did not always keep up to date

detailed records of patients’ care and treatment.

We found that some documentation, such as care plans were incomplete or missing in half of the

14 patient records and risk assessments not always updated in line with policy. Patient progress

notes were comprehensive and all staff (including agency staff) could access them however we

were concerned that trawling through progress notes would be time consuming and also we could

not find a record that all patients had received a copy of their care plan.

When patients transferred to a new team such as a community mental health team or first step,

who provide free talking therapies, a handover between teams would be facilitated. If patients

were transferring to a community mental health team they would be supported by the home

treatment team until at least the week before their first appointment to ensure consistent care was

provided. The electronic patient record system ensured staff from another team could access

patient records.


Nurse medical prescribers worked in the teams and followed good practice in medicines

management (that is, transport, storage, dispensing, administration, recording, disposal) and it

7 Universal PIR P12 SCRSAR

was done mostly in line with national guidance. We observed that medication management was

discussed in morning handovers in terms of safety dispensing and administration in planning care.

However, in Carlisle they held stock items as well as patient medication. A record was kept of

medication but there was no evidence that any form of receipt was available for the 'handing over'

of medication which the service said they would rectify immediately. Barrow-in-Furness did not

hold any medication on site.

We were told that the trust pharmacist visited the services twice weekly and staff told us that they

had positive working relationships with the pharmacy team and GPs in relation to medication

management and physical health monitoring. Staff reviewed regularly (or ensured that other

healthcare professionals reviewed) the effects of medication on patients’ physical health. This

included the review and physical check of patients who were prescribed lithium or antipsychotic

medication. These reviews were line with guidance from the National Institute for Health and Care

Excellence.

The trust had a policy in place and staff from the inpatient ward and nurse medical prescribers

could administer emergency medication, if required, in the health-based places of safety and

would monitor the effect of any medication prescribed.


Between 1 February 2018 and 31 January 2019 there were 10 serious incidents reported by this

service. Nine of the serious incidents were categorised as ‘Apparent/actual/suspected self-inflicted

harm’ and one as ‘Unexpected death’.



by the trust incident reporting system was comparable with STEIS with 10 reported. Although, all

incidents reported to STEIS were categorised as ‘Apparent/actual/suspected self-inflicted harm’.



reporting period.


Type of incident reported (SIRI) Apparent/actual/suspected

self-inflicted harm

Unexpected death Total

ALIS West 5 1 6

ALIS East 2 0 2

ALIS Furness 1 0 1

ALIS South Lakes 1 0 1

Total 9 1 10


The service managed patient safety incidents well. Staff recognised incidents and reported them

appropriately. Managers investigated incidents, staff we spoke with told us that they were kept up

to date with investigations and supported however we have a varied response in terms of how

lessons learned were shared.

All staff knew what incidents to report and how to report them, they reported serious incidents

clearly and in line with trust policy which had a clear escalation procedure and staff spoke

positively about this in terms of out of hours support.

Staff received feedback from investigation of incidents, both internal and external to the service.

Managers debriefed and supported staff after any serious incident. Staff shared with us

experiences of being supported after a serious incident in terms of multidisciplinary team support,

psychology input and support at coroner’s court, where necessary. Managers also gave examples

of learning, for example, patient address changes were updated on the electronic patient record

system by single point of access to ensure accuracy following a serious incident were a patient

could not be located.

During inspection we were told by some staff that they had not been meeting as a team on a

regular basis which made it difficult to discuss feedback resulting from incidents, shared learning

and improvements to patient care. Staff in the West team told us that concerns and issues relating

to the health-based place of safety had been escalated to management, but changes had not

been made following this feedback. However, other teams, such as Barrow-in-Furness spoke to us

about sharing lessons at a regular monthly meeting with the clinical director.

When things went wrong, staff apologised and gave patients honest information and suitable

support. Staff understood the duty of candour. They were open and transparent and gave patients

and families a full explanation if and when things went wrong.

The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all

contain a summary of Schedule 5 recommendations, which had been made, by the local coroners

with the intention of learning lessons from the cause of death and preventing deaths.

In the last two years, there have been three ‘prevention of future death’ reports sent to Cumbria

Partnership NHS Foundation Trust. One of these related to this service, details of which can be

found below.

Date of report: 29 May 2018

A person died as a result of suicide.

The Coroner’s concerns were:

“The ability and ease with which vulnerable individuals can access and receive urgent care for

acute mental health problems in Barrow-in-Furness has been highlighted by this case. In

particular:

• Was it correct that a friend; colleague and trained health professional could not make a

valid referral for an individual to receive acute mental health assessment in such

circumstances?

• Is the trust satisfied that there is adequate liaison on such matters between themselves;

emergency services (such as the Police in this case) and GP practices?

The trust may consider a review of its policies and procedures may be appropriate given the

findings in this case.”

The trust was issued with a regulation 28 report (this report sets out the coroners concerns and

requests that action should be taken) and the trust challenged the regulation 28 on the basis that

they did not accept an open referral to the service. The trust undertook a serious incident review

investigation on receipt of the regulation 28 report. There were no recommendations following this

report and there was one minor change related to the flow charts held within the single point of

access.

All referrals were triaged, and initial contact made with the patient within two hours of receipt. Each

referral was risked assessed and all referrals had been seen and assessed within 72 hours.



Staff assessed the mental health needs of all patients. Staff working for the mental health crisis

teams worked with patients and families and carers but did not always complete the correct

documentation.

Staff completed a comprehensive mental health assessment of each patient. Single point of

access triaged all calls and passed them to the appropriate team. All referrals were allocated, and

patients contacted within two hours of receipt. We listened to two calls received during our

inspection and we found that the practitioners were skilled at developing a rapport. Appointments

were made to visit both patients at their convenience.

The access and liaison integration service had a broad inclusion criteria which included those with

a co-morbid learning disability and there was no upper age limit. Out of hours, children under 16

were the responsibility of paediatrics in absence of children mental health services. All referrals

were discussed in a multi–disciplinary meeting daily. All patients referred were taken into the

access and liaison integration service on the 72-hour pathway for assessment of risk, need and

treatment. During this time, a decision was made regarding further treatment pathways such as

home treatment, admission to hospital or discharge back to the general practitioner. Patients

already admitted to acute wards could be referred for home treatment to facilitate early discharge

from wards.

Patients who were referred to the home treatment team were seen within 24 hours to update any

risks and formulate a crisis plan.

For people admitted to the health-based places of safety, in the Carlisle and Barrow-in-Furness

staff from the access and liaison integration service and home treatment team accepted the

person from the police. In Whitehaven and Kendal staff from the inpatient wards managed the

health-based places of safety. A joint risk assessment matrix was completed with the police and

trust staff on arrival to the health-based place of safety. A doctor and an approved mental health

practitioner would be contacted to undertake an assessment to ensure a patient’s ongoing care

and treatment were appropriate.

Staff ensured that any necessary assessment of a patient’s physical health had been undertaken

(this might have been undertaken by the GP) and that they were aware of, and recorded, any

physical health problems. Staff would also refer patients to their GP or adult social care depending

on the level of physical need.

During inspection we looked at 14 patient records but only half had a completed care plan. The

managers of both access and liaison integration service and home treatment teams confirmed that

only half of all plans had been completed. It was evident that staff assessed patients mental and

physical health needs and all the files contained comprehensive progress notes and all

interactions were recorded with the outcome of any action however it would be difficult to find this

information urgently. Staff told us that a shortage of staff due to sickness and vacancies and an

increase in referrals meant they were undertaking up to six visits a day over a large geographical

area which left no time to update care plans unless they did it in their own time. Managers of the

teams were aware of the need to complete care plans and told us that use of agency and bank

workers, successful recruitment of staff and supporting staff to return to work would improve

completion.

We were able to accompany staff on four visits and we found that staff used a holistic, person-

centred approach to planning care. Patients, families and carers were provided with general

information about time, frequency and duration of visits. On one visit the nurse practitioner rang

the patient just before she was due to leave for the visit and explained this had been agreed with

the patient otherwise they became anxious. All patients and carers are provided with a direct

contact number they can call for help.


Staff used recognised rating scales to assess and record severity and outcomes. They also

participated in some clinical audit, benchmarking and quality improvement initiatives.

The mental health practitioners within the teams could be nurses and nurse prescribers, social

workers and occupational therapists which enabled the teams to provide a range of care and

treatment suitable for the patients in the service. In the Carlisle team the occupational therapist

focussed on specific occupational therapy cases and would assess patients using the model of

human occupation screening tool and then formulate a focussed person-centred care plan

following this. The occupational therapist would support the wider team and also contributed to

team formulation and multidisciplinary team meetings.

Staff made sure patients had support for their physical health needs, either from their GP or

community services. Staff told us that physical health monitoring and care plans on physical health

wellbeing were produced focussing on the Lester tool (a summary poster to guide health workers

to assess the cardiometabolic health of people experiencing psychosis and schizophrenia),

antipsychotic drugs monitoring, Glasgow antipsychotic side-effect scale, physical observations,

early warning scores and electrocardiograms.

Staff told us that they had good relationships with GPs, adult social care, drug and alcohol

services, voluntary organisations, counselling services and health and wellbeing coaches which

enabled staff to support patients to live healthier lives by supporting them to take part in

programmes or giving advice.

Staff delivered care in line with best practice and national guidance and mangers had action plans

in place to ensure NICE guidance was followed.

Access and liaison integrated service worked within the principles of the recovery model. This

meant that patients were able to stay in control of their lives by focusing on building their

resilience, not just on treating or managing their symptoms.

Staff used technology to support patients. Staff could download health and wellbeing applications

to support patients. In Carlisle the medical team were piloting the use of video conferencing with

patient reviews.

Staff took part in some clinical audits, benchmarking and quality improvement initiatives.

Managers told us that they were involved in a number of projects or pilots such as a video

conferencing scheme in Carlisle, in Barrow-in-Furness they were involved in an alcohol project in

collaboration with Furness General Hospital and had requested funding for a project worker. Also,

in Barrow-in-Furness police students would spend time on the unit with the team to gain an

awareness in terms of the health-based place of safety and the role of access and liaison

integrated service and home treatment team.

This service participated in one clinical audit as part of their clinical audit programme 2018 – 2019.

Audit name Audit scope Audit type Date completed Key actions following the audit

Re-audit of Home

Treatment

Care Plan

Audit county

wide

All the mental

health Home

Treatment

teams

Clinical 15/06/2018 Planned/implemented actions

include: training covering

different topics delivered in

organised sessions, team

meetings and clinical and

management supervision.

Review of care plans in clinical

supervision, by clinical lead, and

in handovers and MDTs (using

the UCP board and Rio),

identifying and remedying gaps.

Care plan support team star

chart with results of care plan

audit. Discussion with team

doctors about how

medication/side effects can be

picked up in care planning. Side

effects tool has been clarified

with Pharmacy. The audit

question covering signed care

plan has been amended to

reflect the new Rio procedure.


The mental health crisis teams included or had access to the full range of specialists required to

meet the needs of patients under their care.

The service was made up of nurses, support time and recovery workers, occupational therapists,

social workers, consultants, speciality doctors, received support from the trust pharmacist and

some support into teams from psychology in terms of email, risk assessments and group

supervision.

Staff were experienced and mostly qualified to effectively deliver their role. Not all staff, especially

agency staff, in the access and liaison integration service or home treatment team had been

trained in the prevention and management of violence and aggression. Staff told us they relied on

ward staff attending the health-based place of safety to manage the risk of violent patients. The

trust’s policy states that level three prevention and management of violence and aggression

should be attended by all inpatient staff and staff who may be required to use control and restraint

techniques safely and effectively. Training in the prevention and management of violence and

aggression was not highlighted as part of the trust’s mandatory training for this service.

Staff and agency workers received an appropriate induction to the service which included a trust

and local induction, mandatory training and shadowing opportunities. Managers encouraged staff

to shadow other teams to gain an understanding of the services delivered to patients within the

trust. Substantive staff had completed other training such as nurse prescribing and cognitive

behavioural therapy and in some cases the prevention and management of violence and

aggression, however agency staff were not offered these opportunities although there was high

and long-term use of agency staff within the teams.

Staff told us that they did not have regular team meetings. When meetings did take place, then

minutes were shared by email to all staff. Staff told us that they used the morning handover

meeting to raise any concerns they had. We observed a handover meeting during inspection

which included the mental health practitioners, team manager and medics. A member of the

safeguarding team also attended weekly. During the meeting they discussed the presentation of

patients on the 72-hour pathway and any actions, presenting problems explored, risk reviews,

physical health considerations, medical reviews, referrals to external services such as young

carers and drug and alcohol services.


March 2018), the overall appraisal rate for non-medical staff within this service was 78%. This year

so far, the overall appraisal rate was 54% (as at 31 December 2018). The services with the lowest

appraisal rate at 31 December 2018 were access and liaison integration service in Barrow-in-

Furness with an appraisal rate of 41%, and the home treatment team with an appraisal rate of

31%. Access and liaison integration service East had the highest appraisal rate at 75%. Managers

told us that although formal supervision was not being undertaken they were working towards an

action plan to ensure that staff received supervision in line with the trust policy.

Ward name

Total number of permanent

non-medical staff requiring an appraisal


non-medical staff who have

had an appraisal

% appraisals (as at 31 December

2018)

% appraisals (1 April 2017 – 31

March 2018)

ALIS East 12 9 75% 75%

ALIS Liaison 16 11 69% 67%

ALIS South Lakes 8 5 63% 86%

ALIS West 19 10 53% 89%

Ward name


non-medical staff requiring an appraisal


non-medical staff who have

had an appraisal

% appraisals (as at 31 December

2018)

% appraisals (1 April 2017 – 31

March 2018)

ALIS Furness 17 7 41% 81%

ALIS Home Treatment 13 4 31% -


Trust wide 3167 2618 83% 79%

The trust’s target of clinical supervision for non-medical staff was not provided. Between 1

February 2018 and 31 January 2019, the average rate across all five wards in this service was

21%. The service with the lowest rate of clinical supervision was the Home Treatment team East

who were required to deliver 60 clinical supervisions but had only been able to deliver 6 sessions.

This team had carried several vacancies and two staff had been off work on long term sick leave.

This meant staff who were at work had to manage a higher work load to ensure patient care was

not compromised.




sessions required


delivered


rate (%)

ALIS S Lakes 28 14 50%

ALIS East 56 18 32%

Furness ALIS HTT 84 14 17%

West ALIS/HTT 68 11 16%

Home Treatment

East 60 6 10%



The managers of these services told us that they had prioritised patient care when they had been

short staffed this resulted in supervision and appraisal not being formally completed. All staff we

spoke with said that they were able to discuss any issues at the morning handover and felt

supported by the whole team. We saw that the low supervision rates were on the local risk

registers.

