20171116 900885 Post-inspection Evidence appendix template v3 Page 1 Tees Esk and Wear Valleys NHS Foundation Trust Evidence appendix West Park Hospital Edward Pease Way Darlington County Durham DL2 2TS Tel: 01325552000 www.tewv.nhs.uk Date of inspection visit: 12 June to 25 July 2018 Date of publication: 23 October 2018 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 Tees, Esk and Wear Valleys NHS Foundation Trust was created in April 2006, following the merger of County Durham and Darlington Priority Services NHS Trust and Tees and North-East Yorkshire NHS Trust. In July 2008, they achieved foundation trust status under the NHS Act 2006. As a foundation trust, they are accountable to local people through our Council of Governors and are regulated by Monitor, the health sector regulator. In June 2011 Tees, Esk and Wear Valleys NHS Foundation Trust took over the contract to provide mental health and learning disability services to the people of Harrogate, Hambleton and Richmondshire. On 1 October 2015, they took over the contract to provide mental health and learning disability services in the Vale of York. Tees, Esk and Wear Valleys NHS Foundation Trust employs 6,711 (RPIR) staff and provides mental health, learning disability services across a large geographical area. Their main towns and cities are Durham, Darlington, Middlesbrough, Scarborough, Whitby, Harrogate, Ripon, Vale of York and there are numerous smaller seaside and market towns scattered throughout our patch. They are also in the catchment area for the largest concentration of armed forces personnel in the UK (Catterick Garrison). The trust serves a population of 2 million people and covers 4,000 square miles, 8% of England. It has an annual income of £350 million. Its services are commissioned by nine clinical commissioning groups and NHS England. It also works with nine local authorities. The trust is registered to provide the following activities:
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 Tees, Esk and Wear Valleys NHS Foundation Trust was created in April 2006, following the merger of County Durham and Darlington Priority Services NHS Trust and Tees and North-East Yorkshire NHS Trust. In July 2008, they achieved foundation trust status under the NHS Act 2006. As a foundation trust, they are accountable to local people through our Council of Governors and are regulated by Monitor, the health sector regulator. In June 2011 Tees, Esk and Wear Valleys NHS Foundation Trust took over the contract to provide mental health and learning disability services to the people of Harrogate, Hambleton and Richmondshire. On 1 October 2015, they took over the contract to provide mental health and learning disability services in the Vale of York. Tees, Esk and Wear Valleys NHS Foundation Trust employs 6,711 (RPIR) staff and provides mental health, learning disability services across a large geographical area. Their main towns and cities are Durham, Darlington, Middlesbrough, Scarborough, Whitby, Harrogate, Ripon, Vale of York and there are numerous smaller seaside and market towns scattered throughout our patch. They are also in the catchment area for the largest concentration of armed forces personnel in the UK (Catterick Garrison). The trust serves a population of 2 million people and covers 4,000 square miles, 8% of England. It has an annual income of £350 million. Its services are commissioned by nine clinical commissioning groups and NHS England. It also works with nine local authorities. The trust is registered to provide the following activities:
• Accommodation for persons who require nursing or personal care. • Assessment or medical treatment for persons detained under the Mental Health Act 1983. • Transport services, triage and medical advice provided remotely. • Treatment of disease, disorder or injury.
The trust had 22 locations registered with the CQC (on 7 June 2018).
Registered location Code Local authority
163 Durham Road RX3WE Stockton-On-Tees
367 Thornaby Road RX3LD Stockton-On-Tees
Acomb Garth RX33V York
Acomb Learning Disability Units RX33W York
Auckland Park Hospital RX3AT Durham
Bankfields Court RX3NT Redcar & Cleveland
Cherry Tree House Elderly Assessment Unit RX35E York
Cross Lane Hospital RX3LK North Yorkshire
Durham and Darlington Crisis and Recovery House RX3X5 Durham
Friarage Hospital Mental Health Unit RX3XX North Yorkshire
Lanchester Road Hospital RX3CL Durham
Meadowfields Community Unit RX33Y York
Peppermill Court RX34L York
Primrose Lodge RX3AD Durham
Roseberry Park RX33A Middlesbrough
Sandwell Park RX3NH Hartlepool
Springwood RX3KW North Yorkshire
The Briary Unit RX3YE North Yorkshire
The Orchards RX3YK North Yorkshire
Trust Headquarters RX301 Darlington
West Lane Hospital RX3LF Middlesbrough
West Park Hospital RX3MM Darlington
The trust had 858 inpatient beds across 78 wards, 53 of which were children’s mental health beds. The trust does not have any outpatient clinics or community clinics.
Total number of inpatient beds 858
Total number of inpatient wards 78
Total number of day case beds 0
Total number of children's beds (MH setting) 53
Total number of children's beds (CHS setting) 0
Total number of outpatient clinics a week 0
Total number of community clinics a week 0
The trust provides the following core services; • Acute wards for adults of working age and psychiatric intensive care units. • Forensic inpatient/secure wards. • Long stay/rehabilitation mental health wards for working age adults. • Wards for older people with mental health problems. • Child and Adolescent Mental Health Inpatient wards. • Wards for people with learning disabilities or autism. • Community mental health services for people with learning disabilities or autism. • Community based mental health services for older people. • Community-based mental health services for adults of working age. • Community services for children and young people.
Leadership The trust board had the appropriate range of skills, knowledge and experience to perform its role. The board comprised of eight executive directors including the chief executive who all had career experience in a healthcare setting and relevant qualifications as appropriate for their leadership roles. There were seven non-executive directors 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 by the executive team. The trust had a senior leadership team in place with the appropriate range of skills, knowledge and experience. The executive team were supported by five locality management teams via the chief operating officer and each locality had a director of operations, a head of nursing and a deputy medical director. The trust had plans in place to further support the localities with a professional lead for psychology. Each locality covered a single geographical area and had four directorates; adult services, mental health services for older people, learning disability and children and young people. The forensic locality was an exception spanning two geographical areas and including only forensic services. The chief operating officer was also supported by a Kaizen promotion office, head of psychology, senior clinical directors, chief pharmacist and a director of operations (estates and facilities management). The trust board and senior leadership team displayed integrity on an ongoing basis. The executive director of nursing was the lead for safeguarding adults and children and there was a safeguarding lead supported by two safeguarding teams. The trust had leads for adult mental health and substance misuse; mental health services for older people; learning disabilities, children and young people and forensic services (mental health and learning disability). Senior clinical directors worked to the chief operating officer and they were supported by clinical directors. They covered across the five localities and were grouped into the five specialities of the trust. There were eight executive members of the board and seven non-executive members. The executive board had 12.5% black and minority ethnic (BME) members and 25% women. The
non-executive board had 0% BME members and 28.6% women.
BME % Women %
Executive 12.5% 25.0%
Non-executive 0.0% 28.6%
Total 6.7% 26.7%
Fit and proper person checks were in place. All personnel files for the board contained the necessary information and checks required. 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 had recently had a change in executive management with chief operating officer
and deputy chief executive, while remaining a member of the board (as the deputy chief executive) the member had stepped back from their substantive role as the chief operating officer to focus leading the rectification of defects at Roseberry Park including related legal issues. At the time of the information request and inspection the trust had an interim Director of Finance and Information. However, this post had been permanently appointed to and Patrick McGahon would be in post following the completion of his six month notice period. The trust leadership team had a comprehensive knowledge of current priorities and challenges and took action to address them. Issues were identified, discussed and escalated where necessary through the daily huddles at all levels of the trust, these all used visibility walls. Priorities and challenges effecting the whole trust were identified and managed by the senior management with a weekly executive management team huddle every Wednesday morning. The trust had a council of governors made up of 54 elected and non-elected governors. Trust governors are the direct representatives of local people, patients, stakeholders and staff within foundation trusts. As a group they make up the council of governors (as distinct from the board of directors which includes executive and non-executive directors). Governors do not undertake operational management; rather, they challenge the board of directors and collectively hold them to account for the trust’s performance. It is also the governors’ responsibility to represent their members’ interests, particularly in relation to the strategic direction of the trust. There was a programme of board member visits to services and staff fed back that leaders were approachable. The board visited teams monthly and governors were also invited. These were coordinated so that visits were to the same type of service which improved the discussion and identification of any themes in that service type. The board meetings were monthly and rotated around the different localities of the trust. The senior managers were visible and approachable in the services and had a good understanding of the services they managed. Leadership development opportunities were available, including opportunities for staff below team manager level. The trust provided a range of leadership and management development opportunities for all staff. The programmes offered are constantly revised to adapt to trust strategies with a strong focus being placed on creating a coaching culture that supported recovery and wellbeing. A service user, carer and advocate leadership development programme had been delivered in the trust for 18 years, including adapting this programme for service users with a learning disability. The trust was introducing a programme for staff from a black, Asian and minority ethnic (BAME) background. It aimed to develop the leadership potential of staff within both corporate and clinical services, enabling the development of talented, committed future leaders. The first cohort of level five operational / team leader apprentices started in September 2017 and the trust are training 41 staff internally. There has been a talent management programme in place since 2013, a range of activities to improve recruitment, retention, staff development and succession planning have taken place. The trust introduced a bespoke coaching service called ‘TEWV-Think-On’ on July 2017. This was designed to enable all staff to use a solution focused framework in their work to think about change in relation to themselves, their colleagues, services users and carers. At the time of the inspection the trust had 29 master coaches, 50 TEWV-Think-On coaches, a guiding team and had developed relationships with Kaizen production office and organisational development. The staff across the trust spoke enthusiastically of the positive impact this had had on the services provided by the trust. Succession planning was in place throughout the trust. Trust strategies had a focus on creating a coaching culture that supported recovery and wellbeing. The head of organisational development and talent management lead monitored the recruitment of leaders and managers in the trust to highlight any succession planning issues. The trust reviewed leadership capacity and capability on an ongoing basis. The trust has had a talent management programme in place since 2013. This is
a range of activities to improve recruitment, retention, staff development and succession planning. The process of talent management was aligned to the staff appraisal system in February 2018 and was led by a talent management board chaired by the chief executive and with a key outcome of achieving; ‘80% internal appointments versus 20% external appointments at roles for band 6 and above by ensuring there are two high quality internal candidates consistently applying for posts’. The chief pharmacist was accountable for the pharmacy service. There was good evidence of communication between the pharmacy department and the executive team. The pharmacy leadership team fed into the drugs and therapeutic committee which fed into the quality assurance committee at board level. Medicine optimisation report went to quality assurance committee bi-monthly. The Chief Pharmacist had attended some Carter review sessions. The Chief Pharmacist had a process of communication that included quarterly visits to all main sites and provided opportunity to test the views of staff and communicate strategic changes. The pharmacy team received monthly written pharmacy updates to provide the team with timely information from the pharmacy leadership meeting and other issues / changes affecting them. There was a pharmacy newsletter for all trust staff which highlighted issues such as patient safety and new policies.
Vision and strategy The trust had a clear vision and set of values with quality and sustainability as the top priorities. The trusts vision was to be a recognised centre of excellence with high quality staff providing high quality services that exceed people’s expectations. Each of the values identifies a set of behaviours that constitute 'living the values' and their five values were:
• Commitment to quality - we demonstrate excellence in all of our activities to improve outcomes and experiences for users of our services, their carers and families and staff.
• Respect - we listen to and consider everyone’s views and contributions, maintaining respect at all times and treating others as we would expect to be treated ourselves.
• Involvement - we engage with staff, users of our services, their carers and families, governors, members, GPs and partner organisations so that they can contribute to decision making.
• Wellbeing - we promote and support the wellbeing of users of our services, their carers, families and staff.
• Teamwork - this is vital for us to meet the needs and exceed the expectations of people who use our services. This not only relates to teams within Tees, Esk and Wear Valleys NHS Foundation Trust, but also the way we work with GPs and partner organisations.
Staff knew and understood the trust’s vision, values and strategy and how achievement of these applied to the work of their team. The trust’s quality strategy for 2014-2019 set a clear direction and outlines what the trust expects form its staff as the thrust works towards their vision of providing excellent quality carer. Staff were familiar with the vision and values of the organisation and demonstrated these in their interactions with patients and carers and other staff. The trust carried out a consultation exercise about their values and staff compact during September 2017 to December 2017 which generated ideas about how to improve and communicate the values. The staff compact was ‘the gives and gets’ between the trust and its staff and is displayed on one sheet of paper outlining the trust and the staffs’ commitment. For example, the trust ‘will recognise staff who have achieved excellence and show commitment to value adding work; in return the staff are expected to respond to the changing needs of patients and people who use services. The trust embedded its vision, values and strategy in corporate information received by staff. A quarterly assessment of performance against objectives and the values and behaviours of the Trust was introduced in 2016. Leaders and managers attend an embedding the values 3-day peer development programme and quality improvement system training both emphasising the importance of involvement in change and improvement activities. The trust has refined the values
based recruitment questions to fit their strategic approach. All staff could access 'productive conversations for staff - working towards providing a compassionate culture’ a programme for promoting reflection on the importance of the trust's values and behaviours to promote productive conversations in the workplace. Managers were also encouraged to print copies of the values and behaviours posters for notice boards and to promote them in staff communications and meetings. Staff regularly nominated colleagues for the living the values award and the annual ‘making a difference’ awards.
There was a robust and realistic strategy for achieving trust priorities and developing good quality, sustainable care. The trust’s ‘strategic direction’ which was a combination of vision, mission and five strategic goals. The five strategic goals refer to:
• working constructively with service users and carers to deliver recovery focused services
• continuous improvement in quality and value
• recruiting, developing and retaining an excellent workforce
• working in partnership and
• being well-led and sustainable. These strategic goals did not change significantly from year to year, they were reviewed annually and adjusted where necessary for changes in the external environment. In support of delivering the strategic direction there were a number of core strategies, for example, recovery, quality, workforce, finance. The trust also had a three-year business plan that was refreshed each year. The board identified the key strategic and operational priorities for the organisation to address over the three years to make progress towards delivery of the strategic goals. At the time of the inspection the strategic priorities were:
• promoting recovery and trauma-informed care
• improving the purposefulness and productivity of community services and inpatient services
• ensuring there are the right staffing now and in the future
• promoting the culture of making a difference together and
• digital transformation. The workforce strategy explicitly identifies the workforce race equality standard as a driver for change and includes the need for the trust to be a more diverse and inclusive employer. Local providers and people who use services had been involved in developing the strategy. The trust produced the strategic direction in 2008 using the European Foundation for Quality Management (EFQM) tool. They identified the purpose of the organisation (mission), their overall ambition (vision) and who the key customer/stakeholder were and what they wanted from the organisation which informed the strategic goals. This formed part of the integrated business plan (IBP). As part of the approval of the IBP the trust consulted staff, commissioners and local authorities. The trusts strategic direction did not change significantly from year to year, however the trust reviewed it annually as part of the trust business planning framework. The board and council of governors reviewed the draft of the business plan in February and the final draft signed off by the board in March of any given year. The board spent two days in October with its senior operational and clinical leaders, considering the strategic direction and particularly the strategic and operational priorities. Each of the priorities was allocated to a director lead and progress was presented to another full day session of the board and senior management in January. Staff, patients, carers and external partners had the opportunity to contribute to discussions about the strategy. Prior to the event in October, views on what the key issues facing the trust were gained from wider stakeholders such as staff, governors, experts by experience, service users, commissioners and local authorities.
The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders. This included active involvement in sustainability and transformation plans. The trust was working as part of the combined NHS England North Cumbria and North East (CNE) mental health sustainability and transformation partnerships (STPs) workstream and was engaged with three STP areas. Director leads provided feedback about oversight of the plans implementation to the wider stakeholders engaged earlier in the process. NHS Improvement (NHSI) described the trust as continuing to demonstrate strong operational performance across all standards associated with improving access to psychological therapies, early intervention in psychosis and the improving access to psychological therapies recovery standard. The leadership team regularly monitored and reviewed progress on delivering the strategy and local plans. The trust monitored progress against the delivery of the strategic direction via a quarterly strategic direction progress report at its public board meeting. This report included performance against the strategic direction scorecard which consists of a number of key performance indicators that were identified for each strategic goal. Progress made on the priorities and plans contained within the business plan and other qualitative information that was collected during the quarter. The latter provided further intelligence to the overall consideration of progress (for example external awards won, new investments made by commissioners, inclusion of trust work in best practice guidance/at national conferences etc). In the most recent strategic direction progress report, February 2018, the board noted the overall improvement in terms of performance against the scorecard indicators, the positive progress in year against the business plan and the significant qualitative intelligence for quarter three 2017/18. The trust had a business plan 2017-2019. The board and executive team monitored the progress on delivery of the priorities that make up the business plan, and which impact on the strategic indicators. Progress on the business plan is reviewed each quarter as part of the strategic direction performance report and the executive team receive updates on the strategic and operational programmes in the trust monthly. In addition, the quality assurance committee received quarterly updates on the quality account improvement priorities incorporated into the business plan. The trust had a comprehensive policy for meeting the physical healthcare needs of patients. The trust had physical health nurse practitioners in the services and physical healthcare was led lead by the modern matrons. Patients had access to physical healthcare across the trust and were encouraged to lead healthier lifestyles. The trust had carried out a number of physical health audits across the trust and developed appropriate actions to address any shortfalls. Physical healthcare checks were not always recorded following physical interventions, the trust had recognised this following an audit and was acting to address it. There was a medicine optimisation annual plan and some actions carried forward. For example, electronic prescribing and medicines administration was linked to required system developments from the supplier of the electronic patient record system. Electronic prescribing and medicines administration currently needs further development and has a target date of 2019. Reports went to the board bimonthly and included progress against the annual plan and drug & therapeutics committee updates. The chief pharmacist was accountable to the chief operating officer and they had monthly meetings, there were also regular meeting with medical director.
Culture Staff felt respected, supported and valued. An action plan was developed to address issues arising from the staff survey and this was monitored via the trust board.
In the 2017, NHS Staff Survey the trust had better results than other similar trusts in 20 key areas:
Key finding Trust score National Average for MH
KF11 - Percentage of staff appraised in last 12 months 93% 89%
KF20 - Percentage of staff experiencing discrimination at work in the last
12 months 10% 14%
KF21 - Percentage of staff believing that the organisation provides equal
opportunities for career progression or promotion 90% 85%
KF28 - Percentage of staff witnessing potentially harmful errors, near
misses or incidents in last month 22% 27%
KF17 - Percentage of staff feeling unwell due to work related stress in
the last 12 months 39% 42%
KF18 - Percentage of staff attending work in the last 3 months despite
feeling unwell because they felt pressure from their manager,
colleagues or themselves
50% 53%
KF6 - Percentage of staff reporting good communication between senior
management and staff 40% 36%
KF25 - Percentage of staff experiencing harassment, bullying or abuse
from patients, relatives or the public in last 12 months 27% 32%
KF26 - Percentage of staff experiencing harassment, bullying or abuse
from staff in last 12 months 19% 21%
KF13 - Quality of non-mandatory training, learning or development 4.12 4.06
KF30 - Fairness and effectiveness of procedures for reporting errors,
near misses and incidents 3.84 3.75
KF31 - Staff confidence and security in reporting unsafe clinical practice 3.84 3.71
KF19 - Organisation and management interest in and action on health
and wellbeing 3.84 3.77
KF1 - Staff recommendation of the organisation as a place to work or
receive treatment 3.75 3.67
KF8 - Staff satisfaction with level of responsibility and involvement 3.93 3.88
KF9 - Effective team working 3.89 3.84
KF14 - Staff satisfaction with resourcing and support 3.45 3.35
KF5 - Recognition and value of staff by managers and the organisation 3.64 3.59
KF2 - Staff satisfaction with the quality of work and care they are able to
deliver 3.91 3.83
KF32 - Effective use of patient / service user feedback 3.89 3.72
In the 2017, NHS Staff Survey: the trust had worse results than other similar trusts in one key area:
Key finding Trust score National Average for MH
KF29 - Percentage of staff reporting errors, near misses or incidents
witnessed in the last month 90% 93%
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 was worse than the England average in terms of the percentage of patients who would not recommend the trust as a place to receive care in three of the six months.
Staff felt positive and proud about working for the trust and their team. This was evident across all areas of the trust we visited. Some black, Asian and minority ethnic staff described some bullying and harassment experiences of a racial nature and experience of racial abuse from patients. The trust was aware of the issues and were taking action to address this with initiatives such as; leadership programme; annual board seminars delivered by staff from a BAME background; equality, diversity and human rights steering group; diversity engagement group; analysis of data from service users and staff, and diversity champions. Staff demonstrated some of the work they were involved in to improve the services they worked in and the experience and quality of services patients received. The trust held locality and trust wide events where good practice and developments could be showcased and shared. Some of these were delivered jointly with patients. The trust recognised staff success by staff awards and through feedback. The trust had an annual making a difference awards ceremony where they recognise and thank individual staff and teams who work or volunteer across the trust and who have; gone the extra mile; shown commitment to quality in their work; made a real difference. There were nine categories including, clinician of the year; non-clinical services employee of the year; and volunteer of the year. The trust had a bi-monthly living the values award which recognised staff who had clearly demonstrated the trust’s values in their day to day work. In addition, the executive management team named a weekly team or individual of the week for those who had gone that extra mile to achieve great outcomes.
The trust worked appropriately with trade unions. The trust had a structure for engaging with trade unions that encouraged openness and transparency and recognised staff side representation. There was a bimonthly joint consultative committee chaired by the chief executive, there was also a local consultative committee where the heads of service and heads of nursing were invited. Managers addressed poor staff performance where needed. Managers across the services told us there were process in place to support them to address issues of poor performance. They could describe specific examples where this had been done promptly, effectively, professionally and was also well documented. This would initially be managed within supervision where objectives would be set and coaching offered if appropriate. Managers gave an example of how poor staff performance was managed recently to ensure staff wellbeing whilst ensuring a continued high level of service for patients. Managers also worked alongside the human resources team within the trust to develop plans to support staff back into work where staff had been absent and this was appropriate. We reviewed five disciplinaries, all of which adhered to the trusts policy and procedure. Investigations were thorough and described outcomes in a letter, although one example needed an update on the outcome of the actions.