The medical staff we spoke to during the inspection felt supported in their role and encouraged a

learning environment to maintain workforce sustainability. In Carlisle the medical staff were well

integrated into the team attending multidisciplinary team reviews daily. They would also meet at

the end of every week, usually as conference call, to discuss any current risks with patients,

staffing levels and actions. We saw the minutes of these meetings.


There was good multidisciplinary team working in the teams we visited. The teams had daily

multidisciplinary meetings to review the care and treatment of the patients who used the service.

There was visible and active consultant psychiatrist input within the teams. Medical staff were

supportive and responsive, going out on request to undertake joint assessments when concerns

had been raised. The teams had established positive working relationships with a range of other

service providers such as the inpatient wards, general practitioners, and local services.

The access and liaison integration service had effective working arrangements with the acute

wards to holistically plan patients’ discharge through proactive involvement with daily acute patient

pathway meetings. This meant that crisis staff could plan and support patients to be discharged

from hospital.

Shared care agreements were in place outlining the responsibilities for managing patients and the

prescribing of a medicine, including where care was shared between secondary mental health

services such as the crisis teams and community mental health teams and the patient’s GP. We

saw clear records of communication with GPs following patients having a medication review.

There was a good working relationship with the local police and they had established three police

liaison posts. One of the police liaison officers told us that they were able to sort out any problems

in real time and they participated in the lessons learned reviews. There was a multi-agency

protocol in place for section 136 including the police, ambulance service and local authority.

Included in this policy and staff told us that the police could contact the single point of access for

advice about possible admissions before bringing anyone to a health-based place of safety.

Once a month a psychiatric liaison meeting was held, attendance included trust staff, the police

and social services. We saw the minutes from two of these meetings and they identified issues

with the service provision and identified patients that presented to the different services multiple

times and ways to engage and support them. This allowed them to be aware of what was

happening with the patients across services.


Practice

As of 30 April 2019, 52% of the workforce in this service had received training in the Mental Health

Act. The trust stated that this training is mandatory for all services for inpatient and all community

staff and renewed every year.

Staff told us that training had not been available, but training had now been organised for June

2019.

Staff had access to administrative support and legal advice from the trust’s Mental Health Act

administration office. Staff could also access the Mental Health Act policy electronically, via the

trust intranet.

There was a multi-agency pro forma for recording detentions under section 136. The records that

we were able to view showed that assessments were carried out in line with the guidance in the

Mental Health Act Code of Practice and in accordance with time lines outlined in the protocol.

Trust staff we spoke with had a good understanding of the duties placed on the different agencies

when people were brought in on a section 136.

Records relating to episodes of section 136 showed that most key information was being captured

to show the patients’ details, the circumstances that brought the patient to the health-based place

of safety, details of the assessment and the time taken at each stage and the outcome of the

assessment. However not all the records we viewed showed that patients subject to a 136 section

had been explained their rights as required under section 132 of the Mental Health Act. Whilst

patients on as section 136 cannot appeal against their detention and do not have an automatic

right to independent advocacy input; they do have the right to refuse treatment, the right to seek

legal advice and the right of complaint. It was therefore not clear whether all patients were

informed of this right.

Patients within the health-based place of safety were being cared for under the legal framework of

the Mental Health Act rather than the Mental Capacity Act. As part of the assessment carried out

by the approved mental health practitioner the outline report produced by them highlighted if the

patient could consent to informal admission to hospital or whether the mental health act needed to

be used.


As of 30 April 2019, 82% of the workforce in this service had received training in the Mental

Capacity Act. The trust stated that this training is mandatory for all services for inpatient and all

community staff and is a ‘one off’ training course.

The trust had an up to date policy on the Mental Capacity Act. Staff were aware of the policy and

they could access it through the intranet. Staff were aware of who to contact if they needed advice

regarding the Mental Capacity Act and told us that the Mental Health Act office assisted them

when needed.

Staff gave patients all possible support to make specific decisions for themselves before deciding

a patient did not have the capacity to do so. We saw that information was made available to

patients about advocacy services in the local area.

Staff assessed and recorded capacity to consent as part of the initial assessment process. They

also recorded consent to share information.



Staff attitudes and behaviours when interacting with patients showed that they were discreet,

respectful and responsive, providing patients with help, emotional support and advice at the time

they needed it.

Staff supported patients to understand and manage their care, treatment or condition. On one

home visit we observed staff discussing the care plan with the patient and they were provided with

a copy. The patient’s carer was also present for some of the visit and actively engaged in the

patients care. Staff spoke to the patient about their staying well plan and discussed options to

support recovery such as weekly exercise, a social gym, use of a health and wellbeing coach and

other community resources.

Staff directed patients to other services when appropriate and, if required, supported them to

access those services. This included attending a GP for a physical health issue. They supported

patients to access community resources and helped them in engage activities that kept them well.

We saw that patients were supported to access a residential crisis centre where patients could

access a library, a fitness centre, online cognitive behavioural therapy, an activity room and a

garden. This service helped people by giving them space and support which in turn meant they did

not need to access hospital.

Patients said staff treated them well and behaved appropriately towards them. We received

positive feedback from all patients we spoke with and observed good practice during appointments

in peoples’ own homes, such as gaining consent for us to attend the visit. One patient told us they

felt they had been listened to and their thoughts and feelings taken on board and understood by

the team.

Staff understood the individual needs of patients, including their personal, cultural, social and

religious needs. Translation services were utilised on home visits were English was not a patients

first language. Due to the shift patterns the same named worker could not always be available to

each patient and this was explained to them. During one home visit staff explained to the patient

and their carer who the lead worker would be and informed them who would visit next. Patient

choice was given for appointment location, wherever possible.

Staff said they could raise concerns about disrespectful, discriminatory or abusive behaviour or

attitudes towards patients without fear of any consequences. Staff were encouraged to report any

abuse from patients either on the phone or in person.

Staff maintained the confidentiality of information about patients if they had appointments at the

service interview or physical health examination rooms were private, patients consent was sought

to share information and notes taken on a visit were uploaded onto the electronic patient record

system once the staff member returned to the office.

Involvement in care


Staff involved patients in crisis planning and worked with them to identify actions they could take

whilst at home. This involved relaxation techniques and accessing community resources. Staff told

patients about various apps they could download onto their phones for mindfulness and

meditation. On one home visit we observed that a patient had been given copies of resources to

support her anxiety and techniques for mindfulness and wellbeing discussed.

Staff communicated with patients so that they understood their care and treatment, including

finding effective ways to communicate with patients with communication difficulties. We saw that

they had used the interpreters on the phone and in person for patients whose English was not

their first language or had a disability.

Dedicated staff contacted patients and carers following interactions with the service as responses

to the questionnaires they had been using were not in sufficient quantity to give a comprehensive

overview of the service they had received. Staff told us they were having better responses to the

phone calls and they followed the same script for all calls. In Carlisle the team also had a service

user representative twice a month to gain feedback over the phone from patients.

We observed you said, we did boards in some locations and evidence of changes made such as

comments that the health-based place of safety in Barrow-in-Furness was cold and uninviting, so

some art work had been completed to securely hang in the room.

During inspection we observed a number of leaflets available to patients regarding service

information, complaints and the patient, advice and liaison service, healthwatch, advocacy and a

number of leaflets regarding community services and provision.


The service would establish the patient’s primary carer as part of the assessment process. Patient

information would be given to those brought to the health-based places of safety which included

information about letting their nearest relative know.

Staff informed and involved families and carers appropriately and in line with confidentiality

agreements. Where patients did not want family members involved this was either respected

and/or explored further to identify what the issues were. Staff were fully aware of the impact

families could have on a patient’s recovery and fully recognised that families needed support.

Carers were provided with support when needed from a local carers’ support service and provided

with information about how to access a carer’s assessment.

Staff enabled families and carers to give feedback on the service they received (for example,

through surveys or community meetings). Patients and families could contact the trust’s patient

advice service or give feedback direct to staff and managers. Staff accepted that more could be

done and were looking at other ways. Carers had requested more information and in Barrow-in-

Furness the service had responded by putting up a notice board containing information about

carers groups and support networks.

We saw leaflets regarding the Triangle of Care in services. Cumbria Partnership Foundation Trust

signed up to the Triangle of Care in 2018 which is a scheme that champions the role of carers in

patient care, specifically in mental health.

Is the service responsive?

Access and waiting times

The service had a standard operating procedure and a multiagency protocol in relation to the use

of health-based places of safety. Patients access the service from a variety of different sources.

These included self-referrals through the single point of access or through referrals from GPs,

community teams, and inpatient wards.

Access and liaison integration services had a two-hour response time for all referrals received

within hours and a 24-hour response time out of hours. All of the health-based places of safety

were commissioned for use 24 hours a day, seven days per week.

Referrals were taken by a senior administrative member of staff in the single point of access who

then triaged these into ‘urgent’ and ‘non-urgent’. Urgent referrals were sent to the relevant access

and liaison integration service. This meant that patients were seen within the relevant target times.

We observed this system working well and all referrals were dealt with in an efficient and timely

manner.

There was some primary care mental health service within Cumbria offering low and high intensity

psychological therapies as primary care intervention, however, patients were also referred into the

crisis teams with mild to moderate mental health conditions.

Patients referred to the teams were discussed at the daily multidisciplinary team meetings

attended by all staff on duty. Patients were able to be seen on the same day if necessary. At these

meetings it was also decided when the medical review would take place.

Patients were seen in their own home or could attend the team base, dependent upon level of risk.

There was a 24-hour telephone line that patients could contact in times of distress. The patients

we spoke to who had used this service commented that they had found it to be very helpful.

The Access and liaison integration services teams were gatekeepers for the mental health in-

patient beds and were tasked with sourcing a bed for anyone who had been assessed within the

health-based place of safety who required an admission to hospital. The current state of the bed

provision was available electronically through a clearly designed dashboard. There were

sometimes problems accessing beds within the trust and this meant that patients could be

admitted to hospital a long distance away from home.

Access and liaison integration services were proactive at facilitating early discharge for those

admitted onto acute wards. Staff attended acute admission pathway meetings on the ward daily in

order to assess whether individual patients could be provided with home treatment and to help

plan early discharge.

There had been delays in discharging patients to community mental health teams, however this

was due to the community teams’ capacity to take on referrals. Patients would continue to be

supported when they were referred or transferred between services. Managers told us if the

caseload exceeded 30 then this would be incident reported and monitored.

The team tried to engage with people who found it difficult, or were reluctant, to seek support from

mental health services. The services would give patients choice for appointment location, hand

deliver appointments to clients who did not attend initial appointments and utilise other agencies in

the engagement of hard to reach clients.

If appointments needed to be cancelled then staff gave patients clear explanations and offered

new appointments as soon as possible. Appointments appeared to run on time and staff informed

patients when they did not, for example, if held up in traffic.

The facilities promote comfort, dignity and privacy

The design, layout, and furnishings of interview and physical healthcare rooms supported patients’

treatment, privacy and dignity. The services had a full range of rooms and equipment to support

treatment and care if patients could not be seen at home; staff could organise transport for

patients to attend if necessary.

The health-based place of safety at Barrow-in-Furness and Carlisle were purpose-built suites on

the ground floor of the hospital with its own discrete entrance, ensuite toilet and shower facilities

and access to fresh air, however patients who were in the health-based place of safety overnight

at Carlisle there was an open space to the bathroom and no blackout curtains on the windows

which did not promote the privacy and dignity of patients. In Whitehaven the patient accessed the

health-based place of safety by a separate entrance, the suite had an anti-ligature bed settee and

a chair and access to a toilet and shower however the viewing window to the suite formed part of

another office used by the doctors and other professionals. The health-based place of safety at

Kendal did not promote recovery, dignity and confidentiality. There was no discrete entrance and

the toilet and washing facilities were located outside of the suite. The rooms were bare apart from

an anti-ligature bed settee and chairs.

The ward staff ordered a small number of extra meals and could make snacks throughout the day

to ensure that patients admitted into the health-based place of safety had access to meals whilst in

the health-based place of safety.


Staff supported patients with activities outside the service, such as work, education and family

relationships.

Patients identified goals during their assessment and treatment. These included ‘going to the gym’

‘getting a job’ or meeting others who were struggling with similar issues. Staff directed patients to

a variety of community support services which included services run by voluntary organisations.

These services provided an open non-judgemental and empathetic environment where support

was provided by peers and workers. Information was given to patients about other national

support organisations. Patients could also access a counselling service run by the trust.

Staff encouraged patients to stay in contact with families and carers and were patients consented

involved families and carers in their support.


The service met the needs of all patients – including those with a protected characteristic. Staff

helped patients with communication, advocacy and cultural and spiritual support.

When children were admitted to the health-based place of safety they had to be seen by the child

and adolescent crisis assessment team. This service has not been commissioned to provide a 24

hours service.

The service could support and make adjustments for people with disabilities, the Whitehaven

access and liaison integrated service and home treatment team did not have a ramp to enable

people in a wheelchair to gain access. Staff told us in these circumstances they would see them at

home, in their GP surgery or at a community hospital site.

The access and liaison integrated service provided all patients with a crisis contact sheet giving

information to ensure patients could access information on treatment, local services, their rights

and how to complain.

The service could provide information in a variety of accessible formats so the patients could

understand more easily and staff could request information leaflets in languages spoken by the

patients and local community. Managers made sure staff and patients could get hold of

interpreters or signers when needed.

Listening to and learning from complaints The service treated concerns and complaints seriously, investigated them and learned lessons

from the results, and shared these with the whole team and wider service.

Patients knew how to complain or raise concerns and they received feedback.

Staff understood the policy on complaints and knew how to handle them.

This service received 17 complaints between 1 February 2018 and 31 January 2019. Two of these

were upheld, six were partially upheld and six were not upheld. Two were under investigation and

one was categorised as ‘Other’.

Staff told us that they carried out a lesson learned after every complaint. On one occasion when a

carer had complained they were not listened to, it was identified the member of staff had been

typing whilst talking. As a result of this staff know to concentrate on a call rather than trying to do

two jobs at once. A recent team meeting in one location staff were looking at trying to establish

consistency across the service when answering the phone. Services also had ‘you said, we did’

boards and staff told us that newsletters were sent out to disseminate information to the teams.

Ward name

To

tal C

om

pla

ints

Fu

lly u

ph

eld

Part

ially u

ph

eld

No

t u

ph

eld

Oth

er

Un

der

Investi

gati

on

Wit

hd

raw

n

Refe

rred

to

Om

bu

dsm

an

ALIS - Furness 5 1 1 2 0 1 - -

ALIS - West 5 1 2 2 0 0 - -

ALIS – East 4 0 2 1 0 1 - -

ALIS – South Lakes 3 0 1 1 1 0 - -

Total 17 2 6 6 1 2 - -

This service received 27 compliments during the last 12 months from 1 February 2018 to 31

January 2019 which accounted for 2% of all compliments received by the trust. At Barrow-in-

Furness they had implemented a ‘you said we did’ board that showed what issues had been

raised by patients and the subsequent actions of the staff to address these concerns such as

issues with the mental health liaison room in accident and emergency and the service were

working with estates to improve mental health rooms in accident and emergency departments as a

result of this feedback.

Is the service well led?

Leadership

Managers we spoke to during inspection had the skills, knowledge and experience to perform their

roles. They could explain clearly how the teams were working and had an awareness of the issues

within the teams. Staff spoke of their local teams working well together and supporting each other

however they told us that team meetings and supervision were not consistently undertaken.

Staff were familiar with the service lead but few had seen or spoken with more senior members of

the trust.

We did not find evidence of leadership development opportunities. Staff in some services were

finding it difficult to keep up to date with mandatory training due to high numbers of staff

vacancies, sickness and caseloads. Supervision and appraisal rates were low which did not give

staff opportunities to discuss their professional development.

Vision and strategy

Staff were aware of the trust’s vision and values. The trust had a behavioural framework which

identified how staff should demonstrate these values in their everyday work. Staff were motivated

and dedicated to give high quality care and treatment to patients in receipt of community crisis

mental health services in line with the values and vision. For example, crisis teams ran regular

physical health clinics promoting healthier living for patients. During inspection we observed a

physical healthcare appointment where the member of staff acted professionally and treat the

patient with kindness and respect at all times.

However, staff told us they did not feel able to contribute to service developments or the strategy

for their service. In recent months it had been announced that the trust would be dissolved, and

services would be split between two other NHS trusts. Staff we spoke with did not know what the

changes would mean for them going forward. Staff in the east of the service had received little or

no information regarding the changes.

Culture

Staff were ambivalent about their managers in the service. Some staff told us they didn’t have any

confidence in their manager whilst others said they micro managed staff. Some staff thought that

their manager was supportive.

Morale was low and staff did not feel they could recommend working for the trust. Staff

acknowledged that the high levels of vacancies and sickness had made the work more challenging

and stressful but they were committed to providing quality care which responded to patients’

needs. Staff told us that their teams were generally supportive of each other and worked together

to ensure patient care was not compromised.

Not all staff knew about the Freedom to Speak Up Guardian and some staff were not confident

that any concerns or suggestions raised would be listened to although all were aware of the trust

whistleblowing policy. Staff told us they had raised concerns regarding the safety of the health-

based places of safety in some areas but did not feel that these concerns were being listened to.

Staff had access to support for their own physical and emotional health needs through an

occupational health service. The trust provided access to complimentary therapies, counselling

and stress management service through the occupational health department. The trust also

provided a multi-faith service to meet the spiritual and religious needs of staff. One member of

staff we spoke with told us that the trust supported dragon software (speech recognition software)

as a reasonable adjustment for their individual needs.

Governance

There were some systems and processes in place to assess and monitor the quality of care

delivery, however we saw a lack of clinical audits and where audits were taking place they were

mostly ineffective.

The trust had made improvements in three of the four health-based places of safety which had

improved the environments since the last inspection. However, we found a number of issues with

the health-based place of safety in Kendal and lack of risk assessment in relation to the

environment. We also observed some issues with the comfort, privacy and dignity of patients

utilising the health-based places of safety.

High numbers of staff vacancies, sickness and caseload were impacting on staff time and their

ability to complete all tasks effectively. Staff were not always completing the correct

documentation when planning patient care, managers were aware of this but we did not see

evidence of audits. This also had an impact on the regularity of team meetings, training and

supervision compliance. Staff reported low morale within some teams.

Information provided before the inspection showed that staff were not attending mandatory training

nor were they receiving regular supervision. The service had identified the low compliance and

had an action plan in place to improve mandatory training compliance and updated figures were

provided post inspection. In terms of supervision managers were aware of the staffing pressures

and were taking steps in terms of recruitment and use of bank and agency to reduce these and

increase staff availability to attend supervision sessions.

Effective clinical multidisciplinary team meetings took place within the teams. Collaborative

working and relationships with other providers were positive. There were regular section 136

clinical meetings conducted to discuss areas of development and concern within the health-based

places of safety and with other services such as the police. Managers told us monthly community

task meeting were held with the police.


Each team had a risk register and managers told us they could escalate items to the corporate risk

register. Staff concerns matched those on the risk register.

The service had business continuity plans in place to cover for emergencies.


Patient information was stored on an electronic record system and all staff including agency staff

could access the system. This system was used throughout the trust and this meant staff could

review any interactions with other services as part of the treatment plan.

Staff had access to the equipment and information technology needed to do their work. All records

were kept on the electronic patient record system, however, staff did not have the time to ensure

all records were completed and kept up to date.

Information governance systems included confidentiality of patient records. Staff were required to

undertake information governance training as part of their induction and as an annual refresher

with a trust compliance target of 90%. In refreshed training data the trust provided in April 2019

compliance was above the trust target at 97%.

Engagement

Not all staff felt supported by their line manager, more senior managers or the executive team.

Staff in the east of the service did not feel involved or informed about upcoming changes. Staff in

the west of the service felt that managers had kept them informed and involved in the change

programme. Information about the coming changes were provided through a staff newsletter and

on the staff intranet.

People who used services were contacted by a member of the team to provide feedback on their

experience. Patients and carers could provide feedback for the service through completing an

anonymous questionnaire. We saw that staff reviewed, monitored and acted on the feedback

received.

Staff, patients and carers had access to up-to-date information about the trust through the trust’s

website and in the services noticeboards were up to date and provided a number of information

leaflets about service provision, complaints procedures and initiatives such as Triangle of Care.

Leaders engaged with external stakeholders. A number of external meetings took place to

strengthen relationships, discuss issues or improvements to service provision and outcomes for

patients.







The core service did not participate in any accreditations. However, there was some learning and

improvement that doctors were leading in Carlisle. These topics included; Standardisation of

doctors’ correspondence, quality of mental health assessments of patients presenting in the

accident and emergency department with self-harm, routine clinical formulation in the East home

treatment team and a pilot on the use of video conferencing with patient reviews.

MH – Wards for people with learning disabilities or autism


Location site name Ward name Number of beds Patient group (male, female, mixed)

Carleton Clinic Edenwood 6 Mixed

The methodology of Care Quality Commission provider information requests has changed, so

some data from different time periods is not always comparable. We only compare data where

information has been recorded consistently.

Cumbria Partnership NHS Foundation Trust’s inpatient service for people with a learning disability

or autism comprised one ward: Edenwood based at the Carleton Clinic in Carlisle. The service is a

six bed assessment and treatment unit for men and women with a learning disability who are

currently experiencing a mental health crisis and require acute assessment and treatment.

The unit takes admission for people with a learning disability and autism, though not with just a

diagnosis of autism. Individuals who have autism without a learning disability would have their

needs met within generic mental health wards.

Following our last inspection in October 2016, we rated the service as requires improvement

overall as we found two regulatory breaches of the Health and Social Care Act 2008 (Regulated

Activities) Regulations 2014. These are detailed below as well as another area for improvement:

• Training in some modules of mandatory training had compliance rates below the trust target which was 80% at the time, which was a breach of regulation 12, (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

• There was no clear system in place to learn from incidents. Staff did not feel that they received any constructive feedback following incidents which was a breach of regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

• Patients did not have access to occupational therapy support on the ward.

During this latest inspection, we looked at all of our key lines of enquiry in relation to the service.

We reviewed the regulatory breaches and the other area for improvement identified in our last

inspection.




Over the 12-month period from 1 February 2018 to 31 January 2019 there were no same sex

accommodation breaches within this service. Although male and female bedrooms were along the

same corridor, all patients’ bedrooms had their own en-suite facilities. There were two lounge areas

which included a female only lounge.

There were ligature anchor points on Edenwood within the last 12 months.

Ward / unit

name

Briefly describe risk - one sentence

preferred

High level of risk?

Yes/ No

Summary of actions

taken

Edenwood

Only relatively low risks remain in the

ward following annual risk assessments

and agreed action plans to reduce the

risk over the past 12 years.

No

An action plan has

been agreed and all

identified risks being

addressed.

Any patients assessed as being at risk of self-harm or suicide were placed on enhanced

observations to mitigate the presence of ligature anchor points on the ward. Although there were

no mirrors in use to monitor blind spots on the ward, closed circuit television was in use to allow

staff to monitor patients’ whereabouts.

Patients did not have access to nurse call points which meant calling for assistance was more

difficult for them. However, the hospital was built before 2013 which meant there was no

requirement under Regulation 12 (safe care and treatment) of the Health and Social Care Act

2008 (Regulated Activities) Regulations 2014. Staff did, however, carry their own alarms.

Staff did regular risk assessments of the environment and mitigated any risks identified.

Certificates and other documentation relating to the safety of gas, electrical wiring, portable

appliance testing, legionella, lift servicing and hoist and slings were not held on the ward.

However, we saw evidence that checks, drills, training and risk assessments in relation to fire

were present and up to date. We also saw evidence that repairs to the environment were identified

and rectified accordingly and that the Control of Substances Hazardous to Health Regulations

were adhered to.


PLACE assessments aim to provide a clear message from patients on how the care environment

may be improved. They are undertaken by teams of local people alongside healthcare staff and

assess privacy and dignity, food, cleanliness, building maintenance and the suitability of the

environment for people with disabilities and dementia.

The site at which Edenwood was based was compared to other sites of the same type and the

scores they received for ‘cleanliness’ and ‘condition, appearance, and maintenance’ were found to

be about the same as the England average.


and maintenance

Carleton Clinic MH - Acute wards for adults of

working age and psychiatric

intensive care units


with mental health problem

99.6% 94.2%


and maintenance


learning disabilities or

autism



working age adults


England average

(Mental health

and learning

disabilities)

98.4% 95.4%

Overall, we found the ward to be clean and tidy. The ward had good furnishings and all areas of

the ward were well maintained. Cleaning records were up to date and demonstrated that the ward

was cleaned regularly. Staff adhered to infection control principles and there were handwashing

facilities throughout the ward.

Seclusion room

There was no seclusion room on the ward.


The clinic room on the ward was fully equipped with accessible resuscitation equipment and

emergency drugs which staff checked regularly in line with the provider’s medicines management

arrangements. We saw evidence that a resuscitation equipment checklist was completed daily and

a defibrillator was stored in a cupboard along with emergency medications.

Staff maintained equipment well and kept it clean. Equipment included clear stickers to say when it

was last calibrated and tested.

Safe staffing8

Nursing staff

Managers calculated the number and grades of nurses and healthcare assistants required based

on the acuity of the patients, risks identified and incidents on the ward.

The below chart shows the breakdown of staff in post whole time equivalent in this core service from

February 2018 to January 2019.

8 Staffing Data Safer Staffing Oct to Dec 2018

The below table covers staff fill rates for qualified nurses and care staff during October, November

and December 2018.

Key:

> 125% < 90%


Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)


Edenwood 252.4 183.6 206.7 204.3 110.0 115.0 107.7 106.3 103.6 100.0 102.8 106.5

Edenwood had a fill rate of more than 125% for nurses and care staff at all times in October 2018.




Staff group

Annual

average

establish

ment

Annual

vaca

ncy

rate

Annual

turno

ver

rate

Annual

sickn

ess

rate

Annual

bank

hours

(% of

availa

ble

hours

)

Annual

agenc

y

hours

(% of

availa

ble

Annual

“unfill

ed”

hours

(% of

availa

ble

hours)

hours

)

All staff 36.4 25% 6% 6.8% N/A N/A N/A

Qualified

nurses 10.8 34% 11% 5.2%

3453

(24%)

2140

(15%) 398 (3%)

Nursing

assistant

s

20.2 21% 4% 8.5% 12065

(31%)

4139

(11%) 818 (2%)

Medical staff 1.9 46% 0% 0.0% 0 (0%) 0 (0%) 0 (0%)

Allied Health

Professio

nals

1.0 -21% 0% 0.0% N/A N/A N/A

Annual sickness rates, total vacancy rates and turnover rates were about the same as the average

when compared to similar core services nationally.

Annual vacancy rates for nursing assistants were in the lowest 25% when compared to similar core

services nationally.

Annual turnover rates for qualified nurses and nursing assistants were in the lowest 25% when

compared to similar core services nationally.

The following information and charts highlight specific staffing areas where there is noteworthy

evidence that may prompt further investigation on site.

Medical staff

There was adequate medical cover day and night and a doctor could attend the ward quickly in an

emergency. A specialist GP was attached to the ward two days a week and a duty doctor could

attend the ward within 10 minutes when required for mental health emergencies during the day.

We were told by staff that for physical healthcare emergencies during the night, staff used the

NHS 111 system. However, we understood within the organisation that the agreed arrangements

were to contact Cumbria Health On Call Limited when medical emergencies arose.

Mandatory training


the training courses listed, 16 failed to achieve the trust target and of those, 10 failed to score

above 75%.

The trust stated that training is reported on a rolling month on month basis and the following courses were not offered pre- April 2018: health, safety and welfare, preventing radicalisation level 1 & 2, preventing radicalisation level 3,4 & 5, safeguarding children level 1 and resuscitation level 1

Key:

Below 75% Met trust target

✓


Higher

No change

➔

Lower

Training Module

Number

of

eligibl

e

staff

Number

of

staff

traine

d

YTD

Complian

ce (%)

Trust

Targ

et

Met

Compliance

change

when

compar

ed to

previou

s year

Safeguarding Adults (Level 1) 22 19 86% ✓ ➔

Fire Safety 2 years 22 19 86% ✓









Falls) 22 16 73%


Other (Please specify in next

column) 69 49 71%







Training Module

Number

of

eligibl

e

staff

Number

of

staff

traine

d

YTD

Complian

ce (%)

Trust

Targ

et

Met

Compliance

change

when

compar

ed to

previou

s year


Total 411 290 71%

Staff were still not up to date with their mandatory and statutory training at the time of our

inspection. The trust set a target of 85% for completion of mandatory and statutory training and

95% for information governance training. Overall, mandatory training and statutory training

compliance was 77% as at the time of our inspection visit. The following 12 training modules failed

to achieve the provider’s 85% compliance target. Six were below 75% compliance:

• safeguarding children level 3 – 33%

• safeguarding adults level 2 – 81%

• safeguarding children level 2 – 81%

• fire safety 76%

• resuscitation level 1 – 79%

• resuscitation level 3 adults intermediate life support 71%

• moving and handling 43%

• infection prevention and control level 2 81%

• awareness of prevent 67%

• corporate induction 81%

• local induction 57%

• mental health legislation 12.5%



Staff did risk assessments of patients on admission and updated them regularly. We looked at five

patients’ care records and saw evidence risk assessments were in place for the patients and had

been updated regularly.