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 freedom to speak up guardian was appointed in October 2016 and the trust had recently appointed a deputy freedom to speak up guardian to cover absences. The trust is also developing further roles to support freedom to speak up through dignity at work advisors. 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. In the last six months, up to the end April 2018, the guardian had dealt with nine new referrals, four of which remained open. There were 3 open cases in the trust at the time of the inspection. Issues raised related to quality, safety and bullying.
Staff knew how to use the whistle-blowing process and about the role of the speak up guardian. The guardian supported staff with concerns and staff in the services knew how to access the guardian and raise concerns. They were also engaged in local and national network forums. Staff felt able to raise concerns without fear of retribution. Staff felt confident about raising concerns and knew how to do this. They had a clear understanding of whistleblowing process and felt confident in using it. Staff who had used the process before reported they had felt supported and would do so again if necessary. Of the whistleblowing incidents between October 2016 and March 2018 there were 27 cases (involving 42 staff) half of the cases related to a culture of bullying and the remainder related in small numbers to patient safety, staff safety, leadership, and culture. The rate of concerns about bullying are in line with the national statistics produced by the national guardian's office. The provider information showed of the 27 cases, eight were closed in this timeframe. Some remained open because the concerned person was still unhappy with the outcome of investigations, or they continued to need some pastoral support following the conclusion. There was a concern that some staff felt some level of perceived detriment, whilst most did not report deliberate actions many have said they are left with a sense that they have been 'through the mill' and have lost some mutual trust or respect from fellow team members. The trust had an effective guardian of safe working hours. The guardian had been in the role for
two years and worked two programmed activities (PA’s) per week in the role, they also had four
days per quarter administration support. Junior doctors were introduced to the guardian at
induction where a detailed overview of the role and expectations was given. Junior doctors had a
forum every three month which was mainly held at Darlington or Middlesbrough. There were also
locality forums every three to four months for every rota area. Reports were submitted the board
every quarter and a summary report annually. These highlighted activity, issues and actions taken
including the reporting of exceptions. Rotas and differences across the localities was a theme in
the reports. The guardian reported to the local negotiating committee every three months and
linked into existing trust education and training meetings. The guardian linked with wider
stakeholders such as health education England north east guardian meetings, health education
England in Yorkshire and the Humber guardian meetings, NHS employer national guardian
meetings.
The handling of concerns raised by staff always met with best practice. Staff in the services were
aware of how to raise concerns including the process for whistleblowing and all staff said they felt
they would be protected and supported if they were to raise concerns. Staff had confidence in
managers to address issues of concern and most were aware of the role of the freedom to speak
up guardian. Staff said they could raise concerns about disrespectful, discriminatory or abusive
behaviour or attitudes towards patients. Staff felt they could raise concerns or approach their
managers for support outside of protected supervision or one-to-one time. We saw that
relationships between staff were positive and supportive during our visit and that management
were accessible in their approach.
We reviewed five grievances brought against the trust, all adhered to the policy, had thorough
investigations and were well documented However, in all cases the time between the letter being
received and stage one hearing was longer than 21 days. The trust policy stated this should be
ideally within 21 days.
At our last inspection in 2017 we found the trust were not fully applying the duty of candour requirement. At this inspection we found that the trust applied duty of candour appropriately. We reviewed five incidents where duty of candour was appropriate; all complied with the regulation
and contained sincere written apologies to the appropriate person. The trust had a duty of candour policy that supported staff with a consistent approach to ensure the organisation acts in an open, honest and transparent way if something goes wrong. Staff had a good understanding of the duty of candour in the services and acted in an open and transparent way. Duty of candour was also considered in the trusts incident reporting policy. The trust maintains a register of incidences where duty of candour has been identified and a record of the steps taken. Duty of candour is included on the trusts internal audit programme which monitors compliance and highlights areas for improvement; this is monitored through the patient safety governance group which subsequently feeds into the trusts quality assurance committee.
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 17/18 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 17/18 stayed about the same when compared to the same time last year
There is no reliable data to enable comparison with other individual trusts or all trusts in England.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff 28 February 2018 5965.9 N/A
Total number of substantive staff leavers 1 March 2017–28 February 2018
513.8 N/A
Average WTE* leavers over 12 months (%) 1 March 2017–28 February 2018
9% 8% - 12%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) 28 February 2018 409.2 N/A
Total vacancies overall (%) 28 February 2018 6% N/A
Total permanent staff sickness overall (%) 28 February 2018 5% 4.5%
1 March 2017–28 February 2018
5% 4.5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) 28 February 2018 2231.9 N/A
Establishment levels nursing assistants (WTE*) 28 February 2018 1915.9 N/A
Number of vacancies, qualified nurses (WTE*) 28 February 2018 46 N/A
Number of vacancies nursing assistants (WTE*) 28 February 2018 119.4 N/A
Qualified nurse vacancy rate 28 February 2018 2% N/A
Nursing assistant vacancy rate 28 February 2018 6% N/A
Bank and agency use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017-28 February 2018
5431
(76%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses) 1 March 2017-28 February 2018
752
(11%) N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses) 1 March 2017-28 February 2018
86
(1%) N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 March 2017-28 February 2018
16243
(43%) N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 March 2017-28 February 2018
722
(2%) N/A
Shifts NOT filled by bank staff where there is sickness, absence or
vacancies (Nursing Assistants) 1 March 2017-28 February 2018
133
(0.3%) N/A
*Whole-time Equivalent
As at 31 March 2018, the training compliance for trust wide services was 92% against the trust target of 90%. Of the training courses listed, 10 failed to achieve the trust target and of those, three failed to score above 75%. Those three were ‘Face to Face Medication Assessment’ (70%), ‘Manual Handling Patients Part 1 Update’ (74%) and ‘Manual Handling Patients Part 2 Update’ (74%)
The training compliance reported for the trust during this inspection was higher (better) than the 85% reported during the previous 12 months.
All staff had the opportunity to discuss their learning and career development needs at appraisal. This included agency and locum staff and volunteers. The trust had recently introduced ‘appraisal plus’ which combined appraisal and talent management to improve the quality of the appraisal. This had been well received by staff in the trust. The appraisal and talent management processes were combined in February 2018 following a Kaizen event held in March 2017. This means that all staff are offered talent management conversations as part of their appraisal. The trust’s target rate for appraisal compliance is for all staff to have an appraisal. However, the actual working target was 95% which takes into consideration staff on maternity leave, sickness, and secondments. As at 28 February 2018, the overall appraisal rates for non-medical staff was 95%. The rate of appraisal compliance for non-medical staff reported up to 28 February 2018 was slightly higher than the 93% reported for the previous 12 months.
people with a learning disability or autism 185 178 96%
MH - Long stay/rehabilitation mental health
wards for working age adults 127 121 95%
MH - Specialist community mental health
services for children and young people. 410 390 95%
MH - Wards for older people with mental
health problems 340 324 95%
MH - Child and adolescent mental health
wards 141 128 91%
MH - Community-based mental health
services for adults of working age. 598 551 92%
Other 913 836 92%
MH - Mental health crisis services and health-
based places of safety 196 176 90%
Total 4489 4246 95%
The trust’s target rate for appraisal compliance is for all staff to have an appraisal. However, the actual working target was 95% which takes into consideration staff on maternity leave, sickness, and secondments. As at 28 February 2018, the overall appraisal rates for medical staff was 91%. Seven of the nine listed core services achieved the trust’s appraisal rate. The core services failing to achieve the trust’s appraisal target were ‘Other’ with 89% and ‘Community-based mental health services for adults of working age’ with 67%. The rate of appraisal compliance for medical staff reported up to 28 February 2018 is the same as the 91% reported for the previous 12 months.
Core Service
Total number of
permanent medical
staff who were
required to have an
appraisal within the
last 12 months
Total number of
permanent medical
staff who have had an
appraisal in the last
12 months
%
appraisals
MH - Specialist community mental health
services for children and young people. 24 24 100%
people with a learning disability or autism 1 1 100%
MH - Community-based mental health services
for older people 3 3 100%
MH - Mental health crisis services and health-
based places of safety 2 2 100%
Other 165 147 89%
MH - Community-based mental health services
for adults of working age. 3 2 67%
Total 203 184 91%
Throughout the services staff received managerial, clinical and group/other supervision and felt well supported and supervised. Staff received clinical supervision from a clinical lead within their field to ensure the correct support and guidance was offered regarding skills needed for the role. Staff told us that managerial supervision followed a structure considering aspects including wellbeing, development, training needs, any concerns, and a review of caseload. As well as regular structured clinical supervision, staff had other platforms in which clinical supervision could take place which the trust did not record as part of their overall figures. For example, clinical supervision was offered during the morning huddles if there were staff discussing their caseloads, as well as during team meetings and after debriefs from incidents. There was more focused clinical supervision provided for staff who had made referrals to the local safeguarding authority and had families and children on their caseloads who had protection plans in place.
The trust policy was for staff to receive a minimum of eight supervisions per year including a minimum one clinical supervision every quarter. Managers maintained records of when supervisions were held using an excel spreadsheet, paper files and visual displays. The system was not robust enough to capture actual supervision activity. Some of the compliance rates for supervision were less than we would expect in the services. There was also a lack of an effective and standardised approach for gathering information into locality reporting systems and for senior management oversight. The trust was aware of this and had identified a system for feeding information on clinical supervision from the ward level, through the locality management performance report outs and ultimately to the executive report out wall. This is due to be completed in October 2018.
The trust had also identified issues with the quality of the supervision staff were receiving. The trust had developed new training materials and a standard work process so managers allocated staff protected time to attend supervision. The trust was piloting this new system on five wards in Teesside at the time of the inspection. We were assured staff were still receiving clinical supervision, through other platforms which were not captured in the overall figures. In addition, staff told us that they felt supported and had appropriate levels of supervision. Between 1 March 2017 and 28 February 2018, the overall clinical supervision compliance was 82%. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. One of the core services had a clinical supervision rate of 135% and one provider wide percentage had a supervision rate of 100%.
and psychiatric intensive care units 2766 1873 68%
MH - Wards for older people with mental
health problems 1580.3 1025 65%
TOTAL 21668 17840 82%
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. These included an occupational health service, mindfulness courses, trust retreats, employee support services and an employee psychology service. Sickness and absence figures were not outliers in comparison to other mental health and learning disability NHS trusts. The latest figures released by NHS Digital show that for January 2018 NHS staff sickness absence was 5.03 per cent. The trust average was 5 per cent with an overall target of 4.5 percent. At our last inspection we asked the trust to ensure it has a robust system for continually checking staff against convictions and / or cautions. At the time of the January 2017 inspection the trust was relying on appraisal, annual self-declaration and a possible approach from the police as assurance that staff have not received any cautions or convictions and not using the disclosure barring service check (DBS) update services. The DBS update service affords the trust a significant level of assurance that staff employed in roles working with children and vulnerable adults have an up to date DBS check in place. The trust had taken the decision to use the service prior to our inspection and started the roll out of the project in July 2017. They had prioritised York and Selby area locality and children’s services across the trust. Although the trust had made some progress at the time of the inspection we were concerned at how long it was taking to engage all staff. The trust confirmed that all staff who require a DBS held a current DBS (5730) at the time of inspection, that 30 per cent of staff were confirmed on the update service and 53 per cent were being processed on the update service. Despite the trust recruiting two additional agency workers to work alongside the two DBS administrators it appeared unlikely that the trust would meet this target at the time of the inspection. The trust calculated a short fall of 1,580 staff still to process by
the September target. Although they had identified a shortfall in the September target trajectories for improvement were in place and shared with inspectors at the time of the inspection visit. Not all staff felt equality and diversity was promoted in their day to day work and when looking at opportunities for career progression. Some staff we spoke with felt they were hindered in their career progression and this was racially motivated. The trust was aware of equality and diversity issues in relation to three main areas, verbal racial abuse by patients, staff bulling of a racial nature and progression. The trust board had plans in place to address these equality and diversity issues. The trust board signed off its workforce race equality standard and associated action plan in July 2017 and published them on the trust website. The board were last updated on the action plan in January 2018 at the time of inspection and had made progress with the action plan. However, timescales had been extended for; the black, Asian and minority ethnic (BAME) leadership programme for bands five-seven; the analysis of the research with BAME staff was taking longer than expected due to the unexpectedly high number of responses (284) and the amount of qualitative data received; the bullying and harassment resolution and reporting procedure was in draft format and was undergoing consultation. At the time of the inspection the trust had made progress in these areas. The trust has introduced a programme for staff from a BAME background. It aimed to develop the leadership potential of staff within both corporate and clinical services, enabling the development of talented, committed future leaders. The first cohort of level five operational / team leader apprentices started in September 2017 and they are now training 41 BAME staff internally. The Trust held a board seminar in December 2017 which was delivered by three BAME staff where they shared their experiences and issues could be raised. The trust acknowledges that the experiences of BAME and disabled staff are worse than those of white staff and not disabled staff and the need to be a more diverse and inclusive employer. Staff networks were in place promoting the diversity of staff through the trust equality and diversity initiatives. The trust was signing up to be a disability confident employer. The trust had an equality, diversity and human rights steering group which met regularly and reported to the board via the quality assurance committee. The trust also had a diversity engagement group and spirituality group. Staff training surrounding equality and diversity was mandatory and via e-learning, the trust compliance was high at 96%. The trust had diversity champions across the trust who met regularly in forums. The champions had received training on gender awareness in 2016 and due to the size of the trust a locality driven approach to training was adopted. Dates were available for staff across the trust localities and highlights of the training were made available via social media platforms and the trust Facebook site. The trust considered the data from the community mental health survey each year and has an action plan to address any recommendations. The trust feedback with regards to equality of experience for patients from different backgrounds has been limited as the return percentages from these service user groups were very low. The trust plan to address this internally by adding some questions to their patient experience system to help capture a more rounded view from service users. The trust had undertaken some initial work to identify the percentage of BAME patients who are being admitted, on caseload and subject to any type of mental health detention. The trust plan to benchmark this information with other providers as well as undertaking some targeted work internally to look at ways of ensuring that all service users are treated equally. The trust had an appropriate complaints governance process in place which considered complaints monthly. The quality assurance committee provided assurance to the board of directors and council of governors on the quality and safety of the operational clinical services. The quality assurance committee received a summary report from each locality management and governance board which included complaints received. In addition, the quality assurance committee received a quarterly report from the patient experience group which contained a
summary of all patient advocacy and liaison and complaints issues raised within the quarter and any points of escalation. Complaints were managed well through a complaints department with three complaints managers working in the localities, these were co-located with the patient advocacy and liaison officers and senior administrator. The complaints managers were responsible for investigating, drafting a response identifying lessons learnt and developing an action plan. We reviewed five random complaints records during the inspection and these were all in order. The trust took appropriate learning and action as a result of concerns raised. Quality assurance groups are chaired by clinical directors and report to locality management governance boards which are chaired by directors of operations and deputy medical directors. The quality and assurance groups had a key purpose of developing the quality agenda and standards of best practice, informed for example by lessons learnt from complaints. Senior clinical directors attending the board seminars on a rolling basis to update the board on progress and issues within the relevant speciality. They also attended the quality assurance committee group to feedback where necessary. Each locality had a speciality-specific quality assurance group. The primary function of this group was to monitor the services that are in the directorate through reports and data including complaints. They oversaw the governance systems and appropriate delivery of action plans in their directorate to ensure compliance with all relevant standards. High level themes such as lessons learned from the directorate quality assurance groups was fed back into the directorate quality assurance groups, the senior clinical director incorporated these into the quality improvement and development work programme for that directorate. The pharmacy team had an open culture and staff described the chief pharmacist as very approachable. Fifty percent pharmacists were independent prescribers. The trust had high levels of reporting for medication related incidents showing an open culture. Pharmacy education was important and the trust have developed a guide to incident reporting (DATIX) which was being piloted. A quarterly report was produced and disseminated identifying trends such as issues with medication incidents. Incidents were discussed at the safe medicine practice group and drugs and therapeutic committee. Staff knew how to handle complaints and information for patients and carers was readily available in the services. Information on how to raise concerns and complaints was publicised using multi-media platforms such as trust website, posters and leaflets. The trust advised people that they welcomed feedback about services when things have gone wrong and had a policy of dealing with problems openly and honestly. People were encouraged to speak to clinical and operational staff so they could attempt to and resolve issues quickly, alternatively informed to contact patient advocacy and liaison for advice and support. Where areas for service improvement / learning were identified from complaints, action plans were formulated with clinical services and monitored through quality governance arrangements. The following have been provided as a result of learning from complaints: Concerns around patient falls resulted in specific actions being identified that related to implementation of the clinical link pathway (CLIP) for falls and behaviours and provided more information for carers. A relative complained about a lack of care and support. As a result, it was agreed that a specific intervention plan would be drawn up with input from the patient as part of the management of the patient’s specific diagnosis. Part of a complaint was around discharge meetings and subsequent communication. The investigation found that there was a lack of detail around clinical records or the interactions that had taken place with the relatives/next of kin of the patient. Actions agreed were around reminding
staff of the importance of adhering to good practice in relation to inviting relatives to formulation and discharge meetings to raise the issue in the team meetings. Concerns were raised about the management of providing emergency accommodation and a lack of communication for the transferring of patients. The investigation advised that the transfer of patients between teams should be a seamless process, which on this occasion was both difficult and confusing for the family. Actions agreed were around the policy, notably to ensure transfers of patients between teams is timely and that relatives are appropriately involved. 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
Performanc
e
What is your internal target for responding to* complaints? 3 100%
What is your target for completing a complaint? 60 80%
If you have a slightly longer target for complex complaints please indicate what that is
here N/A N/A
* 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 1579 March 2017 –
February 2018
Number of complaints referred to the ombudsmen (PHSO) in the last 12 months 1
1 March 2017 –
28 February
2018
**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 1235 compliments during the last 12 months from 1 March 2017 to 28 February
2018.
‘Community-based mental health services for adults of working age’ had the highest number of
compliments with 202 (16%) followed by ‘Acute wards for adults of working age and psychiatric
intensive care units’ with 184 (15%).
Governance The trust had effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, directorate committees, team meetings and senior managers. Leaders regularly reviewed these structures. The trust had a board of directors and a council of governors. Committees supported the board;
There was also an executive management team with associated working and project groups. Papers for board meetings and other committees were of a reasonable standard and contained appropriate information. Locality management boards supported the quality assurance committee; speciality development groups; clinical directorate quality and assurance groups. There were also thematic quality assurance committees/groups;
• Patient safety group.
• Patient experience group.
• Clinical effectiveness group.
• Safeguarding and public protection group.
• Infection prevention and control committee.
• Medical devices committee.
• Physical health and wellbeing group.
• Drugs and therapeutics committee.
• Equality diversity and human rights group.
• Research governance group.