Staff assessed patient risk via the recognised functional analysis of care environments (FACE) risk

assessment tool and the provider’s own in-house tool which was built into its electronic care

records system.


Staff were aware of and dealt with specific issues such as falls, potential self-injury and suicide,

epilepsy and other risk to, or posed by patients.

There were blanket restrictions on the ward. The ward was locked as patients were detained

under the Mental Health Act 1983 and access to the two main bathrooms was restricted due to the

presence of ligature points and potential risks to patients with epilepsy. The kitchen door was kept

locked because of the presence of sharp implements, ligature points and risk of burns. Patient

access to the kitchen area was subject to a risk assessment.

Banned articles on the ward included alcohol and blades and other sharp implements.

Any informal patients admitted to the ward were able to leave at will. Patients were issued with a

booklet on admission which informed them of their rights as informal patients and care plans were

developed for any informal patient to explain that they may leave freely at any point.


The provider reported that the service had 301 incidences of restraint (44 different service users)

and no incidences of seclusion between 1 February 2018 and 31 January 2019. This information

was, however, subsequently found to be incorrect as the ward manager confirmed there were 214

incidences of restraint involving nine patients during this period.

The below table focuses on the last 12 months’ worth of data as originally reported by the provider:

1 February 2018 to 31 January 2019.


Patients

restrain

ed

Of restraints,

incidents of

prone

restraint

Of restraints,

incidences of

rapid

tranquilisation

Edenwood 0 301 44 5 (2%) 2 (<1%)

Core service

total 0 301 44 5 (2%) 2 (<1%)

There were five incidences of prone restraint, which accounted for 2% of the restraint incidents.

Over the 12 months, incidences of prone restraint ranged from none to two per month. The number

of incidences (5) had increased from the previous 12-month period (0).

There were two incidences of rapid tranquilisation recorded over the reporting period. Incidences

resulting in rapid tranquilisation for this service ranged from none to one per month for the 12-month

period. However, we reviewed one incident of rapid tranquilisation and found that there was no

evidence of the patient’s observations levels being reviewed following the use of rapid tranquilisation

which was not in line with the provider’s policy.

There were no instances of mechanical restraint over the last 12 months.

The ward was participating in the provider’s restrictive interventions reduction programme.

Staff used restraint only after de-escalation had failed. Staff gave examples of de-escalation

techniques which included verbal de-escalation, distraction techniques, redirection, strategies in

patients’ positive behaviour support plans and the use of massage. Staff were aware that pain

compliance on patients should not be used. Staff understood the Mental Capacity Act definition of

restraint and gave examples to demonstrate their knowledge such as using the least restrictive

option if decisions were made on the patient’s behalf.

We reviewed nine instances of restraint which related to three patients. We found no evidence of

the patients’ physical observations being checked after the restraint had occurred as the forms

completed by staff did not ask for this information. Staff had not completed body maps for five of

the records we reviewed. On each occasion, the patient had been given ‘as required’ medication

but we saw no rationale as to the reasons why this had been necessary. An incident report stated

that a domestic staff member of staff was involved in one of the restraints, but the ward manager

said this was a recording issue and the staff member was actually a healthcare assistant.

There were no instances of long-term segregation over the reporting period. However, one patient whose care and treatment were being funded by learning disability and autism commissioning arrangements was in a seclusion room based on another ward in the hospital’s psychiatric intensive care unit at the time of our inspection visit. Staff from the Edenwood ward continued to monitor and review the patient’s care and treatment. There was a seclusion care plan in place which contained clear and relevant information about the use of seclusion for this patient.

Safeguarding

A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical abuse, emotional abuse, financial exploitation, sexual abuse, neglect and institutional abuse.

Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.

The service made 19 safeguarding referrals during the 12 months prior to our inspection visit.

Staff were not compliant with the trust’s target of 85% for all modules of their mandatory training modules in safeguarding. The provider reported as at 30 May 2019, only 33% of staff had completed safeguarding children level three training and 81% of staff had completed their safeguarding adults and children level two training.

Staff knew how to make a safeguarding alert and could give examples of how to recognise

possible signs of abuse such as unexplained bruising, changes in presentation, financial worries

and self-neglect.

The provider had policies on safeguarding and equality and diversity which helped to protect

patients from discrimination and harassment. Staff worked in partnership with the trust’s

safeguarding team, the local authority and external care providers, each sharing any safeguarding

concerns to ensure protective measures were put into place to safeguard patients.

The trust has submitted details of 18 serious case reviews commenced or published in the last 12 months (1 February 2018 and 31 January 2019), none of which relate to this service.


Staff had access to all information needed to deliver patient care which was in an accessible form.

Care and treatment information was securely stored within the provider’s electronic care records

system which required a username and password to access or in paper form which was kept in

locked cabinets.


Medicines management arrangements were not effective in all areas. During our checks, we found two unlabelled medicines, topical cream and sodium valproate. The sodium valproate was being administered to a female patient of child bearing age on the ward. This drug is known to affect how babies develop in the womb. However, we found no risk assessment in relation to its use within the patient’s care and treatment records.

Staff did not always monitor patients’ medication regularly. One patient’s care plan around the prescription of their ‘as required’ medication had not been reviewed since January 2018.

There was a policy in place for the use of controlled drugs on the ward. Controlled drugs were stored in line with current legislation and the service had its own controlled drugs record book which was stored safely. The ward pharmacist managed the safe disposal of controlled drugs. The trust’s lead pharmacist was the controlled drugs accountable officer for the service.

Fridge temperatures were recorded daily in line with the Royal Pharmaceutical Service and Medicines and Healthcare Products Regulatory Agency guidance. On the day of our inspection, the temperatures of the fridges were correct to store medicines safely. There had been occasions when temperatures had exceeded the maximum temperature for safely storing medication, but staff had addressed this appropriately.

Staff carried out reconciliation of patients’ medication on admission to the ward. Patients’ current prescriptions were checked and ordered via an onsite pharmacy service.


Between 1 February 2018 and 31 January 2019 there were no serious incidents reported by this service which corresponded with the information held by the Strategic Executive Information System (STEIS) over the same reporting period.

When asked for examples of any adverse events on the ward, staff told us of an admission of a patient whose needs had not been able to be safely met on the ward.


Staff knew how to report incidents and what should be reported. Examples included falls, violence and aggression, security issues, deaths, suspected abuse and physical interventions. We reviewed four incident forms which included patient on patient intimidation, assaults on staff and verbal aggression. Staff had responded appropriately in each of the incidents we reviewed.

Not all staff on the ward understood what the duty of candour was. The duty of candour legally requires all healthcare staff to be open and honest when things go wrong, offer an apology and full explanation and find ways to put the matter right. However, four staff members thought it was in relation to changes in responsibility when things go wrong or confidentiality and looking after patients. The trust did, however, have a policy on the duty of candour. There had been no incidents within the last 12 months which met the threshold for duty of candour reports.

Staff received feedback from investigations into incidents including lessons learned via meetings, supervision and appraisal sessions and handovers. Staff were debriefed after every incident on the ward that they were involved in.

The ward had made safety improvements within the last 12 months. These included the installation of frosted glass in bathrooms to ensure patients’ dignity was always assured, the removal of noticeboards after instances in which patients pulled them off the wall and the use of heavier furniture to make it less easy to be thrown around and used to cause injuries.

The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations made by local coroners with the intention of learning lessons from the cause of death and preventing deaths.

In the last two years, there have been four ‘prevention of future death’ reports sent to Cumbria Partnership NHS Foundation Trust. None of these related to this core service.



Staff completed a comprehensive mental health assessment of patients in a timely manner. We looked at the care records for all five patients who were on the ward at the time of our inspection and, in each case, patients had undergone a comprehensive mental health assessment on or soon after admission to the ward. Staff had also assessed patients’ physical health on the day they had been admitted.

One care record contained no evidence that the patient's care plan had been created in collaboration with the patient or their carers or family. It also contained limited information about the patient's strengths, goals, problems and needs. The patient's positive behaviour support plan had not been fully completed which meant that when their behaviours were at their most heightened, there was no guidance for staff on what steps should be taken. The positive behaviour support plan also referred to the patient in the wrong gender. The patient had epilepsy, but their epilepsy plan did not contain steps to be taken to support a safe bathing process.

Staff also monitored patients’ attainment of objectives set in their positive behaviour support plans during formulation meetings which took place every four to six weeks.

A second care record had a care plan in place in relation to the patient’s ‘as required’ medication but this had not been reviewed since January 2018.

Staff created effective positive behaviour plans for patients. These were developed following a functional assessment which included the patient’s history, communication skills, what tended to happen prior to the start of the behaviours that challenge, what the behaviours that challenge involved and the patient’s reaction to environments. The plans provided clear steps and strategies for staff to take when the patient’s behaviours were heightened.


Staff provided care and treatment interventions suitable for the patient group, including cognitive

behaviour therapy, emotional intelligence and dialectical behaviour therapy. Interventions were in

line with the National Institute for Health and Care Excellence guidance. The psychologist was

involved in the development of positive behaviour plans and at the time of our inspection, the

assistant psychologist was in the process of updating them for patients on the ward.

Staff ensured patients had good access to physical healthcare. Patients with diabetes had their

bloods assessed regularly and staff monitored patients’ nutrition and hydration needs. Staff

referred patients to dieticians, speech and language therapists, GPs, dentists and opticians when

required. Staff helped patients to live healthier lives by encouraging them to make healthy food

choices and take regular exercise.

Staff used recognised rating scales to assess and record severity and outcomes. These included

the health of the nation outcome scale, malnutrition universal screening tool and Lester tool.

Patients had access to tablets and mobile phones following risk assessments. There was Wi-Fi

access on the ward so patients could access online therapies using these devices.

Staff within the service engaged in clinical audits. These included audits of:

• patients’ positive behaviour support plans and care records

• physical interventions

• improvement requirements identified during the October 2016 Care Quality Commission

inspection and transformation of care agenda across Cumbria’s learning disabilities

services

• autism diagnosis in a learning disability setting

• ‘this is me’ documents which were easy-read care plans issued to patients on the ward.

An onsite pharmacy service conducted audits of the ward’s medicines management

arrangements.

Findings from these audits included the need to create ‘as required’ medication care plans within

24 hours of patients’ admission to the ward, to update staff training in the use of positive behaviour

support plans and to standardise how documents are named and saved to the provider’s care

records system.

We saw evidence that staff consistently applied strategies to prevent behaviour that challenges as

outlined in patients’ positive behaviour support plans. These included the use of de-escalation

techniques, restrictive interventions and teaching of new skills.


The ward had access to a range of specialists required to meet the needs of the patients. These

included psychiatrists, psychologists, an occupational therapist, speech and language therapists,

pharmacists and dieticians.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of

the patient group.

The trust reported that only 57% of staff on the ward had completed their local induction. Eighty-

one per cent of ward staff had completed their corporate induction. Topics covered during the

induction process included fire, health and safety, care plans, risk assessments and the use of

observations.

Managers provided staff with training in the use and design of positive behaviour support plans. A

band four nurse was also made supernumerary for two days a week to monitor how staff were

using positive behaviour support plans during clinical team meetings.

Managers supported staff in the use of psychotropic medication by providing training in medicines

management including the use of rapid tranquilisation and intermediate life support. Staff were

also trained in the devising a ‘my medication plan’ document for each patient which included any

psychotropic medicines being taken. Staff also had support from an onsite pharmacist service.

The trust’s target rate for appraisal compliance was 90%. At the end of last year (1 April 2017 to

31 March 2018), the overall appraisal rate for non-medical staff within this service was 76%. As at

31 December 2018, the overall appraisal rate was 65%.

Ward name

Total number of

permanent

non-medical

staff

requiring an

appraisal

Total number of

permanent

non-medical

staff who

have had an

appraisal

% appraisals

(as at 31

December

2018)

% appraisals

(1 April 2017 –

31 March

2018)

Edenwood 20 13 65% 76%

Ward name

Total number of

permanent

non-medical

staff

requiring an

appraisal

Total number of

permanent

non-medical

staff who

have had an

appraisal

% appraisals

(as at 31

December

2018)

% appraisals

(1 April 2017 –

31 March

2018)


Trust wide 3167 2618 83% 79%

No medical staff appraisals data was provided for this service.

At the time of inspection all staff within the service had undergone an annual appraisal. We saw

evidence that all appraisals for 2018 were completed and that appraisals for 2019 were scheduled.

The trust’s target of clinical supervision for non-medical staff was not provided. Between 1

February 2018 and 31 January 2019, the average rate for Edenwood was 20%.




sessions required


delivered


rate (%)

Edenwood 97 19 20%



We asked for the latest supervision information for all staff during our inspection as the figures

supplied by the service indicated only 20% of staff were compliant with their supervision. The

latest information showed that there was no record of any supervision taking place for nine staff

members and 14 others had only received supervision between one and three times since August

2018. The overall compliance rate for supervision at the time of our inspection was, therefore,

43%. The provider was aware of problems with supervision compliance and had developed an

action plan to address the issue.

Managers identified the learning needs of staff and provided them with opportunities to develop

their skills and knowledge. Staff had access to specialist training which included the use of

Historical Clinical Risk Management – 20 (more commonly known as HCR-20) risk assessments

for patients known to exhibit violent behaviour, first aid and trauma training. Staff also completed

training in Makaton, positive behaviour support plans and bed safety through a web-based

platform and mobile app called the Cumbria Health and Social Care Learning and Improvement

Collaborative (also known as CLIC). However, two staff members told us that they were finding

difficulty accessing suitable training in autism because the training available was of a very basic

level and did not meet their needs.

The provider had a performance management system which included guidance for managers on

how to effectively and promptly address poor staff performance.


Staff held regular and effective multidisciplinary meetings. Care treatment meetings were held

weekly and patients’ multidisciplinary meetings were held monthly. Multidisciplinary meetings were

attended by all parties involved in the patient’s care and treatment such as cares, families, care

co-ordinators, community mental health nurses and social workers.

Staff shared information about patients at effective handover meetings within the team. This

included details of any medicines the patient had received, incidents and the patient’s current

health status. These meetings also included details of any checks staff on the outgoing shift had

completed such as emergency equipment, controlled drugs, room and fridge temperatures and fire

safety.

Staff had effective working relationships and handovers with other relevant teams both within the

organisation and external teams.


Practice

At the time of our inspection, there were five patients on the ward. All five patients were detained under the Mental Health Act.

Only 12.5% of staff had received training in the Mental Health Act. The trust stated that this training was mandatory for all services for inpatient and all community staff and renewed every year. However, staff were able to demonstrate they had a good understanding of the Act, the code of practice and its guiding principles. Examples included the different sections of the Act and the ways they meant patients’ detentions and rights were affected, a patient’s right to appeal their detentions and section 17 leave.

Staff had access to administrative support and legal advice on the use of the Act via the provider’s Mental Health Act team. This team was also responsible for auditing associated paperwork and ensuring staff adhered to the Act.

Staff had easy access to policies and procedures on the use of the Act via the provider’s intranet which were in line with current guidance and legislation. Paper copies were also held on the ward.

Patients had access to an independent mental health advocate. However, staff had raised an incident report as there were problems in getting an advocate to attend. This was because there were only two covering the whole county.

We saw evidence in patients’ care records that patients had their rights explained. One patient said their rights were explained in writing, so they could understand them clearly.

Staff ensured patients could take their Section 17 leave and ensured there were associated risk plans in place to address any issues such as risk of absconding or addressing behaviours that challenge.

Staff stored copies of patients’ detention papers and associated records correctly and in a way that made them accessible to staff when needed. We checked Mental Health Act associated paperwork on the ward and found it was in line with current guidance, legislation and best practice.

Informal patients were informed that they could leave the ward freely. Informal patients were given welcome packs on admission which included a ‘charter of rights for service users and carers’ document that notified informal patients of their right to leave the ward freely. This document was also displayed in the visitors’ room on the ward. Care plans were developed for any informal patients to explain that they may leave freely at any point.


At the time of our inspection, 86% of staff within the service had received training in the Mental Capacity Act. The trust stated that this training was mandatory for all services for inpatient and all

community staff and is a ‘one off’ training course. Staff were able to demonstrate they had a good understanding of the Act. Examples included always assuming people have capacity, retaining and understanding information, rights to advocacy, best interests decisions and capacity assessments.

Two standard Deprivation of Liberty Safeguards applications and one urgent Deprivation of Liberty Safeguards application were made to the Local Authority for this service between 1 February 2018 and 31 January 2019. None of them were approved.

Staff had access to administrative support and legal advice on the use of the Act via the provider’s Mental Health Act team. This team were also responsible for auditing associated paperwork and ensuring staff adhered to the Act.

Staff had easy access to policies and procedures on the use of the Act via the provider’s intranet which were in line with current guidance and legislation. Paper copies were also held on the ward.

Patients had access to an independent mental capacity advocate. However, the deputy ward manager told us that an incident report had been raised as there were problems in getting an advocate to attend as there were only two covering the whole county.

Staff assessed and recorded capacity to consent appropriately. We saw evidence within patients’ care records that this was done on a decision-specific basis in relation to significant decisions. We also saw evidence that best interests decisions were made and that the patient, full multidisciplinary team involved in their care and treatment, carers and families were invited to any best interests meetings. However, two patients’ care records did not contain confidentiality agreements despite the patients being deemed to have mental capacity.

Is the service caring? Kindness, privacy, dignity, respect, compassion and support

We observed good staff interaction with patients throughout our inspection visit. Staff spoke with patients in a kind, caring and respectful manner. Staff encouraged patients to get involved in colouring in pictures and one staff member put a patient’s hair in plaits at their request although these were the only activities we saw during our inspection. Patients on enhanced observations were always kept in sight of staff members. Staff gave assurance and comfort to any patients who appeared agitated.

Staff supported patients to understand and manage their care, treatment and condition. We saw evidence in care records that staff supported patients to access other services.

We spoke with three patients and two carers who said that staff treated them well and behaved appropriately towards them.

Staff understood the individual needs of patients, including their personal, cultural, social and religious needs. This included giving patients access to spiritual support and various food options.

Staff felt able to raise concerns about disrespectful, discriminatory or abusive behaviour towards patients without fear of reprisals.

Staff maintained the confidentiality of information about patients. Staff had received training in information governance which included the need to adhere to patient confidentiality at all times. However, two patients’ care records did not contain confidentiality agreements despite the patients being deemed to have mental capacity.

The site at which the service was based was compared to other sites of the same type and the scores it received for ‘privacy, dignity and wellbeing’ were found to be about the same as the England average.

Site name Core service(s) provided Privacy, dignity

and wellbeing

Carleton Clinic




problem


autism



79.5%

Trust overall 82.0%

England average (mental health

and learning disabilities) 91.0%

Involvement in care


Staff used the admission process to inform and orient patients to the ward and to the service. In

instances where patients had been moved from another hospital to Edenwood, arrangements

were made for staff from the previous placement to stay with the patient for around an hour to help

them settle in and provide them with reassurance. Patients were introduced to staff and peers on

the ward, given the opportunity to ask questions and told who their named nurse would be.

Staff routinely invited patients to their multidisciplinary meetings so they could be involved in

discussions about their care and treatment. A care record we looked at also evidenced that the

patient had been involved in a person-centred planning meeting around the future for their care

and treatment. Another care record evidenced the patient’s risk assessment had been devised in

conjunction with their wellness recovery action plan.

Staff communicated with patients so that they understood their care and treatment, including via

the use of communication tools for patients with communication difficulties. These included the

use of Makaton, easy-read documents, flash-cards and through access to signers and translators.

Staff involved patients in decisions about the service. An example of this is when a patient was

able to be part of the recruitment panel for the role of deputy ward manager. Staff enabled patients

to give feedback on the service they received via the use of comments cards, a ‘thank you’ board

and the provider’s complaints procedure.

Staff made attempts to ensure patients had access to independent advocacy. However, an incident report had been raised as staff had problems in getting independent mental health and mental capacity advocates to attend as there were only two covering the whole county.

Patients’ rehabilitation goals were set at the point of admission and reviewed throughout the patient’s care and treatment journey. The goals were designed to instil hope for the patient. For example, one patient’s goal was to lead an independent life and be able to drive a car. To help the patient achieve this, staff were taking the patient out as a passenger in a car regularly and were monitoring any incidents that occurred.


Staff informed and involved families and carers appropriately and provided them with support

when needed. Families and carers were routinely invited to multidisciplinary meetings and were

able to ring the ward at any time to check on the patient’s progress.

Staff enabled carers to give feedback on the service they received via the use of comments cards,

a ‘thank you’ board and the provider’s complaints procedure.

Staff provided carers with information about how to access a carer’s assessment within 72 hours

of the patient being admitted to the ward. Social workers also attended multidisciplinary meetings

and reiterated this information to any carers that were present.

Is the service responsive? Access and discharge

Bed management

The trust provided information regarding average bed occupancies for Edenwood between 1 February 2018 and 31 January 2019.

Edenwood reported average bed occupancies ranging above the minimum benchmark of 85% over this period.

Ward name Average bed occupancy range (1 February 2018 – 31 January 2019)


Edenwood Ward 77% - 100%

The trust provided information for average length of stay for Edenwood for the period 1 February 2018 to 31 January 2019.

Ward name Average length of stay range (1 February 2018 – 31 January 2019)


Edenwood 192 – 315 days

This service reported no out of area placements and no readmissions within 28 days between 1 February 2018 and 31 January 2019.

Admissions were not always planned in advance and could be at short notice. However, staff were able to refuse any admissions if the patient’s needs could not safely be met on the ward.

Patients always had access to a bed when they returned from Section 17 leave. Patients were not moved between wards during an admission episode unless it was on clinical grounds and in the patient’s interests.

Staff planned for the discharge of patients, so they could be discharged at an appropriate time of day.

There was no seclusion room on the ward which meant patients were placed in a seclusion room on another ward in the hospital’s psychiatric intensive care unit. There were sometimes difficulties in finding a bed on a psychiatric intensive care unit if a patient required admission to one. We were told on one occasion, it had taken eight weeks to find a bed on a psychiatric intensive care unit for a patient. In the 12 months prior to our inspection, two patients had been moved to psychiatric intensive care units that were not sufficiently close enough to the patient’s home, potentially making maintaining close contact with their families and friends difficult.


Between 1 January 2018 and 31 December 2018 there were 10 discharges within this service. This amounts to less than 1% of the total discharges from the trust overall (2911). For this core service, 50% of the discharges were delayed. Three discharges were delayed due to there being no suitable provision available for the patients.

Staff planned for discharge from the moment the patient was admitted. Discharge was planned in liaison with care co-ordinators, social workers and community health services. The service used a 10-point discharge process which included:

• patient assessments and treatment, including social worker assessments

• an initial discharge plan

• Section 117 aftercare, Deprivation of Liberty Safeguards and community treatment orders

• transitioning arrangements

• funding requests

• procurement processes

• identification of a suitable provider and accommodation

• legal considerations

• transition planning

• final discharge of the patient.

Staff supported patients during referrals and transfers between services. These included referrals

for primary healthcare, community health services and step-down placements.

The service used standard clinical headings in referral and transfer letters to other services which

complied with the transfer of care standards.

One patient whose care and treatment was being funded by learning disability and autism

commissioning arrangements was in a seclusion room based on a ward in the hospital’s

psychiatric intensive care unit. Discussions were ongoing at the time of our inspection as to the

most suitable placement for this patient.


Patients had their own bedrooms which they were able to personalise. Bedrooms contained a

lockable safe in which patients could securely store their possessions.

Rooms on the ward were limited which meant the only quiet area for patients was their bedroom

which they also used for making personal phone calls. Patient activities and therapies were held in

the communal areas or in their bedrooms. There was, however, a visitors’ room, two lounges

including a separate female lounge on the ward.

Patients had access to outside space. There was a garden area that was locked during our

inspection despite being told that there was no restricted access to it, so patients needed to

request access to it. The garden area was overridden with weeds and appeared neglected.

The sites which deliver mental health wards within Cumbria Partnership NHS Foundation Trust

were compared to other sites of the same type and the scores they received for ‘ward food’ were

found to be about the same as the England average.


When appropriate, staff ensured that patients had access to employment opportunities. For

example, patients were supported to access events in the local community such as drama and

gardening groups, day services and volunteering opportunities at charitable organisations. Staff

encouraged patients to maintain contact with the people who mattered to them via phone calls and

encouraging them to take their Section 17 leave.


The service made adjustments for disabled patients. The ward was wheelchair accessible and

staff were able to meet patients’ specific communication via the use of easy-read documentation,

Makaton, flash cards and access to signers and translators.

Staff ensured patients could obtain information about treatments, local services, their rights and

how to complain. This information was included in a pack given to patients on admission and was

provided in a format the patient could understand. However, there were no posters or

noticeboards displayed throughout the ward except the visitors’ room due to recent incidents in

which patients had ripped them off the wall.

Patients did not have access to sufficient therapeutic activities. The only activities we saw on the

day of our inspection was a member of staff putting a patient’s hair in plaits at their request and

staff encouraging patients to colour in pictures. An occupational therapist worked three days a

week on the ward but one of these days involved attendance of multidisciplinary meetings. There

was no activities co-ordinator or assistant occupational therapist on the ward. Activities were not

planned in advance and we were told were decided on a day to day basis. However, we saw little

evidence of any activities taking place on the ward apart from patients using colouring books. One

patient told us that staff took them into the community. A staff member told us that one patient was

involved in maintaining the garden area but the area was overrun with weeds and appeared

neglected so there was no evidence to support this. Three patients also told us they were bored

and hated being on the ward, so the lack of activities was having a negative impact on patients’

morale.

The sites which deliver mental health wards within Cumbria Partnership NHS Foundation Trust

were compared to other sites of the same type and the scores they received for ‘disability’ and

‘dementia friendliness’ were found to be about the same as the England average.


Patients, carers and families were made aware of the complaints process via a welcome pack given to patients on admission, the patient experience team and the ward experience team who visited the ward each month. Complainants received feedback accordingly.

Staff knew how to handle complaints appropriately. Staff informed the nurse in charge of any complaints and the complaint was investigated by the ward manager or deputy ward manager. Details of the complaint were recorded in patients’ care records. Any lessons learned were shared with staff via meetings, supervision and appraisal.

Staff protected patients who raised concerns or made complaints from discrimination and harassment. Where there were any potential concerns, incident reports were completed, safeguarding referrals were made, staff observations were increased and in some cases, the need to expedite discharge was also considered.

This service received one complaint between 1 February 2018 and 31 January 2019. This was not

upheld.

This service received no compliments during the last 12 months from 1 February 2018 to 31

January 2019.


Leadership

Leaders had the skills, knowledge and experience to perform their roles. Staff had previously

worked on assessment and treatment units for people with a learning disability, mental health

problems and complex needs, within community mental health teams for adults and children,

ventilation pathways and end of life care.

Leaders had a good understanding of the services they managed and used dashboard systems to

monitor performance on the ward.

Staff who spoke with us had differing views as to the visibility of leaders in the service. Some staff

said the network manager and service manager visited the service and were both approachable,

whilst other staff said they had not seen any of the senior leaders within the service.

Vision and strategy

Staff knew and understood the provider’s visions and values and how they applied in the work of

their team. The values were kindness, respect, dignity, ambition and collaboration. The vision and

values had been communicated to all staff and were included within screensavers on staff’s

computers.

Staff had the opportunity to discuss the strategy of the service during team meetings, appraisals

and supervision. Recent discussions had been around the transition of the service to another trust

in October 2019.

Culture

There were mixed views from staff around respect, support and morale within the team. Staff felt

some managers were more supportive and respectful than others, that admissions of patients

whose needs had been difficult to meet on the ward had affected morale and there were levels of

both apprehension and positivity about the impending transition to another trust. Staff did,

however, feel proud of their team and felt their work was rewarding.

The staff who spoke with us said they felt they could raise concerns without the fear of reprisals.