• Health, safety, security and fire group. The Trust’s quality governance arrangements provide a locality focus whilst generally maintaining consistency, learning and resilience across our clinical specialities. The quality assurance committee provided assurance to the board of directors and council of governors on the quality and safety of the operational clinical services. Quality assurance committee received from each locality management and governance board a summary report which included aspects of safety and quality. Quality assurance committee also received reports from the various governance groups which contained a summary of all quality and safety issues raised and any points of escalation. Directorate quality and assurance groups were chaired by clinical director and head of service. Each locality had a speciality-specific quality assurance group. The locality had four quality assurance groups and one locality management governance board. The directorate quality assurance groups develop standards of best practice, informed trust activity such as lessons learnt from incidents and patient experience reports. The senior clinical director attends the quality assurance committee group. We were concerned that some detail of information was not regularly being reported to the board from the quality assurance committee or quality assurance groups. An example of this was the use of mechanical restraint use in the trust, the board did not have a good understanding of how often or when this was being used in the trust. The quality assurance systems had not identified inconsistencies in the quality of care across the region in a range of areas in acute and psychiatric intensive care units. There were inconsistencies in the ligature audits, risk management plans, personalisation of care planning and privacy in shared dormitories. Each locality had a speciality-specific quality assurance group. The primary function of this group was to monitor the services that are in the directorate through reports following inspections, user feedback, performance data, audit, untoward incidents, complaints, CQC reports. They oversee the governance systems and appropriate delivery of action plans in their directorate to ensure compliance with all relevant standards. High level themes such as lessons learned from the directorate quality assurance groups are fed back into the directorate quality assurance groups to enable the senior clinical director to incorporate these into the quality improvement and development work programme for that directorate. Locality management and governance boards provide assurance to the quality and assurance committee on a number of key issues. The board receives assurance and exception reports from
the quality assurance groups. Following receipt of this assurance is provided to the quality assurance committee. The drugs and therapeutics committee ensured the review of clinical information including the National Institute for Health and Care Excellence guidance; formulary management; standard operating procedures and protocols, pathways and leaflets. The drugs and therapeutics committee included representatives from staff groups across the trust. There were no gaps seen or reported in the reporting lines between the medicines related committees. The pharmacy team inputted into medicines management training for doctors and nurses at induction. The trust had shadow quality assurance groups across the trust as part of their patient engagement initiatives. These were attended by patients and provided a forum for quality issues to be discussed. We saw examples of minutes which had been adapted into easy read for some patients. The trust has a stable senior leadership team with some recent changes. This has meant there is a level of maturity in the board, governors and executive role and committees. The trust regards good governance as a continuing journey and had commissioned external reviews of its arrangements with Deloitte in 2014 and with Grant Thornton in 2017. This is a demonstration of the trusts willingness to seek corroboration of its governance arrangements. The recent external review described the trust as ‘self-aware and mature’ and was mostly positive about the board and high level of arrangements within the trust. However, the review highlighted some areas for improvement; the development or renewal of the risk management strategy; review how the board receives views form patients, carers and staff; review how the trust committees structure and people reflects the make-up of the population living in the area. The trust is taking a measured response to the external review. Appropriate governance arrangements were in place in relation to Mental Health Act administration and compliance. Oversight of the Mental Health Act was provided through the mental health legislation committee and direct to the board, this also included the Mental Capacity Act monitoring. There was an executive director lead in the director of nursing and a non-executive director was the chair of the committee. There were Mental Health Act administrators based in York, Middlesbrough, Durham and Darlington and they were well supported and supervised in their roles. There were systems and processes in place to ensure compliance with the Mental Health Act and its code of practice. There was a system of scrutiny in place involving ward staff, administrators and medical staff. The trust had recently started to scan documentation to the electronic patient record, this made it easier to ensure the paperwork was in place. Policies had been updated following the implementation of the latest Mental Health Act code of practice. The updated seclusion policy reflected changes to night time reviews of patients. The search policy laid out that searches should be taking place on an individual basis. The trust had recently reviewed their policy on the implementation of section 136 following the changes made by Police and Crime Act 2017. Approved mental health professionals (AMHPs) reported that the trust did not have a trust wide bed management system. AMHPs based in Durham told us that finding an inpatient bed for a patient who was about to be detained under the Mental Health Act could be a frustrating process. They had difficulty identifying who was responsible for managing beds within the trust. The trust had made the decision to make training in Mental Health Act and Mental Capacity Act mandatory, this had been implemented in April 2018. Therefore, percentage of staff training was still very low at the time of the inspection. However, staff in the services generally had a good
understanding of the legislation in their area of responsibility. There was also a training programme provided by the trust prior to April 2018, this was a rolling programme and was also targeted towards specific staff groups and service. There was a service level agreement between the trust and the acute trusts in the area. The trust was responsible for the administration of the Mental Health Act within each of the three trusts. A clear framework set out the structure of ward/service team, directorate and senior trust meetings. Managers used meetings to share essential information such as learning from incidents and complaints and to take action as needed. The trust had introduced a daily lean management structure of ‘huddles’ across all services and all levels in the trust. The provided and effective flow of information up and down the organisation and improved local communication and understanding of key issues. These all used visibility walls and were held daily across services with a weekly executive management team huddle every Wednesday morning. Staff at all levels of the organisation understood their roles and responsibilities and what to escalate to a more senior person. Managers ensured that staff received the necessary specialist training and support to perform within their roles. Staff were positive about the training opportunities provided and gave several examples of being able to access training when requested in support of their role. Team managers could attend leadership workshops and development days run by the trust. Patients in one service commented on how they felt staff were very skilled and knowledgeable in their roles, which enabled them to support patients in their journey towards recovery more effectively. A healthcare support worker had been supported to complete their ‘Care Certificate’; an agreed set of standards regarding the skills, knowledge and behaviour expected within the role. Managers recruited volunteers when needed, and trained and supported them for the roles they carried out. The trust was working with third party providers effectively to promote good patient care. The trust was also a formal delivery partner with third sector organisations for a number of services as the lead contractor or as a sub-contractor. Third sector organisations include voluntary and community organisations (both registered charities and other organisations such as associations, self-help groups and community groups), social enterprises, mutuals and co-operatives. Third sector organisations are generally independent of government. They engage through subcontract monitoring meetings, day to day operational discussions and / or joint service boards. Examples include Durham and Durham improving access to psychological therapies (Mental Health Matters); Offender Health services (Spectrum and Rethink) and the York Crisis Cafe. In the York and Selby service the trust managed a grant pool "York Connects" which third sector organisations could bid into. Further engagement with third sector organisations takes place and is managed at locality level. The trusts developing accountable care partnership had set up a provider forum which third sector and private sector adult learning disability providers found useful. Feedback from third sector organisation was positive. Partnership arrangements were in place for the provision of psychiatric liaison services with appropriate governance arrangements. The trust provided psychiatric liaison services to three areas of the trust in Darlington, Durham and York/Selby. It also provided all age liaison and diversion teams in Middlesbrough, Durham and Darlington police stations. The governance framework addressed the need to meet people’s physical health care needs. The trust had a physical health and wellbeing group which fed in to the quality assurance committee. There was also a physical health and wellbeing policy which outlined the importance of addressing physical health issues in mental health at all aspects of inpatient and community treatment. The policy outlined what was expected at admission, ongoing treatment and when specific issues arose with patients.
The trust provided their board assurance framework, which details any risk scoring 15 or higher (those above) and gaps in the risk controls which impact upon strategic ambitions. The five strategic ambitions outlined by the trust relating to this service are as follows:
1. To provide excellent services, working with the individual uses of our services and their
carers to promote recovery and well-being.
2. To continuously improve the quality and value of our work
3. To recruit, develop and retain a skilled, compassionate and motivated workforce.
4. To have effective partnerships with local, national and international organisations for the
benefit of the communities we serve
5. To be recognised as an excellent and well governed Foundation Trust that makes best use
of its resources for the benefit of the communities we serve
The trust has provided documents detailing their highest profile risks. Each of these has a current
risk score of 15 or higher. However, the information has been provided at locality level and not
ward level.
There were arrangements for identifying and managing the risks facing the organisation. The trust
had an integrated assurance framework and risk register which was used to inform the trust board
agenda and contained strategic risks and significant corporate risks. Each risk in the integrated
assurance framework and risk register had a detailed risk profile outlining the initial, present and
target risk grading, the risk owner, controls and assurances, and any gaps in these. There was
also details of any mitigating actions, implications and recovery plan for mitigating action behind
plan and a contingency plan. The integrated assurance framework and risk register was
considered at the board monthly to update the members. There was necessary consideration and
challenge of the content and progress from both non-executive and executive board members.
The trust has submitted details of two external reviews commenced or published in the last 12 months.
1. One was ‘External Governance Review (under the NHSI requirement for all Foundation Trusts to commission an independent review of its performance against the ‘well-led’ framework every 3 years).
2. The other was an ombudsman review regarding a complaint about the closure of a
rehabilitation unit in Darlington.
Management of risk, issues and performance Providers must report all serious incidents to the Strategic Executive Information System (STEIS)
within two working days of identifying an incident.
Between 1 March 2017 and 28 February 2018, the trust reported 127 STEIS incidents. The most
common type of incident was ‘Apparent/actual/suspected self-inflicted harm, with 110.
‘Community-based mental health services for adults of working age accounted for 69 of these.
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. This trust reported no never
We asked the trust to provide us with the number of serious incidents from the same period on their incident reporting system. The number of the most severe incidents was comparable with the number the trust reported to STEIS. From the trust’s serious incident information, five of the six unexpected deaths were instances of ‘apparent/actual/suspected self-inflicted harm’.
The trust had systems in place to identify learning from incidents and make improvements. The governance team regularly reviewed the systems. The trust produced a patient safety group quality report monthly which was presented at the quality assurance committee. The report included details of the current levels of performance relating to serious incidents, level three incidents (self-harm only), incidents of physical restraint and episodes of seclusion. It described trends over the past 12 months series these were in. The report also highlighted where risks were significant and gave recommendations where appropriate. The trust also produced a patient safety annual report, this report provided a look back over the financial year with regard to incident reporting and associated patient safety activities. It included detail on all incident types reported, serious incidents and identified themes that were emerging from the data. All serious incidents which occurred were reported to the executive management team weekly to ensure any immediate patient safety issues requiring urgent action were addressed. Executive management team reviewed a monthly performance report out in relation to serious incidents and emerging themes and had a quarterly ‘deep dive’ in to patient safety issues. All other incidents were reported in line with the incident reporting policy and investigated by the operational services in which they occur. There was a total of 25,415 incidents reported during the financial year, April 2017 to March 2018 of which 130 were categorised as serious incidents. The report describes incident data and trends in the organisation. It also highlights learning by analysis of the root cause findings and
contributory factors and categorises these by locality and separately by the root cause and contributory factor. The most common finding overall from all serious incidents in the financial year, April 2017 to March 2018 report related to the risk assessment, formulation and intervention planning. The second highest category related to failure to follow policy, followed by communication / information sharing. The report also provides a summary of incidental findings. Incidental findings are minor issues which are picked up as part of the investigation process that need to be learnt from however did not directly contribute to the incident occurring. Incidental findings from the financial year, April 2017 to March 2018 report related to four main categories; policy awareness/failure to follow; recordkeeping; risk assessment and poor/lack of communication. These finding were shared in each locality with key messages through the locality management and governance boards meeting and then cascaded to ward/team manager level so the information can be shared across all services through team meeting discussions. In the core services learning from incidents was embedded into practice and staff could describe where learning had led to service change. Senior management committees and the board reviewed performance reports. Leaders regularly reviewed and improved the processes to manage current and future performance. NHS Improvement has evidence that financial performance has been consistently strong, for example, cash, capital and revenue plans being delivered in line with plans and national requirements. The trust has been rated ‘1’ for use of resources and has seen improvement on all measures. Quarterly review meeting discussions with NHS Improvement and 1:1 meetings have demonstrated that financial risks have been identified and are being mitigated/managed by the trust. The trust has attracted political interest over its management of its Rosebery park private finance initiative (PFI) issue, this has not hindered the trust from undertaking urgent remedial action to address areas of risk. The trust had systems in place to identify learning from safeguarding alerts and make improvements. The trust had a safeguarding lead in the associate director of nursing. There was a clear ‘think families’ focus across the safeguarding team and the trust. There were examples of where learning from safeguarding incidents had been shared across the trust. The trust had some challenges serving eight safeguarding boards but the focus was on a collaborative approach to keep adults and children safe. The safeguarding team reviewed reported incidents in the trust to maintain an overall focus. The trust had a medication safety officer in post which was embedded into the governance
structure within the trust. The chief pharmacist was the controlled drugs accountable officer.
Pharmacy technicians perform monthly medicines management assessments on all wards. These
assessments cover 10 key medicines management standards. The process has been running for
over a year and a high percentage of wards now achieve 100% compliance. Medication safety
alerts were received and actioned as appropriate.
The trust take part in the national prescribing observatory for mental health (POMH) audits. A recent audit for lithium showed significantly high compliance across most standards with some improvements required for weight management. Pharmacy had a section on the trust risk register., for example seven day working. All wards had a clinical pharmacy service five days per week. Work has been done on improving pharmacy workforce skill mix. Leaders were satisfied that clinical and internal audits were sufficient to provide assurance. Teams acted on results where needed. The trust had a clinical audit and an external audit programme for the financial year and an audit committee. The committee met quarterly and monitored the audit programme, there was an annual report and a half yearly report on clinical audit progress. All Trust clinical audit activity is also monitored via the monthly clinical effectiveness group. The trust also produced a clinical audit highlights document which summarised the positive practice changes which were supported by evidence following clinical audit activities.
Internal audits are purchased from Audit one and reported to the Audit Committee. External audit is also undertaken on quality account. Staff had access to the risk register either at a team or directorate level and were able to effectively escalate concerns as needed. Service managers were aware of the risks specific to their geographical area and the risks which spanned across the service. Staff were aware of how to raise issues with their manager and there was a clear process for issues to feed in to the service risk register. Each ward had an issues log for the ward and areas of risk were discussed during the morning huddles, weekly report out meetings, and monthly team meetings. Staff had access to the trust risk register at locality level and staff concerns matched those on the risk register. In January 2015 we told acute wards for adults of working age and psychiatric intensive care units they should ensure that ward managers were aware of local risk registers and how to contribute to them, this had been addressed. Staff gave examples of where they had added items to the risk register, including when vacancies had caused an increase in waiting time for patients, or not having a dedicated sink to clean gastronomy equipment. Risks were discussed at monthly quality assurance groups whereby team managers were required to raise any risks from their logs that they felt needed escalating. Risks would then be scored and any that reached a certain level would be immediately escalated to locality management and the governance board, to quality assurance group and quality assurance committee. The trust board had sight of the most significant risks and mitigating actions were clear. These were detailed in the integrated assurance framework and risk register and had a detailed risk profile outlining the initial, present and target risk grading, the risk owner, controls and assurances, and any gaps in these. There was also details of any mitigating actions, implications and recovery plan for mitigating action behind plan and a contingency plan. The integrated assurance framework and risk register was considered at the monthly board to update its members. In acute and psychiatric intensive care units staff carried out ligature risk assessments on each ward. However, these did not always contain all the ligature points on the ward and some control measures were no longer up to date. There were plans in place for emergencies and other unexpected or expected events. For example, adverse weather, a flu outbreak or a disruption to business continuity. The trust had an internal emergency plan; an external major incident plan; a pandemic influenza plan; and a security policy. The internal emergency plan dealt with situations such as major fire or flood; utility failure; severe weather conditions or any situation which meets their definition, ‘security or health threat which imposes an immediate risk to health, life, property or environment or has a high probability of escalating to cause these situations’. The external major incident plan dealt with emergencies effecting the wider community. The security policy dealt with bomb alert and emergency building lockdown. The plans describe the roles and expectation of staff during emergency and flowcharts
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. We looked at five of the trusts largest value cash-releasing efficiency savings (CRES) schemes and found these all had robust and comprehensive quality impact assessments in place. Where cost improvements were taking place, they did not compromise patient care.
Providers are encouraged to report patient safety incidents to the National Reporting and Learning
System (NRLS) at least once a month. They do not report staff incidents, health and safety incidents
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). The trust reported more incidents from 1 April 2017 to 31 March 2018 compared with the previous 12 months. While the number of incidents reported has increased, the number of ‘Death’, ‘Severe’ and ‘Moderate’ harm incidents reduced.
Level of harm 1 April 2016 – 31 March
2017 1 April 2017 – 31 March 2018
No harm 8,118 11,360
Low 2,454 3,625
Moderate 972 447
Severe 46 23
Death 107 96
Total incidents 11,697 15,551
Information Management The board received holistic information on service quality and sustainability. The trust’s quality governance arrangements ensured a locality focus whilst maintaining consistency, learning and resilience across our clinical specialities. The quality assurance committee had the key purpose of providing assurance to the board of directors and council of governors on the quality and safety of the operational clinical services. The quality assurance committee received from each locality management and governance board a summary report which included aspects of safety and quality. In addition, the quality assurance committee received reports from the governance groups which contained a summary of all quality and safety issues raised and any points of escalation.
Directorate quality and assurance groups were chaired by each clinical director and head of service with a key purpose of developing the quality agenda. The directorate quality and assurance group's developed standards of best practice, informed for example by lessons learnt from incidents, patient experience reports. The senior clinical director from each locality attended the quality assurance committee. Each locality had a speciality-specific quality assurance group. The primary function of this group was to monitor the services that are in the directorate through reports following inspections, user feedback, performance data, audit, untoward incidents, complaints and CQC reports. They oversee the governance systems and appropriate delivery of action plans in their directorate to ensure compliance with all relevant standards. High level themes such as lessons learned from the directorate quality assurance groups are fed back into the directorate quality assurance groups and the senior clinical director incorporated these into the quality improvement and development work programme for that directorate. Locality management and governance boards provided assurance to the quality and assurance committee on a number of key issues, these were also attended by the deputy medical directors. The board receives assurance and exception reports from the quality assurance groups. Following receipt of this assurance was provided to the quality assurance committee. The director of nursing and governance was identified as the Caldicott guardian. 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. Managers could access information on the service dashboards related to staff training compliance, supervision, bed occupancy, patient and carer feedback, complaints, and incidents. Themes and trends were monitored through the trust governance processes and information shared across the service.
The board and senior staff expressed confidence in the quality of the data and welcomed challenge. The trust described the quality of internal and external data as good. They had governance, risk and management controls in place to monitor, action and provide assurance in relation to data quality. This was undertaken using both internal and external validation; Internal Validation:
• Internal validation of dataset submissions prior to submission deadlines
• Standard operating procedures for all data sets
• Segregation of duties from those submitting data and those who review data quality
• Use of Integrated Information Centre (IIC) to have a single repository of key trust data External validation of data quality:
• The data quality maturity index (DQMI), a quarterly publication intended to highlight the importance of data quality in the NHS, the trust was currently at 93.1% for the admitted patient care (APC) data set, MHSDS at 99.1%, IAPT 99.2% with and overall rating of 95.5%.
Information was in an accessible format, timely, accurate and identified areas for improvement. Information provided to NHSI has been consistent and reliable. Information presented at the quality assurance committee and the board was clear and concise. However, the trust has experienced some data quality issues such as appraisal data which was fed from electronic staff record, this had been corrected. Systems were in place to collect data from wards/service teams and this was not over burdensome for front line staff. 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. Each locality had a dashboard detaining each services activity in that locality. The data was categorised into patient activity (length of stay and referrals); quality (for
example; patients seen within four weeks of referral); workforce (for example; number of workforce in post and sickness absence rate) and money (cash releasing efficiency scheme delivery). Although the section on ‘money’ contained no data for the locality services in the example we looked at during inspection. It gave the current activity for that month and activity for the past 12 months. The trust was aware of its performance using key performance indicators and other metrics. This is fed into the weekly operational management team huddle and monthly executive management team huddle on performance.
There was a programme of internal clinical audit to monitor medicines optimisation processes including medicines reconciliation, omitted doses, pharmacist interventions and controlled drugs. Electronic prescribing and medicines administration was part of annual plan and implementation was planned for January 2019. Complete and accurate records about patient’s medicines were maintained in line with professional guidance and were proactively shared with other services when care was transferred. Discharge summaries were sent electronically to patients’ GP’s and to community pharmacies for certain patient groups. Staff could access GP summary care records to investigate medicines related queries. Information technology (IT) systems and telephones were working well and they helped to improve the quality of care. Staff had access to the IT equipment and systems needed to do their work. However, there were some areas in the services where access IT equipment was slow and cumbersome. The trust had plans in place to improve the systems within their digital transformation strategy which was approved by the board in January 2018. The key investment areas were:
• Development of the electronic patient record to include electronic care pathways, service user access portal and improved document handling.
• Integrated Information Centre – an integrated data warehouse that extracted data from a number of the trusts core systems (such as Paris, ESR, Health Roster and Datix) this enabled clinicians to monitor the delivery of their care via a range of key performance indictors (KPI’s), data quality breaches, clinical activity and interventions, clinical outcomes and key quality assurance measures and patient experience.
• Telemedicine – Skype for business was in the process of being piloted within corporate teams, the intention is that it will also be piloted for appropriate clinical consultations.
• Next generation devices – was a project that offered a number of products to improve the patient experience and reduce the time taken by clinicians on ‘administrative activities’. This approach was also enabling the collection and recording clinical information at the point of care.
• Development of an IIC data quality dashboard that reports key NHS data quality items, for example, NHS number, ethnicity, gender, religion, missing CPA level, employment status and accommodation status.
Leaders submitted notifications to external bodies as required. Notifications were submitted to CQC and strategic executive information system (STEIS) as necessary. The trust had completed the information governance toolkit assessment. An independent team had audited it and the trust took action where needed. Reviews were undertaken by AuditOne with exception reporting on the implementation of recommendations to the audit committee. AuditOne has mapped the existing audit programme to the national cyber security centre 10 steps. Additional AuditOne audits had been added to cover: user understanding and awareness; social engineering; and IT security incident management. The trust also carried out compliance checks against International Organisation for Standardisation (ISO) and security standards through on-site visits to suppliers and annual testing of disaster recovery and business continuity plans. Information governance systems were in place including confidentiality of patient records. The trust had established a digital safety board with cyber security identified as a key component. The electronic patient record system was password protected for each member of staff which is
prompted to be changed regularly. The trust had cyber-attack second on their integrated assurance framework and risk register. It had plans in place to improve staff awareness of cyber-attack and align this with the trust information governance training. The trust managed a cyber threat (May 2017) with minimal disruption to the services although it wasn’t directly involved. There have been no recent significant data breaches or network incidents. The board is fully engaged in the digital strategy and it also has oversight of the general data protection regulation.
Engagement The trust had a structured and systematic approach to engaging with people who use services, those close to them and their representatives and were using this to make improvements. NHS Improvement describe the trust as carrying out pre-engagement events and working alongside local clinical commissioning groups (CCG’s) to undertake consultations to ensure the best decisions are reached when a service change is required. Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. This was through staff, patient and carer meetings, surveys, comment cards, tablet computers, consultations, friends and family tests, patient involvement groups, coffee mornings and ‘have your say days’. Wards had a patient experience board that included the most up to date feedback the ward had received including comments. Some services displayed ‘you said, we did’ boards so that patients and carers could see how their feedback had been used to improve the service. Managers used the results of surveys to measure the quality of the service and the experience of people using the service. Patients were also involved in the recruitment of staff and took part in the interview panel. Patients were also involved in quality improvement events to input into how the service could develop from a patient perspective. Results from feedback were collected by ward and aggregated into the trust board dashboard performance reports. The trust had a patient experience group that met regularly and reported to the quality assurance committee. In acute wards for adults of working age and psychiatric intensive care units we told the trust when we inspected in January 2015 they should ensure that the patient survey on the patient experience tracker could be easily understood and provides meaningful data. This had been addressed. Communication systems such as the intranet and 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. The trust had a comprehensive intranet for staff and internet site for the public. There was a quarterly newsletter which provided information about what was happening around the trust. Patients, carers and staff had opportunities to give feedback on the service they received in a manner that reflected their individual needs. At discharge patients were invited to complete a patient experience questionnaire to provide feedback on their experience of the service. In older people inpatient wards, the service had signed up to the John’s campaign, a campaign for extended visiting rights for family carers of patients with dementia. Staff enabled families and carers to give feedback on the service they received. The trust used the friends and family test for patients, carers and staff to provide feedback to the board. The trust sought to actively engage with people and staff in a range of equality groups. The experiences of black, Asian and minority ethnic (BAME) and disabled staff are worse than those of white staff and the need to be a more diverse and inclusive employer is acknowledged by the trust. The trust was taking action to try and address this by providing a BAME staff leadership and management development programme and becoming a ‘disability confident’ employer. The trust has an annual board seminar consisting of a one-hour session delivered by three BAME staff where experiences and issues can be raised. The trust had an equality, diversity and human rights
steering group which met regularly and reported to the board via the quality assurance committee. The trust also had a diversity engagement group and spirituality group. The drugs and therapeutics committee were very engaged with carer and patient representatives. Information about medicines was available on the trust website. Clinical pharmacists were available to patients to talk about medicines and answer questions. The trust offered public Governors ongoing training from appointment. They were actively involved in the operation of the trust. The council of governors have regular meetings and receive a newsletter. There are a number of development days throughout the year for governors and they are asked about what these should contain. Where governor’s request information from the trust this is always supplied. The lead governor had direct access to the chair and chief executive and they always responded. They are also involved in the major appointments in the trust. The trust had a structured and systematic approach to staff engagement. Staff were engaged in the staff survey, staff friends and family test and the investors in people. The investors in people assessment identified the trust as having a demonstrable commitment to developing people, providing a wealth of wellbeing support and a working environment where people are mutually supportive and respectful. The quality improvement system offered an opportunity for staff to be directly involved in activities that improve their working lives and the experiences of the people that they care for. The trust was investing in a coaching based approach to leadership to create successful, healthy, and constructive change at individual and organisational levels. However, the trust had recognised it has issues with corporate communication, the volume of corporate communications, a heavy reliance on electronic communication, a lack of time for staff to read corporate communications and a lack of access to computers have been identified as contributory factors. The trust was taking action to address these issues by refreshing its approach to communications including introducing a crowdsourcing communication platform for use with staff, service users, carers, governors and partner organisations.