The provider had its own whistleblowing policy that staff could access via the trust’s intranet and

there was a paper copy available on the ward. However, four members of staff we spoke with did

not know what the role of the provider’s Freedom to Speak Up Guardian was.

Managers dealt with poor performance when required. The provider had a performance

management procedure which included guidance for managers on how to effectively and promptly

address staff performance issues.

The team worked well together although two members of staff said they did not feel managers

would deal with any difficulties appropriately.

Staff appraisals included conversations about career progression and how it could be supported.

Staff gave examples of how the provider promoted equality and diversity in its day to day work.

These included the provider’s policies and processes in relation to equality and diversity,

communication tools for people with communication difficulties and support given to patients,

families and carers from the provider’s quality and safety team.

Staff had access to support their own physical and emotional health needs. This included access

to occupational health, physiotherapy and discussions around wellbeing during supervision.

The provider recognised staff success within the service via weekly emails and thank you letters.

Governance

Governance systems within the service were ineffective. Although staff undertook and participated

in local audits, these were not always effective. Issues in relation to the incorrect recording of an

incident of restraint and failure to act on areas for improvement that had been found during our

inspection in October 2016 had not been identified during audits. We also found issues in relation

to medicines management despite audits being carried out by an onsite pharmacist service.

Compliance figures in relation to mandatory and statutory training were below the provider’s target

of 85% for 12 modules. Only 43% have staff had received supervision at the time of our

inspection.

Staff had not developed a risk assessment in relation to the use of sodium valproate for a female

patient.

Care records did not always contain confidentiality agreements when required and one lacked

information about the patient’s strengths, problems and goals. Patients did not have access to

therapeutic activities on the ward and were bored.

However, there were effective systems in place for monitoring staff compliance with the Mental

Health Act and Mental Capacity Act. There were enough skilled and experienced staff to deliver

safe care and treatment. Incidents and complaints were reported, investigated and used to

improve the service and the ward was safe and clean. Staff also monitored patients’ attainment of

objectives set in their positive behaviour support plans during formulation meetings which took

place every four to six weeks.

There was a clear framework of what must be discussed during team meetings to ensure essential

information was shared and discussed. Standing agenda items included incidents, complaints,

safeguarding and the five key questions covered during Care Quality Commission inspections.

There was also a communications book in the nurses’ office which provided staff with the latest

information about the service and wider organisation.

Staff implemented recommendations from reviews of deaths, incidents, complaints and

safeguarding alerts. These included the implementation of safeguarding strategies that were

discussed with social workers and the handling of complaints around clinical care by the provider’s

quality and safety team.

Staff understood the arrangements for working with other teams, both within the trust and with

external services to meet the needs of patients.


Staff were aware of the risks on the ward and raised any concerns appropriately. The provider’s

risk register included risks associated with the ward including assaults and aggression towards

staff, patients absconding, discharge delays and an unplanned admission. The service had a

business continuity plan in place which included procedures for emergencies such as outbreaks of

flu or adverse weather conditions.


The service used systems to collect data from wards and directorates that were not over-

burdensome for frontline staff.

Staff had access to the equipment and information technology needed to do their work such as

telephony, emails and an electronic care record system.

Staff had received information governance training which included the need to maintain patient

confidentiality at all times.

Team managers had access to information to support them with their management role. This

included staffing information, performance within the team and patient care and progress.

Information was in an accessible format, was timely, accurate and identified areas for

improvement.

Staff made notifications to external bodies such as safeguarding referrals to the local authority and

notifications to the Care Quality Commission.

Staff promoted the use of tools used to support patients with communication issues to patients,

carers, families, care providers and advocates.

Engagement

Staff, patients and carers had access to up to date information about the work of the provider and

the service via emails, bulletins and meetings.

Patients and carers were able to give feedback on the service they received via the provider’s

complaints process, the provider’s quality and safety team, during multidisciplinary meetings and

informal meetings with the provider’s senior leaders.

Patients and carers were involved in decision making about changes to the service such as being

part of staff recruitment panels.

Directorate leaders engaged with external stakeholders such as commissioners and Healthwatch

during multidisciplinary meetings and care treatment reviews. Commissioners and Healthwatch

had been involved in discussions about the service’s impending transition to another trust in

October 2019.


Staff were given time and support to consider opportunities for improvements during team

meetings, supervision and appraisal.






The provider reported that the core service had not participated in any accreditations. However, at

the time of our inspection, staff within the service were participating in accreditation schemes.

These included leadership and management courses and Stopping the Over-Medication of People

with a Learning Disability and Autism, also known as STOMP.

The provider’s restrictive intervention reduction programme was in line with the Advanced Quality

Alliance’s (AQUA) quality improvement programme.

The service was involved in benchmarking against other services within the trust to whom it was

transitioning in October 2019. Staff within the service were not involved in research or national

audits.

MH – Wards for older people with mental health problems


Location site name Ward name Number of beds Patient group (male, female, mixed)

Carleton Clinic Oakwood Unit 12 Mixed

Carleton Clinic Ruskin Unit 15 Mixed

Dane Garth Ramsey Unit 15 Mixed

The methodology of CQC provider information requests has changed, so some data from different

time periods is not always comparable. We only compare data where information has been

recorded consistently.



Staff did regular risk assessments of the care environment and were maintaining the balance

between safety and a therapeutic environment.

The layout of all wards meant there were several ‘blind spots’ where staff did not have clear lines

of sight. However, staff carried out patient observation in line with the trust ‘supportive

engagement’ policy. Patient observation levels were based on assessment of risk and patient

support needs.

There were potential ligature anchor points on the ward which included hand rails and pull cords.

This was due to the nature of patients on the ward who were at risk of falls. Staff were aware of

the presence of ligature points on the wards, and these were well managed and controlled through

patient risk assessments and observation levels.

The ward complied with guidance on eliminating mixed-sex accommodation. All patient bedrooms

on Ruskin and Ramsey wards were individual rooms with en-suite facilities. On Oakwood ward,

seven patient bedrooms were single en-suite rooms. There were two shared dormitories, one with

two beds and one with three beds.

Staff on all wards carried personal alarms. Patients had access to nurse call alarms in bedrooms,

bathrooms and in general ward areas. Patient beds were fitted with bed sensors, which were

linked to the alarms carried by staff. This enabled staff to be alerted should a patient fall or get out

of bed.


Females on each ward had access to female only day areas if required.

Over the 12-month period from 1 February 2018 to 31 January 2019 there were no same sex

accommodation breaches reported within this service. The tables below show the main risks to each

ward.

Ward / unit name Briefly describe risk - one

sentence preferred

High level of risk?


Oakwood Unit

Only relatively low risks remain -

elderly client group have low

propensity and need domestic type

fittings due to mobility / dexterity

issues with some clients.

No

An action plan has been

agreed and all identified risks

being addressed.

Ramsey Ward

Only relatively low risks remain -

elderly client group have low

propensity and need domestic type

fittings due to mobility / dexterity

issues with some clients.

No



being addressed.

Ward / unit name Briefly describe risk - one

sentence preferred

High level of risk?


Ruskin Ward

Only relatively low risks remain in the

ward following major refurbishment in

2013 along with annual risk

assessments and agreed action plans

to reduce the risk over the past 12

years.

No



being addressed.


All ward areas were clean, had good furnishings and were well-maintained. Cleaners were

visible on all wards daily and cleaning schedules were in place.

Staff adhered to infection control principles, including handwashing. All visitors were

asked to wash their hands before entering the ward using the handwashing facilities that

were available at the main entrance to each ward.

PLACE assessments aim to provide a clear message from patients on how the care environment may be improved. They are undertaken by teams of local people alongside healthcare staff and assess privacy and dignity, food, cleanliness, building maintenance and the suitability of the environment for people with disabilities and dementia. We compared the sites that deliver wards for older people with mental health problems within

Cumbria Partnership NHS Foundation Trust to other sites of the same type and the scores they

received for ‘cleanliness’ and ‘condition, appearance, and maintenance’ were found to be about

the same as the England average.


and maintenance

Carleton

Clinic



units

MH - Wards for older people with

mental health problem


disabilities or autism


health wards for working age

adults

99.6% 94.2%

Ramsey Unit MH - Wards for older people with

mental health problem 99.5% 92.3%


England

average

(Mental

health

and

98.4% 95.4%


and maintenance

learning

disabilitie

s)

Seclusion room

The wards did not have a seclusion room. However, each ward had an extra care area which

could be sectioned off if needed. The areas were safe and clean with bedroom and toilet facilities.

Staff on Ruskin ward had completed a paper on the use of the extra care facilities for the

management of acute episodes of behaviours that challenge and had provided case studies of

where the extra care had been used. The case studies showed positive outcomes for the patient

and staff.


Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs

that staff checked regularly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible.

Safe staffing9

Managers had calculated the number and grade of nurses and healthcare assistants required. There

were two nursing vacancies on Ramsey unit which the trust continued to advertise. This meant that

the ward did not always achieve the planned two registered nurses on duty each day. However, a

clinical lead and assistant practitioner worked on the ward to support with patient care. Where

staffing levels had been below what was required this had been logged as an incident with the trust.

Ward managers could adjust staffing levels daily to take account of case mix. Staffing levels were

increased to take account of patient acuity. Regular bank nursing staff were used to maintain safe

staffing levels and where possible regular bank staff familiar with the ward were used.

There were enough staff to carry out physical interventions. Staff encouraged patients with personal

care. However, some families felt that staff did not always look for ways to help with personal care

when patients resisted.

Ruskin was a nurse-led unit, Ramsey and Oakwood were psychiatrist-led although a nurse

consultant was currently undergoing training to enable Oakwood to be become nurse led. Psychiatric

medical cover was provided on site up to 5pm weekdays on Ramsey unit and up to 12 midnight,

seven days a week on Oakwood and Ruskin units. An on-call consultant psychiatrist for the south

of the region and an on-call consultant psychiatrist for the north of the region provided psychiatric

medical cover outside of these hours. Staff could call the on-call number and speak to someone

over the phone who could attend if needed. For medical emergencies out of hours, staff would

contact Cumbria Health on Call. Staff did not report any concerns about access to medical cover to

meet the physical or psychiatric needs of patients on the ward. Staff told us they rarely required out

of hours psychiatry assistance.

Junior doctors were available on the wards to meet physical health needs. A doctor attended Ruskin

and Oakwood wards who also worked in the community.

9 Staffing Data Safer Staffing Oct to Dec 2018 Turnover super RPIR benchmarking tool Sickness super PIR Benchmarking tool Vacancy super RPIR benchmarking tool

The below chart shows the breakdown of staff in post WTE in this core service from January 2018

to December 2018.

The below table covers staff fill rates for qualified nurses and care staff during October, November

and December 2018.

There was below 90% of the planned registered nurses for day shifts on Ramsey in October 2018

and December 2018.

Key:

> 125% < 90%


Nurses

(%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)


Oakwood 84.0 137.8 100.0 100.0 115.2 107.3 100.0 100.0 118.6 106.3 100.0 85.5

Ruskin 115.1 88.3 100.0 103.2 120.6 98.8 103.2 110.2 117.8 92.4 100.0 107.5

Ramsey 86.0 105.6 106.5 97.8 105.0 109.6 100.0 114.3 77.0 120.2 103.2 112.9




Staff group

Annual

average

establishm

ent

Annual

vacan

cy

rate

Annual

turno

ver

rate

Annual

sickne

ss rate

Annual

bank

hours

(% of

availa

ble

hours)

Annual

agenc

y

hours

(% of

availa

ble

hours)

Annual

“unfille

d”

hours

(% of

availab

le

hours)

All staff 170.8 0% 5% 4.9%

Qualified

nurses 71.2 8% 9% 5.0%

9354

(10%) 238 (<1%) 1654 (2%)

Nursing

assistants 73.5 -11% 2% 5.1%

37389

(22%)

11609

(7%) 5527 (3%)

Medical staff 17.6 1% 0% 3.0% 234 (2%) 1161 (9%) 832 (6%)

Allied Health

Professio

nals

2.9 14% 0% 1.8%

The annual turnover rate for nursing assistants and allied health professionals was in the lowest

25% when compared to other similar core services nationally.

The annual turnover rate for qualified nurses was in the highest 25% when compared to other

similar core services nationally. The trust was struggling to fill nursing posts in the west of the

county.

The annual turnover rate for medical and dental staff was in the lowest 25% when compared to

other similar core services nationally.

The average sickness rate for all staff and for allied health professionals was in the lowest 25%

when compared to other similar core services nationally.

The average vacancy rate for all staff, nursing assistants and allied health professionals was in the

lowest 25% when compared to other similar core services nationally.

Monthly sickness rates over the last 12 months for all staff shows a shift from July 2018 to

December 2018.

Monthly 'agency hours' over the last 12 months for all staff shows an upward trend from April 2018

to August 2018.

Monthly 'bank hours' over the last 12 months for qualified nurses, show a shift from July 2018 to

December 2018.

Monthly 'agency hours' over the last 12 months for nursing assistants shows an upward trend from

April 2018 to August 2018.

Monthly 'sickness rates' over the last 12 months for nursing assistants shows a downward trend

from January 2018 to May 2018.

Monthly 'sickness rates' over the last 12 months for medical staff shows a shift from July 2018 to

December 2018.

Mandatory training

Staff compliance for mandatory and statutory training courses at 31 May 2019 was 91%. Of the

training courses listed, three failed to achieve the trust target and of those, two failed to score

above 75%. There was an issue with availability of Mental Health Act training courses.



The trust has stated that training is reported on a rolling month on month basis and the following courses were not offered pre- April 2018: health, safety and welfare, preventing radicalisation level 1 and 2, preventing radicalisation level 3,4 and 5, safeguarding children level 1 and resuscitation level 1

Key:

Met trust target

✓


Higher

No change

➔

Lower

Training Module

Number of

eligibl

e staff

Number

of

staff

traine

d

YTD

Complianc

e (%)

Trust

Targe

t Met

Compliance

change

when

compare

d to

previous

year

Corporate induction 120 115 97% ✓



Fire Safety 2 years 120 112 93% ✓


Adult Basic Life Support 76 69 96% ✓

Local induction 120 108 94% ✓

Equality and Diversity 120 106 96% ✓

Mental Capacity Act Level 1 112 98 96% ✓

Infection Prevention (Level 1) 120 105 99% ✓

Information Governance 120 103 95% ✓ ➔


Manual Handling - People 64 51 80% ✓

Medicine management training 36 28 81% ✓

Infection Prevention (Level 2) 115 90 98% ✓

Prevent Radicalisation L1&2 120 92 98% ✓


Falls) 120 92 77% ✓ N/A


Resuscitation 108 76 92% ✓



Prevent Radicalisation L3,4&6 57 33 58%

Total 2224 1857 91% ✓



Staff did a risk assessment of every patient on admission and updated it regularly, including after

any incident. Records showed that risks were regularly reviewed, and observations of handovers

showed daily discussion of patient risks. Patients were assessed for risk of falls and this was

shown in care records. The dementia wards had seen an increase in acuity and more patients with

violence and aggression. Staff on Ruskin managed this through formulation meetings and de-

escalation. However, staff on Ramsey ward sometimes struggled to deal with patient acuity.

Patients assessed as having significant physical problems could not be admitted to the wards.

Staff used a recognised risk assessment tool.



This service had 203 incidences of restraint (110 different service users) and no incidences of

seclusion between 1 February 2018 and 31 January 2019. Some incidents which required restraint

to be used were in relation to providing personal care to patients, where patients were refusing

medication and had become aggressive.

The below table focuses on the last 12 months’ worth of data: 1 February 2018 and 31 January

2019.


Patients

restrain

ed

Of restraints,

incidents of

prone restraint

Of restraints,

incidences of

rapid

tranquilisation

Oakwood 0 35 14 0 6

Ramsey 0 78 46 0 11

Ruskin 0 90 50 0 28

Core service total 0 203 110 0 (0%) 45 (22%)

Safeguarding

Staff had received training in safeguarding and had been provided with support from the trust

safeguarding leads. Staff knew how to raise a safeguarding concern and could give example of

how to protect patients.




institutional.





should take place.

Referrals to safeguarding teams had increased due to staff training and a greater awareness of the

need to report. There were currently four ongoing safeguarding strategy meetings taking place

between the local authority and Ramsey ward. Two of the strategy meetings were in relation to the

deaths of detained patients. Investigations were ongoing and continued to be an area of focus.

There had been some communication issues between the trust and the local authority safeguarding

team in terms of staff attending safeguarding strategy meetings.

Designated safeguarding leads from the trust had conducted an assurance visit on Ruskin ward in

July 2018 which had resulted in greater support from safeguarding teams for training and

supervision.


All information needed to deliver patient care was available to all relevant staff (including agency

staff) when they needed it and was in an accessible form. This included when patients moved

between services. The trust had implemented an electronic patient record system in 2016 and

problems identified during the last inspection had been resolved.


Staff followed good practice in medicines management (that is, transport, storage, dispensing,

administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in

line with national guidance.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE

guidance.


Between 1 February 2018 and 31 January 2019 there were five serious incidents reported by this

service. Of the total number of incidents reported, the most common type of incident was

‘environmental incident’ with three. The three ‘environmental incidents’ relate to the deaths of

patients: two while a patient was on Section 17 leave and one while a patient was under Section 3

of the Mental Health Act. The infection control incident relates to a patient ‘being treated for lower

respiratory tract infection’.



by the trust incident reporting system was comparable with STEIS with five reported. Please note

that the incident categories reported to STEIS are different to those reported by the trust in the

CQC’s Provider Information Request.



reporting period.


Type of incident

reported

(SIRI)

Environmental incident Disruptive/ aggressive/

violent behaviour

HCAI/Infection control

incident Total

Ramsey 2 - - 2

Ruskin 1 1 - 2

Oakwood 0 - 1 1

Total 3 1 1 5


All staff knew what incidents to report and how to report them. The main category of incidents

were violence and aggression and falls. Managers reviewed incidents and information was used to

identify trends. This included being able to establish days and times that incidents occurred. There

had been several serious incidents on Ramsey unit which had been investigated and senior

managers were providing support to the ward.

Staff understood the duty of candour. They were open and transparent and gave patients and

families a full explanation when things went wrong. We saw examples of where duty of candour

had been considered and/or applied.

Staff received feedback from investigation of incidents, both internal and external to the service.

Senior managers delivered learning reviews with staff on the wards.

Staff were debriefed and received support after a serious incident. There was evidence of debriefs

taking place where staff had raised concerns about acuity on the wards and staffing. There were

two serious incidents which remained an area of focus. The incidents related to the admission of

patients with declining physical health. The investigations were being completed in partnership

with the general hospital.



Staff completed a comprehensive mental health assessment of the patient in a timely manner at, or soon after, admission. Staff worked closely with patient, families and community teams to get to know patients. They developed life stories, patient likes and dislikes and were able to establish the best way to care for patients on the ward. Staff assessed patients’ physical health needs in a timely manner after admission. Junior doctors worked on the wards and carried out physical health checks. A GP attended Ruskin and Oakwood to carry out physical interventions. However, there had been patients on Ramsey unit whose physical health had deteriorated. Some carers expressed concern over physical health conditions such as chest infections and urine infections not being identified by nursing staff. Staff developed care plans that met the needs identified during assessment. Staff worked with community teams and families to get to know each patient. A wellbeing diary was developed for each patient so that staff could personalise the care and treatment delivered to them. Care plans were personalised, holistic and recovery-oriented. The trust was implementing the see-the-PERSON 2020 project. The project aimed to focus staff to promote the values of person-centred recovery. This aimed to move the focus of care away from mainly concentrating on a person’s diagnosis or symptoms by instead focussing on the persons’ needs.


On Ruskin and Oakwood, a GP visited the ward and supported the delivery of physical healthcare assessment and treatment. Junior doctors worked on Ruskin and Ramsey units. Patient care records contained evidence of physical healthcare monitoring including patients’ weight and body mass index. Staff used the National Early Warning Score tool to monitor respiratory rate, oxygen saturations, temperature, blood pressure, pulse rate and level of consciousness.

Each ward had an occupational therapist who carried out assessments and formulated

recommendations for activities. Wellbeing practitioners supported activities on the wards. Activities

included breakfast clubs, colouring, walks, and pet therapy. Activities on Ruskin and Oakwood

were more established with a greater focus on patients’ strengths.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. There had been an incident on Ramsey unit where a patient had become dehydrated. This had been investigated by the trust and lessons learnt implemented for the team. Some patients due to their condition refused food and fluids and we saw that staff encouraged them to eat and drink.

Staff participated in clinical audit, benchmarking and quality. Each ward had an audit timetable in place and results of audits had been used to make improvements. This had resulted on further training for staff on care planning.

This service participated in five clinical audits as part of their clinical audit programme 2018 - 2019.


Re-audit of Oakwood

documentation/care

plan audit for current

patient files (SUAC

topic)

Oakwood Clinical 30/05/2018 Both trust wide and in-service

review of care plans is

happening to ensure they meet

the needs of patients and are

person centred. Case load

supervision is being used

during management

supervision to support staff to

meet the required standards.

RMNs have been asked to

check the documentation they

create against the standard

specified in the audit questions,

which have been distributed to

all staff.

Re-audit of Ruskin

documentation/care


patient files (SUAC

topic)

Ruskin Ward Clinical 19/09/2018 Uploading the DNAR to RIO has

been addressed with the ward

doctors and outcomes of the

audits feedback to them. Care

plan training will be rolled out to

include Templates created for

physical health care plans such

as monitoring diabetes etc.

Ward manager will establish

which medication concordance

assessment tool should be

used in the September QI

meeting. New carers link

person now in post. New ways

of working and of allocation are

in place.

Audit of clinical

assessment tools

used on Oakwood

Oakwood Clinical 23/03/2018 Action planned: Clinical

Psychologist to deliver staff

training on the assessment

tools.

Re-audit of Oakwood

documentation/care


patient files (re-audit

of MHML06.A.01$C-

1617:P9)

Oakwood

Ward

Clinical 30/01/2019 Care plan training sessions have

been developed and delivered

to staff. These are ongoing and

tailored to ensure that the

targets relating to person-

centered care planning, and

patients having copies of care

plans, will be met. The process

of producing and gathering

information for wellbeing diaries

has been reviewed. Wellbeing

diaries are in the process of

being added to Rio to improve

their accessibility and therefore

increase numbers completed.

Was the post falls

protocol followed

Ruskin Ward Clinical 06/06/2018 A falls reduction working group has

been established. Senior staff


during 1/11/2017

and 1/05/2018 on

Ruskin unit (re-audit

of

MHML09$C1718:P8)

have presented key points from

a falls prevention conference

they attended to the QI

meeting. Current literature

around falls in dementia

settings has been explored and

shared with the team.


The teams included a full range of specialists required to meet the needs of patients on each ward. Ruskin was a nurse-led unit and had access to a consultant if needed. Ramsey was still consultant led and Oakwood was currently in the process of becoming a nurse led unit. Each ward had a mix of nurses, health care assistants, occupational therapists, therapy coordinators, clinical psychologists and, pharmacists. The psychologist had recently started working with staff from Ramsey unit and formulation was still new to the ward. The core service had access to speech and language therapists, dieticians and worked closely with social workers. However, Ramsey did not have access to a dietician. The wards had a dedicated clinical psychologist working within the team. This was a new development on Ramsey unit, which had been having psychological input since February 2019. The clinical psychologist facilitated multi-disciplinary formulation meetings and had facilitated training in formulation techniques, dementia and anxiety management techniques for staff on the units. We observed two formulation meetings, attended by the clinical psychologist, occupational therapist, nurses and health care assistants. Staff discussed individual patient presentation, key risks and issues and developed a collaborative intervention plan to support the patient. Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group. Staff on Ruskin unit had training specific to the patient group which included dementia training, recovery, hearing voices, and managing behaviours that challenge. Managers provided new staff with appropriate induction and support. However, Ramsey unit sometimes used agency members of staff. Managers provided staff with supervision at least every two months. Meetings discussed case management, reflected on practice, discussions around personal support and professional development and appraisal of their work performance. Managers ensured that staff had access to regular team meetings. Group supervision also took place and each discipline had a monthly support session with colleagues from the other wards to share what was working well and any concerns. The percentage of staff that had had an appraisal in the last 12 months was 90%.


Staff held regular multidisciplinary meetings. Daily multi-disciplinary meetings known as SBAR (situation, background, assessment, recommendation) handover meetings took place each day. During these meetings, staff shared a range of information including patient presentation, incidents, risk assessments and physical health issues. We observed two multidisciplinary SBAR handover meetings and found that all staff contributed to provide a rich overview of individual patients. The handover discussions were supported by information from the electronic case

management system. The multidisciplinary working was effective with a shared understanding of roles where all staff felt valued. Clinical psychologists facilitated formulation meetings to develop strategies and plans to support the delivery of patient centred care. We observed a formulation meeting attended by the psychologist, occupational therapist and two nurses. All staff provided valuable information on the patient, their background, likes and dislikes, clinical and social presentation.

Staff worked closely with social work team and community older adults’ teams to facilitate move on

from the ward.


Practice

Fifty-six per cent of staff had had training in the Mental Health Act. There had been difficulty booking staff onto this training which meant that some staff could not receive this training. However, we found that staff had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were. The provider had relevant policies and procedures that reflected the most recent guidance, and staff had easy access to them. Patients had access to information about independent mental health advocacy. However, there had been some capacity issues within the advocacy service which had led to delays in patients being able to access advocacy. Staff explained to patients their rights under the Mental Health Act. Some patients lacked capacity to understand and staff attempted to repeat this in a way that they could understand. This was recorded on the patient records. Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. However, we found that the forms on Ruskin and Oakwood were generic. The section 17 leave for each patient was the same and not individually based or risk assessed. This had been highlighted in the Mental Health Act monitoring visit which took place in February 2019. Staff requested an opinion from a second opinion appointed doctor when necessary. Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them. The service displayed a notice to tell informal patients that they could leave the ward freely. Care plans referred to identified Section 117 aftercare services to be provided for those who had been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment. Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits. However, there had been an incident where a patient had been unlawfully detained after being transferred from another area. The Mental Health Act office had identified the error and placed the patient on a section 5(2) until a Mental Health Act

assessment could be arranged. Staff acted in the best interests of the patient. Staff raised this as an incident after the inspection.


Staff were trained in and had a good understanding of the Mental Capacity Act; 95% of staff had had training in the Mental Capacity Act. The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the provider. Staff took all practical steps to enable patients to make their own decisions. Staff were recording where patients had consented to care and treatment and where they lacked capacity this was recorded. Staff were aware of the need to support patients to make decisions and patients were encouraged to choose meals and what activities they participated in. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis about significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and acted on any learning that resulted from it. This had been an action in the last inspection and we saw that improvements had been made. Staff understood Deprivation of Liberty Safeguards. There were no patients subject to Deprivation of Liberty Safeguards at the time of the inspection.

The trust told us that eight standard Deprivation of Liberty Safeguard (DoLS) applications and eight

urgent Deprivation of Liberty Safeguard (DoLS) application was made to the Local Authority for this

service between 1 February 2018 and 31 January 2019.

Number of ‘Standard’ DoLS applications made by month

Feb

1

8

Mar

1

8

Apr

1

8

May

1

8

Jun

1

8

Jul

1

8

Aug

1

8

Sep

1

8

Oct

1

8

Nov

1

8

Dec

1

8

Jan

1

9

Total

Standard applications made

1 0 1 0 5 0 0 0 0 1 0 0 8

Standard applications approved

0 0 0 0 0 0 0 0 0 0 0 0 0

Number of ‘Urgent’ DoLS applications made by month

Feb

1

8

Mar

1

8

Apr

1

8

May

1

8

Jun

1

8

Jul

1

8

Aug

1

8

Sep

1

8

Oct

1

8

Nov

1

8

Dec

1

8

Jan

1

9

Total

Urgent applications made

1 0 1 0 5 0 0 0 0 1 0 0 8

Urgent applications approved

0 0 0 0 0 0 0 0 0 0 0 0 0



Staff attitudes and behaviours when interacting with patients showed that they were discreet, respectful and responsive, providing patients with help, emotional support and advice at the time they needed it. Staff supported patients to understand and manage their care, treatment or condition. Each patient had a wellbeing diary which reflected their preferences and assisted staff to really understand the individual needs of each patient. Staff directed patients to other services when appropriate and, if required, supported them to access those services. This included private podiatry services. The patients we were able to speak with said staff that treated them well and behaved appropriately towards them. It was difficult to speak to patients on Ruskin and Ramsey due to their illness, but we observed patients to be settled. Staff understood the individual needs of patients, including their personal, cultural, social and religious needs. Staff on Ruskin had worked with a patient’s family to establish that he liked to eat his meals in private with a tray. He had done this all his life and became agitated with communal meal times. Staff supported the patient to eat alone. Staff said they could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards patients without fear of the consequences.