Staff were involved in decision making about changes to the trust services. The quality improvement system offered an opportunity for staff to be directly involved in activities that improve their working lives and the experiences of the people that they care for. The trust was refreshing their approach to communications including introducing a crowdsourcing communication platform for use with staff, service users, carers, governors and partner organisations. It was also designing, delivering and aligning training programmes that enable leaders and managers to coach staff to improve the way that they work and to work with greater autonomy. Supervisors were being trained in the framework for appraisal and talent management conversations which were aligned to the values and behaviours of the trust. The trust was actively engaged in collaborative work with external partners. The trust engaged with clinical commissioning groups with regular contract management board meetings attended by directors. These also had performance, service development and quality subgroups. The chief executive, chief operating officers and directors of operations also had frequent meetings with their equivalents in the nine clinical commissioning groups. In Durham, Darlington and Teesside the trust had agreed to develop an accountable care partnership for mental health and learning disabilities which would be responsible for commissioning and delivering mental health and learning disability services within an agreed financial envelope. A monthly accountable care partnership board had been set up. Discussions to set up a similar approach had recently started across the clinical commissioning groups in North Yorkshire. The clinical commissioning groups have also asked the trust to provide support/solutions when services provided by others are not providing appropriate quality services, for example when nursing homes have issues and the positive work done around transforming care.
The chief executive and / or the directors of operations in each locality attended health and wellbeing board meetings and other multi-agency boards with the local authorities. They also have individual meetings with relevant local authority senior managers such as the chief executive, directors of adult services and directors of children’s services. The trust engaged with local authority staff when identifying significant service change proposals including pre-engagement and formal consultation where appropriate. Relevant operational managers also attended overview and scrutiny meetings to discuss issues of interest to those committees. The trust also engaged with other partners including universities, other mental health trusts, GP’s and third sector organisations. External stakeholders said they received open and transparent feedback on performance from the trust. Positive feedback was received from external stakeholders such as local authorities, clinical commissioning groups, quality surveillance groups and third sector organisations. These described the trust as engaging very well and gave examples openness and transparency during collaborative working. There were service level agreements in place with local acute trusts to provide services to manage the Mental Health Act documentation and provide advice in Durham, Darlington, South Tees and Bishop Auckland. The trust worked closely with local authorities to develop multi-agency policies and protocols for areas such as section 136 place of safety.
Learning, continuous improvement and innovation The trusts quality improvement system (QIS) is a fundamental philosophy of continuous improvement (Kaizen) which was embedded throughout the whole organisation. Staff had training in improvement methodologies and used standard tools and methods. There was a dedicated kaizen promotion office that trained others in the quality improvement methodology, facilitate improvement events and quality assure all improvement events, to ensure rigour and standardisation. The trust used a range of standard QIS tools to provide a structured approach for identifying opportunities for improvement, with observation on the ‘shop floor’ being a critical component in seeing and eliminating wasteful activities. Staff were encouraged to make suggestions for improvement and gave examples of ideas which had been implemented. The trust was active in seeking ideas from staff and working together to develop, test and implement their ideas. This was well established as standard practice. There were organisational systems to support improvement and innovation work. The trust acknowledged that staff knew their systems best and could offer a range of solutions for improvement to create ownership and ‘buy-in’. Target progress reports, to document key metrics associated with all improvement activities, was a key tool in understanding the impact of changes and the plan, do, study, act approach was widely used. Once a month, each of the locality directors hosted a ‘report out’ to hear their teams share benefits, impact and lessons learned from all improvement activity that had occurred that month. These were attended by representatives from community, inpatient and corporate teams. Weekly executive management team ‘report outs’ ensured all improvement work in the planning and post event follow up phases, were monitored at a very senior level to ensure a continued connection to the trust strategic priorities and facilitated shared learning across all locality directors twice a year, the trust held a ‘celebrating success’ event to show case the best of the innovation across the trust. The trust actively sought to participate in national improvement and innovation projects. Over the last year the trust had worked with other local NHS trusts, service users and carers, the Northern England Clinical Network (NECN), Public Health England (PHE), Local Authorities (LA) and Teesside University to develop and launch “A Weight off Your Mind”. This is a plan for people with
lived experience of mental health conditions and/or learning disabilities receiving support from secondary mental health and learning disability services to achieve a healthy weight. The trust had developed a three-year project to implement the plan’s objectives which includes the development of a nutrition clinical link pathway.
The trust was actively participating in clinical research studies. The trust lead for research was the medical director and there was a clinical director and associate clinical director for research. The trust had a comprehensive research and development strategy and was engaged in over 90 clinical trials at the time of the inspection. The trust had links with University of York and was developing this relationship. Effective systems were in place to identify and learn from unexpected deaths. The trust had identified the chair and another non-executive director to take lead responsibility for oversight of progress and to act as a critical friend holding the organisation to account for its approach in learning from deaths. The trust had been working to understand the data around the deaths of service users and had a commitment to learning from deaths. During financial year April 2017 to March 2018 the trust had worked with eight other mental health trusts in the north of England, facilitated by Mazars, and had developed a reporting dashboard that brought together important information to help with this. The trust also undertook a formal mortality review process. The Trust had prioritised working more closely with families and carers of patients who have died to ensure meaningful support and engagement with them at all stages. The trusts learning from deaths report was presented at the board in July 2018 and set out the approach the trust was taking towards the identification, categorisation and investigation of deaths. For people with a learning disability the trust supported the national learning disabilities mortality review process and continued to link with the regional team to improve processes and receive feedback. Learning from the concerns raised by the coroner in Regulation 28 letters were discussed at quality assurance group and appropriate action agreed. The importance of recording communications with families was also discussed at the patient safety sub-group. During the inspection we looked at four serious incidents relating to unexpected deaths. All reports were clearly written and easy to read. Families that had raised concerns had their questions answered in full and had been involved in setting terms of reference. All reports included lessons learnt and an action plan. The chief pharmacist and medicine safety officer attended and feedback from regular regional and national meetings on issues relating to medicines optimisation. This information was used to review the organisations own medicines processes. The trust has employed a stopping of over medication of people with a learning disability, autism or both (STOMP) pharmacist to lead this work within the trust. A trust pharmacist is due to work with care homes starting September 2018 and there is a joint pharmacist post with South Tees hospital. Staff had time and support to consider opportunities for improvements and innovation and this led to changes. The service had a number of successful initiatives which had a made a positive difference to service delivery and patient care. In specialist community mental health services for children and young people the development of a five-day assessment for autism spectrum disorder had been effective in reducing waiting times. The service developed a streamlined assessment model which enabled the assessment period to be condensed to five days. Over 12 weeks, an additional 120 assessments were planned. The impact reduced the waiting list by 12 months. As a result, the service was successful in securing long term funding to roll out the model. The trust expected that over the next 12 months they would clear the waiting list and be able to offer a timelier assessment pathway. In wards for people with learning disabilities or autism staff used quality improvement methodology to improve patient flow and ensure excellent quality patient care, whilst delivering a reduction in bed numbers and the realignment of staff capacity to support more community based activity
enabling patients to stay in their own home. The results demonstrated that providing high quality and timely inpatient treatment reduces the length of stay considerably, allowing people to return to normal life as quickly as possible. This initiative was short-listed for Royal College of Psychiatrists quality improvement practice. In community-based mental health services for adults of working age one of the largest quality improvement projects the community teams were involved in was ‘purposeful and productive community services”. The purpose of this was to improve how services were delivered and managed. It aimed to remove waste so staff could focus on quality patient care. Purposeful and productive community services started in 2016. Since 2016 the trust had completed phase one which saw the implementation of team ‘cells’, and daily huddles, as well as improving caseload management. The service was in the process of phase two at the time of the inspection which focussed on developing the way teams worked, including improving clinical pathways, improving technology and how service users and carers are involved within development of services. In acute wards for adults of working age and psychiatric intensive care units the service at Peppermill Court received clinical team of the year in March 2018 for engaging multi-disciplinary teams across the trust in the purposeful inpatient admissions process (PIPA), this team had been praised for its leadership. The process had led to a significant reduction in the use of beds out of the area, which had a positive impact on patients and their families, as well as a reduction in the average length of stay. There had also been a reduction in incidents of violence and aggression and improved working with crisis team colleagues. Wards for older people with mental health problems Westerdale South ward had piloted an innovative way of implementing and tracking each patient’s journey through the behaviours that challenge pathway, using a visual road map. Since implementing the pathway on Westerdale South ward, all appropriate patients had a behaviour support plan in place, which focused on utilising preventative and least restrictive interventions to meet the patient’s needs. Community mental health services for people with a learning disability or autism had completed an audit against National Institute of Health and Care Excellence guidance for waiting times and as a result the team had undertaken some quality improvement work to reduce waiting times. This included reducing time staff spent travelling between appointments by conducting assessments at specified locations, and by training another member of staff to be able to carry out assessments to enable staff to see more patients in a quicker timeframe. External organisations had recognised the trust’s improvement work. Individual staff and teams received awards for improvements made and shared learning. The trust had been approached by external agencies to demonstrate the benefits of their quality improvement system. The trust also participated in the development of the NHSI publication ‘Valued care in Mental Health – Improving for Excellence’. In the general medical council Medical Trainees survey the trust were rated the best mental health trust by medical trainees and sixth of all trusts. The trust had been awarded investors in people gold standard.
NHSI describe the trust as having a history of delivery to the financial plan and achieving its
control total in financial year April 2017 to March 2018 and qualifying for additional incentive
funding. The trust signed up to the 2018/19 control total and will engage with the cash-releasing
efficiency savings (CRES) programme to support delivery, which it has a history of delivering
against.
We looked at five of the trusts largest value CRES schemes and found these all had robust and
comprehensive quality impact assessments in place.
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 (trust-wide only) and the relevant dates.
Accreditation scheme Core service Service accredited
AIMS - WA (Working Age
Units)
Acute wards for adults of working age and psychiatric intensive care units
Danby & Esk wards at Cross Lane Hospital; Roseberry Park Inpatients July 2017; Farnham Ward Lanchester Road Hospital; Tunstall Ward Lanchester Road Hospital; Maple Ward West Park Hospital Elm Ward West Park Hospital *Bilsdale Ward Roseberry Park Hospital
AIMS - PICU (Psychiatric
Intensive Care Units)
Acute wards for adults of working age and psychiatric intensive care units
Roseberry Park Inpatients (July 2017) Cedar Ward West Park Hospital
Quality Network for Forensic
Mental Health Services
Child and adolescent mental health wards
All secure mental health and learning disability wards at Ridgeway, Roseberry Park Hospital
AIMS - Rehab (Rehabilitation
wards)
Long stay / rehabilitation mental health wards for working age adults
Willow Ward West Park Hospital; Primrose Lodge, Chester-Le-Street
AIMS - OP (Wards for older
people)
Wards for older people with mental health problems
Rowan Lea, Cross Lane Hospital
ECT Accreditation Scheme
(ECTAS)
ECT - (Y&S ECTAS 15/09/17) ECT Suite, Roseberry Park
Home Treatment
Accreditation Scheme (HTAS)
Royal College of Psychiatrists
Y&S Crisis Resolution and Home Treatment Team accredited on 23 March 2016 for the next 3 years - expires 22 March 2019
Memory Services National
Accreditation Programme
(MSNAP)
Ham & Rich Memory Service had revalidation visit 30 Jan 18
Quality Network for Inpatient
CAMHS (QNIC)
- Westwood Ward Received QNIC Accreditation Evergreen Ward QNIC- continuation of Peer review and accreditation Newberry Ward
Between 1 March 2017 and 28 February 2018, there were 104 instances of seclusion. These were
highest in Bedale ward. The number of seclusion incidents reported during this inspection was
higher than the 75 reported in the previous year.
101 95
86
10198
140
154
130
92
117
49
69
12 11 1319 14 14 10 13 8
15 12 80
20
40
60
80
100
120
140
160
180
Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18
Total restraints over the 12 month period
Number of incidents of the use of restraintsNumber of prone restraints
149 (12%)
1083 (88%)
0 200 400 600 800 1000 1200 1400
Restraints Acute/ PICU (1255)
[1156]
Number of incidents
Number of incidents of restraint and prone restraint for this core service over the 12 months
Of the incidents of restraint, howmany were incidents of pronerestraint?Restraints that did not result in pronerestraint
Please note the figures in square brackets ,after the total number of restraints, are the number of different service users restraint was used on during this time period.
The trust had undertaken recent environmental risk assessments on all 16 wards. There were
ligatures identified on all wards, however they presented a lower risk as the trust had taken action
to mitigate them. A ligature point is anything which can be used to attach a cord, rope or other
material for the purpose of hanging or strangulation. The trust had mitigated these risks with the
use of increased observation as required and daily environment checks.
Patients were also individually risk assessed and risk management plans put in place in order to
alleviate ligature risk. These were recorded in patient care records and discussed at a daily
handover meeting.
There were blind spots on all of the wards which were mitigated through increased observations,
individual risk assessments, environmental adaptions, CCTV and daily environmental checks.
Most of the staff and patients we spoke to told us they felt safe on the wards, however two patients
on Sandpiper ward said they felt unsafe, as did a member of staff.
Wards complied with Department of Health guidance on same sex accommodation. There were no mixed sex wards within this service and over the 12 month period from 1 March 2017 to 31 March 2018, there were no mixed sex accommodation breaches within this core service.
Staff carried personal alarms and alarm systems were in place in communal areas on all 16 wards. Patient nurse call alarms were placed in accessible bedrooms and in all the patient bedrooms on Mallard ward.
There were no nurse call alarms throughout the service in the rest of the patient bedrooms. This was raised with the ward managers during our visit who told us they would rely on the patients shouting for help, if needed. Of the patients we spoke to, only one patient on Kestrel/Kite ward raised concerns regarding not having an alarm.
Maintenance, cleanliness and infection control
Ward areas were clean, had good furnishings and were well maintained. Each ward had a
cleaning roster and dedicated domestic support staff who were visible on the wards during our
visit. We saw little evidence of processes to reduce the risk and spread of infection, there was
minimum signage on the wards and there were no antibacterial hand gel dispensers available
around the ward areas. The most recent hand hygiene facilities and staff knowledge audit had
either identified that forensic wards were not applicable for the hand gel dispenser questions or
they were non-compliant, there were no follow up actions to rectify this. However, out of the eight
infection control audits that had been carried out on wards in the first quarter of the year, six of
them were in a green compliance rating and two were in amber. The last hand hygiene audit
carried out for forensic services was 92% compliant.
For the most recent patient-led assessments of the care environment (PLACE) assessment (2017)
Lanchester Road scored higher than similar trusts for cleanliness and lower than similar trusts for
condition, appearance and maintenance, dementia and disability, while Roseberry Park scored
lower than similar trusts for all four categories.
Site name Core service(s) provided Cleanliness Condition
appearance
and
maintenance
Dementi
a friendly
Disability
Roseberry Park
Acute award for adults of working age and psychiatric intensive care units Child and adolescent mental health wards Community based mental health services for older people Forensic inpatient (low/medium) Long stay/rehabilitation mental health wards for adults of working age Mental health crisis services and health based places of safety Other
97.0% 91.4% 63.5% 73.1%
Lanchester Road
Acute wards for adults of working age and psychiatric intensive care units Community based mental health services for older people Forensic inpatient (low/medium) Mental health crisis services and health based places of safety Wards for older people with mental health problems Wards for people with learning disability or autism Other
99.5% 93.7% 80.5% 79.7%
Trust overall 95.7% 91.3% 70.0% 76.9%
England average
(Mental health and
learning disabilities)
98.0% 95.2% 84.8% 86.3%
Seclusion room
Seclusion rooms were located on seven of the wards. All seclusion rooms allowed clear
observation, had access to natural light, had a clock visible to patients and had blinds present, that
were controlled by staff. The lights in the seclusion rooms were also able to be dimmed. Seclusion
rooms had a one-way intercom, however the trust told us that patients could easily attract the
attention of the observing staff and could be heard clearly from inside the room. All rooms had
access to temperature controls and air-conditioning, providing good ventilation for patients.
All seclusion rooms had access to anti-ligature blankets for the patients. They also had access to
lightweight anti-ligature blankets, depending on the patient’s preference. Seclusion clothing was
available for high risk patients.
Seclusion rooms were not available on all wards which meant wards had to share the use of
seclusion suites. Staff on Harrier/Hawk wards raised concerns that they had to transport their
patients quite a long distance to an alternative seclusion room if theirs is in use. Patients would
have to be escorted off the ward area and through the courtyard at Roseberry Park to use an
alternative seclusion facility, on a different ward. This could impact on the patient’s privacy and
dignity as the courtyard is a public area, patients being escorted could be viewed by other
patients, staff members, visitors and potentially members of the public in the main reception area.
Between January 2018 – June 2018 there was only one occasion where a patient had to use
Northdale seclusion suite as a patient from Merlin was in Harrier/Hawk’s.
Clinic room and equipment
Clinic rooms were clean and well maintained. Portable appliance testing stickers were visible on
all relevant equipment. On Lark and Clover/ Ivy wards stickers were not visible. The clinic rooms
were fully equipped with accessible resuscitation equipment and emergency drugs that staff
checked regularly. Emergency bags on Newtondale. Runswick/ Hawthorn, Merlin and Nightingale
wards were located in the staff office or on top of high cupboards in the clinic room, which made
them less accessible to staff.
There were inconsistencies in the recording of the room temperature on Linnet and Sandpiper
wards, with nine gaps across a two-month period.
The highest clinic room temperature was frequently recorded as over 25 degrees on seven of the
wards. We noted that on Nightingale ward the temperature was above 25 degrees for the full
duration of May and June 2018, with no action taken. This was not in line with trusts ‘medicines –
ordering, storage, transfer, security and disposal’ policy which stated any consistent temperatures
over 25 degrees should be escalated to pharmacists and estates and added to the risk register.
Temperature checks were within range and consistent on Ivy/Clover, Kestrel/ Kite, Thistle, Merlin,
Jay, Northdale, Harrier/ Hawk and Lark wards.
The range for fridge temperatures should be between two and eight degrees, as stated in the
trusts’ ‘medicines – ordering, storage, transfer, security and disposal’ policy. We noted highs of
nine degrees for eight days throughout May on Swift ward. The fridge temperatures across all
other wards were within two and eight degrees throughout May and June.
Safe staffing
Nursing staff
Ward staffing levels had been calculated and established when the ward opened based on ward type and patient group. The wards relied heavily on bank staff to meet their required establishment levels. Between March 2017 and February 2018 there was no shifts that were unable to be filled by bank or agency. Agency staff were used rarely and only on the learning disability wards. The baseline staffing establishment levels for each ward were as follows: Northdale Centre - Days: two qualified, six unqualified and Nights: one qualified, four unqualified Harrier/ Hawk wards – Days: two qualified, five unqualified and Nights: one qualified, two unqualified Kestrel/ Kite wards – Days: two qualified, four unqualified and Nights: one qualified, three unqualified Clover/ Ivy ward – Days: two qualified, four unqualified and Nights: two qualified, two unqualified Merlin ward – Days: two qualified, four unqualified and Nights: two qualified, two unqualified Nightingale ward – Days: two qualified, three unqualified and Nights: one qualified, two unqualified Linnet ward – Days: two qualified, three unqualified and Nights: one qualified, one unqualified Mandarin ward – Days: two qualified, five unqualified and Nights: one qualified, five unqualified
Newtondale ward – Days: two qualified, four unqualified and Nights: two qualified, two unqualified Lark ward – Days: two qualified, three unqualified and Nights: one qualified, two unqualified Sandpiper – Days: two qualified, four unqualified and Nights: two qualified, two unqualified Swift ward – Days: two qualified, four unqualified and Nights: one qualified, two unqualified Brambling ward – Days: two qualified, three unqualified and Nights: one qualified, two unqualified We did not obtain figures for Thistle ward, Jay ward or Mallard ward during our visit. When bank and agency staff were used they received a trust and security induction. Most bank staff were used regularly on the wards which meant they were familiar with the environment and patients. If a member of bank or agency staff was new to the ward they worked alongside a permanent member of for their first shift to ensure they familiarised themselves with the ward and patients. Ward managers could adjust staffing levels depending on case mix, this was discussed at a daily morning meeting between ward managers and modern matrons. Wards with high acuity levels would be prioritised for additional staff. The staff would regularly work between different wards within the service depending on patient risk. Wards were often short staffed due to the service not being able to secure additional bank and agency staff for shortfalls in their establishment levels, and substantive staff being reassigned to wards with greater acuity. Wards with higher acuity levels used staff from other wards that were already scheduled for that day. Therefore, this was regularly leaving wards below their baseline establishment figures. Between January 2018 – March 2018 15 out of 16 wards fell below their establishment levels. This resulted in leave being cancelled at short notice and blanket restrictions being put in place. Access to the courtyard on Merlin ward had to be requested 24 hours a day as there were not enough staff to accommodate the courtyard being open at all times. This was not in line with the trusts Restrictions policy. Staff shortages often resulted in staff cancelling escorted leave or ward activities Staff working across different wards meant that leave was often cancelled at short notice. Out of the 36 patients that we spoke to during our visit, 21 of them told us their leave was cancelled regularly due to staffing levels on the ward. The trust had processes in place to monitor cancelled leave. Between April – June 2018 9% of planned leave had been cancelled, which equates to 777 episodes. Of the 777 episodes of cancelled leave, 252 were due to staffing levels. The worst performing ward was Lark, out of the 67 episodes of cancelled leave on the ward, 48 were cancelled due to staffing, in the same period. Staff, patients and carers told us that this could often have an impact on patient behaviour and mood. This was raised with the service leads during our visit who told us that they were carrying out work to introduce more group leave for patients, however this wasn’t always possible for every patient, depending on individual risk assessments. Although we received strong feedback from the patients and carers that leave was cancelled due to staffing, the overall actual figure was low and we were unable to find any evidence from the data provided by the trust to corroborate the feedback. Between April – June 2018 out of 8573 planned instances of leave, only 3% was cancelled because of staffing. We also found that the trust was taking positive steps in trying to facilitate more frequent and regular leave for the patients. The table below shows staffing overview figures for this core service:
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff 28 February 2018 485.4 N/A
Total number of substantive staff leavers 1 March 2017–28 February 2018
36.8 N/A
Average WTE* leavers over 12 months (%) 1 March 2017–28 February 2018
8% 8% - 12%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) 28 February 2018 21.5 N/A
Total vacancies overall (%) 28 February 2018 4% N/A
Total permanent staff sickness overall (%) 28 February 2018 6% 4.5%
1 March 2017–28 February 2018
7% 4.5%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) 28 February 2018 213 N/A
Establishment levels nursing assistants (WTE*) 28 February 2018 308 N/A
Number of vacancies, qualified nurses (WTE*) 28 February 2018 -0.83 N/A
Number of vacancies nursing assistants (WTE*) 28 February 2018 22.2 N/A
Qualified nurse vacancy rate 28 February 2018 -0.5% N/A
Nursing assistant vacancy rate 28 February 2018 7.5% N/A
Bank and agency Use
Shifts bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 March 2017-28 February 2018
2077 N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses) 1 March 2017-28 February 2018
98 N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses) 1 March 2017-28 February 2018
0 N/A
Shifts filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 March 2017-28 February 2018
5563 N/A
Shifts filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 March 2017-28 February 2018
1 N/A
Shifts NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants) 1 March 2017-28 February 2018
0 N/A
*Whole-time Equivalent
This core service reported an overall vacancy rate of -0.5% for registered nurses at 28 February 2018. This means the service had an over establishment of qualified nurses.