We compared the sites that deliver wards for older people with mental health problems within


received for ‘privacy, dignity and wellbeing were found to be about the same as the England

average.

Involvement in care


Staff used the admission process to inform and orient patients to the ward and to the service. Welcome booklets were available to patients and their families. Where possible staff involved patients in care planning and risk assessment. This was difficult on Ruskin and Ramsey due to the patient’s organic illness. However, staff used the wellbeing diaries to understand the patients likes and dislikes. Staff communicated with families to help involve patients. Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff encouraged patients to give feedback on the service they received. Community meetings took place on Oakwood. The meetings gave patients the opportunity to feedback things that were working well and things that could be improved. Patients on Oakwood had functional mental health problems and so were more able to get involved in their care and treatment. Staff ensured that patients could access advocacy.


Staff informed and involved families and carers appropriately and provided them with support when needed. Families were encouraged to provide life stories of their loved ones and we saw that families visited the ward and were involved in activities such as garden parties. However, three carers on Ramsey unit said that they received limited information about the service and were not informed of incidents on the ward where their loved ones had been restraint. Staff enabled families and carers to give feedback on the service they received (for example, via surveys or community meetings). Regular carers’ meetings took place on Ruskin. We spoke with 12 family members who had mixed experiences of the wards. Carers from Ruskin spoke positively of the ward and said they were kept up to date with any incidents and that their loved ones were cared for on the wards. Family members attended meetings and the staff would accommodate this where possible around their availability. However, three carers from Ramsey had concerns about the care on the ward. Staff provided carers with information about how to access a carers’ assessment. Carers assessment and support were not directly provided by the trust. However, carers were directed to other support services and informal support took place on the wards. The wards were working to strengthen work with families by implementing the triangle of care. The triangle of care is a working collaboration, or “therapeutic alliance” between the service user, professional and carer that promotes safety, supports recovery and sustains well-being.

Is the service responsive?

Access and discharge

The trust provided information regarding average bed occupancies for all three wards in this service

between 1 February 2018 and 31 January 2019.

All the wards within this service reported average bed occupancies ranging above the minimum

benchmark of 85% over this period. However, there was always a bed available when patients

returned from leave and beds were available for patients living in the catchment area. There were

five adults on Oakwood ward who would normally be admitted to an acute ward. These patients had

been risk assessed as being appropriate to be admitted to Oakwood. The wards worked closely

together in the care and treatment of each patient and the psychiatrist from the acute ward managed

the patients.

A weekly bed management call took place weekly between the wards for older people, community

older adults’ teams and the service bed manager. Discharges were discussed at this meeting to

explore how staff could effectively discharge patients once assessment and treatment was

complete. A dedicated bed manager had responsibility for all older adults’ services and worked

closely with commissioners, independent hospitals and care homes. The bed manager had formed

good working relationships with partners. The bed manager kept in touch with patients who had

been moved out of area with a view to bringing them back as soon as possible. We spoke with a

relative who was currently in this situation where the trust was attempting to bring the patient back.

Patients were not usually moved between wards during an admission episode unless it was justified

on clinical grounds and was in the interests of the patient. However, there had been occasions when

patients had been moved from Ramsey ward to Ruskin due to staffing issues.

When patients were moved or discharged, this happened at an appropriate time of day. Patients

were discharged to care homes, independent hospitals or home if their presentation allowed.

Ward name Average bed occupancy range (1 February 2018 – 31 January 2019) (current inspection)

Oakwood 88% - 98%

Ramsey 66% - 95%

Ruskin 66% - 94%


Between 1 January 2018 and 31 December 2018 there were 184 discharges within this service.

This amounts to 6% of the total discharges from the trust overall (2911). For this core service, 47%

of the discharges were delayed. Delays occurred when suitable community placements were not

available, ward staff worked closely with commissioners, community teams, carers and adult social

care teams to facilitate the discharge process.


Patients on Ramsey and Ruskin had their own bedrooms and private bathrooms with toilet and

shower facilities. However, some patients on Oakwood slept in bed bays. Beds were separated by

curtains. Each dormitory had a shared en-suite facility with toilet, washbasin and shower. Staff and

senior managers accepted that patient accommodation on Oakwood unit was not fit for purpose. A

business case for relocation and upgrade of Oakwood ward to another building within the Carleton

Clinic site had been approved in 2017. The plans were in place but had been delayed due to the

transfer of services. The ward environment was raised at monthly governance meetings as not

being fit for purpose. Each patient referred to this ward was discussed at the weekly bed

management meeting to establish any risks and concerns in relation to ordinary style

accommodation. The ward would accommodate patients who required their own room if possible.

Patients could personalise bedrooms and we saw that photos and personal belongings were in

patient bedrooms. Each bedroom had a memory box at the entrance. Patients had somewhere

secure to store their possessions.

Staff and patients had access to the full range of rooms and equipment to support treatment and

care. This included a clinic room to examine patients, activity and therapy rooms, spacious

communal areas and quieter lounges. Each ward had female only areas. The space on Ruskin

ward was homely and therapeutic. Each ward had laundry facilities where patients’ clothes could

be washed in exceptional circumstances. However, patients’ families usually took laundry home or

an independent company was used. There had been situations where patients’ clothes went

missing and staff encouraged families to label clothing to reduce this.

There were quiet areas on the ward and a room where patients could meet visitors. We saw that

visitors could also sit with patients in communal areas or in the outside spaces. Each ward had

excellent and well-kept outside areas that patients could access freely. Patients were involved in

maintaining areas and we observed a gardening activity taking place on Ruskin ward where

patients were involved in planting.

Patients could make a phone call in private and could have their own mobile phone if they wanted.

The food was of a good quality. Food was made on site and brought over to the wards. We saw a

good choice of food being served.

Patients could make hot drinks and snacks 24 hours a day. All wards had kitchen facilities where

patients could make their own drinks or be supported by staff to do so.

We compared the sites that deliver wards for older people with mental health problems within


received for ‘ward food’ were found to be about the same as the England average.

Site name Core service(s) provided Ward food

Carleton Clinic




problem


autism



85.2%

Ramsey Unit MH - Wards for older people with mental health

problem 94.8%

Trust overall 89.6%

England average (mental health and learning disabilities) 92.2%


Staff supported patients to maintain contact with their families and carers. Carers’ meetings took

place on Ruskin ward and families were invited to observe activities. On the day of the inspection

families had been invited to a garden party where their loved ones were involved in maintaining

the gardens; cake and coffee was also being served.

Staff encouraged patients to develop and maintain relationships with people that mattered to them,

both within the services and the wider community.


The service made reasonable adjustments for disabled patients by ensuring access to premises

and by meeting specific communication needs. Each ward had an assisted bathroom.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights

and how to complain. A welcome booklet was available to patients and their families when patients

were admitted to the wards.

The information provided was in a form accessible to the patient group.

Staff made information leaflets available in languages spoken by patients.

Managers ensured that staff and patients had easy access to interpreters and/or signers.

Patients had a choice of food to meet the dietary requirements of religious and ethnic groups.

Staff ensured that patients had access to appropriate spiritual support. For example, a patient had

been assisted to attend church.


This service received eight complaints between 1 February 2018 and 31 January 2019. One of

these was upheld, two were partially upheld and five were not upheld.

Ward name

To

tal C

om

pla

ints

Fu

lly u

ph

eld

Part

ially u

ph

eld

No

t u

ph

eld

Oth

er

Un

der

Inv

esti

gati

on

Wit

hd

raw

n

Refe

rred

to

Om

bu

dsm

an

Oakwood 4 1 1 2 0 0 0 0

Ramsey 4 0 1 3 0 0 0 0

Patients and their families knew how to complain or raise concerns. Information was displayed on

the ward and in the welcome booklet. The patient experience team dealt with some complaints

and supported the wards.

When patients complained or raised concerns, they received feedback. Managers would attempt

to resolve complaints locally, however there were some complaints that became formal complaints

as they had not been resolved locally.

Staff protected patients who raised concerns or complaints from discrimination and harassment.

Staff knew how to handle complaints appropriately.

Staff received feedback on the outcome of investigation of complaints and acted on the findings.

Senior managers conducted lesson learnt reviews with staff.


Leadership

Leaders had the skills, knowledge and experience to perform their roles. The manager from

Ruskin also had responsibility for Oakwood ward. This was a short-term solution with support from

the network manager. A decision had been made to advertise the post for a permanent manager.

Ramsey ward currently had two ward managers who shared responsibility for the ward. This

arrangement was in place to give more support to the ward which had been through a difficult

time.

Leaders had a good understanding of the services they managed. They could explain clearly how

the teams were working to provide high quality care.

Leaders were visible in the service and approachable for patients and staff. However, three carers

from Ramsey unit told us that they had not met the ward manager. Senior leaders were visible

during the inspection and had a good understanding of concerns within each team. Senior

managers provided support to the wards.

Leadership development opportunities were available, including opportunities for staff below team

manager level.

Vision and strategy

Staff knew and understood the provider’s vision and values and how they were applied in the work

of their team. The services were currently in the process of being transferred to new mental health

trusts. Services in the south had started discussion with the new provider and felt confident about

the move. The provider in the north of the county had started to lead joint work between the two

organisations.

The provider’s senior leadership team had successfully communicated the provider’s vision and

values to the frontline staff in this service. Staff felt supported and informed about the upcoming

transfer.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially

where the service was changing.

Staff could explain how they were working to deliver high quality care within the budgets available.

Culture

Staff felt respected, supported and valued.

Staff felt positive and proud about working for the provider and their team. Staff felt able to raise

concerns without fear of retribution. Staff knew how to use the whistle-blowing process and about

the role of the Freedom to Speak Up Guardian.

Managers dealt with poor staff performance when needed and this was picked up in supervision.

Teams worked well together and where there were difficulties managers dealt with them

appropriately.

Staff had access to support for their own physical and emotional health needs through an

occupational health service. Staff were supported by ward managers and senior managers. There

had been incidents on Ramsey with police involvement where senior managers had attended to

give extra support to staff.

The provider recognised staff success within the service. Managers were able to put staff forward

for awards. The advanced practitioner had been nominated for staff recognition for going ‘over and

above’ for patients.

Governance

The wards for older people were managed within the trust’s memory and later life services. This

was a network which included inpatient wards and community services and worked alongside the

other networks in the mental health care group. The network managers met monthly as part of the

county-wide mental health and learning disabilities care group. This meeting was chaired by the

medical director.

There was a clear framework of what must be discussed at a ward, team or directorate level in

team meetings to ensure that essential information, such as learning from incidents and

complaints, was shared and discussed. A monthly governance meeting took place where themes

around incidents and complaints could be explored. Managers had access to a performance

dashboard which gave them detailed information about each ward. Managers used this

information to support and manage the wards.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and

safeguarding alerts at the service level.

Staff undertook or participated in local clinical audits. The audits were enough to provide

assurance and staff acted on the results when needed.

Staff understood the arrangements for working with other teams, both within the provider and

external, to meet the need of patients. However, there had been occasions when staff had not

attended safeguarding strategy meetings in relation to patients in their care. This was discussed

during inspection and the trust were looking into what had gone wrong in terms of communication.

The wards worked closely with the community teams, care homes and social workers from the

local authority.


Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level

could escalate concerns when required. Each ward had identified local risks which were specific to

their ward. Staff concerns matched those on the risk register which included staffing for Ramsey

ward and the environment for Oakwood.

The service had plans for emergencies, for example adverse weather or a flu outbreak.

Monthly meetings took place and included discussions around: the review of a serious incident

and associated learning, sickness levels and support required to reduce this, performance

dashboard and support to improve key performance indicators and a review of guidelines.


The service used systems that were not over-burdensome for frontline staff to collect data from

wards and directorates. Managers were able to use the performance dashboards which gave them

up to date information on incidents, safeguarding and complaints.

Staff had access to the equipment and information technology needed to do their work. The

information technology infrastructure, including the telephone system, worked well and helped to

improve the quality of care. Issues with staff use of the patient information system had been

resolved since our last inspection. Staff were now confident in using the system and information

was stored correctly.

Information governance systems included confidentiality of patient records.

Team managers had access to information to support them with their management role. This

included information on the performance of the service, staffing levels, training figures and patient

care.

Information was in an accessible format, and was timely, accurate and identified areas for

improvement.

Staff made notifications to external bodies as needed.

Engagement

Staff, patients and carers had access to up-to-date information about the work of the provider and

the services they used. Welcome booklets were provided to patients and their families. Staff had

access to the intranet and felt informed about upcoming changes to the trust.

Patients and carers could give feedback on the service they received in a manner that reflected

their individual needs. It was difficult for the trust to collect receive feedback from patients on

Ramsey and Ruskin due to their organic illness and families were supported where possible to

give feedback. Community meeting took place on Oakwood where patients could discuss the

running of the ward and voice any concerns. Evidence of meetings was displayed on notice

boards.

Managers and staff had access to the feedback from patients, carers and staff and used it to make

improvements.

Patients, carers and staff could meet with members of the provider’s senior leadership team and

governors to give feedback. A family member was meeting with a member of the senior team on

the day of the inspection. The outcome of this meeting had been positive in addressing the

concerns raised.

There was close working and engagement with clinical commissioning groups, local authorities,

police and neighbouring mental health trusts.


Staff were given the time and support to consider opportunities for improvements and innovation

and this led to changes. Staff from Ruskin had given presentations across the North East and to

senior managers on the impact of psychological input in older people’s settings. The work had

demonstrated a positive impact on patients in reducing levels of violence and aggression and a

positive impact on staff in terms of stress levels and sickness.

Managers from the service facilitated monthly quality improvement days. Staff from each discipline

were given time to meet and share good practice for dissemination across the wards.

The trust was introducing a memory nurse advisor. This was following completion of a successful

pilot. The innovative approach would integrate services at primary care levels to enable delivery of

seamless memory assessment and diagnosis within primary care, while also reducing reliance on

GPs for annual dementia reviews. The nurse would also work into the inpatient setting.

Staff had opportunities to participate in research. Staff from Ruskin recently had an article

published in the psychology journal.

NHS trusts can participate in several accreditation schemes whereby the services they provide are

reviewed and a decision is made whether to award the service with an accreditation. A service will

be accredited if they are able to demonstrate that they meet a certain standard of best practice in

the given area. An accreditation usually carries an end date (or review date) whereby the service

will need to be re-assessed to continue to be accredited.

The core service has not participated in any accreditations.

cumbria partnership nhs foundation trust · 2019. 9. 25. · cumbria partnership nhs foundation...

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