This core service reported an overall vacancy rate of 7.5% for nursing assistants.
The sickness rate for this core service was 6% between 1 March 2017 and 28 February 2018. The most recent month’s data (February 2018) showed a sickness rate of 5%.
The below table covers staff fill rates for registered nurses and care staff during January, February and March 2018.
Eagle/Osprey ward was reported to be below the planned staff fill rate for both nurses and care staff for day shifts for all three months. These wards closed in March 2018 and were no longer in operation during our inspection. The wards were closed as a result of the transforming care agenda.
There were five wards that reported to be below the planned staff fill rate for nurse day shifts in January, eight wards that reported to be below the planned staff fill rate for nurse day shifts in February and six wards that reported to be below the planned staff fill rate for nurse day shifts in March.
There were eight wards that were reported to be above the planned fill rate for care staff night shifts in January, nine wards that were reported to be above the planned fill rate for care staff night shifts in February and 10 wards that were reported to be above the planned fill rate for care staff night shifts in March.
Patients told us that staff were visible and there was always a member of staff available when
needed, we also saw that staff were present in communal areas on the wards during our visit. Two
patients on sandpiper ward told us that they felt unsafe due to patient mix and staffing.
Medical staff
There was good input from medical staff across all of the wards. Each ward had input from at least
one consultant psychiatrist and support from junior doctors. All wards had an on-call system in
place. All wards had access to on-site doctors in the health centre and out of ours doctors that
could attend the ward quickly in an emergency.
Between 1 March 2017 and 28 February 2018, information was provided for the number of shifts, filled/not filled by agency staff to cover sickness, absence or vacancy for medical locums. However, the data was provided at hospital location and it was impossible to determine the ward/team allocation.
Mandatory training
The compliance for mandatory and statutory training courses at 28 February 2018 was 93%. Of the training courses listed six failed to achieve the trust target and of those, one failed to score above 75%.
Face to Face Medication Assessment was the one course that was below the CQC target of 75%.
Training in the Mental Health Act and Mental Capacity Act had the lowest compliance rate with figures falling below 70%. However, the trust told us there was an error on the training system which was preventing the compliance figure from being updated. We saw evidence that staff were in the process of completing this training during our visit and staff told us they felt they had a good understanding of the Mental Health Act and Mental Capacity Act. Although training was being carried out before it became mandatory, the trust told us they had a proposed date for all staff to have completed the training by March 2019.
The trust provided different types of resuscitation training. Nursing staff complete basic life support training, which complies with the Resuscitation Council’s training requirements for mental health inpatient services.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target % Trustwide mandatory/ statutory training total %
There were 265 incidents of prone restraint which accounted for 14% of the restraint incidents. Staff told us that they did use prone restraint when needed, but would always try to end the episode of restraint as soon as possible by turning the patient over as soon as possible. The staff were also able to describe alternative de-escalation techniques they would use before using prone restraint. We reviewed incident data during our visit that showed alternative de-escalation techniques were the first line of intervention and had been attempted in all the incident data we reviewed.
Over the 12 months, there was an unusually high use of restraint in May 2017, where there was a total of 238 incidents. From October 2017 to February 2018 restraints were stable ranging between 115 and 135 incidences. The highest number of restraint used was on Sandpiper. This was discussed with the ward manager during our visit who told us restraints were more frequent on that ward due to the patient mix being at high risk of self-harm.
Incidents resulting in rapid tranquilisation for this core services seem to have been stable with the highest numbers in April 2017 (73). Staff followed National Institute for Health and Care Excellence guidance when using rapid tranquilisation. Staff documented when rapid tranquilisation had been used, reported it as an incident and ensured observation monitoring was carried out after.
Staff used Mechanical restraint appropriately and followed the trusts policies and procedures when doing so. There were 19 instances of mechanical restraint over the reporting period. Mechanical restraint was used mostly on Merlin ward when transferring patients from hospital to court hearings. We saw evidence of the restraint being planned and documented in care plans. There were also clear processes in place to escalate the use of mechanical restraint to the trust board.
When mechanical restraint was used, the ward manager would fill out a form prior to the episode of restraint, senior managers were then responsible for authorisation. An incident form is completed and the use of restraint is then discussed and escalated through security group meetings, quality assurance group meetings and matron report meetings. The ward manager told us they had developed close links with the local courts and had negotiated with them to use video links for court hearings to prevent them having to take the patients off the ward and use mechanical restraint.
The number of restraint incidents reported during this inspection was higher than the 1508 reported in the previous year.
The number of seclusion incidents reported during this inspection was higher than the 102 reported
for the previous 12 months (1 March 2016 to 28 February 2018). Staff used seclusion appropriately
and followed best practice when doing so. Episodes of seclusion were monitored and recorded
electronically within patient notes. The trust had an allocated seclusion team, staff were selected
from different wards to form part of the team. The team were responsible for reviewing episodes of
seclusion to ensure protocols were being adhered to and medics were also involved in this process,
as required.
265 1642
0 500 1000 1500 2000 2500
Number of incidents
Number of incidents of restraint and prone restraint for this core service over the 12 months
Of the incidents ofrestraint, howmany wereincidents of pronerestraint?
There was one instance of long term segregation over the 12 month reporting period.
Safeguarding
Both adult and children safeguarding training compliance was 95% across this core service. The trust had a safeguarding team and safeguarding lead in place. Staff felt they had good relationships with the safeguarding team and knew how to contact them when needed. Staff were confident in the process of raising a safeguarding alert and did this when appropriate across all wards. Staff could give examples of how they would protect patients and how to identify any patients that were at risk of harm.
Staff told us they had good working relationships with the local authority safeguarding teams and could give us examples of when they had worked in partnership with them. They were also aware of how to locate safeguarding policies.
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.
This core service made 53 safeguarding referrals between 1 March 2017 and 28 February 2018, of which 52 concerned adults and one concerned children.
Tees Esk and Wear Valley NHS Foundation Trust have submitted details of five serious case reviews commenced or published in the 12 months 1 March 2017 to 28 February 2018. However, none that relate to this core service.
The service had processes in place to ensure children were safe when visiting family, which staff were aware of and able to explain to us during our visit. Patients were risk assessed before visits
1816
23
20
17
20
9
14 14 14 13
19
0
5
10
15
20
25
Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18
from children took place. If they presented as too high risk, staff would rearrange the visit when the patient no longer presented as high risk to safeguard the child. There were no children allowed in the perimeter of Roseberry park, there was a dedicated visiting room in the main reception for children visits.
Staff access to essential information
Staff used a secure electronic recording system for all patient records. The only paper form of
patient records used were patient appointment letters and individual section 17 leave forms. These
were stored in locked cabinets in the ward offices, which were locked at all times. Information was
easily accessible to all staff, including when patients were transferred between wards and teams.
Medicines management
Medicines were stored securely on the wards and the trust’s pharmacy team provided good clinical support. Staff told us they had strong relationships with the pharmacists and pharmacy technicians, who visited every ward at least twice a week and could be easily contacted when needed. All staff received medicines management training, the compliance rate was 90% for this core service during our inspection. The trust also carried out an annual medical assessment with staff. Ward managers were responsible for carrying out daily audits of medication management. The trust held a monthly medicines management meeting which was chaired by a consultant and attended by modern matrons, physical healthcare nurse practitioners and pharmacists. Staff used this meeting to discuss audit outcomes and actions going forward. This allowed the service to learn from audits and encouraged continuous learning. Prescription charts were checked to ensure compliance with the Mental Health Act and administration recording. Pharmacy and medical staff undertook medicines reconciliation. During the inspection we reviewed the medicines administration records for 68 patients. All prescription charts had been signed and dated, apart from one on Mandarin ward. The service had protocols in place to regularly review the effects of medication on patients’ physical health, in line with National Institute for Health and Care Excellence guidance, using a recognised rating scale. This was evidenced in patient care records.
Track record on safety
Providers must report all serious incidents to the Strategic Information Executive System (STEIS) within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there was one STEIS incident reported by this core service. Of the total number of incidents reported, the only incident was a commissioning incident meeting SI criteria.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with STEIS.
Staff had a good understanding of duty of candour and informed patients when something went
wrong, including near misses. They told us they would have face-to-face discussions with patients,
followed up with a letter if needed and inform patients’ carers, if the patient had given consent.
Incidents were discussed as part of a monthly meeting between ward managers, clinical leads,
modern matrons and members of the multi-disciplinary team. Ward managers also fed back
information on incidents to service leads on a weekly basis. Information from these meetings was
escalated to senior management meetings and fed down to the ward staff. Staff told us they
received de-briefs after incidents and received feedback through supervision and team meetings.
The trust offered an employee assistance programme to support staff after incidents, if needed. A
care programme approach day had recently taken place with staff, which focussed on how the
frameworks could help staff to understand their responses to distress at work, including when
patients were distressed.
A member of staff on Nightingale ward gave us a specific example of learning from an incident,
whereby a patient went missing after using toilet facilities during leave with an occupational
therapist. On reflection of the incident they found that the section 17 form conditions differed to the
patient’s occupational therapy leave form. Staff developed and implemented a standardised form
which meant the section 17 leave and occupational therapist leave forms were the same,
minimising the chances of a similar incident happening again.
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 were six ‘prevention of future death’ reports sent to Tees Esk and Wear Valleys NHS Foundation Trust. None of these related to this core service
The trust’s target for appraisal compliance was for all staff to have an annual appraisal. As at 28
February 2018, there were no medical staff eligible for appraisals for this service.
The trust’s measure of clinical supervision data was 100% (8hrs clinical supervision per year)
Between 1 March 2017 and 28 February 2018, the average rate across all teams in this core service was 85% of the trust’s target. The trust average was 82%. All wards in this core service failed to achieve the trust target of 100%
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide.
Managers identified the learning needs of staff through supervision and provided them with
opportunities to develop their skills and knowledge. There was good access to specialist training.
Staff on Linnet ward told us they had completed training in diabetes and positive behavioural
support. Staff on Mallard ward had completed advanced training in physical healthcare, falls,
moving and handling, end of life and palliative care.
There were processes in place to manage staff performance effectively which involved informal
and formal discussions when required, increased supervision and one-to-one time and peer
support.
Multi-disciplinary and interagency team work
Staff held weekly multidisciplinary meetings on all wards. The meetings were led by the doctors
and attended regularly by nurses, occupational therapists, psychologists, social workers and
dieticians and pharmacists. Speech and language therapists would attend when required.
Staff on all wards attended handovers before each shift where they shared information about
patients within the team. Staff discussed patient behaviours, changing risks, leave and allocated
staff responsibilities for the shift.
The 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 and local authorities.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
During our visit we saw evidence that staff had completed training or were booked on to training courses in the future. Staff we spoke to had a good understanding of the Mental Health Act and the Code of Practice.
The trust had up to date and relevant policies and procedures that reflected the most recent guidance. All staff had access to local Mental Health Act policies and procedures and to the Code of Practice through the trust’s intranet.
Staff had easy access to the Mental Health Act office. Staff told us the Mental Health Act team were very helpful and approachable. Staff often contacted the office if they needed any advice regarding the Mental Health Act.
Staff explained to patients their rights under the Mental Health Act in a way they could understand and repeated this as required. We noted during our visit that this was recorded in patient care records.
We reviewed 50 care records during our visit in relation to the appropriate documentation of
Mental Health Act records. Staff stored patients’ detention papers and associated records correctly
and they were easily accessible to staff on the electronic recording system. Relevant consent to
treatment forms were dated and present for all patients. Section 17 leave documentation
(permission for patients to leave hospital) was also stored electronically and in date. One section
17 leave form on Merlin ward had not been crossed through to indicate that the authority was no
longer valid. We discussed this with the ward manager who told us that forms were removed from
the system by the central Mental Health Act team, the team had made a request for the form to be
removed.
The Mental Health Act team carried out audits of documentation and provided feedback on errors
to ward managers, which were shared with the team through email or supervision. The ward
managers also carried out monthly audits of the electronic recording system which included
Mental Health Act documentation.
Good practice in applying the Mental Capacity Act
Most of the staff we spoke to said they had received training in the Mental Capacity Act. As of 31 March 2018, there was no information provided in relation to Mental Capacity Act Training. During our visit we saw evidence on visual boards that training had recently been completed and staff were booked on to training courses.
Most of the staff had a good understanding of the Mental Capacity Act and the five statutory principles, including some healthcare assistants.
The trust had an up to date policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and told us 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.
We reviewed 50 care records and saw evidence that mental capacity assessments were being carried out or that capacity had been assumed on 49 of the records. One care record Nightingale showed no evidence of capacity assessment.
Mental capacity assessments were recorded appropriately. When patients lacked capacity, staff made decisions in their best interests, recognising the patient’s wishes, feelings, history and culture which was evident in care records.
Ward managers were responsible for auditing Mental Capacity Act documentation and took action on any learning that resulted from it. Hawthorn/Runswick ward had completed work with the staff on the ward around what should be documented, after feedback from a recent audit.
The trust told us that 52 Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority between 1 March 2017 and 28 February 2018. However, none pertained to this service.
Is the service caring? Kindness, privacy, dignity, respect, compassion and support
We spoke to 36 patients across all wards who gave us mixed feedback about the staff. 14 patients reported that the staff were polite, caring, and responsive to their needs, whilst, whilst other patients thought staff could be quite abrupt and demanding towards them. Not all the patients we spoke to wished to comment on the attitudes of staff.
We saw that staff knew the patients well during our visit and supported them to understand and manage their care. Staff displayed their understanding of the needs of patients including their, personal, cultural, social and religious needs during our visit. Merlin ward had recently introduced a multi-cultural menu for patients on their ward.
Staff directed patients to other services when appropriate and supported them to access services, if required. This was corroborated by the patients on the wards and written notes in patient care records. Staff maintained the confidentiality of patients throughout the wards.
The 2017 Patient-led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at Lanchester Road scored higher similar organisations, while the score at Roseberry Park was lower than at similar organisations
Site name Core service(s) provided Privacy, dignity
and wellbeing
Roseberry Park
Acute award for adults of working age and psychiatric intensive care units Child and adolescent mental health wards Community based mental health services for older people Forensic inpatient (low/medium) Long stay/rehabilitation mental health wards for adults of working age Mental health crisis services and health based places of safety Other
89.8%
Lanchester Road
Acute wards for adults of working age and psychiatric intensive care units Community based mental health services for older people Mental health crisis services and health based places of safety Wards for older people with mental health problems Wards for people with learning disability or autism Other
91.0%
Trust overall 87.7%
England average (mental health
and learning disabilities) 90.6%
Involvement in care
Involvement of patients
There were processes in place to orient patients on to the wards on admission. Patients were
given a welcome pack on admission which contained information regarding the ward, meal times,
visiting times, advocacy services and information about the patient’s rights. Patients were also
given information about the staff on the ward and informed who their named nurse was.
The trust provided information regarding average bed occupancies for all wards in this core service between 1 March 2017 and 28 February 2018.
The wards within this core service reported average bed occupancies ranging above the provider benchmark of 85% over this period.
We were unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the time period that was covered.
Ward name Average bed occupancy range (1 March 2017 to 28
February 2018) (current inspection)
FMH RP Lark Ward Low Sec Male 97.4% - 110.4%
FLD RP Thistle Med Sec 97.3% - 100.0%
FMH RP Mandarin Ward Med Sec Male 93.8% - 100.0%
FMH RP Brambling Ward 93.6% - 100.0%
FMH RP SWIFT WARD MED SEC FEMALE 92.9% - 100.0%
NORTHDALE CENTRE - HAWTHORNE AND
RUNSWICK WARD 91.7% - 100.0%
FMH RP NIGHTINGALE WARD 87.5% - 100.0%
FMH RP Newtondale Ward 87.4% - 96.8%
FLD RP CLOVER IVY WARD 83.3% - 91.7%
FLD RP KESTREL KITE ASD 80.0% - 87.5%
FLD RP HARRIER HAWK WARD 80.0% - 100.0%
FMH RP SANDPIPER WARD 76.2% - 100.0%
MERLIN WARD 74.7% - 100.0%
FMH RP Linnet Ward 74.2% - 100.0%
FMH RP Jay Ward Low Sec Male 53.6% - 98.7%
FLD RP EAGLE OSPREY WARD 50.0% - 100.0%
FLD LRH Langley Ward 30.0% - 59.0%
FMH RP Mallard Ward 0.0% - 93.8%
ARNSGILL-MALLARD 0.0% - 86.0%
Core service total 0.0% – 110.4%
The trust provided information for average length of stay for the period 1 March 2017 to 28 February 2018.
We were unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the time period that was covered.
Ward name Average length of stay range (1 March 2017 to 28
The trust reported 545 out area placements between 1 March 2017 and 28 February 2018. None of these placements related to this core service. Beds were available when needed for patients living in the catchment area of the trust. If there was not a bed available for the patient, they would be admitted to the nearest locality and ensure they were moved into their catchment area as soon as possible, if this reflected the patients’ wishes.
This core service reported no readmissions within 28 days between 1 March 2017 and 28 February 2018
The staff told us there was always a bed available when patients returned from leave.
Discharge and transfers of care
Between 1 March 2017 and 28 February 2018, there were eight discharges within this core service. This amounts to 0.4% of the total discharges from the trust overall (4138). Of the eight discharges for this service three (38%) were delayed.
The graph below shows the trend of delayed discharges across the 12 month period.
Staff planned for patients’ discharge from the point of admission. The service used visual boards
located in offices on the wards to monitor and plan each patients’ discharge. The staff looked at
indicative dates for each point in the treatment and discharge process and shared timescales with
the ward team and external teams. Staff discussed this process with patients and monitored
progress in formulation meetings, multi-disciplinary team meetings and weekly bed management
meetings. There was evidence of discharge planning in patients’ care records.
Staff supported patients during referrals and transfers between services. We saw evidence in care
records that staff had accompanied patients to external appointments and facilitated transfers of
patients. On Runswick ward staff had given one of the patients a photo of them outside of their
new placement, to help them visualise where they were going. The patient fed back that this had
There were no activity schedules or therapeutic activities taking place on the weekend on 10 of the
wards. This was not in line with the National Institute for Health and Care Excellence guidance
which states that services must ensure activities are planned on weekends. Staff told us that ad
hoc activities could take place on the weekends, if the patients requested this. Patients on three of
the wards commented that there was minimal to no activities available on the wards. Three carers
also fed back that there was a lack of activities.
There were processes in place to measure the outcomes of structured activities being carried out
by the occupational therapy staff and what impact they were having on the patients. Occupational
therapists used a standardised assessment tool that demonstrated positive outcomes and
progression in skills for service users.
Patients had access to mobile phones on lower risk wards following a risk assessment and could
make private phone calls. Patients assessed as at risk of having their own phone could use the
ward phone in a private room to make calls.
Patients on all wards had access to outside space. Depending on staffing levels, patients could
not access the outdoor space 24 hours per day. We found that patients on Merlin ward were
regularly restricted from using the courtyard throughout the day. This was not in line with the
trust’s Restrictions Policy which stated that limited access to outdoor space should only occur
during night times.
Patients had access to hot drinks and snacks 24/7 on all wards except for Merlin ward. Staff told
us that they restricted the drinks and snacks that were available to patients, due to it being
consumed too quickly by them. This was not in line with the trust’s policy that stated that access to
snacks and foods should only be limited due to a service user having a severe food allergy.
The 2017 Patient-led Assessments of the Care Environment (PLACE) score for ward food at both of the locations scored higher than similar trusts.
Site name Core service(s) provided Ward food
Roseberry Park
Acute award for adults of working age and psychiatric intensive care units Child and adolescent mental health wards Community based mental health services for older people Forensic inpatient (low/medium) Long stay/rehabilitation mental health wards for adults of working age Mental health crisis services and health based places of safety Other
98.3%
Lanchester Road formerly known
as Earls House
Acute wards for adults of working age and psychiatric intensive care units Community based mental health services for older people Forensic inpatient (low/medium) Mental health crisis services and health based places of safety Wards for older people with mental health problems Wards for people with learning disability or autism Other
100.0%
Trust overall 97.2%
England average (mental health and learning disabilities) 91.5%
Leaders had the skills, knowledge and experience to perform their roles. They had a good
understanding of the services they managed and 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. All the staff we spoke
to felt supported by their managers and felt they could raise concerns or approach their managers
for support outside of protected supervision or one-to-one time. We saw that relationships
between staff were positive and supportive during our visit and that management were accessible
in their approach.
Leadership development opportunities were available, including opportunities for staff below team
manager level. We spoke to a number of staff who had progressed to management positions
within the trust.
Vision and strategy
Staff we spoke to were aware of the trusts’ visions and values. It was evident the senior leadership team and service leads had successfully communicated the visions and values of the trust to the frontline staff in the service. Staff felt they could contribute to discussions about the strategy for their service and could contribute to changes within the service. The service takes part in a project called model wards. This allowed frontline staff to look at what a perfect ward would be and staff held regular meetings which provided an opportunity to input ideas and encourage change across the service.
Culture
Staff we spoke to felt respected, supported and valued. Staff were positive about working for the
trust and spoke highly of their colleagues and team.
Staff felt able to raise concerns without fear of retribution and knew how to use the whistleblowing
process and knew about the role of freedom to speak up guardian.
Managers dealt with poor staff performance when needed and appraisals included conversations
regarding development and how staff could be supported in this. Teams worked well together and
provided peer support in difficult situations.
During the reporting period there were seven cases where staff had been either suspended, placed under supervision or were moved to a different ward. One staff member had been suspended and six were placed under supervision.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
Suspended Under supervision Ward move Total
1 6 0 7
Staff reported that they were supported in career progression. There were staff members who
were currently acting up as ward managers during our visit. The staff told us they were well
Staff felt they had access to the equipment that they needed to do their job. Staff understood how
the systems worked, however, some staff fed back that the electronic recording system for patient
records was sometimes difficult to navigate.
Patient records were held securely on password protected systems to ensure confidentiality.
Team managers felt they had access to information to support them in their role, this included
information on the performance of the service. They had close working relationships with the
service leads and felt like they made an impact on their wards.
Staff made notifications to external bodies, as needed. We saw evidence of this during our visit.
Engagement
The trust held regular away days and team events which aimed to engage staff, patients, carers
and care partners to make changes that improve the service. During our visit we observed a
healthy eating event taking place at Roseberry Park, in which staff and patients were involved.
Staff also told us that being able to put forward ideas to wards managers and service leads for
away days has encouraged them to contribute more and makes them feel more involved in service
changes.
Staff received regular trust bulletins via email and could access updates on the intranet. Patients
and carers were kept up to date through communication on the ward, posters and meetings.
Patients and carers had further opportunities to feedback on the service through regular surveys.
Managers had access to the feedback from patients and carers and used it to implement
improvements on the wards. On Mallard ward the staff had introduced cooking sessions with the
patients after they received feedback from them that they would like to cook more, we saw that the
patients were actively involved in this during our visit to the ward.
Service leads held regular external stakeholder engagement events and meetings to ensure
regular communication.
Learning, continuous improvement and innovation
Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. We spoke to a number of health care assistants who had been enrolled on a three-year course at a local university to gain qualifications in health care.
Staff also had a links with a local university and were carrying out a piece of work around the use of seclusion, linking in with high secure services and looking at research to understand how they could reduce the use of seclusion across the service.
Staff used quality improvement methods and knew how to apply them. The service had implemented a quality project called ‘model wards’. The overarching objective of the Model Ward project was to improve the quality, safety and patient experience through improving productivity. They had selected wards that were performing well as an example to the other wards across the service. The two model wards across the service were Nightingale and Kestrel/Kite. The model wards had weekly meetings, involving patients to understand where improvements could be made.
The model wards also took responsibility of trailing new processes before they were rolled out across the service. On Nightingale they had introduced a ‘recovery champion’ scheme to encourage patients to engage in the model wards programme. Patients would vote for a monthly recovery champion and the winner would receive an online shopping voucher. Model wards produced a regular newsletter for the service which included a programme update, ‘you said, we did’ section, upcoming improvement events and contact details for the model wards lead.
The trust used quality improvement projects such as ‘Kaizen’ events and ‘Rapid Process Improvement Workshops’. Four of these events had taken place in 2018 concentrating on review
of security induction, care programme approach/ recovery meeting and healthy eating. The staff we spoke to had either been involved or invited to take part in these events and were able to give us examples of improvements to the service following the events.
A project was undertaken to look at how our nurses effectively manage their shifts. A new electronic diary was introduced to prevent tasks being lost in paper diaries, and a daily coordination board was set up so that staff could see at a glance where they were supposed to be and what they are supposed to be doing. Staff told us this process had improved communication and organisation on the wards.
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 in order to continue to be accredited.
The service is a member of the Royal College of Psychiatrist Quality Network Accreditation.
This core service reported an overall vacancy rate of 12% over establishment for registered nurses and 24% over establishment for registered nursing assistants at 28 February 2018.
This core service has reported a vacancy rate for all staff of 19% over establishment as of 28
February 2018.
The trust does not have a target for vacancies.
Registered nurses Health care assistants
Ward/Team Vacancies Establishment Vacancy
rate (%) Vacancies Establishment
Vacancy
rate (%)
CLD IP ROSEBERRY
PARK BAYSDALE 0.3 7.7 4% 1.0 15.3 6%
CHILD AND YP IP
WLH NEWBERRY
CENTRE
-3.1 14.0 -22% -2.5 17.9 -14%
CHILD AND YP IP
WLH WESTWOOD
CENTRE
-1.3 17.1 -8% -12.6 19.3 -65%
CLD WPH HOLLY
UNIT -1.5 5.3 -28% -0.1 5.5 -2%
Evergreen Centre -1.3 15.7 -8% -5.1 21.5 -24%
Core service total -6.9 59.8 -12% -19.3 79.5 -24%
Trust total 46 2231.9 2% 125.8 1915.9 6%
NB: All figures displayed are whole-time equivalents
During the previous inspection we identified areas of concern in relation to the provider ensuring
ward managers had an accurate record of staff supervision to demonstrate that trust policy is
being followed. We found this had improved for this inspection.
Staff had regular supervision and felt supported by management. The trust protocol was for all
staff to receive eight hours of supervision each year which can include group supervision, with one
supervision every three months on a 1:1 basis. Staff confirmed supervision was being carried out
on each of the five wards, however three wards compliance stated in the table below were 70% or
below which was not in accordance with policy. The trust had recently audited staff supervision
and there was an action plan in place to improve the recording and monitoring of it.
Between 1 March 2017 and 28 February 2018, the average rate across all five teams in this core service was 80% of the trust’s target.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.
Ward name Clinical supervision
sessions required
Clinical supervision
sessions delivered
Clinical supervision rate
(%)
Holly 56 56 100%
Baysdale 200 216 108%
Newberry Ward 143 78 55%
Westwood Ward 159 111 70%
Evergreen Centre 165 114 69%
Core service total 723 575 80%
Trust Total 21668 17840 82%
Multi-disciplinary and interagency team work
The teams operated within a multidisciplinary team framework and we observed a collaborative
approach to care and treatment.
Regular and effective multidisciplinary meetings took place and we attended two during our
inspection. The meetings were planned, well-structured and demonstrated clear, effective
communication of information which encouraged joined up working. Discussions were
comprehensive, covering areas such as risk, changes in presentation and safeguarding concerns.
Discussions consisted of the reviewing individual patients including their current presentation;
responding quickly to changing needs, identifying key concerns and issues and updating daily risk
assessments; reviewing medication and reviewing the level of support required. New risks and
behaviours were also identified and responded to. Peer support and advice was offered within the
meetings.
Handover formats were comprehensive and well planned. The information discussed, allowed full
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 table below shows which services within this core service have been awarded an
accreditation although the trust have not provided applicable dates of the accreditation.
Accreditation scheme Service accredited
Quality Network for Inpatient
CAMHS (QNIC)
Westwood Ward Received QNIC Accreditation Newberry Ward QNIC – Accredited with Excellent Evergreen Centre QNIC- continuation of Peer review and accreditation
Royal College of Psychiatrists
Centre for Quality Improvement
(CCQI)
Westwood Centre - CQCI Quality Network for Inpatient CAMHS Accreditation, PIPE team at HMP Low Newton - Enabling Environment Award
Nationally, the trust participated in the New Models of Care pilot. This entailed managing the
budget for the Tier 3-4 Children’s and adolescent mental health services pathway. For example,
they used an evidence based approach to improving the provision of children’s and young
people’s crisis services in the North Yorkshire area to reduce the demand on inpatient beds.
We conducted a tour of the environment on all the wards we visited. Ward layouts were seen to be appropriate for the specific client groups Although not formally accredited to the University of Stirling, Dementia Services Development Centre standards, organic wards were seen to be modelled on the standards to reflect the needs of patients. Ward layouts enabled patients to walk around the communal areas to prevent them becoming disorientated and the use of pictorial signs helped to identify the function of specific rooms for example a bathroom or a bedroom. Handrails were installed to the walls to aid patients with mobility difficulties.
Staff were aware of where the blind spots were and the wards mitigated these using CCTV, individual patient risk assessment and observations. Staff completed daily checks to identify any potential environmental risks. When an environmental risk was identified this was reported to the estates department for repair. All wards had a current environmental audit including a ligature assessment. There were ligature risks on 13 wards within this service. The trust had undertaken recent (from 5 April 2017 onwards) ligature risk assessments at 11 locations. All wards had a ligature risk assessment in the last 12 months. None of the wards presented a high level of ligature risk however all wards presented a lower risk due to a multitude of risks. The trust had taken actions in order to mitigate ligature risks. Where it was not possible to remove ligature risks patients were individually risk assessed regards their ligature risk and individual risk management plans were used. However, ligature risks were not scored or rated to indicate the severity of the risk and the ligature risk assessment completed on Rowan ward did not take account of the garden area and any associated risks. Over the 12 month period from 1 March 2017 to 31 March 2018 there were no mixed sex
accommodation breaches within this service.
There were nine mixed sex wards across the service and we found all nine wards were compliant
with guidance on mixed sex accommodation. Each ward had a separate female only lounge and
patients could access bathrooms from their bedroom without having to pass rooms occupied by a
patient of the opposite sex.
Ward 14 and Rowan ward had beds in dormitory style bays. Beds on ward 14 were separated by a
divider with a curtain at the end of the bed and beds on Rowan ward were separated by a curtain.
All bays were single sex bays with a shared sink. Patents could access a communal bathroom
without having to pass rooms occupied by a patient of the opposite sex.
At the last inspection patients who used the bed bays told us that they felt unsafe and that if
another patient was unwell this could disturb their sleep and impact on their privacy and dignity.
However, at this inspection patients we spoke with did not raise any concerns regards their safety
or dignity. However, patients on Rowan said the problem with the bed bays was that not all beds
had a window and access to natural light.
Managers told us they had installed dividers on ward 14 between the beds as an interim measure
to improve the environment. However, this had not been possible on Rowan ward as the trust did
not own the building. Staff managed the safety of the dormitory environment through individual
intervention plans, staff awareness of patient need and an increased presence around the bays.
Staff were located on the corridors at night to ensure they could observe the environment.
There was a plan in place to reduce the use of dormitory accommodation within the service.
Staff carried wireless call alarms to call for assistance during an incident. Procedures were in
place for staff to check the alarms regularly ensuring they were working. Spare batteries were
available for alarms which were not rechargeable.
However, there were no nurse call alarms available in-patient bedrooms and some communal
areas on Acomb garth, Meadowfields and ward 14, this meant patients were unable to summon
assistance in these areas in the event of an emergency. Ward managers on Acomb garth and
Meadowfields told us where there was a risk this could be mitigated against in bedrooms using
bed sensors and infrared movement sensors. Although, patients were still unable to summon help
directly themselves.
Windows in patient rooms on Meadowfields and Acomb Garth were partially obscured. However, as the windows were not fully obscured, this meant that patients in other wards could potentially see in to the bedrooms across the courtyard. This was mentioned to the ward manager who advised they would place a request for estates to address the issue.
Maintenance, cleanliness and infection control
Each ward had dedicated housekeeping staff who worked on the wards which were seen to be
clean and well maintained, cleaning schedules were in place demonstrating daily and periodic
cleaning was completed. Cleaning products were appropriately stored in a locked cupboard and
the relevant control of substances hazardous to health data sheets were available in the cupboard.
Staff were observed adhering to infection control principles and were seen to use appropriate
protective equipment including aprons and gloves where necessary. Sinks and alcohol gel were
available for staff use and staff were seen to wash their hands before and after direct patient
contact.
For the most recent Patient-Led Assessments of the Care Environment (PLACE) assessment
(2017), all the locations received a score lower than other similar trusts for cleanliness, other than
Lanchester Road FKA Earls House which scored 99.5%. compared to 98% nationally.
For condition, appearance and maintenance all locations scored below the national average of
95.2%,
For dementia friendly, all locations scored below the national average of 84.8%.
For disability, Meadowfields scored above the national average of 86.3% but all other locations were
Acute wards for adults of working age and psychiatric intensive care units Forensic inpatient (low/medium) Mental health crisis services and health based places of safety Wards for older people with mental health problems Wards for people with learning disability or autism Other
99.5% 93.7% 80.5% 79.7%
Springwood Wards for older
people with mental
health problems
85.4% 89.4% 82.6% 84.7%
West Park Hospital Acute wards for adults of working age and psychiatric intensive care units Child and adolescent mental health wards Long stay/rehabilitation mental health wards for adults of working age Mental health crisis services and health based places of safety
Wards for older
people with mental
health problems
97.6% 90.7% 73.9% 75.1%
Sandwell Park (closed at
time of inspection)
Wards for older
people with mental
health problems
96.4% 91.2% 63.6% 72.6%
Friarage Hospital Acute wards for adults of working age and psychiatric intensive care units Mental health crisis services and health based places of safety
There was a clinic room on each of the wards. They were all fully equipped with accessible
resuscitation equipment and emergency drugs. Registered nurses had access to the keys to the
clinic rooms and sufficient staff were available with access as required in an emergency. All clinic
rooms were clean and well maintained and tidy.
There were appropriate arrangements for the management of controlled drugs (medicines that
require extra checks and special storage arrangements because of their potential for misuse).
Staff monitored the temperature of the fridges and the clinic rooms to ensure temperature ranges
remained within an acceptable range to store medications.
Staff undertook regular comprehensive checks of all equipment, resuscitation equipment,
controlled drugs and stock medication to ensure everything was in working order and in date.
Safe staffing
Nursing staff
Managers told us minimum staffing levels had been calculated based on the anticipated level of patient needs and was different for each ward. The base line staffing for the wards was two qualified staff and two nursing assistants during the day and one nurse and two nursing assistants at night. Managers had the authority to increase staffing levels to meet the level of patient needs and said the service recognised the needs of the patient group not only related to observation levels due to patient behaviour but also took account of patients’ frailty and personal care support needs. Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff 28 February 2018 394.8 N/A
Total number of substantive staff leavers 1 March 2017–28 February 2018
45.0 N/A
Average WTE* leavers over 12 months (%) 1 March 2017–28 February 2018
NB: All figures displayed are whole-time equivalents
At the time of the inspection the trust provided data to indicate that as of 31 May 2018 the overall vacancy rate had reduced to 13.08 whole time equivalent posts, 3.93% of the overall establishment. Acomb Garth, Rowan Lea and Cherry Tree House had the highest overall vacancy rate.
Managers told us the service had been working to reduce the vacancy rate and had been actively recruiting to vacant posts. The service had recruited an additional nine health care assistant posts above the trust establishment. When in post these roles would work across the service and could be deployed to where they were most needed.
Between 1 March 2017 and 28 February 2018, bank staff filled 808 shifts to cover sickness, absence or vacancy for qualified nurses.
In the same period, agency staff covered 249 shifts for qualified nurses and 56 shifts were unable to be filled by either bank or agency staff.
The sickness rate for this core service was 7.0% between 1 March 2017 and 28 February 2018. The most recent month’s data (February 2018) showed a sickness rate of 5.4%.
Over the 12-month period, the core service reported sickness rates between 5% and 9%, with December 2017 reporting the highest sickness with 9%.
Ward/Team
Total % staff
sickness
(at latest month)
Ave %
permanen
t staff
sickness
(over the
past year)
D&D MHSOP - Bowes Lyon Picktree Ward (closed at time of
inspection) - 0.0%
D&D MHSOP - Bowes Lyon Roseberry Ward 0.5% 4.3%
D&D MHSOP - Bowes Lyon Wards 0.0% 0.9%
D&D MHSOP - Ceddesfield CB 4.2% 8.5%
D&D MHSOP - Hamsterley Ward 4.2% 12.4%
D&D MHSOP - Medical Staff 1.9% 1.1%
D&D MHSOP - Oak Ward 4.0% 5.2%
NY MHSOP - H&R Medical Staff 0.0% 1.9%
NY MHSOP - Hambleton and Richmondshire Ward 14 6.6% 2.7%
NY MHSOP - Scarborough Cross Lane Rowan Lea 6.9% 7.1%
Tees MHSOP - Junior Medical Staffing - 0.8%
Tees MHSOP - Medical 1.2% 0.5%
Tees MHSOP - Sandwell Park Wingfield (closed at time of inspection) 0.0% 5.5%
Tees MHSOP - South Tees Medical Inpatients - 0.2%
Tees MHSOP - Westerdale North 13.2% 12.8%
Tees MHSOP - Westerdale South 5.2% 6.3%
Y&S AMH - IP Dementia OT - 0.0%
Y&S MHSOP - Acomb Garth 10.3% 13.6%
Y&S MHSOP - IP BPH Cherry Tree House 8.9% 8.9%
Y&S MHSOP - IP Selby Worsley Court Cue - 6.0%
Y&S MHSOP - IP York Meadowfield Cue 6.8% 9.4%
Y&S MHSOP - Medical 0.0% 0.5%
Core service total 5.4% 7.0%
Trust Total 5.2% 5.3%
The below table covers staff fill rates for registered nurses and care staff during January, February and March 2018.
Westerdale South ward reported to be below the planned fill rate for night nurse shifts for all three months, while Cherry Tree House was reported to be below the planned fill rate for night nurse shifts in January. Oak, Rowan Lea Springwood, Ward 14 and Westerdale South all reported to be below the planned fill rate for day nurse shifts in March 2018. Acomb Garth and Westerdale South wards reported to be over the planned fill rate for care staff in both day and night shifts consistently across the three month period. Key:
Between 1 March 2017 and 28 February 2018, information was provided for the number of shifts, filled/not filled by agency staff to cover sickness, absence or vacancy for medical locums. However, the data was provided at hospital location and unable to determine the ward/team allocation.
At the time of inspection, the trust provided data to confirm the service did not have any vacant medical posts in this core service. There were a total of 8 consultants one locum consultant providing an average of 118 clinic sessions per week across the service.
Mandatory training
The compliance for mandatory and statutory training courses at 31 March 2018 was 90%. Of the training courses listed, 12 failed to achieve the trust target and of those, three failed to score 75%.
The trust compiles the training data figures as a final figure at year-end.
The training compliance reported for this core service during the most recent 12 months was higher (better) than the 81% reported in the previous year.
Core service total 1 1173 1086 7 (0.6%) 109 (9.3%)
There were seven incidents of prone restraint, which accounted for 0.6% of the restraint incidents.
Incidents resulting in rapid tranquilisation for this core service ranged from three (in February 2018) to 18 (in January 2018).
There has been one instance of mechanical restraint recorded over the reporting period. This was on Oak Ward in December 2017 where a patient was transferred back to the ward form a corridor using a trans-e-slide following an incident of rapid tranquilisation.
The number of restraint incidents reported during this inspection was higher than the 1038 reported at the time of the last inspection.
68
85
57
66
108
169
137
106
80
94
119
84
0 1 1 0 1 0 0 2 0 2 1 00
20
40
60
80
100
120
140
160
180
Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18
Total restraints over the 12 month period
Number of incidents of the use of restraints Number of prone restraintsNumber of mechnical restraints Number of incidents resulting in the use of rapid tranquilisation
Over the 12 months, there was one incident of seclusion, which occurred August 2017.
There were zero seclusion incidents reported during the previous 12 months.
There have been zero instances of long-term segregation reported in the last two years.
Managers told us that since the introduction of the Clinical Link Pathways (CLiPs) which included
the positive behavioural pathway the use of restraint had reduced. Staff received positive
approaches training and used supportive engagement in place of observations to support patients
more effectively. Staff told us that restraint would only be used as a last resort and that this would
usually take the form of light holds. Staff said it was rare for prone restraint to be used and that they
would use ‘mova’ bags (large beanbag chairs) to place patients in a safe comfortable position if they
required to be restrained for a period of time or for the administration of rapid tranquilisation.
Restraint records we reviewed supported this and were in line with the trust policy. However, we
found the recording of restraint used to facilitate personal care on Rowan lea and springwood lacked
detail regards the timeframe of the restraint and the type of intervention used.
0 200 400 600 800 1000 1200 1400
Restraints Olderpeople wards(1173) [1086]
Number of incidents
Number of incidents of restraint and prone restraint for this core service over the 12 months
Of the incidents of restraint, howmany were incidents of pronerestraint?
Please note the figures in square brackets ,after the total number of restraints, are the number ofdifferent service users restraint was used on during this time period.
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 its 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.
This core service made 66 safeguarding referrals between 1 March 2017 and 28 February 2018, all of which concerned adults.
Number of referrals
Adults Children Total referrals
66 0 66
106 7
42 3
810
53 4 4
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
10
6 74
2 3
810
53 4 4
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
0 0 0 0 0 0 0 0 0 0 0 0
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
Adult
Child
Total referrals (1 March 2017 to 28 February 2018)
The average compliance for safeguarding adults training was 94% and 93% for safeguarding children training. The staff we spoke to were aware of the trusts safeguarding procedures, including how to raise concerns and make a referral. Staff could give examples of when they would be concerned and the actions they would take to reduce the risk.
Tees Esk and Wear Valley NHS Foundation Trust have submitted details of five serious case reviews commenced or published in the last 12 months. None relate to this core service.
Staff access to essential information
The trust used an electronic patient record system which was accessible to all staff and bank staff.
Agency staff were not routinely given access to the system due to not been able to complete the
required training. However, where agency staff were used on a regular basis the trust would
provide them with access to the system. There was a daily handover and staff were updated on
the patients care needs and risks.
Where paper records were used, for example Mental Health Act documentation, there was a
process in place for these to be scanned and uploaded on to the system. At Acomb Garth,
Meadowfields and Cherry tree house there was a delay in the process between the wards and the
Mental Health Act office meaning some of the section 17 leave paperwork was outdated on the
electronic system. However, current and up to date paper records were available on the wards.
Medicines management
At the last inspection concerns were identified regard the staff practice in relation to medication management. Staff compliance with medication management and rapid tranquilisation training was low. Staff were not completing or acting upon regular medication audits including daily checks of emergency medication. There were gaps in medical records including missing patient information and best interest decisions had not been completed for the administration of covert (hidden) medication.
During this inspection we found staff compliance with both medication management and rapid tranquilisation training was above the trusts compliance rate of 90%.
Each ward had a dedicated pharmacy service. Pharmacists provided clinical review of the prescription charts and were available to speak with patients or carers on request. Additionally, at Auckland Park hospital, pharmacists offered a ‘medicines session’ as part of the hospitals six-week carers programme. The trust had access to a range of medicines information sources for patients and carers. Remote, out-of-hours pharmacist advice was available through a rota.
In addition to medical prescribing, both nurse and pharmacist non-medical prescribers actively prescribed medicines across the wards we visited, helping to provide faster access to medicines.
We looked at 140 prescription charts across all wards. The prescription charts were up-to-date and clearly presented to show the treatment people had received. Where required, the relevant legal authorities for treatment were in place and monitored by the ward pharmacist and nursing staff. Suitable safeguards were in place should covert medicines administration be used including documented best interest decisions.
The previous inspection highlighted concerns regarding the completion of patient prescription records with 144 gaps identified in records across the service. During this inspection we found two gaps in the prescription charts on Acomb Garth and five gaps in the charts on Cherry Tree House. However, one prescription chart on Meadowfields relating to the administration of covert Risperidone, an antipsychotic medication, had not been completed for 17 out of 26 administrations.
Records we reviewed on Hamsterley, Ceddersfield, Oak and Rowan recorded the use of rapid tranquilisation. We found that trust policy for completing physical health observations following the
use of rapid tranquilisation was not always adhered to. The refusal of physical health observations and the use of visual observations where observations had been refused were not always documented. This is important to demonstrate the patient’s wellbeing has been monitored.
Staff completed checks of patients’ physical health on admission using the Lester Tool and coordinated appointments with patients’ GP’s or specialists, as needed. We found that care plans generally considered people’s physical health needs, However, we found that care plans relating for example, to agitation or anxiety contained clear information about non-pharmacological support but only limited information about the use of prescribed ‘when required’ medicines. This information is particularly important where patients are prescribed more than one ‘when required’ medicine. However, this information was available on patients’ prescription charts and nurses generally made entries in patients’ notes regarding the reason for ‘when required’ medicines use, and the outcome, to aid clinical review of ‘when required’ medicines use.
Medicines including controlled drugs were safely and securely stored. Pharmacy staff completed quarterly controlled drugs audits and the required reports were sent to the Controlled Drugs Local Area Network. Nurses completed checks to ensure that equipment and medicines for medical emergencies were available for use, if needed. However, checks of the tamper-evident medicines seal were not documented. Pharmacy technicians completed regular checks to ensure that medicines stock was rotated and in date. However, we found that nurses did not always date medicines with a reduced shelf life on opening, at first use. Additionally, we found that the medicines fridges on Oak and ward 14 contained stocks of medication that where no longer required.
Both room and fridge temperature were monitored daily. The monitoring form included a normal range for fridge temperature, but no range or guidance about when advice should be sought regarding clinic room temperature.
Track record on safety
Providers must report all serious incidents to the Strategic Information Executive System (STEIS) within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there were eight STEIS incidents reported by this core service – all incidents were ‘Slips/trips/falls’ and one resulted in the unexpected death of a patient.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS.
Reporting incidents and learning from when things go wrong
Incidents were reported and recorded on an electronic system. The system automatically informed
the relevant people to ensure investigation of incidents were completed. The system would identify
where an incident met the threshold for the duty of candour and that the relevant actions including
an apology were completed.
Staff told us that feedback was provided from the learning of incidents and that this could be in
supervision, team meetings or in regular trust emails depending on the nature of the incident and
the learning.
Managers told us that they could access incident data on the service dashboards and that themes
and trends were monitored through the trust governance processes and information shared across
the service.
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 six ‘prevention of future death’ reports sent to Tees Esk and Wear Valleys NHS Foundation Trust. One of these related to this core service, details of which can be found below.
Learning from coroners’ reports were shared in the same way as learning from incidents through
discussions in team meetings, emails and individual supervisions.
Is the service effective?
Assessment of needs and planning of care
Staff completed an initial assessment within the first 12 hours of admission including an
assessment of the patients’ mental and physical health based on a range of assessment tools
relevant to the patients’ needs and care pathway. These included the Addenbrooke's Cognitive
Examination, Geriatric Depression Scale, the Cornell Scale for Depression in Dementia, Bristol
Activities of Daily Living skills, Brief Psychiatric Rating Scale, the Lester Tool, Early Warning
Scores, assessment of frailty and baseline physical health assessment.
Psychologists worked with patients and their carers from the point of admission to develop a
formulation which influenced the content of the care plan. A formulation is described as a personal
story or narrative that professionals develop with patients and carers taking account of an
individuals’ relationships, social circumstances and life events. Staff used the formulation to
understand individuals’ likes and dislikes, how best to support them and to plan their individual
outcomes.
Following the initial assessment staff held a 72-hour assessment meeting with the patient and their
carers to review the initial assessment and plan the patients care.
Between 1 March 2017 and 28 February 2018 the average rate across all teams in this core service was 65% of the trust’s target.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.
Ward name Clinical supervision
sessions required
Clinical supervision
sessions delivered
Clinical supervision rate
(%)
Acomb Garth - - 100%*
Cherry Tree House - - 100%*
Meadowfields - - 100%*
Ceddesfeld 108 78 72%
Hamsterley 88 69 78%
Oak 71 51 72%
Roseberry 82 68 83%
Cherry Tree House 161 36 22%
Acomb Garth 180 42 23%
Meadowfields 246 25 10%
Westerdale North 114 94 82%
Westerdale South 123 106 86%
Rowan Ward 80 47 59%
Springwood 53.7 59 110%
Rowan Lea 79.2 27 34%
Ward 14 194.4 323 166%
Core service total 1580.3 1025 65%
Trust Total 21668 17840 82%
*Comments provided by Director of Ops - 100% as per job plan
Staff received managerial, clinical and group/other supervision. The trust policy was for staff to
receive a minimum of eight supervisions per year including a minimum one clinical supervision
every quarter. Managers maintained records of when supervisions were held. At the time of the
inspection the average compliance rate for clinical supervision was 80%. With Meadowfields and
Rowan Lea having the lowest compliance at 41% and 64%.
Staff informed informal patients on admission that they could leave at will. And we observed signs
displayed on the wards to remind patients they could leave the ward freely.
Good practice in applying the Mental Capacity Act
The trust told us that seven Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority for this core service between 1 March 2017 and 28 February 2018.
The greatest number of DoLS applications were made in October 2017 with three. The trust had submitted the relevant notifications to the Care Quality Commission when applications had been authorised.
Number of DoLS applications made by month
Mar
2017
Apr
2017
May
2017
Jun
2017
Jul
2017
Aug
2017
Sep
2017
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Tota
l
Applications made
0 0 1 0 0 0 1 3 1 0 0 1 7
Applications approved
0 0 1 0 0 0 0 1 1 0 0 0 3
Managers informed us Mental Capacity Act training had only become mandatory in April 2018
therefore the compliance rate for the training was currently low.
Data provided by the trust confirmed that the average compliance for Mental Capacity Act training
was 16%. The highest rate of compliance was springwood with 40% with Hamsterley and Rowan
Kindness, privacy, dignity, respect, compassion and support
We spoke with 44 patients and 22 carers. We received four comment cards from carers, one
comment card from a patient and carried out three short observational frameworks for inspection
observations on Ceddersfield, Rowan and Ward 14. A short observational framework for
inspection is an observational tool used to help us collect evidence about the experience of people
who use services, especially where people may not be able to fully describe these themselves.
Staff demonstrated a respectful and caring approach towards patients, demonstrating genuine
care and concern for patients, treating them with warmth and respect at all times.
Comments from patients and their carers were all positive about the attitudes of the staff. They
told us that the staff were kind and that they helped them in a compassionate way.
The 2017 Patient-Led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at five of the six core service locations scored lower when compared to similar organisations.
Site name Core service(s) provided Privacy, dignity
and wellbeing
Meadowfields Wards for older people with mental health problems 86.9%
Lanchester Road FKA Earls House
Acute wards for adults of working age and psychiatric intensive care units Forensic inpatient (low/medium) Mental health crisis services and health based places of safety Wards for older people with mental health problems Wards for people with learning disability or autism Other
91.0%
Springwood Wards for older people with mental health problems 86.3%
West Park Hospital
Acute wards for adults of working age and psychiatric intensive care units Child and adolescent mental health wards Long stay/rehabilitation mental health wards for adults of working age Mental health crisis services and health based places of safety Wards for older people with mental health problems
87.1%
Sandwell Park (closed at time of
inspection) Wards for older people with mental health problems 87.1%
Friarage Hospital
Acute wards for adults of working age and psychiatric intensive care units Mental health crisis services and health based places of safety
Patients were referred to the ward from the community via the community mental health teams.
Emergency referrals were accepted out of hours from crisis teams, hospital liaison teams and a
patient’s general practitioner. The service held daily calls between the wards and community
teams in each locality to identify potential referrals and where appropriate beds were available
based on the needs of the patient. Managers told us that where possible patients would be
admitted to their nearest ward or to plan to move the patient to that ward at the earliest
opportunity. However, on occasions the decision may be made to admit patients to another ward if
it was closer to a family member and may make it easier support regular family visits.
The trust provided information regarding average bed occupancies for 14 wards in this core service between 1 March 2017 and 28 February 2018.
Twelve of the 14 wards within this service reported average bed occupancies ranging above the nationally recommended minimum threshold of 85% over this period.
We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the period that was covered.
Ward name Average bed occupancy range (1 March 2017 – 28 February
2018) (current inspection)
MHSOP AP CEDDESFELD CB 53.1% - 99.8%
MHSOP AP Hamsterley 60.4% - 93.8%
MHSOP BOWES LYON ROSEBERRY W
D 60.2% - 100.2%
MHSOP IP BPH CHERRY TREE HOUSE 60.8% - 102.0%
MHSOP IP Friarage Ward 14 81.9% - 101.0%
MHSOP IP HARROGATE ROWAN 49.4% - 98.2%
MHSOP IP Malton Springwood 49.7% - 84.1%
MHSOP IP Sandwell Pk Wingfield 0.0% - 111.9%
MHSOP IP SCARBOROUGH ROWAN
LEA 62.4% - 97.7%
MHSOP IP Selby Acomb Garth 48.8% - 99.7%
MHSOP IP YORK MEADOWFIELD 34.5% - 61.8%
MHSOP RP WESTERDALE NORTH 80.6% - 118.6%
MHSOP RP Westerdale South 66.4% - 112.6%
MHSOP WPH Oak Ward 80.1% - 107.5%
Managers told us bed occupancy could vary and recognised at times there could be a pressure on
beds. Where possible patents were admitted to their nearest ward. However, if a patient was
admitted to a ward out of their geographical area this remained within the trust which made it easy
to develop a plan to transfer a patient to their nearest ward once a bed was available.
Managers and staff told us that there were occasions, when, to avoid an out of area placement
they would admit a patient to a leave bed if the patient on leave was assessed as being settled
and at low risk of the leave breaking down. Managers told us this would only generally be done if
the patient on leave was due to be discharged following a successful leave period or another
patient on the ward was imminently due to be discharged.
The trust provided information for average length of stay for the period 1 March 2017 to 28
February 2018.
We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the period that was covered.
Ward name Average length of stay range (1 March 2017 – 28 February 2018)
(current inspection)
MHSOP AP CEDDESFELD CB 31 - 51
MHSOP AP Hamsterley 47 - 75
MHSOP BOWES LYON ROSEBERRY W
D 32 - 90
MHSOP IP BPH CHERRY TREE HOUSE 50 - 96
MHSOP IP Friarage Ward 14 67 - 96
MHSOP IP HARROGATE ROWAN 35 - 48
MHSOP IP Malton Springwood 423 - 570
MHSOP IP Sandwell Pk Wingfield 31 - 65
MHSOP IP SCARBOROUGH ROWAN
LEA 46 - 113
MHSOP IP Selby Acomb Garth 70 - 122
MHSOP IP YORK MEADOWFIELD 69 - 160
MHSOP RP WESTERDALE NORTH 38 - 72
MHSOP RP Westerdale South 38 - 117
MHSOP WPH Oak Ward 36 - 78
This service reported 137 out area placements between 1 March 2017 and 28 February 2018. The trust advised that these placements reflected where a patient had been admitted to a ward which was not the closest ward to where they lived but was still within the trust.
As of 16 March 2018, this service had 38 ongoing out of area placements. There was one placement that lasted less than one day, and the placement that lasted the longest amounted to 136 days (completed placement).
This core service reported 39 readmissions within 28 days between 1 March 2017 and 28 February 2018.
Twenty-five of readmissions (64%) were readmissions to the same ward as discharge.
The average of days between discharge and readmission was 13 days. There were two instances whereby patients were readmitted on the same day as being discharged and one instance where a patient was readmitted the day after being discharged.
Number of
readmissions (to
any ward) within 28
days
Number of
readmissions (to
the same ward)
within 28 days
% readmissions to
the same ward
Range of days
between discharge
and readmission
Average days
between discharge
and readmission
39 25 64% 0 – 28 13
The trust told us that seven patients had moved wards at night between 1 March 2017 and 28 February 2018.
Ward name Mar 2017
Apr 2017
May 2017
June 2017
July 2017
Aug 2017
Sept 2017
Oct 2017
Nov 2017
Dec 2017
Jan 2017
Feb 2017
Total
MHSOP IP BPH
CHERRY TREE
HOUSE
0 0 0 0 0 0 0 0 1 0 0 0 1
MHSOP IP
HARROGATE
ROWAN
0 0 0 1 1 0 1 0 0 0 0 0 3
MHSOP IP
SCARBOROUGH
ROWAN LEA
0 0 1 0 0 0 0 0 0 0 0 0 1
MHSOP RP
WESTERDALE
NORTH
0 0 1 0 0 0 0 0 1 0 0 0 2
Total 0 0 2 1 1 0 1 0 2 0 0 0 7
Discharge and transfers of care
Staff considered plans for a patient’s discharge in multi-disciplinary meetings. Staff from the
relevant community teams attended meetings for patients due to leave the ward to ensure a
smooth transition and effective onward care.
Between 1 March 2017 and 28 February 2018, there were 577 discharges within this core service. This amounts to 14% of the total discharges from the trust overall (4138).
The trust reported that in the same period there were 284 delayed discharges.
Managers advised us that the reason for delayed discharges was predominantly associated with discharges to care homes and the need to wait for an appropriate placement to become available. There was a limited resource available and not all placements would accept patients with more complex needs. The service was trying to be proactive in addressing this and had been providing training to providers specific to the needs of the patient and their formulation. This included staff working in the providers care home and the provider’s staff shadowing on the ward. Assistant psychologists had also spent time with providers to further develop the patient’s formulation to reflect
the support provided in the care home. The service was recruiting additional psychology input to increase the provision of this support.
Facilities that promote comfort, dignity and privacy
Wards were clean, well maintained and welcoming. Décor was homely with pictures hung in
communal areas. There were separate lounge and dining areas and mixed sex wards had female
only lounges. Patients could personalise their rooms if they requested and could have access to
their rooms through the day. However, only six wards (Hamsterley, Ceddersfield, Oak, Westerdale
South and Springwood) provided all ensuite facilities. The other seven wards either had limited
ensuite provision or entirely communal provision.
Ward 14 and Rowan ward continued to have beds in dormitory style bays which does not support
people’s privacy or dignity. The trust had installed dividers on ward 14 between the beds as an
interim measure to improve the environment. However, this had not been possible on Rowan ward
as the trust did not own the building. Instead beds were separated by a curtain which could be
closed around the bed. This arrangement did not maintain the dignity and privacy of patients.
Bays were single sex with a shared sink. Patents could access a communal bathroom without
having to pass rooms occupied by a patient of the opposite sex. There was a plan in place to
reduce the use of dormitory accommodation across the trust.
Windows in patient rooms on Meadowfields and Acomb Garth were only partially obscured which
meant that patients in other wards could potentially see in to the bedrooms across the courtyard.
Wards had access to activity and therapy rooms, where these were not available wards had
‘multipurpose rooms’ which could be used for providing therapy or activities.
There were well maintained and secure outside gardens for all the wards. The doors to the outside
areas were unlocked during the day.
Patients could make a phone call in private. They could use their own mobile phone or use a
portable ward phone in their bedrooms.
Facilities were available on the wards for patients to make drinks and snacks were readily
available in communal areas.
Patients we spoke to were generally positive about the food and told us they could choose what
they wanted to eat.
Staff told us they could provide meals to meet both religious and cultural needs as well as specific
diets to meet the nutritional needs of patients including fortified diets or soft diets.
The 2017 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at five of the six core service locations scored higher when compared to similar organisations.
Site name Core service(s) provided Ward food
Meadowfields Wards for older people with mental health problems 84.9%
Lanchester Road FKA Earls House
Acute wards for adults of working age and psychiatric intensive care units Forensic inpatient (low/medium)
Mental health crisis services and health based places of safety Wards for older people with mental health problems Wards for people with learning disability or autism Other
Springwood Wards for older people with mental health problems 97.4%
West Park Hospital
Acute wards for adults of working age and psychiatric intensive care units Child and adolescent mental health wards Community based mental health wards for older people Long stay/rehabilitation mental health wards for adults of working age Mental health crisis services and health based places of safety Wards for older people with mental health problems
99.7%
Sandwell Park (closed at time of
inspection) Wards for older people with mental health problems 100.0%
Friarage Hospital
Acute wards for adults of working age and psychiatric intensive care units Mental health crisis services and health based places of safety Wards for older people with mental health problems
97.9%
Trust overall 97.2%
England average (mental health and learning disabilities) 91.5%
Patients’ engagement with the wider community
Staff supported patients to maintain contact with their families and carers. Family members we
spoke with told us that communication with ward staff was very good
There were Chaplains who visited the wards and an accessible multi-faith room. Patients could
utilise authorised leave to access the community with the support of staff and carers.
Patients could access to the internet through WIFI provided by the trust or through patient
computers available on the wards.
Meeting the needs of all people who use the service
All wards were equipped to care and treat people with significant mobility issues. The wards were
on ground floor level with easy access throughout the ward areas and to outside garden space.
Wards had appropriately placed grab rails, bed sensors, pressure relieving mattresses and
adapted bathrooms. There were bariatric beds, commodes walking aids and wheelchairs if
The trust managed the mental health services for older people across four geographical locations, Durham and Darlington, Teesside, North Yorkshire and York and Selby. Each of the four localities were managed by a service manager. Locality managers managed a portfolio of services including community and inpatient services with the geographical area. During the inspection we talked to three service managers and three locality managers.
Managers demonstrated the skills, knowledge and experience to perform their roles and had a good understanding of the services they managed.
Ward managers had access to leaders training and other management specific training courses. They supported staff with their training needs through the appraisal and supervision process.
All the staff we spoke with felt supported by their immediate manager. They told us their managers were approachable and familiar with all the activities on the ward.
Vision and strategy
The staff we spoke to were aware of the trusts values and although not always able to list them,
could articulate them in a way which had meaning to themselves. Staff were seen to demonstrate
the trusts values within their interactions and activities on the wards.
Culture
Staff told us they felt valued and respected in their roles. Staff demonstrated a commitment to the
service and the patients through the conversations they had with us and through the interactions
we observed. Staff in the York services told us there had been pressures recently due to current
staffing levels and use of agency staff. However, they also told us they felt supported by their
managers and that managers shared their concerns.
Staff were aware of the support mechanisms available to them including supervision, access to
confidential counselling and referrals to occupational health. Managers were able to give
examples of where they had made adjustments to support staff to remain in work including
reducing hours and arranging for staff to work on other wards.
Staff were all aware of how to raise concerns including the process for whistleblowing and all staff
said they felt they would be protected and supported if they were to raise concerns. Staff had
confidence in managers to address issues of concern and managers told us there were processes
in place to support them to address issues of poor performance. However, although staff were
aware of the role of the freedom to speak up guardian, few could name who this was but said they
would be able to find them on the trusts intranet if they wished to contact them.
During the reporting period, there were six cases where staff have been either suspended, placed under supervision or were moved to a different ward. Four members of staff were placed under supervision and two were moved wards.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.
system for agency staff where this was necessary and systems in place to share information
where staff did not have access.
Ward managers had information management systems to report on, and monitor performance
indicators such as incidents, mandatory training and appraisals.
We saw evidence of staff making notifications to external bodies as needed, for example,
safeguarding referrals.
Engagement
The trust had good links with external stakeholders including clinical commissioning groups and
NHS Improvement.
Staff had access to the trust intranet system, which enabled staff to access key documents,
policies, information, updates, and newsletters about the trust.
The trust had a well-maintained website that provided a range of information to the public about
the services they provided.
Everyone had opportunities to give feedback about the service. This could be through staff, patient
and carer meetings, surveys or comment cards. Managers used the results of surveys to measure
the quality of the service and the experience of people using the service.
Learning, continuous improvement and innovation
The trust had a framework and approach to continuous quality improvement based on Kaizen
principles. Kaizen means ‘change for the better’ and this system was fundamental to how the trust
operated. All staff felt able to make suggestions and innovations were taking place in the service.
Staff were given time and support to consider opportunities for improvements and could feed
these in to bring about positive change within the service, we saw ‘ideas’ sheets in staff areas
across the service for staff to log their idea and how it could improve quality. For example, using a
photograph in a stock cupboard to demonstrate how the cupboard should look to ensure stock
was properly stored and accessible.
Managers were encouraged to partake in the Quality Improvement Systems for leaders training
during which they would undertake a service wide quality improvement project, for example,
purposeful inpatient admission, which had reviewed the admission process to make it more
meaningful to patients.
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 in order to continue to be accredited.
The table below shows which services within this core service have been awarded an accreditation together with the relevant dates of accreditation.
Accreditation scheme Service accredited Comments and date of
The tables below include teams that have vacancies only. The assumption should be made that any teams not listed here has zero vacancies or are over established.
NB: All figures displayed are whole-time equivalents
There was no bank and agency data provided for this core service between 1 March 2017 and 28 February 2018. In the last 12 months, the Hambleton and Richmondshire locality used agency staff due to a high number of staff leavers. Regular agency staff were block booked over a 3 month basis.
This core service had 76.7 (9%) staff leavers between 1 March 2017 and 28 February 2018.
The average turnover rate for this core service was at the lower end of the trust target of 8%-12%.
The table below includes teams where they have had staff leavers in the last 12 months. The assumption should be made that any teams not listed here had zero leavers, thus making them have a 0% turnover rate.
The sickness rate for this core service was 5% between 1 March 2017 and 28 February 2018. The most recent month’s data (February 2018) showed a sickness rate of 5%.
The table below includes teams that have an average sickness rate of 1% or more. The assumption should be made that any teams not listed here had an average sickness rate of 0% for the last 12 months.
The trust worked in close partnership with the local authority, however not all trusts community
mental health teams were fully integrated with their respective local authority. In the teams which
were not fully integrated, local authority staff and community mental health teams shared separate
electronic recording systems and had separate referral routes. Staff felt there were challenges not
working as an integrated service, but still worked closely with the staff from social care to share
intelligence.
Patients and staff told us there was timely access to see a psychiatrist. Each team had a
consultant psychiatrist as part of its ‘super cell’. In addition, the ‘super cell’ constituted of an
advanced practitioner, consultant psychologist, psychologist and a team manager. The team
leader and had overall responsibility of the ‘cells’. As well as consultant psychiatrists some teams
had GP trainees working in the community teams as part of their training, as well as speciality
doctors. This provided additional medical support. Staff told us patients could be seen by their
team doctor within 24 to 48 hours if the patient was unwell. Team doctors told us they were flexible
with their diaries and offered daily emergency slots. Out of hours, patients could access the crisis
team who could offer appropriate intervention until the next working day.
Mandatory training
The compliance for mandatory and statutory training courses at 31 March 2018 was 92%. Of the training courses listed, six failed to achieve the trust target and of those, none failed to score 75%.
The trust compiles the training data figures as a final figure at year-end.
The training compliance reported for this core service during the most recent 12 months was higher (better) than the 85% reported in the previous year.
Key:
Below CQC 75% Between 75% & trust target Trust target and above
Training course This core service % Trust target %
ground them, for example distraction techniques and mindfulness exercises. Patients and carers
told us they felt their crisis plans had sufficient information to aid them in a period of crisis.
Management of patient risk
Staff responded to a deterioration in a patient’s health in a timely manner. Patients and carers
provided us with examples and we also observed this during a multidisciplinary meeting where
members of the team discussed patients where they had identified increasing concerns and
appropriate responses.
All the mental health community teams for adults had morning huddles in their ‘cells’ where they
reviewed their caseloads and discussed any areas of risk. Consultants and psychologists in the
‘super cells’ and the team leaders (cell leads) also met daily providing further oversight and
assurance in relation to managing identified risk issues. We observed five huddles and found staff
were fully engaged in the process, they understood risks and concerns which applied not only to
their personal caseload but those in their ‘cell’ team. We observed one example where staff
decided to carry out patient visits in twos as they felt the patient risk had significantly increased. If
staff had on-going concerns, they could also see patients in the trusts community sites for
additional safety.
The trust had a ‘Lone Working’ policy place which outlined clearly what precautions staff had to
take when working in the community, and there was evidence that staff followed them. All the
teams had a sign in and out board at reception, where staff detailed their appointments and finish
times. Administration staff and the duty worker had oversight of this and confirmed staff were safe
once the visit was over. If a member of staff had a community visit outside of normal working
hours, the crisis service would be made aware as well as their ‘cell lead’. Some teams had code
phrase staff could use if they found themselves in a challenging situation; staff could ring the office
and say the phrase to which an appropriate response would be taken. As part of the ‘Purposeful
Productive Community Services’ all staff had to have an up to date electronic diary which
everyone could access. This meant staff knew where each of their team members would be during
the day. There were no incidents in the last 12 months relating to the safety of staff during home
visits or as a result of lone working.
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 its 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.
This core service made 301 safeguarding referrals between 1 March 2017 and 28 February 2018, of which 183 concerned adults and 118 children.
All staff we spoke with were aware of their responsibilities under safeguarding vulnerable adults and children. As part of the trusts mandatory training framework all community teams had to undergo three levels adult safeguarding and children’s safeguarding training. Compliance with this training was above 95%.
Staff were well supported throughout the community teams with issues around safeguarding. For example, the ‘Psychosis Team’ and ‘Affective Disorders Team’ at Parkside had two large displays in the staff room, clearly identifying what they should do if they had safeguarding concerns for children and adults.
Referrals
Adults Children Total referrals
183 118 301
20 2226 28 27
22
35
27
1621
24
33
0
10
20
30
40
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
1618
13 1412
2224
15
9
14
9
17
0
5
10
15
20
25
30
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
4 4
13 14 15
0
11 12
7 7
15 16
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
Adult
Child
Total referrals (1 March 2017 to 28 February 2018)
Staff were encouraged to bring any concerns to the morning huddles where they could be discussed in a team setting. Staff told us they would speak to the trust’s safeguarding team for advice and then make the appropriate onward referrals. The safeguarding team offered additional safeguarding supervision for staff who had complex cases, which involved families and children. The teams had a “think family” approach to caring for their patients and it was evident staff were thinking holistically about safeguarding, and the wider impact.
The multidisciplinary nature of the teams meant that staff could share and exchange views from
both a health and social care perspective including protecting patients from harassment and
discrimination. Staff told us they had access to specialist social care staff employed by the local
authority who would visit the team on a regular basis. Staff could discuss particular safeguarding
concerns and get advice on case-by-case basis. Social care staff although were not integrated into
the teams, were co-located often in the same office space or buildings, which made having
safeguarding discussions easier.
The teams were involved in multi-agency public protection arrangements and multi-agency risk
assessment conferences. These are specialist safeguarding meeting where different agencies
discuss patients who present the highest risks.
Tees Esk Wear Valley NHS Foundation trust had one serious case progress relation to the
Hartlepool Affective Disorders team, the community mental health teams for adults. The review is
still in progress.
Staff access to essential information
All staff had access to a computer or laptop. The trust was rolling out smart phones for community
staff so they had instant access to electronic diaries and could plan appointments more effectively.
The community mental health teams all used the same electronic recording system to record and
store information. Staff could access patient records, update contemporaneous notes and upload
any key documents. Staff told us the system overall worked well and the trust had improved it over
time.
The community mental health teams also had access to other information systems to ensure they
could respond to medical results in a timely manner. Teams facilitated regular lithium and
clozapine clinics and so it was important they could access blood results to address any concerns
immediately. Therefore, selected staff within each of the community mental health teams could
access an electronic record system to see blood results. This meant teams were not waiting for
pathology teams to send information to them. This provided additional assurance for patients
receiving medication which needed regular monitoring.
We observed a multidisciplinary meeting where staff used the electronic recording system to
access relevant patient information to formulate plans. This was then updated as the meeting was
happening.
Medicines management
The service had a detailed medication management policy in place to which staff adhered to. The
community teams we inspected were storing and disposing of medication appropriately. Fridge
temperatures were monitored daily and the teams could access support from a pharmacist if
required. The community teams did not store stock medication, and only kept what they needed
for each patient. There was a process of ensuring there was enough medication in stock and it
We reviewed a sample of 70 medication cards across all the community teams we visited.
Records in most cases had been signed appropriately and had the correct review dates in line with
the trusts pharmacy policy on monitoring psychotropic medication. We found eight medication
cards all across the Durham and Darlington teams which did not have review dates on them. We
reviewed those patients’ electronic records and found staff had recorded the appropriate
information electronically, but not up dated it on the paper based record. The trust were in the
process of reviewing the paper based ‘Kardex’ records.
The service carried out physical health monitoring with patients prescribed anti-psychotic
medication in line with guidelines produced by the National Institute for Health and Care
Excellence. Staff, where possible completed a baseline physical health check prior to initiating
patients on antipsychotic medication. These checks included blood pressure, height, weight body
mass index, electrocardiogram and blood tests, for example, blood glucose and cholesterol levels.
Teams had robust lithium monitoring processes whereby a physical health lead was responsible
for ensuring patients were having their regular reviews by the GP. Where this had not happened,
the care coordinator was responsible for ensuring the relevant checks were completed.
One patient spoke to us about how the staff at the trust worked hard to get his lithium medication
“right” and provided him with the relevant information, as well as arranging physical health
reviews.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS) within two working days of an incident being identified.
Between 1 March 2017 and 28 February 2018 there were 72 STEIS incidents reported by this core service. Of the total number of incidents reported, the most common type of incident was ‘Apparent/actual/suspected self-inflicted harm’ with 69.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS.
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 six ‘prevention of future death’ reports sent to Tees Esk and Wear Valleys NHS Foundation Trust. None of these related to this core service.
All staff had access to the electronic incident reporting system used by the trust. Staff knew what
incidents to report and could describe situations where they would report incidents. Staff were able
to give us examples of reporting incidents and how they felt they were encouraged to do so by
management. Staff were clear on the escalation process, and understood how the incident would
be reviewed and by whom.
Following serious incidents, staff confirmed that managers provided appropriate support and de-
briefs. We observed a ‘super cell’ meeting with the team leaders after a serious incident had
happened. Due to the significant impact this had had on staff, a psychologist had a debrief with the
team leaders to discuss how they could support the care coordinators, and support staff.
Team managers told us there were various platforms in which staff could be supported after an incident had occurred, including psychology led debriefs either individually or as a group, individual supervisions, and through accessing staff wellbeing services.
Staff felt well supported after incidents and the trust demonstrated sensitivity as well as working in
collaboration with teams to investigate findings. Staff felt there was a ‘no blame culture’ during
investigations and were open to supporting the process.
The service demonstrated continuous learning from incidents. Reviewing serious incidents was
embedded within the governance process and enabled learning from incidents to be shared more
effectively. We were provided with an example of how a patient death led to the service improving
its response time to assessing people with substance misuse issues.
The Duty of Candour is the responsibility of the hospital to be open, transparent and honest with
patients and carers when things go wrong, as well as providing a written apology in some
circumstances. Most of the staff we spoke to understood what the Duty of Candour was, and what
Between 1 March 2017 and 28 February 2018, the average rate across all four teams in this core service was 90% of the trust’s target.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.
Name of hospital site or
location
Name of in patient ward, unit or
team
Clinical
supervision
sessions
required
Clinical
supervision
delivered
Clinical
supervision
rate (%)
Chester le Street Health Centre Durham, Derwentside and
Chester le Street Psychosis 28.0 37.0 132%
Goodall Centre South Durham Psychosis 111.0 127.0 114%
Goodall Centre Wear Valley and Dales Affective 76.0 85.0 112%
Chester le Street Health Centre North Durham EIP 116.0 121.0 104%
Huntington House/Worsley
Court/ Acomb Garth Community services 144.0 144.0 100%
Hartlepool Hartlepool 4.0 4.0 100%
Redcar Redcar 4.0 4.0 100%
Middlesbrough Middlesbrough 3.0 3.0 100%
Stockton Stockton 4.0 4.0 100%
Huntington House AMH YS Assertive Outreach
Team 80.0 80.0 100%
Huntington House North East CMHT 216.0 216.0 100%
Hambleton & Richmondshire west CMHT 76.0 76.0 100%
North Yorkshire Primary care 81.6 81.6 100%
St Aidans house South Durham EIP 88.0 84.0 95%
Redcar Redcar 268.0 254.0 95%
SWR S'bro CMHT 89.0 84.0 94%
Middlesbrough Middlesbrough 172.0 160.0 93%
Stockton Stockton CMHT 260.0 239.0 92%
Derwent Clinic - Shotley Bridge
General Hospital
Derwentside and Chester le
Street Affective 130.0 118.0 91%
Whitby Whitby CMHT 60.0 54.0 90%
Hartlepool Hartlepool 112.0 98.0 88%
Huntington House AMWS 59.0 42.0 71%
Enterprise House Sedgefield Affective 90.0 62.0 69%
The trust had a clear referral criteria and care pathway for patients to access its secondary care
services. The team leaders told us over 80% of referrals came from the patients’ GPs, however,
there were other routes by which patients could access the service. For example, patients could
be referred into the service from other inpatient services in the trust. If a patient was ready to be
discharged from inpatient services the community teams would take them onto their caseload.
Referral could also be made from the tertiary sector like substance misuse services.
The teams in Teesside, Durham and Darlington had an access team which managed referrals and
carried out assessments. The access teams made the appropriate onward referrals to the
‘Psychosis Teams’ ‘Affective Disorders Teams’ who offered patients longer term community
treatment. The teams within North Yorkshire, York and Selby managed referrals through a single
point of access. Staff within the community mental health teams were trained to carry out their own
assessments and triage patients within their teams. Staff across all the regions told us they would
make further referrals to more appropriate services if the patient did not meet secondary care
criteria.
The trusts key performance indicator from referral to initial assessment was 28 days. We found all
the community mental health teams met the referral to assessment target, apart from the adult
mental health team in Hambleton and Richmond, which averaged 29 days.
All of the teams who reported data in this core service met the referral to assessment target set with the exception of ‘AMH Ham and Rich Primary Care’ – details are in the table below.
Name of
team Service Type
Days from referral to
initial assessment
Days from
assessment to
treatment Comments, clarification
Target Actual
(mean)
Target Actual
(mean)
AMH HAM
AND RICH
PRIMARY
CARE
ASSESSMENT
AND BRIEF
INTERVENTIO
N (incl PMHT)
90%
(Local) 29 - 0
All community teams - 90% of
patients to be seen within 4
weeks for a first appointment
following an external referral.
There was no wait time for patients to access the community mental health team once their assessment had been completed. The trust offered a timely and responsive secondary care pathway. Teams allocated new referrals during the morning huddles, each ‘cell’ group was aware of the new patients on their caseload and planned initial visits during the huddle. Patients had excellent access to psychological intervention. All community mental health teams offered low level psychology by trained staff whilst patients underwent a formulation. Once the formulation was complete patients were offered the appropriate psychological intervention to address issues such as trauma. There were little wait times for this due to the skill set within each team, and the presence of a clinical psychologist in each ‘Super Cell’. Team managers told us the
longest a patient had to wait for psychological intervention was two to three weeks. The York and Selby locality had no wait time to access psychology at the time of the inspection. Teams were regularly discharging patients back into primary care. However, team managers felt this was more difficult to do in some cases, as patients who were on specific medication regimes would not be overseen by their GP. As a result the teams had to continue to monitor them. The trust had improved their care pathways within community mental health services for adults for it to be needs led services opposed to diagnosis led. This meant the service offered a more quality service, and interventions were time bound and meaningful. Patients could access services up to six months of discharge without going through the formal route of a referral and assessment. This offered patients a safety net upon discharge. We saw good examples of teams within the trust working with each other to ensure transitions between services were seamless. For example, care coordinators began engaging with the Child and Adolescent Mental Health teams at an early stage to begin transitional work. We found examples of work being done up to six months before the young person turned 18 years of age. Staff also worked closely with inpatient services, engaging with patients prior to discharge to ensure they were fully supported when in the community. We found examples of teams responding to concerns for patients frequently missing initial appointments. The Parkside Access Team tried to change its methods of communicating with patients and introduced ‘text alerts’ as well as telephone calls and letters. Other teams were considering the use of social media through ‘Apps’ and understanding what communication methods suited their local demographic. The teams demonstrated flexibility in appointments and ensured appointments were not missed where possible. During absence, sickness or leave, staff were able to pick each other’s caseload up during the morning huddles. Due to the nature of the meetings, staff understood each person’s caseloads and any associated risks. We observed a team planning to cover colleague’s appointments as they had unexpectedly gone off sick.
The facilities promote comfort, dignity and privacy
Staff primarily saw patients within community settings, such as their homes. However, all teams
had a community base where patients could visit. The community bases were well equipped with
the appropriate facilities including therapy rooms, clinics and interview rooms. All locations had a
welcoming reception area, some were larger than others depending on the building. The
community mental health teams at Parkside were operating from newer purpose-built building
which had an excellent range of facilities.
All the buildings had disability access for people with mobility issues.
Furniture and decorations across all the services were appropriate for use and provided a
comfortable environment for patients to be in. Rooms offered good levels of privacy and dignity
through adequate sound proofing.
Patients’ engagement with the wider community
Staff told us they worked in a family focused way, to ensure they could use the patients close
network as part of their rehabilitation. Staff were also trained in family therapies which enabled
them work with the family and carers as well as the patient.
The community mental health teams offered specific therapies around relationship building,
including Cognitive Analytic Therapy. This gave patients the opportunity to develop their
Staff were involved in the development of the services the trust delivered through various
avenues, including, rapid improvement events and away days. We found an example where the
trust’s senior leader listened to how staff in the North Yorkshire and York region wanted their
community services to be structured. Staff within those teams were anxious about how the
changes of being managed by a new trust would impact on them when Tees Esk Weir Valley NHS
Foundation Trust took over their services in 2015, but told us the trust managed it well and
involved them throughout the decision-making processes.
Culture
All the staff we spoke with felt supported and respected within the organisation. Staff provided us
with examples during times of difficulty on how they were able to access the trust’s staff wellbeing
service for support. Due to the support made available to them, many of them returned to work
after a short period. Staff at all levels were overwhelmingly positive about working for this trust and
said that it was a good organisation to work for.
Staff told us they felt comfortable in raising any issues or concerns to their line of manager without
fear of reprisal. Staff felt as though the trust had an open culture, which was evident across all
levels of management. Most of the staff we spoke with knew who the Freedom to Speak up
Guardian was, and how to whistle-blow should they feel they needed to.
Staff were receiving annual appraisals and regular supervision. Appraisals included discussions
on personal and professional development needs and action plans to achieve their development
goals. All staff commented on how their professional development had been well supported.
During the reporting period, the trust reported three cases where staff had been either suspended, placed under supervision or were moved to a different ward.
Suspended Under supervision Ward move Total
0 3 0 3
Team managers were able to give us examples of how they managed poor performance, and
supported staff in developing until they were able to work at the expected level. Team managers
accessed appropriate support from human resource staff to ensure everything was being done to
support the member of staff.
Sickness levels were lower than the trust average, and in many teams accounted individual staff
being on long term leave.
Staff were recognised for their hard work through various platforms including the, ‘Making a
Difference Award’ for individual staff, through quarterly improvement events where teams could
share their success, and ‘Team of the Week’ which was done on a locality level and trust wide
level. Staff were also thanked for their hard work through the weekly trust newsletters.
Governance
There was a clear governance framework which demonstrated the organisational structure and
where there was oversight of decision making and quality assurance. The trust had an escalation
process from the community teams up to board level and back down to the community teams. The
meeting structures meant that teams discussed essential information such as, risk issues, learning
from incidents and audits on a weekly basis and information was escalated through governance
framework and back down again. Team managers attended monthly quality assurance
phones for staff after a successful pilot. The smart phones would enable staff to manage their
electronic diaries more accurately as part of the ‘Purposeful and Productive Community Services’
quality improvement.
All care records were electronic and were updated regularly. Staff did not use any paper records
apart from medication cards for patients. Medication records were also available electronically.
Staff felt the record system was fit for purpose and told us the trust had continuously reviewed this
to improve it.
Engagement
Staff had access to an internal intranet where the trust posted regular bulletins and staff could find
updates on the trust’s policy and procedures. This also updated staff on any key changes the trust
was undertaking.
Patients and carers had opportunities to feedback into the trust at different levels. Patients were
involved in the recruitment of staff and sat on the interview panel. Patients were also involved in
quality improvement events to input into how the service could develop from a patient perspective.
Patients were also involved within the governance framework in providing feedback about
services. There were service user and carer involvement forums which fed directly into the adult
mental health quality assurance group.
Each community team we visited had an electronic tablet in the reception area where patients
could feedback about services. Some services had boards in reception informing staff how their
feedback had changed the delivery of the service, ‘you said we did’ boards.
Senior management teams had partnership board meetings where they met with the leads of other
key stakeholders such as the local authority, commissioners, public services and third sector
organisations. These meetings enabled services to work closely together and establish
partnership working arrangements.
Learning, continuous improvement and innovation
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 in order to continue to be accredited.
This core service was not part of any accreditation scheme.
Although the trust was not part of any accreditation scheme we found many examples of how this service was trying to drive improvement through various mechanisms, including quality improvement initiatives, rapid improvement events and working alongside universities as part of research and development. Staff were given opportunities to consider improvements and innovation within the organisation through away days, where teams looked at specific pieces of work to improve processes and quality.
One of the largest quality improvement projects the community teams were involved in was ‘Purposeful and Productive Community Services”. The purpose of this was to improve how services were delivered and managed. It aims to remove waste so staff could focus on quality patient care. Purposeful and Productive Community Services started in 2016. Since 2016 the trust had completed phase one which saw the implementation of team ‘cells’, and daily huddles, as well as improving caseload management. The service was in the process of phase two at the time of the inspection which focussed on developing the way teams worked, including improving clinical pathways, improving technology and how service users and carers are involved within development of services.
As part of the ‘Purposeful and Productive Community Services” the trust was using the ‘Kaizen Principles’ as part of their quality improvement work streams. The ‘Kaizen Principles’ is based upon a Japanese business model which translates directly to “continuous improvement”. Some of the work focused on improving transitions between inpatient, crisis and community services to make them seamless.
We observed the service using “The Toyota Way” principles in improving efficiency during the morning huddles. This principle enabled staff to have more concise discussions in these huddles.
The teams were using innovative frameworks to develop their care pathways, for example, the psychosis pathway reformulated an industry model named “Model Lines”. This model looked to develop a pathway from a patient perspective, improving how services were delivered and ensuring it was tailored towards the patient.
